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This document outlines the framework for developing a Care Plan within the Home Health Plan of Care (HHPOC) context, focusing on the importance of reconciling multiple care plans from various providers. The recommendation highlights the necessity to modify the description of the Care Plan to emphasize its role in addressing conflicts between different Plans of Care for the same patient. Furthermore, it discusses the essential components such as goals, interventions, and patient preferences, alongside the coordination required for effective longitudinal care.
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Care Plan - CDA Document Type Development Thursday, July 25, 2013
Home Health Plan of Care (HHPOC) • Discuss • Scope? • Sample file based on CMS-485
Care Plan (Document-level) template • Recommendation to change second paragraph of description to the following: "A Care Plan represents one or more Plan(s) of Care and serves to reconcile and resolve conflicts between the various Plans of Care developed for a specific patient by different providers. While both a plan of care and a care plan include the patient’s life goals and require Care Team Members (including patients) to prioritize goals and interventions, the reconciliation process becomes more complex as the number of plans of care increases. The Care Plan also serves to enable longitudinal coordination of care."
Relationships (Happy Path) – SC changes RELATES TO • Observation [mood EVN] Health Concern [mood EVN] Goal [mood GOL] REASON FOR EVALUATES REASON FOR IS COMPONENT OF SUPPORTS RELATES TO Intervention [mood: INT/ RQO/ etc.] [mood: EVN] Outcome Observation [mood EVN] CAUSES
Templates to discuss • Goal Observation • Patient Preference • Provider Preference • Health Concern Act • Intervention Act
Other topics • Related documents?
