Planning is part of the series of processes in the delivery of patient care (described in another article). It is a series of cognitive processes that are then documented. These consist of:
- Identifying the Objectives of Care
- Deciding and choosing the approach and methods
- Deciding on and scheduling the sequence and layout of actions
- Ensuring that resources are available to carry out the plan
- Assigning responsibilities
- Documenting the plan
Place of Planning in the Overall Clinical Care Process
THE PLANNING PROCESS
The task of planning and the documentation goes together with other care processes. It should not be separated from them. The popular ‘SOAP’ method of documenting case notes follows this sequence.
SOAP Clinical Process Sequence and Method of Documentation (Taken and modified from http://intranet.tdmu.edu.ua/data)
The Ever-changing Plan
Plans are revised frequently based on the changing needs (daily or more frequently in the case of acute illness and at almost every visit in chronic illness).
Planning can be performed in an ad hoc or formalized manner. Currently, the need to regulate health services, streamline health care funding and ensure uniform quality of care, have resulted in wider acceptance of the use of standardized documented (ready-made) plans.
THE PLANNING METHOD
AD HOC PLANNING
Because of their training, healthcare professionals are capable of planning the care of a patient spontaneously. They rely on their knowledge and experience and when necessary refer to practice guidelines, manuals and protocols or even textbooks. Indeed, it is quite usual for clinicians, to think out a plan but do not document it. They express it only as orders or interventions.
There are many disadvantages of ad hoc planning (explained later). Yet, there are instances where preconceived plans are not available or inadequate and therefore the the skills of ad hoc planning need to be put to use.
Example of an Ad Hoc Plan
USE OF STANDARDIZED CARE PLANS
The Development of SOPs and Care Plans is discussed in detail in a separate article
In the formal method of planning, the Care plan is chosen from a manual or library of plans and then modified to suit the case. Care plans, as a rule, are concise and direct. They are derived from a more elaborate document, the Standard Operating Procedure (SOP). Hence it is assumed that the care provider is conversant with or are able to consult SOPs when providing care.
When using a standardized care plan as a guide, the planning process is done in two major steps i.e.:
- Choosing the appropriate the Reference (Model) Plan from the library of pre-prepared care plans
- Converting the chosen plan into an Actual (Operations) Plan by customizing it to cater for the special needs of the patient
The care provider uses his/her own special knowledge, skills and discretion to choose and modify the plan that matches the needs of the individual patient. He/she then ensures that the plan is carried out. The desired outcomes are monitored and if necessary the plan is rectified based on the response and outcome achieved.
For the care provider, the use of pre-designed (pre-prepared) plans provides many advantages including:
- Facilitate a more structured care delivery
- Ensure comprehensive (complete) content
- Encourage appropriate selection of investigations and treatment; remove redundancy/duplication & wastage
- Provide information and decision support (through prompts & reminders)
- Give a clear picture of future actions
- Communicates intentions to the whole care team (thus encouraging shared objectives and understanding)
Standardized plans are generic in nature i.e. applicable to typical patients with a typical disease condition. They are used as reference and are customized before being applied to the actual care of an individual patient. If the patient has more than one health problem, then combination of the generic plans would be necessary.
Standardization promotes uniformity in the care of patients suffering from similar disease, syndrome or symptom complex, among all care providers and at all facilities within the same organization. Because it is a guide, it does not, in any way, discourage practitioners from altering practices in response to peculiar situations and requirements. Allowance for variations is written into the plans.
The Reference Plan is selected from a comprehensive library of documented plans provided (by whatever means). The Actual Plan is derived from the Reference Plan. When documented, it will becomes part of the Medical Record.
Choosing a Model Plan from a Library of Care Plans
CHOOSING THE APPROPRIATE PLAN
The care of a patient is led by a care provider termed as the ‘primary provider’ or ‘provider in charge”. Usually, he/she is a doctor but it can be any practitioner depending on the scope and complexity of care of the patient. The primary provider chooses a care plan that matches the diagnosis made. During the course of patient care, the amount and clarity of information available to the care provider increases and the diagnosis becomes clearer or new problems emerge. If these changes are significant, another more relevant plan is chosen. If the change is minor then the plan is revised accordingly.
