Coordinated Care Plan (CCP) User Guide

Coordinated Care Plan (CCP) User Guide

v2-5

Coordinated Care Plan (CCP)

User Guide

Guidelines and examples

2014-08-07

1

v2-5

Table of Contents

Purpose ...................................................................................................................................................................................................................... 3

Guiding Principles for CCPs ........................................................................................................................................................................................ 3

CCP template information fields ................................................................................................................................................................................ 4

All sections ............................................................................................................................................................................................................. 4

My identifiers ......................................................................................................................................................................................................... 4

My care team ......................................................................................................................................................................................................... 8

My health ............................................................................................................................................................................................................. 10

My known, current medications .......................................................................................................................................................................... 13

My plan to achieve my goals for care .................................................................................................................................................................. 15

My situation and lifestyle ..................................................................................................................................................................................... 19

My assessed health needs ................................................................................................................................................................................... 26

My most recent hospital visit ............................................................................................................................................................................... 26

My other treatments ........................................................................................................................................................................................... 28

My current supports and services........................................................................................................................................................................ 29

My appointments and referrals ........................................................................................................................................................................... 29

Appendix A: Assessment Types and Examples ........................................................................................................................................................ 31

Appendix B: Sample CCP Scenarios .......................................................................................................................................................................... 32

2

v2-5

Purpose

This document describes how the coordinated care plan (CCP) template is intended to be used and the purpose of each individual information field that is part of the CCP. A “user” of the CCP could be a care coordinator authoring the plan, a clinician viewing the plan, the 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.

Many Health Links continue to develop coordinated care planning processes that define how providers, patients and their families work together to coordinate and deliver care for Health Link patients. The CCP 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 CCP to be a useful tool, the user guide does suggest some guiding principles on using CCPs (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.

Guiding Principles for CCPs

When potential users of coordinated care plans (CCPs) trust in their quality, accuracy and reliability, they are more likely to adopt and embed

CCPs into their workflow. This creates a positive feedback loop whereby the more CCPs are used, the greater their value, since more frequent use leads to more comprehensive and timely information being captured in CCPs. Comprehensive and timely information furthers users’ trust in

CCPs, and the cycle continues. Thus, it is crucial that guiding principles that ensure the integrity of CCPs are agreed upon and shared by all users.

Trust

Value Adoption

3

The following are five guiding principles to encourage the trust, use, and value of CCPs:

v2-5

1. The patient is informed of all information included in the CCP, who has access to the information and how the information is intended to be used.

2. Each CCP is developed with direct input from the patient. CCPs reflect patients’ stated goals, needs and preferences and are written in clear, accessible language, using patients’ own words where possible.

3. CCPs are accessible to patients and the circle of care in any setting where care may be delivered.

4. CCPs are actively used and reliably maintained according to the clinical practices established in each Health Link by all in the circle of care.

5. CCPs are based on current evidence and use generally accepted clinical guidelines.

CCP template information fields

This guide applies to CCP template version 0-6-2F.

All sections

Two information fields are common to all sections: 1) “Last verified” and 2) “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

Last verified

Last verified by

What it tries to capture

The most recent date on which the information in this section was verified and/or reviewed for accuracy

The name of the individual who most recently verified and/or reviewed this section

How to fill it out

A date in the format

YYYY-MM-DD

Free text

Examples

2014-01-18

Fred Flintstone

Mickey Mouse

My identifiers

This section helps to establish the identity of the patient by providing both basic information about him/her (e.g. name, date of birth, address, etc.) as well as other information that will help the care team understand the patient, such as his/her ethnicity, religion, marital status and living conditions.

4

Information Field

Given name

Preferred name

Surname

Gender

Option

Male

Female

Transgender male

Transgender female

Other

Decline to answer

Date of birth

Health Link

Address

City

Province

Postal code

OHIP insured

Option

Yes

No – uninsured

What it tries to capture

The patient’s given name

The name by which the patient prefers to be identified

How to fill it out

Free text

Free text

Examples and key questions

Michael

Mike

Do you prefer to be called by a different name?

Jones The patient’s surname or family name

The patient’s date of birth

Free text

The patient’s identified gender Choose from the drop-down list

Description

The patient identifies as a male

The patient identifies as a female

The patient identifies as a transgender male

The patient identifies as a transgender female

The patient identifies as a gender other than the ones listed

The patient declined to answer

A date in the format

YYYY-MM-DD

Free text

1965-10-15

Barrie Community The name of the Health Link from which the patient’s CCP was created

The address of the patient’s primary residence

Free text 123 Main Street

The city of the patient’s primary residence

The province of the patient’s primary residence

Free text

Standard two-letter format

Ottawa

ON

The postal code of the patient’s primary residence

Whether or not the patient has

OHIP coverage

Description

Standard six-character format

Choose from the drop-down list

The patient has OHIP insurance

The patient does not have any insurance for core services

A1A1A1

v2-5

5

Information Field

No – other coverage

Decline to answer

Health card #

Telephone #

Alternate telephone #

Email address

Preferred contact by

Option

Telephone

Email

Translator

Other

Decline to answer

Mother tongue

Official language

Option

English

French

Neither

Decline to answer

Ethnicity/culture

What it tries to capture How to fill it out

The patient has non-OHIP insurance for core services (e.g. RCMP)

