Catalyst Program 2: Implementing Customized Care Plans

Catalyst Series Part 2: Implementing Customized Care Plans

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 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!

Join us next time as we discuss our Controlled Substance Management Program and how it helps identify substance abuse issues specific to your community and what you can do to improve this complex care issue.


Those of us working in the Complex Care community have pain points—areas within our systems that, if functioning better, would work better for our high-utilization clients, our staff, and our bottom lines. With this in mind, CBC Solutions (CBCS) has crafted five (5) individual programs that can help target what we have found to be the most pressing issues that once solved will make a big impact. Learn more here:


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Best Practice for a Community High Utilization Program – Customized Patient Care Plans
Immediately upon client enrollment staff will conduct a thorough intake assessment with the new enrollee and contact community resources individuals are already engaged with – primary care providers, medical specialists, care coordinators and/or current treatment programs they may be involved with.  These activities provide a wealth of information that staff then summarized into an individualized patient care plan.

Many patients enrolled in high utilization programs will already have care plans of some form.  These are an extremely valuable resource, and staff should review these thoroughly.  That said, in many cases existing care plans can be quite detailed – often several pages long.  The value of care plans is primarily for the end-users, most often providers treating the individual – an emergency physician in a crisis event, a hospitalist or social worker during hospitalization, or an outpatient provider at a scheduled visit.  Practitioners treating patients in these environments have limited time to sort through large amounts of data.  Detailed care plans are often ignored in these circumstances; there is tremendous value in being able to provide the most pertinent of details in a short, succinct fashion, particularly if the information is outlined/highlighted in a method that stands out to them and makes pertinent information readily available at a glance.

We strongly recommend care plans be succinct – ideally nor more than a page in length. Community end-users will find plans to be of most value when they have accurate information that is reliable, “up-to-date”, and actionable.  Information should be separated into short segments such as:

  • Demographics (including reliable contact information)
  • Existing providers
  • Medical history, current medications and allergies
  • Psychosocial history, including substance use/abuse
  • Potential violence notices
  • Pending appointments
  • Actionable provider recommendations for crisis events

Care plans are of most value when updated frequently.  “Care Plan Fatigue” is a detrimental phenomenon experienced in several communities that have implemented mandates for care plan implementation without close regard to the quality of the product being produced.  When providers encounter care plans which are not updated or are merely a templated format common to all patients irrespective of their unique issues, they quickly consider this wasted time and will be unlikely to continue engaging in care plan review.

Care plans should be updated:

  • After each emergency department visits and/or hospitalization, and out-patient visit
  • After each out-patient (primary care or specialist) visit
  • With any pertinent medical or psycho-social patient change
  • When any new actionable item is recommended by a patient’s provider and/or coordinator

When updated in this fashion, and made readily available to pertinent community resources, customized care plans are an indispensable patient’s treatment tool.

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