Care Plans – Part 1

Health Home Staff TrainingService Model Developed with

Primary Care Development Corp

Objectives

• Increase confidence in ability to develop good care plans

• Understanding of the purpose of care planning

• Understand the difference between care planning for COBRA and for Health Homes

• Understand the link between the assessment, motivational interviewing techniques, and care planning

• Understand how use basic motivational interviewing techniques in everyday work with clients

Agenda

• 9:30am Introduction • 9:35am Fears, Concerns, and Questions Exercise • 9:50am Care Planning in COBRA vs. Health Home• 9:55am Purpose of Care Plan • 10:15am Care Plan Development Skits • 10:35am Care Plan Development Activity: Case

Study• 11:20am Summary/Take Away Points • 11:30am Close

Fears & ConcernsExcited about sharing these tools with you to make work easier & more

efficient

Concerned training may

not go as smoothly as

planned

• Sharing questions, concerns, fears, positive thoughts about– This training– Health Homes– Developing care plans– Anything else related

• Write down 4 – 8 to share with group

COBRA vs. Health Home

COBRA HEALTH HOMETask oriented Intervention oriented

Entirely based on client goals Based on a collaboration with all of a client’s provider’s goals AND the client’s goals, especially medical and mental health

Cookie cutter Interventions should be specific to the client’s needs

Could see the same care plan over and over again (the cobra model was process oriented, so as long as we were following up on the goals, there wasn’t so much attention paid to the goals being accomplished)

Care plan is always moving forward. The expectation is that interventions will be accomplished and then completed, or that the goal will be changed altogether (Health Homes is outcome oriented, meaning that the state expects to see a changed health outcome. In order to see a changed outcome, we must build goals that can be accomplished, interventions that help our client succeed, and ultimately complete those goals and create new ones)

What is care planning?

What is Care Planning?

• Setting SMART goals relevant to the most important issues identified in the assessment

• Care planning recognizes and supports the person’s strengths ,weaknesses and abilities and lists strategies to respond to their needs.

 • The care plan is a living document which can be adjusted and refined as

relationships and trust develops between the person, the service provider and their community care workers.

 • Involves balancing relative and competing needs, and helping the person

make decisions appropriate to their needs, wishes, values and circumstances.

 • Requires input and data from a range of sources to develop an

appropriate solution.

SMART Goals

S• Specific

M• Measurable

A• Achievable

R• Relevant

T• Time Bound

What is the purpose of a care plan? Why is it

important to us and to the client?

What is the purpose of a care plan?

• To have a shared understanding of desired outcomes with the client, providers and social supports.

• Reminds the multidisciplinary team that the client is an active partner in the management of their chronic disease

• Allows care manager to provide client with structure to manage health and wellness

• Provides a “road map” for working with the client.

• Tool for clients, providers and care managers to measure progress towards goals.

• Client more likely to be successful because interventions are based on client-identified strengths

• Provides a point of focus for all involved in client’s care

• Promotes buy-in and communication between patient and providers

Why is it important to us?

Why is Care Plan Important to the Client?• Including the client in his or her treatment

• Teaching goal setting

• Providing a point of focus and motivation

• Allows clients to identify their strengths and weaknesses themselves

• Allows client to see their own progress

• Promotes client buy-in

Linking the

ToolsCare

Plan

Assessment

Core Servic

es

Care Coordinat

ion

Conferencing

Care Plan Development Skits

– Skit 1 – Bad Example: How not to involve the patient in care planning and writing ineffective goals/interventions

– Skit 2 – Good Example: How to effectively collaborate with the patient using motivational interviewing techniques like the Brief Negotiated Interview sheet and writing effective goals/interventions

– Facilitated discussion/debrief about skits – what worked, what didn’t and why

Good Care Plan

• Client-centered plan

• Distinction between goals vs.

interventions vs. tasks

• SMART goals

• Includes strengths as well as

weaknesses

• Emphasize link between assessment work to the care plan development

Case Study

• “Lisa”

• Identify 1 issue– Describe issue– Create goal from issue description– Identify strengths and weaknesses– Create 3 interventions based on that

goal.

• “Lisa” is a 52 yo Puerto Rican transgender male to female. Enrolled in health home for help navigating the healthcare system and help securing appropriate housing. Actively abusing crack cocaine. Consistently no-shows for scheduled appointments with PCP and Mental Health Provider.

