Elements of a Care Plan

A care plan gives the healthcare team a history of the patient and the progress or challenges related to their health. A care plan can have any number of problems, goals, and tasks that you can track from the person's tab in the console. You can also manage the associated team of professional and personal caregivers from a care plan. When you create a care plan, the person you create it for is added to the care team automatically.

A care plan is a combination of Problems, Goals, and Tasks, with a Care Team to manage them all. This example is just one way you can lay out a care plan on users’ screens.

• Problems: The Reason There's a Care Plan
  Problems are health issues that range from a specific diagnosis to more general conditions. Problems 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. A problem can be clinical, such as a chronic bronchitis diagnosis, or non-clinical, such as needing assistance with daily activities in the home. When you assign a priority to problems, they appear in order of priority.
• Goals: Shaping the Care Plan
  Goals are the patient objectives that help achieve an improved outcome for a problem. A problem can have multiple goals. 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. As the patient progresses toward the goal, make sure to update the status of the goal.
• Tasks: Primary Drivers of the Care Plan
  Tasks help you track and measure the activities associated with your patients or members. From the console, 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 to complete.
• Care Team: Carrying Out the Care Plan
  Care Team members are a focused group of caregivers who are responsible for the successful completion of tasks related to a care plan. You can assign ownership of care plan tasks to members of the care team, including other health professionals, patients, plan members, and family members.