The patient declined to answer

The patient’s health card Free text number, if they have one, including the version code if applicable

The patient’s primary telephone number

An alternate telephone number by which to contact the patient

The patient’s primary email address

Telephone number as

XXX-XXX-XXXX

Telephone number as

XXX-XXX-XXXX

Free text

Examples and key questions

0123456789VG

613-555-1234

613-555-4321 [email protected]

The method by which the patient prefers to be contacted

Choose from the drop-down list

Description

The patient prefers to be contacted by telephone

The patient prefers to be contacted by email

The patient prefers to be contacted via a translator

The patient prefers to be contacted by a method other than the ones listed (e.g. mail)

The patient declined to answer

The patient’s mother tongue

The official language in which the patient is most comfortable

Free text

Choose from the drop-down list

Arabic

Description

English is the official language in which the patient is most comfortable speaking

French is the official language in which the patient is most comfortable speaking

The patient is unable to speak in either official language (neither English nor French)

The patient declined to answer

The patient’s self-identified ethnicity or culture

Free text Inuit

v2-5

6

Information Field

Religion or social group

Marital status

Option

Never married

Married or common-law

Separated

Divorced

Widowed

Decline to answer

Where I currently live

Option

Private dwelling

Assisted living home

Retirement home

Group home

Long-term care home

Hospital

Hospice

Correction centre

Shelter

Rooming house

Homeless

Other

Decline to answer

People who live with me

Option

No one

Partner only

Partner and others

What it tries to capture How to fill it out Examples and key questions

The patient’s self-identified religion or social group

Said patient’s marital status

Free text

Choose from the drop-down list

Description

The patient has never been married

The patient is currently married or in a common-law relationship

The patient is separated from his/her spouse

The patient is divorced from his/her spouse

The patient is widowed/a widower

The patient declined to answer

Choose from the drop-down list The patient’s current living arrangements

Description

Residence that is privately owned or leased by the patient

Residence that provides support services but no medical monitoring

Residence that provides care for seniors

Residence that provides for persons with developmental disabilities

Licensed home providing 24-hour nursing care or supervision

Institution that provides treatment to injured or sick persons

Home for end-of-life care

Institution that houses offenders serving sentences from 60 days to 2 years

Temporary residence for homeless persons

Residence where inhabitants share a kitchen and bathroom

Lacking stable, permanent, appropriate housing

Residence other than the ones listed

The patient declined to answer

Choose from the drop-down list Those people with whom the patient currently lives

Description

The patient lives alone

The patient only lives with his/her partner

The patient lives with his/her partner and others (e.g. children)

Hindu

Freemason

v2-5

7

Information Field What it tries to capture How to fill it out Examples and key questions

Children only

Parent(s) or guardian(s)

Sibling(s)

Other relative(s)

Others

Decline to answer

People who depend on me

Primary contact

Relationship to me (primary contact)

Telephone # (primary contact)

The primary contact’s primary telephone number

Emergency contact

The patient only lives with his/her children

The patient lives with his/her parent(s) or guardian(s)

The patient lives with one or more of his/her siblings

The patient lives with one or more relatives other than the ones listed (e.g. cousin, uncle)

The patient lives with one or more people other than the ones listed

The patient declined to answer

Those people who are dependent on the patient (e.g. to whom patient is a caregiver)

Free text My two children

The name of the patient’s primary contact (should match what is given in My care team)

The relationship to the patient of the primary contact

The name of the patient’s emergency contact who is to be contacted when primary contact cannot be reached

Free text

Free text

Telephone number as

XXX-XXX-XXXX

Free text

Donald Duck

Who is your main “go-to” person who you would want involved in your care?

Parent

416-555-1234

George Jetson

In an emergency, if Donald wasn`t available, who would you want us to call?

Free text Cousin

Relationship to me (emergency contact)

Telephone # (emergency contact)

The relationship to the patient of the emergency contact (e.g. son)

The emergency contact’s primary telephone number

Telephone number as

XXX-XXX-XXXX

519-555-1234

v2-5

My care team

This section records the members of the patient’s care team, including both formal and informal caregivers, and provides some information to describe each member’s role in the care team. This section also serves as a “directory” for anyone who may view the care plan. Where possible, individuals should be identified although in some cases it may be more appropriate to identify an organization (e.g. a retail pharmacy). Where

8

v2-5 care team members are listed elsewhere in the care plan (e.g. “primary contact”) their name and contact information should be the same as it is listed in this section.

Information Field

Name

Role or relationship

Organization

Telephone #

Regular care team member

Option

Yes

No

What it tries to capture

The name of the particular care team member

The care team member’s professional role or relationship to the patient – if the care team member has been designated to make decisions on the patient’s behalf if the patient is incapable of making decisions by him or herself, include the fact that they are a substitute decision-maker

(SDM)

If applicable, the organization with which the care team member is affiliated

The care team member’s primary telephone number

Whether or not the patient sees the care team member at least once a year on a planned basis

Description

The patient sees the care team member at least once a year on a planned basis

The patient does not see the care team member at least once a year on a planned basis