CHOICE OF PLAN BASED ON DIAGNOSIS
At the initial phase, only a broad or general diagnosis is made but as more investigations and monitoring data are available, a more specific diagnosis is possible. The type of care provided reflects this degree of accuracy in diagnosis, the variant of the disease and the stage of its natural history. Through categorization, staging, severity grading and risk stratification, the more appropriate care path and care plan is chosen.
Variation of Care Plans with Changes in Diagnosis and Phase of Care
A discussion on Diagnosis is available in another article.The care plan for symptom complexes / syndromes contains mainly diagnostic investigations, symptomatic relief and supportive therapy where applicable. Later when the diagnosis is more definite, the plan for a specific disease entity incorporating definitive treatment, monitoring and rehabilitation is used. If the effectiveness of therapy comes into question, the reliability of the diagnosis need to be reviewed.
CHOICE BASED ON CARE OBJECTIVES
At the outset of every phase of patient management, the care objectives is determined and clearly stated. Preferably, definitive treatment is started only when an accurate diagnosis is made but much can be offered to the patient in the interim.
These are the likely treatment or therapy objectives:
- Remove or lessen effects of illness (relief symptoms, provide comfort)
- Maintain, restore, or improve health status and physiological function (provide support)
- Avoid or minimize complications of treatment
- Cure the disease (if possible)
- Prevent deterioration or recurrence
For a given illness, not all of the above objectives can be achieved. While many diseases are eminently curable, some can only be contained or their harmful effects mitigated. Yet others are inherently incurable or are too far advanced. Depending on the potential for altering the progress of the disease, there are three main treatment strategies:
- Curative therapy
- Containment therapy (by 2O or 3O Prevention)
- Palliative therapy
When there is potential for cure or complete resolution of the disease process, the plan is directed towards achieving it. However when there is no possibility for cure, the plan offers other beneficial therapeutic options aimed at restoring functions, symptom relief and providing comfort.
CHANGE IN PLAN WITH THE PHASE OF CARE
After selecting a plan based on the initial diagnosis, the care provider may alter or revise the plan based on:
- Changes in the understanding of the illness affecting the patient (the certainty and comprehensiveness of the diagnosis )
- Evolution of the disease along its natural history
- Advancement of the workflow
- Other emerging issues
The characteristics and behaviour of a disease varies with each occurrence. Its progress may be typical or atypical. It may become better or worse. The care provider changes the plan to cope with these variations. Usually, the work flow advances as and when all tasks are completed. Although the process of care is continuous, it is convenient to divide the care into periods or phases. The phases of care of both acute and also chronic diseases are categorized into:
- Phase of diagnosis, stabilization and immediate care
- Phase of initiation and optimization of therapy
- Phase of maintenance of therapy, re-evaluation and modification
- Phase discontinuation of therapy following resolution of illness
There are instances when the workflow cannot progress according to plan (delayed) due to various impediments or circumstances. In those cases or if the prescribed treatment plan is ineffective, unacceptable or unsafe for the patient, an alternative approach or modality is used. Non-compliance by care providers or patients is also a factor that affects the progress of the workflow as well as the success in achieving the desired outcome.
Need to Change Care Plan
Plans are also modified or revised if various other emerging needs appear. If pre-designed plans are not available then the care provider needs to devise the various plans him/herself. Hence, it is necessary to design and put together a comprehensive library of Care Plans to cater for certain periods/phases or scenarios in the care of a patient for each illness or healthproblem.
Division of a Care Episode into Phases and its Relation to Visits
A care episode is defined as the period within which the entire care of the particular disease or health problem, affecting a patient, takes place i.e. beginning with the time of first contact with a health care practitioner to resolution of the illness/problem or death of the patient. In that episode, the patient may make several visits and during each visit. He/she may have encounters with many health care providers and may be subjected to many care events and experience various incidents.
