Hi, my name is Maria and I’ll be guiding you through this module on Developing an Integrated Plan of Care.
An Integrated plan of care lists problems and needs that are important to the patient and addresses their health and wellness. It can include a diverse set of physical, social, and behavioral perspectives to accomplish these goals. Developing an integrated plan of care often requires the expertise and input of diverse health professionals and health care services.
In this module, you will learn about developing and applying an integrated plan of care.
We’ll begin with a discussion of why integrated care plans are important for high quality patient care and about team members involved in developing an integrated plan. Next, we will identify the steps in designing an integrated plan. Last, you’ll have an opportunity to try out this information in a patient scenario.
So let’s get started!
You should see two tabs in the left-hand column of the player - Menu and Notes. The menu provides navigation links to primary sections in the module. The notes contain the narration transcripts for each slide that has narration.
In the upper right corner of the player you will see links to additional resources and a glossary. You will have access to these throughout the module. When a slide has a glossary term, you will see this “glossary” icon on that slide. You can click the icon to see definitions for the term or terms on that slide. You can also visit the glossary tab in the upper right at anytime to get a full listing of glossary terms associated with this module.
The Core Competencies for Interprofessional Collaborative Practice (2011) define the essential knowledge, skills, and values for health professions students to “work together effectively as members of clinical teams.” The content in this module addresses one or more of the core competencies for interprofessional collaborative practice. Click the IPC link to view the full list of interprofessional competencies . You’ll be able to review exactly which competencies are addressed in each section through a link on the section home screen. Visit the resources tab to view the complete IPEC core competencies report.
There are four sections in this module, and you can reach the different sections by clicking on these tabs.
When you are ready to begin, click the button to start the first section, Why Develop an Integrated Plan of Care.
Why develop an integrated plan of care? There are many unique challenges to receiving quality care in the US primary health care system, navigating health care resources, and improving our populations’ health and wellness – integrated health care and an integrated plan of care is a solution.
After completing this section, you should be able to describe the value of an integrated plan of care and its role in meeting national goals for improving health care outcomes.
Click the IPC link to see which interprofessional competencies will be addressed by this learning goal.
When you’re ready to begin, click the button to start the section.
Numerous initiatives are underway to improve the quality and value of health care in the United States. Models for the delivery of primary care services, in which patients and families receive preventive care as well as continuous chronic illness care, continue to change and evolve. The focus on integration of health care services and the development of a single integrated plan of care are part of national goals for improving the health of patients and communities.
Integrated care brings together an interprofessional team to provide patients with a comprehensive and coordinated set of services that meets their needs and preferences.
Ideally, this team interacts with the patient across time and health care settings to maintain continuity of care, ensuring the coordination of health and social services to support and build individual and community needs and wellness.
In short, integrated care is an important means to improve and transform health care. An integrated plan of care is a key tool for guiding integrated care.
The US has many challenges to improving its primary care system. Shortages of primary care professionals limit access and timeliness of services. We know that many health and social factors create barriers to achieving healthy outcomes. Research findings show that the majority of adults struggle with understanding and managing their health care needs. People with both chronic medical and mental health illnesses are especially vulnerable to poor health outcomes.
Integration of care and an integrated plan of care are important strategies for using available resources effectively and efficiently while addressing patient and family preferences and needs more comprehensively.
Overall, integrated care and use of an integrated plan of care keeps the patient and family at the center of care. It promotes effective teamwork and use of limited resources. Importantly, integrating care and developing one integrated plan of care holds substantial promise for improving health outcomes for patients, families and communities while reducing unnecessary costs.
Before we go any further, let’s take a look at an example of an integrated plan of care. You’ll see this example again in the last section of this module.
The US health care system is the most costly in the world with rising social and health disparities.
The integrated plan of care is an important part of the national quality plan to improve patient care and the patient’s experience of health care, and more broadly, to improve the health of populations of people in the U.S. and reduce health care costs overall.
An integrated plan of care contributes to these three goals by enhancing the effectiveness and efficiency of all health care providers and services as they work together to ensure that patient and family needs and preferences are addressed in a coordinated and timely way.
In the next three slides, we’ll look specifically at how an integrated plan of care contributes to each of these three important goals.
The first goal, an essential mission of the integrated plan of care, is to improve the patient’s experience of health care.
