Creating an individualized, patient-specific care plan that includes a comprehensive review of all problems, a clear set of unified goals, and an integrated care strategy with meaningful interventions is paramount to the standard practice of case management. However, that is easier said than done.
It is possible for case managers to create their own care plan for each case and manually enter it into the software workflow or care management system, if the patient has one condition with relatively simple needs. But how often does that happen? Case managers, by definition, typically care for chronically ill patients with co-morbidities and complex needs. Trying to create an effective, actionable care plan each time for each patient, by finding and integrating different guidelines and other clinical resources, is difficult, tedious, and time-consuming. Relying on one’s own knowledge of each condition and the inter-relatedness of symptoms, risks, and treatment options to create a complex, individualized care plan is almost impossible – leaving the process open to duplication or, worse yet, omission of important care plan components for each condition. These difficulties can result in the creation of care plans that tend to focus more on the primary condition or disease; minimizing or overlooking important aspects of the other conditions. Creation of comprehensive, effective care plans is a key challenge for clinicians.
Ideally care plans should not be created by each case manager, based solely on their own knowledge and experience. Healthcare is far too complex today. Care plans should be created using information from the most appropriate clinical practice guidelines, chosen from the myriad of guidelines available, and be individualized for each patient. However, it is difficult and time-consuming for case managers to research guidelines, choose the most appropriate one(s), and then manually create customized care plans for each patient. Doing all that makes it difficult to find time to manage their caseload of patients and creates difficulties in being able to monitor and report patient and program outcomes due to the inconsistency of care plan data.
That is why most organizations today are creating pre-defined care plans based on research and review of evidence-based clinical practice guidelines from specialty associations or organizations like: the National Guideline Clearinghouse, medical societies, clinical decision support vendors, and disease-specific organizations. Once the guidelines are chosen, the content is used to develop pre-defined care plans that can be used by all members of an interdisciplinary team. The development of these care plans take a great deal of time and effort, but they are worth it, since they assure the use of up-to-date standards of practice, improved consistency of practice, increased efficiency and productivity, consistent documentation, improved reporting capabilities, and improved patient and program outcomes.
These care plans allow case managers to focus on the patients and their needs; not on researching and going through the tedious, repetitive process of manually creating a new care plan for each patient. It is important to note that these are not “canned” care plans; they are patient-specific care plans, manually selected by the case manager and individualized by reviewing a list of suggested problems, goals, and interventions, and either accepting, changing, or deleting each one. Additional care plan components can also be added to address other unique patient needs. This process is not only faster and easier, but also more easily adapted for use with patients with co-morbid conditions.
In addition, today’s technology can make this process even easier and faster by automating some of the manual processes. Almost all care management software systems allow information collected from health risk assessments, patient interviews, clinical data, and other sources to be manually entered. But a few of the leading systems also provide a totally automated process that: allows the data to be downloaded into and/or synchronized with the system; automatically identifies risk factors from the data based on pre-determined triggers; and automatically creates and presents a patient-specific care plan to the case manager, based on the risk factors. The case manager can then individualize the care plan further by accepting, changing, or deleting the suggestions or adding new components to meet the patient’s unique needs.
Creating pre-defined care plans and implementing automated processes takes time, but they are well worth it, since they result in better standardization and consistency of practice, as well as improved patient and program outcomes. Of course, clinical oversight is imperative throughout this process to assure the care plans are kept up-to-date and used correctly, and the automated workflows are optimized and monitored to assure they are providing the expected outcomes.
Some systems only allow organizations to manually create their own in-house developed care plans, while others also offer the choice of purchasing “ready-to-use” care plans that have been researched, developed, and designed to be used as-is or customized, based on the organization’s needs. So organizations need to determine if they want to spend the time and resources to research and develop their own care plans and keep them updated on an annual basis, or purchase ready-made care plans that are updated by the vendor each year. The technical systems also need to be reviewed and analyzed closely to make sure they fit the organization’s goals, objectives, and workflow processes.
Because of the continued development of new clinical guidelines and medical breakthroughs, health IT systems will continue to assume an instrumental role in helping clinicians develop, integrate and customize care plans that are flexible and transparent, thereby resulting in better transitions of care and health outcomes.