CARE PLAN FOR AN ENTIRE EPISODE
The Need to Revise Plans with Changing Diagnosis and Phases during a Care Episode
When the diagnosis is uncertain the plan for the whole care episode cannot be very definite. The care provider can put up a plan only for the initial stage. When the diagnosis is clearer, the broad overall plan of care can be determined. Even then, because the workflow may take variable paths, only an outline of the latter stages can be stated. Once a definitive diagnosis is made and the appropriate treatment regimen is known, then the care for the rest of episode may be planned.
All in all, the plan for the entire care episode is described in the Standard Operating Procedure which should be referred to but in the medical record, a brief statement will suffice, e.g. “to treat patient as case of Acute Coronary Syndrome”.
CONVERSION OF REFERENCE PLANS TO ACTUAL PLANS
Once a model care plan is chosen for reference, the next step is to modify, customize and convert it into the Actual care Plan for use. This plan is then communicated to other care providers by documenting it in the medical record or the Clinical Information System. Since the care of a patient is a multidisciplinary effort, each care provider has the opportunity to put into effect (operationalise) the part of the plan in their area of expertise during their encounter with the patient. They may modify their portion of the plans when needs arise. Yet, there should be consultation with other members of the care team. The patient also needs to be aware of the plan, be allowed to make queries and be involved in it.
The the actual care plan contains:
- A title
- lists of tasks to be performed arranged in segments grouped and named according to the purpose of processes to be taken
The title is written as a statement of intent expressing the indication, the scope and objectives. The care provider in charge will vet and endorse each task suggested by the plan and add more if necessary.
Relationship between Plan, Performance and Documentation
Care providers may then create their own task lists based on their role. In a computerized environment, these task lists are automatically generated but can still be amended to vary the urgency, frequency, duration, location and assignment. The next step is to perform the tasks hence executing the plan.
MATCHING PLANS WITH VISITS AND SERVICE DELIVERY SETTINGS
The health care provider delivers care at encounters with the patient, usually during a visit i.e. when the patient comes to the health care facility (or are visited by health care provider). The type of visit and the service setting deemed suitable depends on the nature of the illness. For example a patient on an outpatient follow-up may have to be admitted for in-patient care if certain complications occur. For practical reasons and convenience, service managers schedule visits to coincide with the anticipated change-over from one phase to the next. As such, tasks to be performed and other events that the patient will experience or likely to happen is known to the care providers looking after the patient and the patient alike. The arrival for a visit may trigger a plan. However, the decision to execute the plan is made only if the patient’s status allows for or warrants the change-over.
The care plans for the First visit is quite different from that for the Follow-up visit because at the very first visit the diagnosis is usually uncertain, while at subsequent visits, the diagnosis is more definite. Also, at later visits some part of the care process has been completed; plans need to be made only for the remainder.
Service delivery may be provided in various settings including:
- Outpatient visit
- Emergency visit
- Inpatient visit
- Day Care visit
- Home Care visit
- Teleconsultation visit
The most appropriate setting for a particular phase of care can can also be decided in advance. Decisions to start, continue or abandon plans are dependent on the data available. In inpatient care, the data available are results of clinical reassessment, monitoring data and routine investigations. For outpatient care, these data can be made available by asking patients to come for a preliminary visit when investigations and other assessment are performed. As part of sel-care, patients may also submit records of symptom characteristics and measurements they make themselves (B.P., Temperature, Blood sugar level etc.).
However, there are situations where the transition in the plan is predictable such that a change-over of the plan can be initiated as and when the visit takes place. A good example is the care plan for the care of a patient with normal pregnancy or a patient undergoing Knee Replacement surgery.
The difference in settings do not significantly change the clinical content of the Care Plans but impinges mainly on administrative processes, workflow and use of resources.
PLANNING THE FREQUENCY AND DURATION OF VISITS
The extent of each phase, is a variable period. It can span a duration of mere minutes or can stretch across encounters and visits. Case managers or the primary provider set the frequency of encounters and visits based on the patient’s expected response. The number of visits per episode is by nature variable but may be intentionally fixed in a service package. A visit requires one or more identified physical resources such as room/bed within a clinic complex or ward. During the visit, the patient may have one or more encounters with different care providers using the same or different resource. The duration of each encounter is defined as time slots. All these need to be planned. In a computerized HIS, this planning is done using the scheduling and resource allocation application.