Our health care system is complex. It’s easy for patients, especially those with multiple complex health needs to get confused and overwhelmed. One clear and patient-centered plan of care highlights patient priorities and helps the patient, family and health care team organize and focus on important goals.
The second goal focuses on improving population health.
The thinking that goes into developing an integrated plan of care goes beyond the individual person and family. In working with an integrated plan of care, team members place the patient and family in a broader context of populations and communities. Team members think about: how does this person reflect the needs and risks of a larger set of individuals; how may we influence the outcomes of these individuals more broadly?
Through integrated care and the use of integrated plans of care, teams of health professionals extend evidence-based best practices to individuals and their communities. Significant population health problems, like obesity or diabetes, may be addressed individual by individual as well as by expanding to community interventions according to the needs of the population and community.
Now let’s look at how an integrated plan of care contributes to the third goal, reducing health care costs.
Integrated care planning and the use of an integrated plan of care increases the likelihood that all providers and services involved in a patient’s care know the priorities for care and can work together to ensure a good match between needs and services. This is key to avoiding duplication and use of unnecessary care, which drive up the costs of health care as well as contribute to patient dissatisfaction. Ideally, an integrated plan of care keeps everyone on the same page and working toward the same goals effectively and efficiently.
Match each benefit of an integrated plan of care to the national quality goal by dragging and dropping each benefit onto one of the goals. Each time you correctly match a benefit to a goal, the benefit will be outlined in green and you will receive feedback. If you drag and drop a benefit to the incorrect goal, it will be outlined in red and you can try again.
In this first section, we learned that an integrated care team and care plan are important strategies for addressing challenges in the US primary health system. Through integration we can coordinate care while meeting the unique needs of individuals, families, and communities toward health and wellness.
Collaboration among health professionals is the foundation for developing integrated care plans. In 2010, the World Health Organization declared that interprofessional collaborative practice happens “when multiple health professionals from different professional backgrounds work together with patients, families and communities to deliver the highest quality of care.”
After completing this short section, you should be able to identify members of the interprofessional team who may be involved in developing an integrated plan of care.
Click the IPC link to see which interprofessional competencies will be addressed by this learning goal.
When you’re ready to begin, click the button to start the section.
The integrated plan of care relies on an interprofessional team. An effective plan brings together the goals and needs of the patient and family and the knowledge, skills and values of each team member. Primary care teams often consist of several core members and expand to include a range of other professionals, family members, friends and community members depending on the needs and priorities of the patient.
An integrated plan of care centers around the needs and preferences of the patient. The patient and family are members of the team developing the plan. It is an important part of care planning to assist patients to understand and carry out their role as a central manager of their own health and wellness experience.
In addition to the patient, the typical core primary health care team consists of his/her primary care provider, nurses and nursing assistants, and behavioral health providers. Behavioral health providers may have different professional backgrounds – often in psychiatry or psychology, marriage and family counseling, social work, and/or nursing.
At times, the team may be extended to include professionals who specialize in patient education, care coordination, different health conditions and therapies. Many primary care teams include community members to bridge between primary care services and the patient’s own community.
Developing an effective integrated plan of care relies on each team member understanding the role and contributions of every member on the team.
Here are a few members of the core primary care team. Click each team member to reveal their role in primary care, and in the creation of the integrated plan of care.
Primary care teams may be extended to include several other team members needed to contribute to the integrated plan of care.
In the box below each role, write in what you think a person in this role contributes to the integrated plan of care. Click submit when you are done in order to receive feedback on your answer. You must click each submit button before you can continue.
The development of an effective plan of care is closely connected to effective teamwork and collaboration.
In this section, we learned about the importance of understanding the members of the integrated care team and their roles and contributions.
An integrated plan of care identifies problems and needs that are important to the patient and family and sets out a plan with strategies for meeting these needs.
After completing this section, you should be able to identify the steps in building an integrated plan of care.
Click the IPC link to see which interprofessional competencies will be addressed by this learning goal.
In the next and final section of this module, you’ll have the opportunity to apply these steps to a patient scenario.
When you’re ready to begin, click the button to start the section.
To get started in developing an integrated plan, you need to consider how you will involve the patient and family in identifying problems and needs and coming up with workable options for addressing them.
As emphasized in the previous section, it is essential to engage the patient and family in identifying problems, and options for responding to them. Often, the information and ideas needed to develop a meaningful and feasible plan of care will emerge from collaboration between the patient and family and different members of the primary care team.