• Medical Providers: Dr. Samuels @ Calen-Lorde Community Health Center, PCP; Michelle Latimer, NPP @ HELP/PSI, Mental Health; Dr. Feelgoode @ ABC Clinic, Queens, Internist (uses Dr. Feelgoode for Rx refills sometimes); MMTP – Mt. Sinai

• PM/SHx: Asthma with 3 ER visits during past year to treat exacerbation; HTN; Hospitalized for overdose of “some pills” after mother’s death 10 years ago. Two in-patient admissions for detox, 9/2010 and and 12/2012. Admitted for 28-day in-patient rehab 9/2010, 8/2011, and 1/2013. Left last rehab (1/2013) AMA after 5 days. In MMTP since 2/2013.

• Medications: Estradiol, Spirinolactone, and Depo-Provera for feminization; Methadone for opiate addiction; Clonazapam for Bi-polar disorder (Diagnosis not confirmed, client reports given diagnosis during 2009 detox admission. Not prescribed by current MH provider M. Latimer, NPP.)

• Substance Use: Marijuana occasionally, crack cocaine “when I can get it”

• Social/Work Hx: High school graduate, no work history, lives in basement apartment of boyfriend’s house but wants to move. Boyfriend lives in house with his wife. Began gender reassignment treatment at 30 years old.

• Family Hx: Raised by both natural parents, both of whom are deceased. Forth of 5 children, 3 brothers, 1 sister. No relationship with brothers, sees sister 1-2 times/year. Sister’s husband and children not aware of his existence. Describes relationship with parents as “wonderful”. Reports childhood “blissful”.

“Lisa”

• Describe the issue• Create a goal• Identify strengths & weaknesses– Strength• Open to seeking help

–Weakness• Not consistent with treatment

• Create 3 interventions

Care Plan Format (TREAT)

Issues/Needs Title:Issues/Needs Details:Goals:Strengths/Resources:Challenges (Weaknesses):Treatment/Rehabilitation/Intervention:

Plan: Start:End:

Comments:

Identifying needs

• Need/Issue: client is not adherent to her medical appointments.

• Need Issue description: client consistently no shows for her medical appointments, but states that she is concerned about her health. Client states that she “gets confused” about when and where her appointments are.

Goal

• Goal: Client will adhere to all of her medical appointments

• Time frame: 12/5/2013- 2/5/2013

Identifying strengths and weaknesses

• Strengths: client wants to get better, client is seeking help, client likes her PCP.

• Weaknesses: substance use causes client to have an irregular schedule. Client doesn’t have a way to keep track of her appointments. Client has many providers in different locations.

Interventions

• Discussion: After a discussion with the client we find out that she has a medicaid phone that has a calendar and alarms.

• Intervention: Client and CM will set an alarm for the day before and the day of her medical appointments

• Strength/Challenge: This intervention draws on her strength of seeking help and counters her challenge of not remembering

Intervention #2

• Discussion: After discussing clients substance use, CM and client find that client misses morning appointments because when she is out using she is disoriented, broke and “not in a good place” and is embarrassed/not motivated to come in. She is more likely to use near the first of the month.

• Intervention: Client and CM will work with provider to schedule medical appointments in the afternoon and towards the middle of the month when possible.

• Strength/Challenge: Drawing on clients strength of wanting to get care and countering her challenge of substance use

Intervention #3

• Discussion: client is unsure of her ability to make it to her next appointment and wants assistance getting there.

• Intervention: Tm will provide a reminder phone call and PN will escort client to her next appointment on 12/31/13.

• Strength/challenge: this draws on her strength of seeking help and counters her difficulty keeping track of appointments

• Other possible interventions?– discuss moving all providers to one

location.– Assist client with reminder phone calls

to help her feel supported in getting to her appointments when someone is not physically with her.

– As the team notes additional barriers and strengths, new interventions may be added to the original care plan.

Take a way

• Gets everyone on the same page

• SMART goals

• Client centered – pay attention to strengths and weaknesses

• Building care plan starts with assessment and case

conferencing

• Emphasize that obtaining information for assessment and

for care planning occurs during same visit with provider

• Individualized interventions are based on your client’s needs