Example: Care Plan for Patient with Severe Osteoarthritis Admitted for Unilateral Knee Replacement
MODIFICATION OF PLANS
Standard plans cannot satisfy a patient’s needs fully. Patient care plans need to be individualized and customized by the care provider by synthesizing all available information, choosing the most relevant plans, combining them and adding or omitting certain options.
Besides the attention to the illness and its effects, care plans also need to consider the general needs of the patient (i.e. a sick person).
Customization of Case Management Plan for an Individual Patient with Multiple Needs
ALTERNATIVES, VARIATIONS, OPTIONS AND CONTINGENCIES
Care Plans are often criticized for being rigid and didactic. In fact, by offering different directions and paths, care pathways provide alternatives in managing a patient based on various valid criteria. In the same way, care plans are different for different anticipated scenarios. Where there is a choice of methods or material without major difference in effectiveness or safety, the care provider is given an option to choose the one best suited or available. In instances where there is a deviation from policies and procedures (intentional or otherwise), the care provider need to indicate this variance and the reasons for it.
INDICATIONS AND CONTRAINDICATIONS FOR USE OF A MODALITY
Investigation and treatment modalities, however efficacious, have limitations such as unwanted side effects, interactions, and ineffectiveness in certain situations. Care providers need to be reminded of these indications and contraindications as part of the decision making process.
EXECUTION OF PLANS
Plans are realized by executing orders (planned tasks). While in the Reference plan, tasks are grouped according to purpose or function, for purposes of execution they are assigned to identified members of the care team. For example rehabilitation tasks are allocated to the Physiotherapist or Occupational therapist. The dietitian takes on the provision of appropriate diet. The social worker will address the social support issues. These care providers will have to be alerted regarding their involvement in the care of the patient through e-mail (in-box), by phone or other methods of referral.
PROCESSES AND TASKS
Traditionally, the plan for the overall care of a patient is done by the doctor in charge (or any primary care provider). By choosing a Care Plan he/she communicates the to members of the care team on what needs to be done for the patient.
Multi Patient Task List View
In a computerized Clinical Information System, planned tasks take the form sets of orders. The computerized provider Order Entry application (CPOE) is used to create task lists for various functions. The type of tasks within a care-set would include any or all that is necessary to carry out the patient care processes i.e.:
- Administrative tasks (Admission, Referrals, Transfer and Discharge, visit registration, follow up appointment, referral and discontinuation of visits.)
- Generation, gathering and collection of data about the patient’s illness and the effect on his/her health. Data collection tasks e.g. Clerking or Assessment using a specific clerking form and Progress reviews guided by various note types.
- Analysis and interpretation of data to determine the diagnosis and needs of patients
- Investigation tasks, Diagnostic tests
- Planning the case management
- Treatment using various modalities including therapeutic procedures, medication to be supplied or administered, blood product supply and transfusion
- Review of progress of disease (including assessment of outcome)
- Monitoring of the progress of the illness, status of the patient’s health, effects of treatment
- Review of diagnosis and management
- Patient education
- Nutrition provision
- Any other therapeutic tasks
- Continuation of care or Final disposal of the case
The care set for a particular patient will consist of all or some of patient care processes. It may also include clinical administration tasks. For inpatients, these can be admission, referrals, transfer and discharge. For outpatients, these can be visit registration, follow up appointment, referral and discontinuation of visits.
ORDER SETS (Care Package, Care-Set, Care-Bundle)
The tasks that addresses all aspects of the patient’s health problems for the short term, make up the content of the Actual Plan. It is often called the Care Set, Order Set or Care Bundle.
Each Care Plan is executed using pre-constituted but modifiable order sets. In a system based on paper the orders are transcribed (copied) manually from a printed copy of the Reference Plan or from a stand-alone computer. In a computerized Clinical Information System, the care provider may use the order set suggested by the system or choose one from a given list. Depending on the context or scenario, order sets can be didactic or flexible in content. In any case, the set can then be modified by exclusion or inclusion of orders. The tasks are then assigned to the relevant provider group as a task list. Tasks are performed according to the orders.