Prior to developing the plan of care, it is important to identify criteria that will be used to evaluate it. Determining what success looks like up front helps to set the path toward achieving it. All team members are best involved in this step to build shared value and commitment to achieving the vision and goals for an integrated plan.
Here are several examples of criteria you might select to guide your plan of care. Click on each example to learn more about what to look for in a plan of care.
Each health care team will have its own process for developing a plan of care. Here are ten important steps in developing a plan that achieves the criteria discussed in the previous slide.
Click each development step to learn more about what it involves.
After you complete the ten steps to developing an integrated plan of care, there are a few simple ways to briefly assess how well your care plan is likely work for the patient and the health care team. Two simple tools for assessing a plan of care are SMART and the 5 W’s.
The SMART criteria offer a good check on your statement of goals and outcomes. Goals are specifically stated in understandable language, measurable and behavioral, designed to achieve outcomes and be action oriented, realistic and relevant for the patient, and accompanied by timeframes are more likely to be accomplished. Goals are always reviewed to ensure they match the patient’s motivation, language, and readiness.
Similarly the 5 W’s is a good check for completeness of your plan. Have you covered the who, what, when, where, and why for each element of the plan?
The use of simple tools to review the plan of care helps to make sure that you’ve covered all the bases so everyone has the information needed to effectively implement the plan.
Let’s practice the SMART tool for assessing an integrated plan of care. Drag and drop the letters of SMART to their matching assessment criteria.
A final note about communication in developing the integrated plan of care.
Communication with the patient and health care team is central to the development of an effective plan of care. Establishing a relationship with the patient and family in which they feel able to express what is important or problematic to them is essential. Otherwise, the plan of care may not be complete or include feasible interventions.
Resources for effective communication are plentiful. Here are just a few important tips.
As you engage the patient in dialogue, it is often helpful to listen and repeat the words that the patient uses to describe his or her experience and needs. The choice of words are clues to understanding patient concerns.
Open-ended questions such as “what brings you here today? What are your goals?” or “Tell me about…”– rather than closed “yes-no” questions – allow the patient to elaborate and reveal information that may be important in identifying problems or diagnoses as well as what the patient may hope or want to do about them.
When pressed for time, health professionals often lapse into medical jargon and complicated language. It’s important to use language that the patient understands – assessing health literacy will assist you in determining what works best.
And finally, team members must be kept in the loop about changes in problems and the plan of care. This is critical for coordination of care, not to mention patient satisfaction.
Developing an integrated plan of care begins with creating a framework for engaging the patient and family in the planning process and establishing criteria for success. The plan develops through an ongoing process of dialogue with the patient, eliciting and prioritizing problems and needs, and determining intervention strategies.
Throughout this module, we talk about how this process is collaborative: involving the patient and family and team members whose expertise is needed to address the problems and needs.
In this section, you learned about ten important steps involved in developing an integrated plan of care, you were introduced to some tools for evaluating and assessing a plan’s effectiveness, and we looked at the importance of communication to a plan’s success.
Now its time to apply what you’ve learned to a patient scenario in the last section of this module.
An integrated plan of care lists problems and needs that are important to the patient and addresses their health and wellness.
The plan includes a diverse set of physical, social, and behavioral perspectives to accomplish these goals.
In this section, we are going to identify the important pieces of building an integrated plan of care, specific conversation topics, and engage it in action.
After completing this last section, you should be able to apply the steps in developing an integrated plan of care in a patient scenario.
Click the IPC link to see which interprofessional competencies will be addressed by this learning goal.
When you’re ready to begin, click the button to start the section.
Here’s your chance to practice developing an integrated plan of care using a patient scenario. Your patient’s name is Jean Johnson.
Mrs. Johnson is a new patient in your primary care clinic. When she made her appointment, she shared that she has been feeling very tired for a few weeks. She thinks this may be due to skipping doses on her medication for high blood pressure.
When Mrs. Johnson registered for today’s visit, she provided this information in the new patient survey.
There are a few things go consider before you begin the ten steps to develop and integrated plan of care, including how you will engage Mrs. Johnson in planning her care, what should be included on her problem list, and who should be on her interprofessional care team.
To begin with, name two things you would do in the first visit to engage Mrs. Johnson in her care. Write your responses in the box, and click submit when you are done to see some examples. You can click the “open patient file” button if you need to review her history.
