Creating and Automating Care Plans

Care Plans
C R E A T I O N & A U T O M A T I O N
P A T S T R I C K E R , R N , M E D

Introduction
Creating an individualized, patient-specific care plan that includes a
comprehensive review of all problems, a clear set of unified goals, and an
integrated care strategy with meaningful interventions is paramount to the
standard practice of case management. However, that is easier said than done.

Patient Needs
It is possible for case managers to create their own care plan for each case and manually
enter it into the software workflow or care management system, if the patient has one
condition with relatively simple needs. But how often does that happen? Case managers, by
definition, typically care for chronically ill patients with co-morbidities and complex needs.
Trying to create an effective, actionable care plan each time for each patient, by finding and
integrating different guidelines and other clinical resources, is difficult, tedious, and time-
consuming. Relying on one’s own knowledge of each condition and the inter-relatedness of
symptoms, risks, and treatment options to create a complex, individualized care plan is almost
impossible – leaving the process open to duplication or, worse yet, omission of important care
plan components for each condition. These difficulties can result in the creation of care plans
that tend to focus more on the primary condition or disease; minimizing or overlooking
important aspects of the other conditions. Creation of comprehensive, effective care plans is a
key challenge for clinicians.

Ideally
Ideally care plans should not be created by each case manager, based solely on
their own knowledge and experience. Healthcare is far too complex today. Care
plans should be created using information from the most appropriate clinical
practice guidelines, chosen from the myriad of guidelines available, and be
individualized for each patient. However, it is difficult and time-consuming for
case managers to research guidelines, choose the most appropriate one(s), and
then manually create customized care plans for each patient. Doing all that
makes it difficult to find time to manage their caseload of patients and creates
difficulties in being able to monitor and report patient and program outcomes
due to the inconsistency of care plan data.

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N A T I O N A L
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M E D I C A L
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C L I N I C A L
D E C I S I O N
S U P P O R T
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Clinical Guidelines
That is why most organizations today are creating pre-defined care plans based on
research and review of evidence-based clinical practice guidelines from specialty
associations or organizations. Once the guidelines are chosen, the content is used to
develop pre-defined care plans that can be used by all members of an interdisciplinary
team. The development of these care plans take a great deal of time and effort, but
they are worth it, since they assure the use of up-to-date standards of practice,
improved consistency of practice, increased efficiency and productivity, consistent
documentation, improved reporting capabilities, and improved patient and program
outcomes.
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Care Plans
These care plans allow case managers to focus on the patients and their needs;
not on researching and going through the tedious, repetitive process of
manually creating a new care plan for each patient. It is important to note that
these are not "canned" care plans; they are patient-specific care plans,
manually selected by the case manager and individualized by reviewing a list of
suggested problems, goals, and interventions, and either accepting, changing,
or deleting each one. Additional care plan components can also be added to
address other unique patient needs. This process is not only faster and easier,
but also more easily adapted for use with patients with co-morbid conditions.

Easier & Faster
In addition, today’s technology can make this process even easier and faster by
automating some of the manual processes. Almost all care management software
systems allow information collected from health risk assessments, patient
interviews, clinical data, and other sources to be manually entered. But a few of
the leading systems also provide a totally automated processthat: allows the data
to be downloaded into and/or synchronized with the system; automatically
identifies risk factors from the data based on pre-determined triggers; and
automatically creates and presents a patient-specific care plan to the case
manager, based on the risk factors. The case manager can then individualize the
care plan further by accepting, changing, or deleting the suggestions or adding
new components to meet the patient’s unique needs.

Why Automation?
Creating pre-defined care plans and implementing automated processes takes
time, but they are well worth it, since they result in better standardization and
consistency of practice, as well as improved patient and program outcomes. Of
course, clinical oversight is imperative throughout this process to assure the care
plans are kept up-to-date and used correctly, and the automated workflows are
optimized and monitored to assure they are providing the expected outcomes.

Conclusion
Because of the continued development of new clinical guidelines
and medical breakthroughs, health IT systems will continue to
assume an instrumental role in helping clinicians develop, integrate
and customize care plans that are flexible and transparent,
thereby resulting in better transitions of care and health outcomes.

Thank You
F O R R E A D I N G
W W W . T C S H E A L T H C A R E . C O M

Creating and Automating Care Plans

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