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The Key to Better Complex Care? Improved Care-Plan Sharing

Coordinating care for patients has never been more difficult. And unless things change, this task will only get harder in the years ahead.

If you work in health care, you’ve seen the trends. You know that chronic disease rates are growing (by a whopping 14% each year), along with the demand for services in the community. You’re also aware that now, more than ever, patients are struggling with multiple conditions that require complex care.

In this new landscape, professionals involved in delivering care services must embrace collaboration. They must carefully coordinate their actions to meet the growing tide of complex needs. Perfecting care planning is a good place to start.

Care plans provide roadmaps for complex patients, simplifying their interactions with the health care system. When they’re well formed and executed, these documents allow coordinators and frontline workers to operate more efficiently.

It’s important to note that a care plan works best when everyone within a patient’s circle of care is committed to it. Unfortunately, there are many barriers to access and regular use.

This post will look at a few of these barriers; it will also provide some tips for finding the right tools for care-plan sharing.

Complex Care Planning: A Patient-Centred Approach

Those who receive health care services in Canada are more empowered than ever before. Most patients want to make informed health decisions, and many have come to expect a high degree of control over their medical information.

Patient empowerment is good for coordinators, service providers, and the health care system in general. Engaged patients are often healthier than those who play less-active roles in their own care. In many cases, they also cost the system less.

Consider the results of a Commonwealth Fund-supported study that looked at patient activation (levels of skill and confidence patients have when it comes to managing their health conditions). Study participants with the lowest activation scores (those who were less engaged) incurred costs that were 8 to 21% higher than those who were more engaged.

There’s also evidence that there are positive associations between patient experience and health outcomes.

Given these and similar findings, it makes sense that many health authorities and care-coordinating organizations are focusing on patient-centred care. Ontario’s Health Links, which use patient goals as the foundation for individualized care plans, are an example.

When it comes to care planning, putting patients first can clarify the direction that coordinators and practitioners need to take. Often, when a patient’s journey through the health care system is the primary focus, next steps are obvious.

This clarity is especially important when it comes to treating people with very complex needs.

Creating strong support networks is, of course, an important component of patient-centred planning. Identifying family caregivers and other circle of care members improves patient care. In some cases, it can also conserve resources.

The health care system can evolve to support more patients with more complex conditions. Greater patient and family engagement will be crucial. And true engagement starts with accessible information. For this reason, every member of a circle of care should have access to the same care plan.

Breaking Down the Silos

Care should be planned around the needs, goals, and preferences of patients. This sounds like common sense. Unfortunately, putting patients first isn’t so simple. If you work in health care, you’re all too familiar with the complications.

Many issues with patient-centred coordination can be attributed to what experts call “silo syndrome”. In essence, many Canadian health care practitioners, facilities, and organizations don’t work together the way they should.

Needless to say, siloing threatens our system’s ability to deal with the coming influx of chronic and complex patients. It makes smooth continuity of care and cross-discipline collaboration impossible.

No matter what care environment you work in, you’ve probably seen the effects of siloing. They’re the effects of communication breakdown between care providers. They increase wait times and can even lead to errors in care.

An important part of tackling this issue is improving the coordination of care for individual patients.

A health care worker should think beyond the next treatment she needs to complete, appointment she needs to set, or set of test results she needs to track down. To fundamentally improve patient care – and ultimately, health outcomes – she should also think about the information she needs to pass along to the next practitioner.

This, of course, is where care plans come in. Some care-coordinating organizations have improved these documents by changing the processes through which they’re created. For example, Ontario’s Health Links focus on patient goals and circles of care to ensure better coordination.

Unfortunately, it’s possible for even the best plans to be underused when they aren’t easily accessible. For this reason, it’s extremely important to focus on improving care-plan sharing.

It goes without saying that technology is the solution. Digital platforms and tools have made it possible to communicate and share information across the globe. The only question is, how can these capabilities be harnessed to improve care-plan sharing?

Better Care-Plan Sharing: Get in Sync and Stay in Sync

A woman has cancer. Her son takes time off of work to drive her to an oncology appointment two hours away. When they arrive, her oncologist is missing a set of test results that were supposed to be delivered the previous week.

A home care nurse doesn’t receive a doctor’s update regarding the dosage of a patient’s pain medication. The patient receives the wrong dosage.

Within circles of care, communication breakdowns aren’t as infrequent as we’d like to believe.

Paper documents aren’t always seen by the right person at the right time. Text messages and emails aren’t sent reliably – not to mention, they can get health care professionals into trouble. And unfortunately, many medical technologies are incompatible with one another.

For each patient, a plan that’s accessible to everyone within the circle of care is ideal. Fortunately, a growing number of digital tools are being developed to make this possible. The right care-plan sharing technology should meet the following criteria:

  • Accessible on mobile devices

The right tool will make care plans accessible on smartphones, tablets, and other mobile devices. This way, the patient living at home, the travelling home care nurse, and the doctor at the office can all view updates when they need to.

  • Capable of supporting real-time updates

Sometimes, it’s important to get up-to-the-minute information on a person’s symptoms, prescription changes, and health status. For this reason, technology that makes it possible to enter and view updates in real time are best.

  • Intuitive and easily accessible for all patients

Many patients have trouble engaging with technology due to mobility issues, cognitive impairments, or other   conditions. A tool that’s friendly for all users will include intuitive features such as large, clear images and touch screen navigation.

  • Includes features that enable communication

Care-plan sharing is critical. But there are times when circle of care members need to communicate more directly. Note sections, direct messaging features, and videoconferencing capabilities are all extremely useful additions.

Making it Work

For a lot practitioners, breaking down the health care silos that impede coordination will be difficult. It will mean collaborating on a wide scale with many different health care professionals – as well as patients and their family members.

The organizations responsible for funding, coordinating, and delivering care need to keep these realities in mind.

But optimism is equally important. With the right attitudes and the right tools, circles of care can create better health outcomes for patients. Effective care-plan sharing represents a gigantic step in the right direction.

Feature image courtesy of Dave Crosby

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