You must click the submit button before you can continue.
Now think about what you would place in the problem list based on what you already know about Mrs. Johnson. Write in what you believe should be on Mrs. Johnson’s problem list.
When you are done, click submit to reveal the answers. You must click the submit button before you can continue.
As your first visit with Mrs. Johnson ends, you agree to follow-up on the beginning interventions you’ve discussed related to evaluating her fatigue, monitoring her blood pressure and taking her medications. She has indicated that she’d like to think about losing some weight, especially if her blood sugar is high again.
Think about the members of your team who might be helpful in working with Mrs. Johnson on these interventions in the future. Include your own profession in your thinking about putting together a team for Mrs. Johnson.
Drag and drop the people you feel will be the most beneficial members of an integrated care team for Mrs. Johnson.
Now it’s time to develop the integrated plan of care in order to be successful in working with Mrs. Johnson.
Match the activity with the steps in developing an integrated plan of care by dragging and dropping each activity onto the appropriate step. After you click submit, the correct matches will appear in green.
This slide includes steps one through five, and the next slide covers steps six through ten.
You can click the “Review 10 Steps” button if you would like to review the development steps that were covered in the previous section.
Continue to match each activity with steps six through ten in developing an integrated plan of care.
Now that you have had a chance to practice developing a plan of care, let’s take a look at what final integrated plan of care might look like for Mrs. Johnson. Click the button to expand Mrs. Johnson’s integrated plan of care.
You’ve completed the last section in the module! In this last section you had the opportunity to develop an integrated plan of care in a patient scenario. You also practiced engaging the patient in their care, creating a problem list based on the patient’s history, and choosing an interprofessional care team.
In this module on Developing an Integrated Plan of Care, we covered the importance of an integrated plan of care, who is involved, and practiced putting it together.
An Integrated plan of care is a comprehensive, coordinated plan of care to improve patient success toward individual health and wellness needs. It is part of the national quality plan and supports the three goals of improved patient care and satisfaction, improved population health, and reduced costs.
Remember, an integrated plan of care is completed to build trust, rapport, and strengthen the patient’s role on the care team. Once the patient feels understood and supported, then they are more likely to engage in goals toward health and wellness.
These are the Core Competencies for Interprofessional Collaborative Practice. Click the colored boxes to see the competencies within each domain.
The Core Competencies for Interprofessional Collaborative Practice report was published in 2011 by the Interprofessional Education Collaborative - also known as the “IPEC” expert panel. You often will hear the interprofessional competencies within the report referred to as the “IPEC competencies.”
Members of the IPEC expert panel wrote in the introduction to the report that this work was (and I quote) “inspired by a vision of interprofessional collaborative practice as key to the safe, high quality, accessible, patient-centered care desired by all." They viewed interprofessional education and practice as absolutely pivotal to quality health care.
The IPEC competencies are organized in four key areas or domains that the members of the expert panel identified as essential to effective collaborative practice - these four areas are: 1) values and ethics, 2) roles and responsibilities, 3) interprofessional communication and 4) teams and teamwork.
At the beginning of each section in this module, you will have an opportunity to review the specific IPEC competencies addressed in that section.
It should be noted that in 2016, the IPEC Board released an update to the Core Competencies. This module was produced prior to that update and refers to the 2011 competencies.
You can visit the “Resources” tab to view the 2011 Core Competencies for Interprofessional Collaborative Practice report, as well as the 2016 updated report.
Click the colored domain boxes to see which competencies will be addressed in this section. The competencies addressed in this section will appear in bold.
Click the colored domain boxes to see which competencies will be addressed in this section. The competencies addressed in this section will appear in bold.
Click the colored domain boxes to see which competencies will be addressed in this section. The competencies addressed in this section will appear in bold.
Click the colored domain boxes to see which competencies will be addressed in this section. The competencies addressed in this section will appear in bold.
That’s it for the module on “What is Interprofessional Education or IPE.”
You now should have a simple working definition of Interprofessional Education, and be able to recognize when a learning activity achieves the intent of the definition – and when it doesn’t.
Remember, interprofessional education requires an opportunity to learn about, from, and with other team members.
You also should be able to identify several of the health outcomes that can result from effective teamwork, like improved patient satisfaction and fewer adverse events like medication errors or preventable hospitalizations.
