A PPT on care planning integrated with concepts of people centered care. A modified approach to Care planning where provider, client and family partnership leads the way in deriving goals and measurable elements for improvement that are most important to clients and their families. Partnership in care planning instills rightly a greater sense of investment and ownership among client and their families which promotes better compliance, and eventually results in better clinical outcomes.

1. CARE PLANNING
Getting Better Together.
Dr. Syed Mohammad Tayib

2. Objectives
• Best practice
• Quality and Patient safety
• Person Centered Care
Rationale for improvement
• SMART Goals
• Goals concept
• Care Plan Parameters
Settinggoals and measuring them
Modified Pare Plan
IntegratedCare Planning

3. Defining Care Planning
Building a Care Plan: Care plans include,
but are not limitedto,the following:
Prioritized goals for a patient’s healthstatus
Established timeframes for reevaluation
Resources that might benefit the patient,includinga
recommendationas to the appropriate level ofcare
Planningfor continuity of care, includingassistance
making the transitionfrom one care settingto another
Collaborativeapproaches to health, includingfamily
participation
Guiding Principle
A care plan should enhance the patient’s treatment
plan by providinga list of identified health conditions or
problems with a correspondingprioritized list of
interventions to meet the patient’s goals. [2]

4. Best Practice
• Quality & Patient Safety
• Safety and efficiency is achieved
through effectivecommunication,
collaborationand standardized
Processes to ensure that the
planning, coordination,
implementation and of care supports
and responds to each patient’s
unique needs and goals

5. Best Practice
• PersonCenteredCare
• incorporating person-centered care
planning principles
• Person-centered care begins with the
individual’s goals and respects and
addresses their preferences and needs
• improve their health and social
outcomes by developing and
implementing individualizedcare plans
based on the goals that are most
important to the individual.
• Ownership - engagementin setting goals
has been demonstrated to affect not
only their participation in and adherence
to treatment, but their health outcomes
and quality of life

6. Setting Goals and
Measuring Them
• SMART Goals:
• Specific: The goal should be specific to
the patient’s situation and focused on
one desired outcome.
• Measurable: The goal must be a
measurable, evidence-based outcome.
• Achievable: The goal must be
reasonably achievable based on
patient’s condition
• Relevant:The goal mustbe
individualized to the patient, based on
stated needs, desires, and assessment
findings
• Time Specific:Goals need to include a
target date that is achievable.

7. Setting Goals and Measuring Them
• Goal Concepts:
• Problem statementwith an action plan that is measurable,
obtainable,and important to the patient.
• What is highest priority for the patient?
• Identify what the patient wants to happen/do, when to have it
completed, and how you will as the PCP/MRP know that it is
done.
• Barrier(s): Any factor that can limit the patientfrom achieving
the goals set forth in the care plan (i.e., lack of transportation,
financialissues, social issues, lack of knowledge.
• Intervention(s): The steps that need to be taken to assist the
patient to reach the goal(s):
• Interventionmust be prioritized and customized for each
patientto resolve the issue/problem that will have the
highest impact on patient’shealth status
• Continuousreprioritizationof the care/interventionsfor
the patient must occur based on the most recent
interactionsand new information from clinician.
• Evaluation: Ongoing review and revision of the care plan until
goals or met. Thismay include developmentof new goals.

8. Setting Goals
and Measuring
Them
Care Plan Parameters
1. Problem List
2. Goals
a) In patient’s own words (family if
involved is also included)
b) Goals defined in clinical terms
based on the problem list.
Prioritized based on clinical
condition and patient buy in.
i. Measurable Elements for
improvement defined
3. Identify Barriers to achieving goals
4. Establish intervention
5. Instructionsand follow up

9. Modified Care
Planning
• Goals are reassessed and modified in
conjunction with the patient
• Information captured will be in the
same format as the care plan

10. IntegratedCare Planning
When multiple
clinicians are
involved in the
care of the
patient
Care plans of
other clinicians
are derived from
that of the
physician’s
The care plans
are Ideally
integrated and
are visible in the
same page/
sheet.
All measurable
elements of
improvement
link to the goals
of patients

11. References
1. PatientCentered Primary Care: Care Plan Development;Anthem– Blue Cross. [web link:
https://www22.anthem.com/providertoolkit/ss3_updatedcareplanplaybook_abcbs.pdf]
2. Goals to Care: How to keep the person in “person-centered”;The National Committee for
Quality Assurance [web link: https://www.ncqa.org/wp-
content/uploads/2018/07/20180531_Report_Goals_to_Care_Spotlight_.pdf]
3. Writing Good Care Plans: A Good Practice Guide; Oxleas, NHS, Care Coordination Association. [
weblink: http://oxleas.nhs.uk/site-media/cms-
downloads/Writing_Good_Care_Plans_Oxleas.pdf ]
4. Complex Care Management Toolkit; California Quality Collaborative, California Healthcare
Foundation. [web link:
http://www.calquality.org/storage/documents/cqc_complexcaremanagement_toolkit_final.pdf
]