Question

write the objective of formulating the care plans​

Answer 1

Answer:

Building a Care Plan

Care plans include, but are not limited to, the following:

 Prioritized goals for a patient’s health status

 Established timeframes for reevaluation

 Resources that might benefit the patient, including a recommendation as to the appropriate level of care

 Planning for continuity of care, including assistance making the transition from one care setting to another

 Collaborative approaches to health, including family participation

Guiding Principles

 A care plan should enhance the patient’s treatment plan by providing a list of identified health conditions or

problems with a corresponding prioritized list of interventions to meet the patient’s goals. Standard

assessment domains are used as a basis for this list of problems and corresponding goals.

 There is no single template that must be followed for creating a care plan, but there are critical elements that

should be included. The format will vary based on the provider’s charting process and electronic capabilities.

The care plan format should fit into the provider’s current workflow and should not require duplicative

documentation. (Refer to the provider toolkit for sample care plans).

A Systematic Approach to Care Planning: A step-by-step guide

1. Identify a patient with complex health needs who is at high risk for readmission or an adverse medical event.

This can be done during an interview, physical examination, obtaining a health history, reviewing diagnostic

data, or our reports such as the Hot Spotter report, inpatient authorization report or Care Opportunity reports.

(See illustration below for more information about which patients can benefit from care plans).

2. During a patient assessment, use assessment domains and

Member Medical History Plus (MMH+) data to guide questions

and focus on potential areas of concern. (Click here for more

information about assessment domains).

3. Identify which of the patient’s conditions or health concerns

place him or her at the highest health risk. Review the domains

for guidance on problems identified.

4. Create Goals for Care that address education around, patient

support, and treatment for the conditions or problems already

identified in the care plan. Place goals in order of priority. (Click

here for more information on goal development and examples

of goals.)