How to fill it out

Free text

Free text

Free text

Examples and key questions

Fred Flintstone

Dietitian

Parent, SDM

Priest

Guelph FHT

Telephone number as

XXX-XXX-XXXX

Choose from the drop-down list

613-555-1234

9

v2-5

Information Field

Lead care coordinator

I rely on most at home

The people I rely on most at home are feeling…

Option

Able to continue

Not satisfied

Angry or distrustful

Unable to continue

What it tries to capture

A flag to identify which member of the care team is the lead care coordinator and primary author of the coordinated care plan

A flag to identify which member of the care team the patient relies on the most at home or informally – up to patient’s discretion

An indication of “caregiver burnout” - the ability of informal members of the care team to continue to provide support to the patient

Description

The care team members have no difficulty in continuing to provide care for the patient

The care team members are dissatisfied with some aspect of the situation, but are able to continue providing care

The care team members are angry or distrustful due to some aspect of the situation, but are able to continue providing care

How to fill it out

Check box

Check box

Choose from the drop-down list

Examples and key questions

The care team members cannot continue providing care to the patient without new supports

My health

This section records the various factors that may negatively affect the patient’s health ranging from physical and mental conditions to social conditions. This section serves to provide a holistic assessment of the patient’s health by giving brief descriptions of each aspect of their health as well as some chronology by providing dates of health issue onset. Entries in the physical health row should pertain to problems, issues, or concerns of the body as should entries in the mental health row pertain to problems, issues, or concerns of the mind. Social health relates to social determinants of health such as relative income level, relationships with others, or any aspect of a patient’s social history that may indirectly affect impact their health.

Information Field What it tries to capture How to fill it out Examples and key questions

10

Information Field

Description

Clinical description

Date of onset

Stability

Option

Stable

Unstable

Notes

Baseline vitals

Height

Height unit of measure

Option

m

What it tries to capture

A plain language description of one of the patient’s health issues

(it can be related to physical, mental or social health)

A clinical description of the patient’s health issues

The approximate month and year the patient first became aware of the issue or was diagnosed with the issue

An indication of whether the issue is stable or not – note that this is at the discretion of the care team considering likelihood of deterioration, disease flare, crisis, or other relevant factors

Description

The patient is stable in regards to the particular health issue

The patient is unstable in regards to the particular health issue

Any other notes to explain or contextualize the issue

How to fill it out

Free text

Free text

A date in the format

YYYY-MM

Choose from the drop-down list

Free text

A number

Examples and key questions

Arthritis

Osteoarthritis

1995-11

ED visits due to pain

How severe are your symptoms?

What triggers tend to cause your disease to flare?

1.65 Height of patient using the specified unit of measure

The unit of measure of the patient’s height

Description

Metres

Highlight one unit of measure

v2-5

11

Information Field

in

Weight

Weight unit of measure

Option

kg lb

HbA1c

Allergies and intolerances

Substance

Allergy or intolerance

Option

Allergy

Intolerance

Symptoms

Option

What it tries to capture

Inches

Weight of patient using either the imperial or metric system – up to provider discretion to pick one and ensure it’s noted

The unit of measure of the patient’s weight

Description

Kilograms

Pounds

How to fill it out

A number

Highlight one unit of measure

Examples and key questions

92

A number Most recent HbA1c test result (a proxy for the average level of blood sugar over time), reported in percent

Name of the compound or factor, which elicits a reaction – if it’s a medication follow the naming guidelines in the medication section

Free text

Whether the reaction between the patient and the substance is that of allergy or intolerance

Choose from the drop-down list

Description

Immune system dependant hypersensitivity reaction to said substance

Inability to digest or dispose of said substance

A description of which bodily system is most affected by exposure to the substance

Choose from the drop-down list

6.6

Corn

Aspirin

Description

v2-5

12

v2-5

Information Field

Skin

Respiratory

Gastrointestinal

Behavioural

Blood

Others

Severity

Option

Mild

Moderate

Severe

Life-threatening

What it tries to capture

The level of danger in regards to the substance allergy or intolerance as perceived by the care team

Description

How to fill it out

The skin is primarily affected by said substance

The respiratory system is primarily affected by said substance

The stomach and intestines are primarily affected by said substance

The mental or motor response of the patient is primarily affected by said substance

The blood is primarily affected by said substance

The parts of the body that are primarily affected do not fall under the ones listed

Choose from the drop-down list

Examples and key questions

Symptoms could be ignored by patient with minimal effort

Symptoms cannot be ignored by patient, but do not limit his/her daily activities

Symptoms cannot be ignored by patient, limit his/her daily activities, and require extensive treatment

Symptoms endanger patient’s life without treatment

My known, current medications

This section lists current and past medications, providing details such as drug name, method of drug delivery, the pharmacy that provides the drugs, and the prescriber’s name. The start dates and change dates create a chronology of the patient’s medication usage and how they may have changed over time.