Finally, you’ve had an opportunity to think about ways to grow your teamwork and collaboration skills. We hope you’ll try some of them out in your classroom and clinical experiences.
The term behavioral health is used to emphasize the broad applicability of integrated health services in health care. Behavioral health encompasses behavioral factors in chronic illness care, care of physical symptoms associated with stress, and health behaviors, as well as mental health and substance abuse conditions and diagnoses. This care may address mental health and substance abuse conditions, health behaviors (including their contribution to chronic medical illnesses), life stressors and crises, stress-related physical symptoms, and ineffective patterns of health care utilization.
BH providers come from a behavioral and motivational perspective in relation to developing a plan of care. They are essential in assessing readiness, roadblocks, and identification of support.
Behavioral health providers are often licensed mental health professionals such as doctorate level psychologists and behavioral health providers, licensed social workers, marriage and family therapists, counselors; however, at times, allied health care professionals are trained to operate as a behavioral health provider as well.
Disparities: Inequality. Health Disparities can be defined as inequalities that exist when members of certain population groups do not receive and/or benefit from the same health services and status as other groups.
The degree to which individuals have the capacity to obtain, process and understand basic health information needed to make appropriate health decisions and services needed to prevent or treat illness.
An Integrated plan of care lists problems and needs that are important to the patient and addresses their health and wellness. The integrated plan of care can includes a diverse set of physical, social, and behavioral perspectives to accomplish these goals.
When multiple health professionals from different professional backgrounds work together with patients, families, and communities to deliver the highest quality of care” (WHO, 2010) the integrated team is born.
When students from two or more professions learn about, from, and with each other to enable effective collaboration and improve health outcomes. - World Health Organization, 2010.
A joint effort by several educational associations to promote and encourage interprofessional learning experiences that help prepare health professions students for effective team-based patient care and improved health outcomes.
Special words or expressions that are used by a particular profession or group and are difficult for others to understand.
Nursing is a profession within health care focused on the care of individuals, families, and communities so they may attain, maintain, or recover optimal health and quality of life. Nurses often assist with providing extended communication, care, and follow up with the patient in order to ensure successful completion of the integrated plan of care. Nurses often bring a more developed identification of the community and family needs in relation to the plan of care. Nurse Practitioner (NP) is an advanced practice registered nurse (APRN) who has completed advanced coursework and clinical education beyond that required of the generalist registered nurse (RN) role.
Questions which do not have a one word answer, require explanation, questions which elicit conversation, depth.
The patient is the most essential partner on the integrated care team and in developing the integrated plan of care. Integrated plans of care must meet the literacy levels, expectations, and prioritized goals and steps that the patient is motivated and ready to accomplish. The patient identifies their motivations, support needs, roadblocks, and engages in developing SMART goals to fit their lifestyle and ability level.
Providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions. (Institute of Medicine 2001)
The PCP identifies the overall health and wellness needs of the patient and urgency related. They may come from a single episode of care or continuity of care perspective.
MD is a doctor who trained at a medical school. DO stands for doctor of osteopathic medicine, who trained at a college of osteopathic medicine. They represent two branches of medicine that started out completely separate but have grown more alike over 125 years. Both types of Providers spend the same number of years training, must pass a licensing exam, and are licensed to provide all types of medical care.
Family medicine doctors: Also called family practice doctors, they see people of all ages, including infants, children, teens and seniors. They are educated and board-certified in their knowledge of the body at all ages.
Internal medicine doctors: Also called internists, they generally care for people age 14 and up (the starting age can vary by practice). They are educated and board-certified in the understanding of the internal organs of the adult body. Some internal medicine and family medicine Providers also can provide care that you might not expect, like routine gynecologic care, dermatology and sports medicine.
Geriatricians: They have special education to address the specific needs of adults over age 60. They provide routine primary care, as well as medication management, physical and mental assessments related to falls, memory issues and other aspects of aging.
Pediatricians: Every child needs to see a doctor – in fact, more often than adults. Pediatricians are specially educated to care for children, ranging from newborns through age 21.
Physician Assistant (PA): A Physician Assistant or Physician Associate is a healthcare professional who is licensed to practice medicine as part of a team with Providers.
An outreach worker in a Hispanic community who is responsible for raising awareness of health and educational issues.
The defined act and manner of dealing with something.