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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