Person-Centered #CarePlanning – What Data?

More about person-centered #CarePlanning. (If you missed my first post go here)

Our health teams struggle to communicate at transitions (between team members, when adding a new team member, between people, offices, and settings) – it’s a perfect tower of Babel.

In its simplest form communication is who, what and how.  Who needs to communicate? What do they need to communicate? How will they communicate?

#CarePlanning focuses on the whatWhat are the goals of the person on the health journey? Who’s going to do stuff to get there? When? How will these goals and activities be tracked and shared across time and settings?

Let’s engage to better understand #CarePlanning from the point-of-view of the person (mostly as patient, sometimes not; usually including family and/or caregiver), rather than from the point-of-view of the doctor, the hospital, or the insurer. What does the person want to accomplish, who on their team (including the person) is going to do what? by when?  Let’s also narrow our focus to #CarePlanning that can be to communicated during transitions between settings rather than within settings (For example,  between home and clinician office, between hospital and rehab center, between home and work or school. Not within the home, hospital, clinic, or agency). Next, let’s look at #CarePlanning during illness rather than wellness or prevention. Edward Suchman (1965) devised an approach for studying illness behavior with five key stages of illness experience: (1) symptom experience; (2) assumption of the sick role; (3) medical care/healthcare contact; (4) dependent patient role; and (5) recovery and rehabilitation. (my italics added).  Finally, let’s be sure to include the social determinants of health or as us non-academics call it, life.

So, we’re considering #CarePlanning from a person point-of-view, between settings, when people are sick, and including life, not just medicine. #CarePlanning happens when we talk to and text with each other, when we write stuff down (lists and logs) and electronically in electronic records and apps. I’ve never met anyone who doesn’t strongly advocate for and believe in #CarePlanning, it’s a no-brainer. At the same time, I haven’t yet seen a universal description of what goes into a person-centered care plan. What are the minimum data elements for a care plan – verbal, written, and electronic formats. With others (you?), I’m participating in an inventory of data that the many vendors, associations, advocacy and information standards groups and professions call care planning. I submitted a new hashtag #CarePlanning to Symplur, an organization that logs and tracks the thousands of healthcare hashtags on social media. (What does it say that there isn’t one already?) Thanks to Geri Lynn Baumblatt from EMMI Solutions, Bevin Croft from HSRI, Ileana Balcu from the Society of Participatory Medicine, Juhan Sonin, Beth Herlin, Edwin Choi from Involution Studios, and Todd Katzman from Boston Children’s Hospital for their time and brains. See Involution Studios http://www.goinvo.com/features/careplans/ for their fine work. More to come. Onward!

Danny

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