Information Field

Date of last medication reconciliation

Performed by

What it tries to capture

The date on which the most recent medication reconciliation was performed by a qualified member of the care team

The name of that qualified member of the care team

How to fill it out

A date in the format

YYYY-MM-DD

Free text

Examples and key questions

2013-09-23

Mickey Mouse

13

Information Field

My last medication change was

It made me feel

Option

Better

Worse

About the same

Aids I use to take my medications

Option

Dosette

Blister packs

Other

Challenges I have taking medications

Drug name

Dose

Route

Option

What it tries to capture

A plain language description of the most recent change

(addition, deletion, modification, etc.) to the patient’s medication

How to fill it out

Free text

Examples and key questions

Increase ibuprofen

A plain language description of how that change made the patient feel

Choose from the drop-down list

Description

The medication change made the patient feel better

The medication change made the patient feel worse

The medication change did not produce an effect that could be detected by the patient

A description of the aids that the patient uses to take his/her medications

Choose from the drop-down list

Description

A container intended for the storage and organization of a patient’s medication

Packaging used for storing and protecting a patient’s medication

Any aids other than the ones listed

A plain language description of the challenges the patient has in

Free text I have difficulty remembering to take my medication taking his/her medications

The generic name of the particular medication that the patient is currently taking

The quantity of the particular medication that the patient is currently taking

Free text

Number + unit of measurement

Ibuprofen

20 mg

The route by which the patient takes the particular medication

Description

Choose from the drop-down list

v2-5

14

Information Field

Oral

Topical

Inhaled

Injection

Direction

Reason

Pharmacy

Start date

Change date

Prescriber

Special notes or instructions

What it tries to capture How to fill it out

The patient takes the medication by oral means

The patient takes the medication by application to a body surface

The patient takes the indication by inhalation

The patient takes the medication by injection

Free text The prescribed method or frequency at which the patient takes the particular medication

Free text The reason that the patient was prescribed/directed to take the particular medication

The pharmacy from which the patient acquired this particular medication

Free text

The date that the patient started taking this particular medication

The date of the most recent change to any aspect of this particular medication

The care team member who prescribed/directed the patient to take this particular medication

A date in the format

YYYY-MM-DD

A date in the format

YYYY-MM-DD

Free text

Any other notes that do not fall into previous categories pertaining to the patient’s medications and their use

Free text

Examples and key questions

Daily

Pain/arthritis

Rexall, Oak St.

2005-02-13

2013-05-14

Homer Simpson

Do not take with aspirin or alcohol

v2-5

My plan to achieve my goals for care

This section describes the analysis of the current situation and the “care plan” for the patient.

The patient informs the plan generally by communicating his or her priorities and concerns about his or her health. More specific goals are articulated below which should represent the agreed upon goals for the patient and care team. Several specific actions to achieve the goals are listed, each with a person responsible for

15

v2-5 ensuring the completion of the goal identified. The “My plan for future situations” subsection describes what the patient should do in certain situations, such as a sudden decline in health or function. Finally, there is a sub-section to provide process-related information about the patient’s advanced care planning.

Information Field

Care team members who contributed to this plan

What is most important to me right now

What it tries to capture

The names of all the care team members who directly contributed to the care plan

The single highest priority of the patient both within and outside the context of their health

How to fill it out

Free text

Free text

Examples and key questions

Me, Donald Duck, Mickey

Mouse, Homer Simpson

Enjoying time with my family

What parts of your day do you look forward to the most? What is really important to you and your family?

What concerns me most about my healthcare right now

What I hope to achieve

What we can do to achieve it

Who will be responsible

The single greatest concern of the patient within the context of their health

The patient’s articulation of his/her key goals (not limited to medicine or healthcare), considering the advice of the care team

The actions that the care team will take to accomplish those goals; i.e. the “follow-up”

The names of care team members who will be responsible for completing the actions described

Free text

Free text

Free text

Free text

Being able to afford my prescription medication

What is most concerning about the state of your healthcare?

Walk my daughter down the aisle at her wedding on June 30

What are the top 3 things you want to be able to do? What do you want to improve or work on?

Make an appointment with the physiotherapist and follow exercise regimen

What are some steps we can take to work toward this goal?

Me

Who do you want to help you do this?

16

Information Field

Expected outcome

Barriers and challenges

Results achieved so far

Review date

My plan for future situations

Future situations

What I will do

What I will not do

Who will help me

What it tries to capture

A measurable articulation of the patient’s goal

How to fill it out

Free text

Those barriers or challenges, identified by any care team member that could prevent the patient from reaching his/her goals

Free text

A description of the patient’s progress towards completing the goal

Free text

A future date on which progress on the patient’s goals will be assessed by the care team and the patient

A situation that the patient may be faced with, based on their current situation, in the near future

Actions that the care team has agreed the patient should do in this situation

Actions that the care team has agreed the patient should not do in this situation

Those people who will help the patient in this situation and are aware of their inclusion in the plan

A date in the format

YYYY-MM-DD

Free text

Free text

Free text

Free text

Examples and key questions

Weigh 80 kg

How will you know when you’ve achieved your goal?

Spouse unwilling to modify diet with me

How confident are you that we can do this? What do you think might stop you from getting there?

Lost 3 kg since March 2013

What progress have you made toward accomplishing this goal?

2013-10-17

v2-5

Severe chest pain

What are some future situations that we should plan for?

Call 911

Do not bathe independently or take Tylenol

Donald Duck

Who are some care team members who will be ready to help you if these things happen?

