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Elements of Enhanced Care Plans
In Integrated Care Management, you have five elements that are part of a care plan. Some of these elements are similar to standard care plans. However in enhanced care plans, these elements are more closely aligned with FHIR R4 and USCDI standards, and can directly use a patient or member’s clinical data in their care plans.
Required Editions
Available in: Lightning Experience Available in: Enterprise and Unlimited Editions with Health Cloud |
Case
Like standard care plans, a case record is the base of every care plan. However, with enhanced care plans, the case record is a parent record while the care plan has its own dedicated record
Conditions
Conditions are health issues that range from a specific diagnosis to more general conditions. Conditions are identified through many sources—the primary care physician, a lab test, an issue reported by the patient or member, a diagnosis, or a stage of a disease. In enhanced care plans, conditions are stored as Health Condition records. And so, any existing Health Condition record can easily be added to a patient’s care plan with the necessary record updates. Conditions are one of the two types of problems you can record in enhanced care plans.
Social Determinants of Health
Social determinants of health are barriers that prevent a person from accessing the healthcare that they need. Social determinants can come in many varieties—financial factors such as poverty, social factors such as race, geographical factors such as location, and so on. In enhanced care plans, social determinants are stored as Care Barrier records. And so, any existing Care Barrier record can easily be added to a patient’s care plan with the necessary record updates. Social determinants are one of the two types of problems you can record in enhanced care plans.
Goals
Goals are the objectives that help achieve an improved outcome for a problem, or improve a person’s general health. You can have one or more goals under a problem, or directly under a care plan. For example, a patient with arthritis could have the goals to keep daily pain levels under 4/10 and to keep or increase range of motion. In enhanced care plans, goals are stored as Goal Assignment records.
Interventions (Known as tasks in standard care plans)
Interventions are the actions you, or someone else on a care team takes to help improve a patient or member’s health. You can ask a caregiver to drive a patient or member to an appointment, remind yourself to follow up on a missed appointment, or send a pre-admission survey. In enhanced care plans, interventions are assigned at the goal, problem, or care plan level, and are stored as Task records. You can find an intervention on the Care Plan, Health Condition, or Goal Assignment record that it’s associated with.
Action Plans
Action plans are groups of related interventions. In an action plan, you can have interventions that are dependent on other interventions. For instance, you can have an intervention task to enroll a patient or member in an assisted physiotherapy program, but it can only be completed after an intervention task to get them vaccinated is completed. In Integrated Care Management, all intervention tasks are ideally meant to be part of one action plan or another.