Order Set for “Acute Coronary Syndrome”
The care provider retains control of decisions and choices. The plan is a recommendation. Quality control mechanisms such as detection of deviations or variance from the plan, unexpected results and tasks not completed via check lists are put in place.
Incorporation of Care Plan in CIS is discyssed in another article“>Incorporation of Care Plan in CIS is discussed in another article
PRACTICAL CONSIDERATIONS IN EXECUTING PLANS
For a chosen plan, the transition from one phase of care to the next depends on:
- completion of planned tasks
- achievement of objectives for the phase
Failure to complete tasks can be due to non-conformance by care providers or non-compliance by patients. Failure to achieve objectives may be due to the two aforementioned issues or due to an inappropriate hence ineffective plan. The latter is likely to be due to inaccurate or wrong diagnosis, in which case further efforts need to be made to clarify the diagnosis. A change in plan may then become necessary.
CARE PLAN FOR ACUTE ILLNESS
Care of a patient with an acute illness is characterized by varying levels of urgency and uncertainty. Setting priorities is of overriding importance. Most tasks need to be performed simultaneously. The Care plan is an indispensable aid in ensuring:
- quick action by defining the process sequence
- readiness of equipment,
- defining care-provider roles
- preparedness for any eventuality
Phase of Diagnosis and Immediate Care
In acute illness at the immediate phase, efforts are directed towards symptomatic relief, resuscitation, stabilization and support (physiological, psychological, social and spiritual). At the outset, observation and monitoring are initiated. Investigations is aimed at determining the patients general physiological status and functions of various systems. The priority for Diagnostic investigations is to determine the system or site involved or the like pathology. Therapy must not wait for want of an accurate diagnosis.
Yet every effort must be made to obtain a definitive diagnosis so that the plan for specific treatment can be started as early as possible. The diagnosis need to be further refined to clarify the variant of disease, severity grade, stage of illness, risk and expected or desired outcome.
Customization of Case Management Plan for an Individual Patient with Multiple Needs
Phases of Care in a Patient with Blunt Chest Trauma
Phase of Maintenance of Therapy, Re-evaluation and Modification
Once the patient has been stabilized, attention is paid to:
- relief of symptoms
- monitoring various parameters
- maintaining normal physiology,
- providing nutrition,
- giving psychological support
- taking preventive actions
- treatment of ongoing problem
The progress of the patient is reviewed regularly to detect deterioration or improvement, occurrence of complications of illness or treatment. The care provider reviews the diagnosis and the effectiveness of therapy. He/she then, may have to revise the Care plan and modify the treatment.
Depending on the illness, this phase may spread over a considerable period. The patient may be discharged from in-patient care and the care continues in the outpatient setting or at home.
Phase of Continuation/Discontinuation of Therapy
Depending on the nature of the illness and the response to therapy the care may reach a stage where it can be discontinued. This could be because the patient has fully recovered or the health problem has resolved or been cured.
If the illness appears to have resolved, discontinuation may be abrupt or phased out. The plan conveys the manner in which care is to be stopped including how medication or other treatment is to be tapered and what evaluation criteria need to be met to declare it safe for the care to be terminated.
On the other hand, the acute illness/health problem may be a manifestation of an underlying chronic disease. The acute illness may also give rise to permanent or semi-permanent disability, deficiency or handicap. In both instances, long term care will then be planned and provided.
CARE PLAN FOR CHRONIC ILLNESS
When a chronic illness is discovered RISK FACTORS
INITIATION, STABILIZATION, MAINTENANCE, RESPONSE
These three broad strategies may contain all or some of the following therapeutic approaches i.e.:
- Definitive therapy
Phase of Initial Consultation
The care of a patient with chronic illness begins with the initial contact with a health care provider. The disease process itself may be at an early or later stage of the natural history of the disease, depending on whether the patient seeks treatment early or late. In this phase, the main objective is to determine the diagnosis as accurately and comprehensively as possible. The main tasks are clinical data gathering and diagnostic investigations. At the beginning of this phase, the data available may allow the clinician to determine the diagnosis in terms of symptom complexes or syndromes.