17

Information Field

Telephone #

Review date

I have received information about advanced care planning

Option

Yes

No

Decline to answer

I have a completed advanced care plan

Option

Yes

No

Decline to answer

My ACP is located here

I have a Power of Attorney

(POA) for personal care

Option

Yes

No

Decline to answer

What it tries to capture

The primary telephone number(s) for the persons listed to help the patient in this situation

How to fill it out

Telephone number as

XXX-XXX-XXXX

Examples and key questions

613-555-0173

A future date on which the patient’s plan for future situations will be reviewed by the care team and the patient

A date in the format

YYYY-MM-DD

2013-10-26

The patient has been informed by a member of their care team about advanced care planning

Choose from the drop-down list

Is there someone whom you trust to care out your wishes if you are unable to speak for yourself?

Description

The patient has received information about advanced care planning

The patient has not received information about advanced care planning

The patient declined to answer

Affirmation of whether the patient has an oral or written advance care plan

Choose from the drop-down list

Does your Attorney for Personal

Care know your healthcare wishes?

Description

The patient has a completed advanced care plan

The patient does not have an advanced care plan

The patient declined to answer

The physical location of the patient’s ACP

Free text I have a copy in my jewelry box and my daughter has a copy too

The patient has a legal document that gives someone else the right to act on their behalf for care and medical treatment

Choose from the drop-down list

Description

The patient has an Attorney for Personal Care

The patient does not have an Attorney for Personal Care

The patient declined to answer

v2-5

18

Information Field

My POA document is located here

POA for personal care’s name

Relationship to me

Telephone #

As I understand it, my advanced care plan says

What it tries to capture

The physical location of the patient’s POA document

The name of the Attorney for

Personal Care

The relationship of the Attorney for Personal Care to the patient

The primary telephone number(s) for the Power of

Attorney

The patient’s plain speak interpretation of what his/her

ACP entails

How to fill it out

Free text

Free text

Free text

Telephone number as

XXX-XXX-XXXX

Free text

Examples and key questions

In a drawer at home

Jane Porter

Father

202-555-0163

I want my life to be prolonged and that I am provided with all life-sustaining treatments applicable to my condition.

What is your advanced care plan?

v2-5

My situation and lifestyle

This section begins to capture some of the social determinants of health about the patient that will likely impact health and care. Where possible, the impact of the information on the patient’s health and care is the focus of the data, rather than the information itself (e.g. impact of income, rather than the magnitude of income).

Information Field

How I work

Option

What it tries to capture

A description of the patient’s involvement (or not) with the labour force

Description

How to fill it out

Choose from the drop-down list

Examples and key questions

19

Information Field

Student

Self-employed

Full-time

Part-time/seasonal

Volunteer/unpaid

Unemployed

Retired

Decline to answer

How adequate my income is for my health

Option

More than adequate

Adequate

Less than adequate

Much less than adequate

Decline to answer

Supplementary benefits I receive (select all that apply)

Option

Private insurance

ODB

ODSP

Ontario Works

GAINS

SSAH

Veteran’s Benefits

GIS

I follow my recommended diet

What it tries to capture How to fill it out Examples and key questions

Patient is enrolled in a school or college full-time, or is home-schooled

Patient’s income comes directly from own profession or business

Patient has a formal employer and works 30 hours or more per week

Patient has a formal employer and works less than 30 hours per week or only for part of the year

Patient is performing services willingly and without pay

Patient is without a job either by choice or by circumstance, excepting retirement

Patient has left/ceased to work; reasons may include age, personal choice, or legal reasons

The patient declined to answer

A measure of the patient’s sense of whether or not his/her

Choose from the drop-down list income impacts his/her health – up to patient’s discretion

Description

The patient feels living and health related expenses are easily covered by his/her income

The patient feels living and health related expenses are covered by his/her income

The patient feels living and health related expenses are close to being met by his/her income

The patient feels living and health related expenses are not being met by his/her income

The patient declined to answer

Identifies the supplementary benefits that the patient receives

Choose from the drop-down list

Description

Insurance plans that are arranged between the patient and a third-party

Ontario Drug Benefit – pays most of the cost of prescription drugs for qualifying patients

Ontario Disability Support – provides financial support for qualifying disabled persons in financial need

Program that provides financial aid and services for qualifying persons in temporary financial need

Guaranteed Annual Income System – provides financial aid to qualifying seniors

Special Services at Home – provides services and financial aid to families caring for a disabled child

Various benefits provided to qualifying military veterans

Guaranteed Income Supplement – a federal government supplement for individuals with low income

An indication of the patient’s sense of compliance with his/her recommended diet

Choose from the drop-down list

v2-5

20

Information Field

Option

Yes

No

I don’t have one

I don’t know

Decline to answer

How adequate my food is for my health

Option

More than adequate

Adequate

Less than adequate

Much less than adequate

Decline to answer

How I travel

Option

Independently

Dependently on friends or family

Dependently on public transit

Dependently on accessible transit

Decline to answer

Other

How difficult it is to travel

Option

What it tries to capture How to fill it out Examples and key questions

Description

The patient follows his/her recommended diet

The patient does not follow his/her recommended diet

The patient does not possess a diet recommended by a medical authority

The patient does not know if he/she possesses a recommended diet or, if he/she possesses one, whether he/she follows the recommended diet

The patient declined to answer

A measure of the patient’s sense of how his/her food source impacts his/her health

