Jeanine Davis,  RN, BAAS, CMCN

Clinical Liaison

Care plans are either the bane of a care manager’s day or an invaluable tool to help focus efforts. Whatever end of the spectrum you fall on, love them or despise them, individualized care plans are a required component of many regulatory agencies. Knowing care plans are required doesn’t help move the needle towards the “love” side of the equation. What would be helpful is an explanation, in simple terms, of why personalizing a care plan makes a difference, peppered with some practical advice on how to make it easier to personalize a standardized care plan.

Let’s start with the rational, “why would you want to personalize a care plan in the first place?” If you and your member don’t know why you are creating an individualized care plan, the “how to” doesn’t really matter. The exercise of creating a care plan shouldn’t be a “check the box” chore. In addition to being a requirement, a care plan should be tailored to the member’s specific needs and diagnosis, as well as being utilized as a guide, teaching tool, or road map for continuity of care activities. Sounds great, right? Sure, but so far, this is just a reiteration of the fundamentals. Let’s get to “why” it is important to personalize a care plan.

It all comes down to the goals. Goals need to be meaningful, not to the care manager, but to the member. If the member doesn’t think the goal in their care plan is important, they are not going to be compliant or achieve their goal. So, how do you determine what is most important to the individual? You need to start by asking the member. While that sounds simple enough, there are countless facets in this equation. Everyone has a unique story or circumstance, and these factor into a person’s values, motivators, principles, barriers and resources. All the stuff that makes an individual unique should be considered and included. If we start the conversation from the perspective that the member is the expert in knowing what their personal goals and priorities are, then we can start to connect health care goals to personal goals.

Next, we need to help the member sustain their motivation by setting clear expectations, targets, and interventions in support of the goal. Straight forward enough, however, all the unique factors that are included in a person’s values, motivators, principles, barriers, and resources need to be included when formulating targets and interventions. Also, do a reality check. Are the targets and interventions reasonable? Are they realistic and achievable for this person? Discuss them with the member and ensure that he/she understands what the targets are. You want the member to be engaged and excited enough with the process to track and monitor their own progress towards the goal.

We now have personalized goals that motivate the member. Let’s loop back to the “why do you want to personalize a care plan?” In a word, “outcomes”.  Outcomes are how we measure the member and the care team’s success. Simply put, a personalized care plan that is meaningful to the member will result in better outcomes. A goal that means something to the member will keep that person engaged throughout the process because they can easily connect what is important to them to the health care intervention in their care plan.

Now that we understand the “why”, we move to the “how”. We are all very busy and want to work smarter rather than harder, so let’s not reinvent the wheel. Start with utilizing those wonderful evidence-based standardized care plans and turn them into something that a member can relate to. When you personalize a standardized care plan, you want to keep in mind that there is a balancing act between the evidence-based practices of the standard care plan and the member’s personal experience, individual needs, and perspective.

If you haven’t done so already, go back to the member and glean a few more details about them directly. Ask what is important to that person and what their personal goals are. Once you have obtained this, start thinking about how to tie the two parts together, namely, their personal goals to their health care goals. We are still looking for some quick and easy, practical tips on “how” to utilize a standardized care plan as the base for an individualized care plan.

 

An Example of an Individualized Care Plan

 

Still looking for some quick and easy tips on “how” to use a standardized care plan as the foundation for an individualized care plan? The following example will illustrate this. This is one problem pulled from the TCS Asthma Standardized Care Plan Tool:

The Problem: Exercise intolerance due to Asthma symptoms.

The Goal: Member will maintain appropriate activity level.

The Interventions:

  • Assess current activity level, exercise tolerance, and symptoms.
  • Assess medication regimen and treatment plan.
  • Instruct on medication regimen, treatment plan, and symptoms to report.
  • Refer to provider re: need for inhaler or other medications prior to exercise.

The Outcome: Member’s activity or exercise is not limited by Asthma symptoms.

