v1.0.0 Coordinated Care Plan User Guide Guidelines and Examples 2015-07-27 COORDINATED CARE PLAN USER GUIDE 1 v1.0.0 Table of Contents Purpose ........................................................................................................................................................................................................................... 3 Guiding principles for coordinated care plans ....................................................................................................................................................................... 3 Coordinated care plan template information fields ................................................................................................................................................................ 4 All sections ................................................................................................................................................................................................................... 4 My identifiers ................................................................................................................................................................................................................ 5 My care team .............................................................................................................................................................................................................. 10 My health issues ......................................................................................................................................................................................................... 12 My known, current allergies and medications ................................................................................................................................................................. 14 My plan to achieve my goals for care ............................................................................................................................................................................ 18 My situation and lifestyle .............................................................................................................................................................................................. 22 My recent health assessments ..................................................................................................................................................................................... 29 My most recent hospital visit ........................................................................................................................................................................................ 30 My other treatments .................................................................................................................................................................................................... 32 My current supports and services ................................................................................................................................................................................. 33 My appointments and referrals ..................................................................................................................................................................................... 34 Appendix A: Assessment types and examples .................................................................................................................................................................. 35 Appendix B: Field options for care coordination tool ........................................................................................................................................................... 36 COORDINATED CARE PLAN USER GUIDE 2 v1.0.0 Purpose This document describes how the coordinated care plan template is intended to be used and the purpose of each individual information field that is part of the plan. A “user” of the coordinated care plan could be a care coordinator authoring the plan, a clinician viewing the plan, the client/patient for whom the plan was made, or an informal caregiver. The descriptions in this guide allow users to have a common understanding of the information contained therein so that these clinical documents can be used consistently and reliably. Note: This user guide applies to coordinated care plans regardless of how they are created (e.g., using the Care Coordination Tool or the Microsoft Word template). Many Health Links continue to develop coordinated care planning processes that define how providers, clients/patients and their families work together to coordinate and deliver care for Health Link clients/patients. The coordinated care plan user guide is not meant to impose any particular processes on Health Links nor be a substantive tool to help Health Links develop those processes. However, recognizing that there should be some common aspects of care coordination in place in order for the coordinated care plan to be a useful tool, the user guide does suggest some guiding principles on using care plans (noted below). These guiding principles may inform the development of coordinated care planning processes, although for the most part, they simply reflect the work that is underway in many Health Links already. Please note that information collected using the Care Coordination Tool is personal information or personal health information and must be collected, used, and disclosed only for the purposes of providing health care or assisting in the provision of health care to the client/patient to whom the coordinated care plan relates, as permitted by and in compliance with PHIPA. Guiding principles for coordinated care plans Trust When potential users of coordinated care plans trust in their quality, accuracy and reliability, they are more likely to adopt and embed coordinated care plans into their workflow. This creates a positive feedback loop whereby the more coordinated care plans are used, the greater their value, since more frequent use leads to more comprehensive and timely information being captured in care plans. Comprehensive and timely information furthers users’ trust in care plans, and the cycle continues. Thus, it is crucial that guiding principles that ensure the integrity of coordinated care plans are agreed upon and shared by all users. Value Adoption Below are five guiding principles to encourage the trust, use, and value of coordinated care plans: 1. The client/patient is informed of all information included in the coordinated care plan, who has access to the information and how the information is intended to be used. 2. Each coordinated care plan is developed with direct input from the client/patient. Care plans reflect the client/patient’s stated goals, needs and preferences and are written in clear, accessible language, using the client/patient’s own words where possible. 3. Coordinated care plans are accessible to clients/patients and the circle of care in any setting where care may be delivered. 4. Coordinated care plans are actively used and reliably maintained according to the clinical practices established in each Health Link by all in the circle of care. 5. Coordinated care plans are based on current evidence and use generally accepted clinical guidelines. COORDINATED CARE PLAN USER GUIDE 3 v1.0.0 Coordinated care plan template information fields This guide applies to coordinated care plan template version 1.0.0. All sections Two information fields are common to all sections: “Last verified” and “Last verified by”. They help to establish the authorship of each section as well as the currency of the information in that section. Information field What it tries to capture Paper form / CCT Format Examples The most recent date and time on which the information in Last verified Free text / Auto-populated YYYY-MM-DD HH:MM:SS 2014-01-18 14:51:43 this section was verified and/or reviewed for accuracy The name of the individual who most recently verified Last verified by Free text / Auto-populated Kate Austen and/or reviewed this section COORDINATED CARE PLAN USER GUIDE 4 v1.0.0 My identifiers This section helps to establish the identity of the client/patient by providing both basic information about him/her (e.g., name, date of birth, address), as well as other information that will help the care team understand the client/patient, such as his/her ethnicity, religion, marital status and living conditions. Examples (red) & Information field What it tries to capture Paper form / CCT Format probing questions (blue) Given name The client/patient’s given name Free text Michael Mike Preferred name The name by which the client/patient prefers to be identified Free text Do you prefer to be called by a different name? Surname The client/patient’s surname or family name Free text Jones The client/patient’s identified gender Drop down (Refer to list below) Gender Option Description Male The client/patient identifies as a male Female The client/patient identifies as a female Transgender male The client/patient identifies as a transgender male Transgender female The client/patient identifies as a transgender female Other The client/patient identifies as a gender other than the ones listed Decline to answer The client/patient declined to answer Date of birth The client/patient’s date of birth Free text / Date picker YYYY-MM-DD 1965-10-15 A flag to indicate that the client/patient’s date of birth is an Date of birth