Choose from the drop-down list

Description

The patient feels his/her nutrition requirements are being easily met

The patient feels his/her nutrition requirements are being met

The patients feels his/her nutrition requirements are close to being met

The patient feels his/her nutrition requirements are not being met at all

The patient declined to answer

A description of the primary day to day mode of transportation

Choose from the drop-down list for the patient

Description

The patient is able to travel independently without the aid of another person

The patient is able to travel with the help of friends or family

The patient is able to travel with the help of public transportation services (or a taxi)

The patient is able to travel with the help of accessible transit (e.g. Wheel Trans)

The patient declined to answer

Some mode of transportation or way of travelling other than the ones listed

A measure of the patient’s sense of how difficult it is for him/her to travel (e.g. to appointments)

Description

Choose from the drop-down list

v2-5

21

Information Field

Not at all difficult

Somewhat difficult

Very difficult

Homebound

Bedbound

Decline to answer

How difficult it is to read and understand information about my health

Option

Not at all difficult

Somewhat difficult

Very difficult

Decline to answer

I smoke tobacco

Option

Yes

No

Decline to answer

# of cigarettes/day

What it tries to capture How to fill it out Examples and key questions

The patient feels he/she has no difficulty travelling

The patient feels he/she has some difficulty travelling but it does not affect his/her independence

The patient feels he/she has much difficulty travelling and this negatively affects his/her independence

The patient is unable to travel outside of his/her home

The patient is unable to get out of his/her bed

The patient declined to answer

A measure of the patient’s sense of how difficult it is for him/her to understand written information about their health and/or treatments

Choose from the drop-down list

Description

The patient has no difficulty in understanding information about his/her health

The patient has some difficulty in understanding information about his/her health, but is able to cope

The patient is extremely limited in his/her capability to understand information about his/her health

The patient declined to answer

An indication of whether or not the patient currently smokes products containing tobacco

Choose from the drop-down list

Description

The patient smokes products containing tobacco

The patient does not smoke products containing tobacco

The patient declined to answer

The patient’s estimate of the number of cigarettes per day he/she smokes

A number 5

v2-5

22

Information Field

# of pack years

Quit date

I drink alcohol

Option

Yes

No

Decline to answer

# of drinks in one sitting

# of drinks/week

I have ever used other substances

What it tries to capture

The patient’s estimate of the highest number of drinks (beer:

341ml/drink, wine: 148ml/drink, spirits: 44ml/drink) he/she has had in one sitting in the last 14 days

How to fill it out Examples and key questions

The patient’s estimate of the number of pack-years he/she has smoked – Pack years = number of packs smoked per day multiplied by the number of years spent smoking e.g., half a pack per day X 20 years = 10 pack years

If applicable, the date that the patient quit smoking, or the date of the most recent quit attempt

A number

A date in the format

YYYY-MM-DD

An indication of whether or not the patient currently uses alcohol

Description

Choose from the drop-down list

The patient consumes products containing alcohol

The patient does not consume products containing alcohol

The patient declined to answer

3

2013-09-23

A number 3

The patient’s estimate of the number of drinks he/she typically has in one week

An indication of whether the patient has ever used other substances beyond alcohol, tobacco, and medications prescribed to him/her

A number

Choose from the drop-down list

5

v2-5

23

Information Field

Option

Yes

No

Decline to answer

Which

Option

Marijuana

Cocaine

Hallucinogens

Stimulants

Opiates

Sedatives

Solvents

Other

Decline to answer

How Recently

Option

More than 6 months ago

Within the last 6 months

Decline to answer

What it tries to capture How to fill it out

Description

The patient has used the above described substances

The patient has not used the above described substances

The patient declined to answer

Examples and key questions

A description of the other substances that the patient has used in the past

Choose from the drop-down list

Description

The patient has used marijuana, a plant that produces the psychoactive THC, which may distort perception, disrupt cognitive functions and cause loss of motor function

The patient has used cocaine, a stimulant commonly used in powdered and freebase (crack) forms

The patient has used a hallucinogen, a drug belonging to a class of psychoactive substances that include

LSD, ketamine, etc., which may cause hallucinations

The patient has used a stimulant, a drug belonging to a class of substances that increase alertness, attention, and energy

The patient has used an opiate, a drug belonging to a class of depressant painkillers derived from the opium poppy

The patient has used a sedative, a drug belonging to a class of substances that induces sedation by reducing irritability or excitement

The patient has used a solvent, a drug belonging to a class of substances that are inhaled by people for their psychoactive effects

The patient has used any substances other than the ones listed e.g. non-prescribed use of prescription drugs, other people’s prescription drugs

The patient declined to answer

An indication of how recently the patient has used the substances he or she indicated he or she has used in the past

Choose from the drop-down list

Description

The patient has used the above indicated substances at some point in time more than 6 months ago

The patient has used the above indicated substances within the last 6 months

The patient declined to answer

v2-5

24

Information Field

I gamble responsibly

Option

Yes

No

Unsure

Decline to answer

More recent date I gambled

# days in last 90 days

I get 30 minutes of physical activity 3x/week

Option

Always

Sometimes

Never – I am unable to

Never – I do not want to

Decline to answer

Other considerations (e.g. sleep habits)

What it tries to capture

The patient’s estimate of how many days in the last 90 days on which he gambled at least once

How to fill it out Examples and key questions

An indication of whether the patient, in his or her opinion, has responsible gambling practices

Choose from the drop-down list

Description

The patient believes he or she is gambling responsibly (see, for example, the Short Problem Gambling

Screener available at www.problemgambling.ca

.)