Once the diagnosis is ascertained the care provider needs to clarify the objectives of care (expected outcome, therapeutic end points). A more definite Care Plan is then chosen and customized.
Phase of Initiation, Re-assessment and Optimization of Definitive Therapy
In this phase, the disease entity/entities and accompanying health problems affecting the patient are already established with some certainty. An appropriate definitive management plan (curative, palliative / supportive, rehabilitative) is adopted and implemented. Depending on the disease, the objective of treatment would be to be the combination of any of the following:
- cure the illness,
- contain it or control the progress
- mitigate the effects
As such, the care provider defines the treatment end points, chooses the plan offering the most suitable treatment approaches or modalities. As such, treatment end points need to be defined and measurements made to determine whether these end-points have been achieved.
An example of the model care plan for this phase is shown below. (yet to be written)
Phase of Maintenance of Therapy, Re-evaluation and Modification
The main aim of this phase is to optimize the benefit of care given. The main tasks in this phase is monitoring, reassessment and progress review addressing both the disease and also the treatment. The results will reveal the behaviour of the illness and various developments. The progress of chronic diseases vary in many ways including:
- speed of deterioration
- active vs inactive periods
- emergence of complications
Another important aspect is the evaluation of response to and effects of therapy. These factors are assessed:
- conformance to the plan
- patient compliance
- detrimental effects of therapy
In this phase because of the above factors, modification and revision of the plan is often necessary.
Measurement of outcome and comparison with planned targets is an integral activity of care at this stage. Scoring systems and check lists can be used. Optimization is considered achieved when the treatment regimen produces the best possible level of benefit. The plan is then continued with minimal change.
Phase of Discontinuation / Continuation
Chronic illnesses are usually characterized by continuous progression or persistence. The care is therefore long term and usually extend throughout the life of the individual. Some may resolve and be dormant only to appear again later.Temporary cessation of therapy with planned follow up reviews may be necessary.
Rarely some diseases runs through its course and dissipates. The care can then be phased out.
It is essential that the care provider plans for the continuity of care well and ensure that it happens. He/she may delegate the responsibility to others for the convenience of the patient. The primary care doctor, family doctor or school/factory nurse are the most appropriate care providers to take on this responsibility. If it is a disability or handicap, depending on the type, then therapists, counselors, optometrists, audiologists or social workers may be more appropriate. Self-care, home care and care by voluntary bodies may be adequate or may supplement those given by health care professionals.
Periodic review by the provider who initiated the plan may be necessary.
VARIATION BASED ON EMERGENCE OF SPECIAL NEEDS
In managing a patient, an integrated plan that will cater for all of his/her needs is necessary. For a particular disease, there are individual variations in how the disease or health problem affects a patient. How the patient responds to them also varies. The continuation of a care regimen to the next phase is contingent on the completion or success of the previous phase.
To some extent the difference in response is contributed by the patient’s pre-morbid health status (pre-existing problems including chronic illness), physiological condition and psychological make up.
After making a diagnosis, the clinician categorizes his/her patient according to possible risks, severity of illness, stage of development and therefore prognosis. Categorization in turn allows the clinician to choose the right pathway and initiate an appropriate care plan. It is also a determinant of applicability, availability, timeliness and cost effectiveness. Grading and scoring systems for various diseases have been developed and tested.
Cessation and Introduction of New Plans
Plans need to change with variations in progress of the disease, severity, complications, different phases of care and outcomes. Changes can be made manually or be suggested based on a trigger. Planned tasks may end or continue as the phases evolved.
Tasks can continue or retained in new plan. Tasks no longer necessary are not included in next plan any task can be cancelled from the task list at any time
Whether the changes are slight or major, in a computerized system, it is best that the old plan is terminated and replaced by a new plan. Previous orders that are to retained are cancelled and the orders are remade. The new order set will then contain previous and new orders. Hence, the task list is also renewed. This will prevent confusion as to which order is to be retained and which to be continued.