I am on a health journey, trying to meet my health goals with the support of a care team. Who’s doing what? When are they doing it? That’s my plan of care for me.
Most people don’t normally think in terms of a plan of care for themselves. Let’s peek into their minds:
Plan of Care – What’s Going on in Their Minds?
Patient: What’s wrong with me? Should I tell the doctor? What does she want me to do? Can I afford it? Does it (will it) hurt? Can I (will I) still be able to take care of my family (go to work, go out, have fun)? What happens next? How’m I doing now? Did the med (the procedure, the diet…) work? Did it help me? What should I worry about? What should I do if it happens (again)?
Clinician: What’s on his mind? What’s wrong with him? What should I do next? What did I prescribe before? Did he do it, did he take it? Will he tell me the truth? If he did it, did it work? What do the tests tell me? What should I prescribe next? What are other doctors doing (ordering)? Has he been to the hospital since I saw him last?
Questions, questions, questions. So many bumps in the road and detours in the health journey. Few maps, spotty GPS at best.
Plan of Care – The Caregiver’s Dilemma
I’m the child, Custodian and Healthcare Proxy of my 89-year-old mother, Alice. I live in a different state than my mom. My mom has diabetes and is depressed. Her care team, beside herself and me, includes medical providers in various health settings, community support agencies, and a full-time caregiver that helps her schedule and get to health-related services. My problem is to understand what my mom wants for herself and to track who says they’re doing something for her (including my mother and me), what they’re doing, and when they’re doing it. I want to know what it takes to do it (Can she afford it? Can she get there? Does it agree with her? Who will be with her? etc.). I want to know if the actions have the effects we thought they would. I want to know what her risks are and how we plan to prevent or respond to them. I want to able to keep track of all this and keep it current. I want to share it or have it shared from day-to-day and from setting to setting even if I’m not present.
Plan of Care – How Does It Fit?
Essentially, the medical part of the health journey is:
- Diagnose (Finding out what’s going on).
- Plan care (What needs to happen, by whom, when? What do we expect to happen when we do it (outcome)? What could go wrong, how can we prevent it, and how will we deal with it if it happens?)
- Learn (Checking if the plan worked. Did I get the outcomes I was expecting or hoped for?)
- Adjust (If not, try something else.
The plan of care is an experiment of one – us. Neither the patient nor the clinician can plan care alone. They need each other and much support – the whole team – care partner, family members, other professionals, and technology. Most of all – they need communication with each other. Eventually, everyone plans care – usually over and over. Our health system doesn’t seem geared toward planning care. Ten-minute infrequent visits between patient and clinician-not much time to plan care. The office visit process and technology can’t really handle the dynamic, constantly changing information flow of planning care. The information certainly isn’t easily available to everyone on the team when they need it. Few, if any, rules (standards) exist for patients or clinicians putting information into the health record about the plan of care.
Plan of Care – An Example
As you know, I have multiple sclerosis. My wife is my care partner and my team is extensive. My personal goals are to progress as slowly as possible, maintain my pathological optimism, and keep playing the bari sax.
At the beginning of the summer, I got pneumonia. It was seriously annoying. More annoying than the MS. I was short of breath. I was coughing so much I hurt my back. I was exhausted. My daughter-in-law helped me put together a care plan when it was really bad. 12 steps in the plan:
- Hydration all day long – everybody reminds me to drink water
- Antibiotics daily for 5 days as ordered
- Albuterol inhaler every four hours, even at night, to open up my airways
- Steam as I can tolerate, in the shower, over a steaming pot, whatever works
- Sleep/walk/sit alternating every 15 min with a timer
- Stretch every four hours
- Alternating Ibuprofen and Tylenol for pain management
- Ativan at night or Benadryl
- No saxophone till I stop coughing
- Acupuncture next week.
- Ask my PCP questions via portal unless I was getting worse, then call her.
- If I’m not significantly better in 10 days or if I’m worried about myself go see the doctor directly.
That’s a care plan. Most of the stuff is me doing it. Others helped me stick to it, walked with me, and commiserated with me. (I’m over it now, thanks for asking)
Plan of Care – In Summary
I am on a health journey, trying to meet my health goals with the support of a care team. Who’s doing what? When are they doing it? That’s my plan of care for me.
People: When you speak with a clinician about an acute problem, agree upon a plan of care. Bring your care partner if you can. Set up a way to ask questions as they come up and to report on status, be it portal, email, phone, or keeping a journal.
Clinicians: Use the words plan of care. Write the plan down. Let your patients know how to communicate with you: report status and ask questions as they come up before the next visit.
Everyone: Expect your electronic health records to be able to record and track care planning. They don’t now.
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