The patient acknowledges that they do not gamble responsibly

The patient is unsure whether they gamble responsibly

The patient declined to answer

The most recent date that the patient has gambled

A date in the format

YYYY-MM-DD

2013-05-13

A number 4

The patient’s estimate of whether or not he/she gets the indicated amount of physical activity

Choose from the drop-down list

Description

The patient always gets the above described amount of exercise

The patient sometimes gets the above described amount of exercise

The patient never gets the above described amount of exercise because they’re unable to

The patient never gets the above described amount of exercise because of lack of motivation

The patient declined to answer

Any issues that should be brought to the attention of the care team that have not been covered by any of the previous fields

Free text Only able to get four hours of sleep a day

v2-5

25

My assessed health needs

v2-5

This section lists the health needs that have been identified by the patient’s providers. This section attempts to capture a more quantitative assessment of the patient’s health using the results obtained by various health assessments. Assessment types will be detailed in the appendix.

Information Field

Assessment name

Completed

Option

Yes

No

Date Completed

Score

Actions taken

What it tries to capture

The name of the particular assessment that was conducted for the patient

An indication of whether or not said assessment has ever been completed for the patient

How to fill it out

Free text

Drop-down list

Description

Said assessment has been performed for the patient

Said assessment has not been performed for the patient

The date that the most recent instance of said assessment was completed

A date in the format

YYYY-MM-DD

A number Where applicable, the numerical outcome of said assessment

Where applicable, the actions that were taken by the care team in response to said assessment

Free text

Examples and key questions

LACE (for Hospital re-admission risk)

2013-05-13

3

None

My most recent hospital visit

This section provides some information about the patient’s most recent hospital admission or ED visit. The section tries to capture details about the visit such as any complications that may have arisen during the visit, the attending physician at the time, and any follow-up appointments or advice that may have occurred or been given out respectively.

Information Field What it tries to capture How to fill it out Examples and key questions

26

Information Field

Hospital name

Type of visit

Option

ED visit only

Scheduled admission

ED visit then admission

Date of visit

Date of discharge (if applicable)

Reason for visit

Complications

Name of hospital physician

Telephone #

Key advice from hospital physician

Follow-up appointment made with

What it tries to capture

The name of the hospital where the patient most recently visited the ED or was admitted (not meant to capture outpatient visits)

How to fill it out

Free text

Examples and key questions

The Ottawa Hospital

Have you been to a hospital or an ED in the past 6 months?

The type of hospital visit (e.g. ED visit, admission, etc.)

Choose from the drop-down list

Description

The patient only visited the ED

The patient was directly admitted into the hospital

The patient visited the ED and then was admitted to the hospital

The date that the visit started 2013-04-13

The date that the patient left the hospital

A date in the format

YYYY-MM-DD

A date in the format

YYYY-MM-DD

Free text

2013-02-19

Severe shoulder pain A plain language description of the reason for the visit

A plain language description of the complicating issues that may have exacerbated the visit

The name of the physician most responsible for the patient during the visit

The telephone number for said physician

Free text

Free text

Telephone number as

XXX-XXX-XXXX

Free text

I couldn’t move my arm

Homer Simpson

613-555-9284

Increase ibuprofen to 400 mg, 3x daily and start physiotherapy

A plain language description of the key advice from said physician or a summary of the discharge order

The name of the primary care provider with whom a follow-up appointment has been made

Free text Mickey Mouse

v2-5

27

Information Field

Date of follow-up appointment

What it tries to capture

The date on which said follow-up appointment is scheduled

How to fill it out

A date in the format

YYYY-MM-DD

Examples and key questions

2013-05-26

v2-5

My other treatments

This section lists common interventions that are related to or may influence the patient’s current health status. This section includes information about the use of equipment, current self-monitoring, any coaching received and other interventions. It is intended to capture primarily medical or clinical activities, whereas the subsequent section is intended to capture activities more related to social health and well-being.

Examples and key questions

Pacemaker

Peritoneal dialysis catheter

Information Field

Significant surgeries and/or implanted devices (e.g. pacemaker, transplant, stent)

Health education or counselling

(e.g. group counselling)

What it tries to capture

A list of surgical devices the patient depends on or significant surgical changes

How to fill it out

Free text

Next planned date

Assistive devices (e.g. oxygen cylinder, wheelchair)

Self-monitoring routines (e.g. daily home blood pressure readings)

Other treatments

A list of the counselling or education services that the patient is currently receiving

The date of the next planned health education or counselling session

A list of the assistive devices that the patient uses

Free text

A date in the format

YYYY-MM-DD

Free text

A brief description of the selfmonitoring that the patient conducts

A brief description of any treatments or interventions that the patient is undertaking or exposed to other than the ones listed

Free text

Free text

Diabetes education program

2014-01-13

Uses a walker

CPAP machine

Blood glucose monitoring

Acupuncture

28

v2-5

My current supports and services

This section describes all the formal and informal supports and services provided to the patient that are more related to the patient’s social health and well-being, as opposed to the preceding section which was focused on medical or clinical activities. This section includes basic information about who the primary contact is and contact information for each support or service, and what and when services were provided.