Although this portion of a care plan is nice, it is not as individualized as it could be. The member isn’t likely to relate to the goal, making it unlikely that the outcome will be achieved. Here is the key– you don’t need to make huge sweeping changes. Just making small changes will make huge differences toward creating an individualized plan. Start with taking those personal details you just captured from the member and insert them into the care plan. Once you insert a couple of personal details about the member, you change a standardized care plan into a personalized care plan.  Where do these personal details go? Continuing with the example above, modify a few things, like:

The Problem: “Exercise Intolerance Due to Asthma Symptoms.” This doesn’t need to change! The member does have this problem and it does need to be addressed.

The Goal: This does need to change for this person. The original goal is vague and most likely doesn’t mean much to your member. However, this is where a few small changes to the words can make a huge difference by making the goal individualized and meaningful to your member. For instance, the new goal could be “Member will be able to resume daily walks to the corner store.” Now your member has a direct connection. Now the interventions that are set standards of care make sense for this person. Now you have some “buy in” and willingness to participate in assessments, medication adherence, and the rest of the interventions which will make it more likely that the desired outcome will be achieved.

The Interventions: All are still relevant for this problem and goal.  They don’t need to be modified for your member.

The Outcome: This will need to be tailored to match the member’s personal goal of being able to walk to the corner store every day. The new outcome could be “Member will be able to walk to the corner store.”

By creating goals and outcomes that prioritize what is most important to the member you avoid conflict or worse the dreaded non-compliance to the care plan. Utilizing standardized care plans is a typical practice across the industry and most agree that standardized care helps to promote quality, consistency and contain cost, however be aware of the pit falls to utilizing standardized care plans. The chief risk is that care managers are busy and sometimes overlook personalizing the care plan. Unfortunately, this oversight will lead to a failure to meet the NCQA standard of “Develop personalized, patient-centered care plans”

The bottom line– a care plan needs to work for an entire health care team, including the member, as a guide to getting to a goal. Knowing what your member’s obstacles, preferences, values, and needs are can help develop how the goals are formulated and how the member understands the connection between their personal goals and health care goals. Identifying and understanding why each goal is important specifically to that person is crucial in motivating members toward and achieving their goals. Personalizing the care plan to the member will go a long way in ensuring achievement of those goals.

References:

  1. 3/30/2017, Can You and Your Patients Have It All? Why You Should Personalize and Standardize Care PlansHealthwise Care Coordination Team,https://www.healthwise.org/about/blog/march-2017/can-you-and-your-patients-have-it-all-why-you-sho.aspx
  2. 01/19/2015, Standardization vs. Personalization: Can Healthcare Do Both? HIT Consultant by James Dias.  http://hitconsultant.net/2015/01/19/standardization-vs-personalization-can-healthcare-do-both/
  3. 11:13 AM on March 6, 2017  The Bridge;  Why ‘standardized’ and ‘personalized’ care are two sides of the same coin. by Shobhita Narain. https://www.advisory.com/research/health-care-industry-committee/the-bridge/2017/03/standardization-and-personalization
  4. Quality and Safety Education for Nurses (QSEN) article originally printed in Nursing Outlook Special Issue: Quality and Safety Educationhttp://qsen.org/competencies/pre-licensure-ksas/
  5. NCQA Case Management Accreditation©2012 National Committee for Quality Assurance. Setting Goals with People with Complex Needs: A Collaborative ApproachHEDIS & Quality Measurement » Research » Setting Goals with Vulnerable People HEDIS & Quality Measurement » Research » Setting Goals with Vulnerable People.  http://www.ncqa.org/hedis-quality-measurement/research/setting-goals-with-vulnerable-people.
  6.  And http://www.ncqa.org/Portals/0/Programs/Accreditation/Case%20Management/NCQA%20Case%20Management%20Accreditation_9.25.13.pdf?ver=2013-09-25-154104-000
  7. TCS Asthma Standardized Care Plan Tool