Customized Care Plan Development and Emergency Department Relations are integral components of every Complex Care program. As medical professionals, we know the importance of reducing future re-admissions and a solid care plan is crucial for our high resource patients. 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.
Typically, this is a 4-month project with our clients. CBCS develops care plans with an emphasis on:
- Input from patients, providers, and pertinent community resources
- Input from the patient’s recent ED visits and/or admissions
- Focus on end-user effectiveness
- Emergency department, admission, and out-patient providers
- Timely and effective care plan updates
- Medication reconciliation
- Recommended actionable items for end-users
- Upcoming patient appointments and/or current treatments
- Key triggers such as violence warning
CBCS also promotes care plan recognition and use within the community by meetings and the education of target community resources such as emergency department staff, hospitals, and hospital-based care coordinators, outpatient providers and their staff, regional behavioral health and chemical dependency centers, and other pertinent resources as identified.
By focusing on the individual patient and ensuring their needs are identified and addressed within a Customized Care Plan, re-admission rates go down, and therefore so does the cost to the healthcare system. A win-win for everyone!