Information Field

Contact name

Organization

Services provided

Telephone #

Email address

Start date

What it tries to capture

The name of the patient`s primary contact or support/service provider for a particular support/service

If applicable, the name of the organization with which said person is affiliated

If applicable, a description of the services provided

The primary telephone number for the contact

The primary email address for the contact

The date on which the patient started using the particular support/service

How to fill it out

Free text

Free text

Free text

Telephone number as

XXX-XXX-XXXX

Free text

A date in the format

YYYY-MM-DD

Examples and key questions

Wily Coyote

YMCA

Aerobics Class

613-555-9999 [email protected]

2012-09-21

My appointments and referrals

The “Appointments and referrals” section lists the basic information on upcoming health-related appointments. These could include visits to or from formal or informal supports or services or visits to or from care team members.

Information Field What it tries to capture How to fill it out Examples and key questions

29

Information Field

Date

Time

Provider name

Purpose

Notes

What it tries to capture

The date of an upcoming appointment with a member of the care team

The time of said upcoming appointment

The name of said member of the care team

A brief description of the purpose of said appointment

A brief description of any other important context related to said appointment (e.g. information to bring, travel plans, etc.)

How to fill it out

A date in the format

YYYY-MM-DD

24 hour time in the format hh:mm

Free text

Free text

Free text

Examples and key questions

2013-10-24

10:15

Mickey Mouse weight loss follow up

Delilah here at 0900

v2-5

30

Appendix A: Assessment Types and Examples

Frailty: A measure of the patient’s capability of recovering after stress events.

Example: Rockwood Frailty Scale

Health Literacy: A measure of the patient’s desire and ability to make use of information that promotes and maintains good health

Example: Test of Function Health Literacy in Adults (TOFHLA), Rapid Estimate of Adult Literacy in Medicine (REALM-SF)

ADL: A measure of the patient’s ability to perform basic tasks of everyday living like dressing and eating

Example: InterRAI ADL Hierarchy Scale

IADL: A measure of the patient’s ability to perform activities related to independent living like housework and shopping

Example: InterRAI IADL Involvement Scale

Pain: A measure of the amount of pain felt by the patient

Example: InterRAI Pain Scale

Hospital re-admission risk: A measure of the possibility that patients will be readmitted into a hospital within a specified time interval after hospital discharge

Example: LACE, MAPLe

Cognition: A measure of the patient’s cognitive ability or impairment

Example: InterRAI Cognitive Performance Scale (CPS), General Practitioner Assessment of Cognition (GPCOG)

Aggressive Behaviour: A measure of the patient’s propensity for causing physical or emotional harm to others

Example: Aggressive Behaviour Risk Assessment Tool (ABRAT)

Risk of self-harm: A measure of the patient’s likelihood of hurting him or herself

Example: InterRAI Severity of Self-harm (SOS), OCAN Safety to Self

Mood: A measure of the patient’s emotional state

Example: InterRAI Depression Rating Scale (DRS), Positive and Negative Affect Schedule (PANAS

v2-5

31

Appendix B: Sample CCP Scenarios

v2-5

This care plan guide package also includes two hypothetical scenarios: “Daisy Duck” and “Bruce Wayne”. These two try to exemplify two different but likely scenarios, where the first shows a patient with a common chronic disease and the second shows a patient whose care is more focused on treating his mental health. While the “Daisy Duck” scenario includes only one care plan, “Bruce Wayne” contains two, representing a failed first attempt and how the care plan was revised for the subsequent second try.

Each scenario includes a narrative and a care plan. The narrative’s purpose is to allow readers to quickly form a general impression of the patient so that they are able to see how said scenario was mapped to a care plan template. These sample CCP scenarios were created in response to our clinical focus group’s demand for a clearer picture of how a CCP might look like. They are an attempt at approximating real life scenarios so that they can be valuable to the care coordinator while not intending to guide actual care decisions. These scenarios are fictitious cases and are not intended to represent any patient, provider or organization.

The scenarios and care plans do not describe all of the detailed steps required to create the care plans. We expect that these steps will vary greatly between Health Links. However, it has been noted that there are several common stages involved in the creation of a care plan, for example:

Initially, care plans tend to be “pre-populated” with demographic and basic health and treatment information, often by a nurse, case manager or administrative assistant;

One or more interviews with the patient are held to try to understand the patient’s goals for care and develop a draft care plan;

These patient interviews usually occur before and/or after a more comprehensive gathering of a large number of the patient’s care team members in a “case conference” where the draft care plan is developed, discussed and/or confirmed.

More detailed information could be provided about best practices in each of these stages should these be considered valuable additional training tools, and as clear best practices begin to emerge from Health Links.

FILES:

Daisy Duck’s Narrative – “DaisyDuckNarrative v2.docx”

Daisy Duck’s Care Plan – “DaisyDuckCarePlan v5.docx”

Bruce Wayne’s Narrative – “BruceWayneNarrative v4.docx”

Bruce Wayne’s First Care Plan – “BruceWayneFirstCarePlan v5.docx”

Bruce Wayne’s Second Care Plan – “BruceWayneSecondCarePlan v5.docx”

32

Was this manual useful for you? yes no
Thank you for your participation!

* Your assessment is very important for improving the work of artificial intelligence, which forms the content of this project

Download PDF

advertisement