What is the purpose?
The purpose of the Care Planning Change Package is to assist primary care clinics in optimizing a care planning processes for paneled patients with rising complex health needs.
What is the aim statement?
By a specific date, the clinic team will have completed a specific number of care plans using a patient-centered approach.
What is the outcome measure?
The number of patients with rising complex health needs with a documented care planning offer within the last twelve months.
What constitutes the balancing measure?
The time to the third next available (TNA) appointment.
What do I need to do before proceeding?
These are the prerequisite change packages that should be reviewed:
Panel Processes Change Package Summary Relational Continuity Change Package SummaryHigh Impact Changes
-
Improve the patient experience
Potentially Better Practice
Establish a multidisciplinary quality improvement team and consider including a patient advisor
Process Measures
Team meetings are scheduled regularly.Tools
Patient Representative Guide -
Identify paneled patients for care planning
Potentially Better Practice
Prioritize and select a patient population for care planning.
Process Measures
Develop a definition of eligible patients.
Tools
HQCA Primary Healthcare Panel Reports Identifying Patients with Complex Health Needs
Potentially Better Practice
Generate lists of patients eligible for care planning and review as a team.
Process Measures
The number of patients eligible for care planning.
Tools
EMR Resources -
Optimize care planning processes
Potentially Better PracticeS
Define and coordinate care team roles, processes, and interactions
Tools
Team Assessment - Care Planning Roles and Responsibilities Template Process Mapping Introductions with Intention
Potentially Better Practice
Offer eligible patients a care planning appointment and invite them to bring a trusted friend or family member to the appointment.
Process Measures
The number of patients offered care planning.
Tools
Scripting Elements
Potentially Better Practice
Test a process for asking patients what matters to them.
Potentially Better Practice
Engage the patient in the care planning process and setting patient-centred goals.
Process Measures
The number of patients with care plans completed in the last 12 months.
Tools
Care Plan Template with Prompt Setting Effective Patient-Centred Goals Guide -
Standardize documentation
Potentially Better Practice
Create processes in the EMR to identify the patient as part of a specific population for care planning.
Process Measures
The number of patients eligible for a care plan.
Tools
EMR Resources
Potentially Better Practice
Document all aspects of the care plan in the care plan template.
Process Measures
The number of patients with care planning template in the chart.
Tools
Care Plan Template with Prompt
Potentially Better Practice
Use reminders in your EMR to establish a process for care planning with outreach and opportunistic strategies for follow up activities
Process Measures
The number of patients with care plan completed due for a follow up.
Tools
EMR Resources -
Coordinate care in the medical home
Potentially Better Practice
Ensure completed care plan is made available to all team members who care for the patient within the medical home.
Process Measures
The number of other providers the care plan has been shared with.
Team Huddles Guide -
Coordinate care in the health neighbourhood
Potentially Better Practice
Provide the patient with a copy of their care plan (if not connected in patient portal)
Process Measures
A care plan is printed for the patient.
Potentially Better Practice
Establish a process to share the care plan with other providers outside of the primary care clinic (AHS, specialty programs, specialists, community, etc.)
Process Measures
The number of other providers the care plan has been shared with.
Tools
Process Mapping
- Patient Representative Guide
- Identifying Patients with Complex Health Needs
- Care Plan Template with Prompt
Developed by
