Establish Protocols and Clinical Workflows to Manage and Treat Your Patients

Develop a Shared Care Plan

A shared care plan is a patient-centered health record designed to facilitate communication among members of the care team, including the patient and providers. Rather than relying on separate medical and behavioral health care (treatment) plans, a shared plan of care combines both aspects to encourage a team approach to care.

Giving patients the opportunity to help develop and negotiate their care plans transforms the relationship between patients and providers. By emphasizing transparency and cooperation in developing shared care plans, your practice can reshape and improve its relationship with patients. When patients are engaged in the process, providers can better understand patients’ preferences and values in relation to their health and health care. In addition, patient engagement through shared care plans promotes shared decisionmaking between patients and providers.

In integrated care settings, it is vital that all members of the care team have access to the same information and can build upon the shared care plan. Team members must act in coordination toward a common goal to provide quality integrated care and avoid errors.

North Star

Patients are routinely part of creating care plans and making decisions. All members of the integrated care team have access to the care plan and practice in accord with it.

What is the North Star?

The North Star

The North Star reflects ideal practices of an integrated behavioral health and ambulatory care setting. The North Star can act as a goal or guide toward your desired state of integration.

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How Do You Do It?

The development and use of a patient-centered care plan requires the ongoing participation of multiple members of the care team. Every professional who is part of the patient’s care should be familiar with the patient’s care plan. This familiarity should become an expectation within the practice’s or health system’s culture.

A shared care plan can be used as a tool for easy exchange of clinical information, medication reconciliation, and other forms of coordination between primary care providers, behavioral health providers, and other members of the care team. It is critical that all care team members refer to the care plan when managing and treating patients, and that they indicate any changes in treatment or patient status.

A shared care plan may include some or all of the following elements:

  • Team roles and goals—the team members responsible for specific goals or tasks, including a list of other providers in the larger health network who have standing permission to exchange information.
  • Documentation of dialogue with the patient about the benefits of having a shared record, discussion of any risks or patient concerns about shared records, and explanation of precautions taken to protect the confidentiality of behavioral health records.
  • Patient education about conditions, treatments, and self-management.
  • Medical treatments, including pharmacologic treatment (shared problem list and medication list).
  • Role of psychotherapy, community groups, or other non-pharmacologic behavioral health or substance abuse therapy or support.
  • Counseling or coaching (e.g., motivational interviewing, behavioral activation).
  • Plans tailored to the patient /family context (e.g., patient demographic information, a list of family members the patient provided to the health system, a list of family members with whom the health system has permission to share information, profession, education).

Here are some additional elements that are important to include in the care plan:

  • The patient’s preferences for what he/she would like to be called by members of the integrated care team.
  • Names and roles of community-based support or services outside the health system and the status of permission to exchange information with each of them.
  • A “sign-out” summary consisting of the integrated care team’s brief overview of the patient’s health status at each episode of care.
  • The patient’s short-term and long-term health goals and the action plan for achieving them.
  • The patient’s wishes regarding life-saving treatments.
  • A record of shared decisionmaking processes that have taken place.
  • Documentation of conflict resolution strategies between patients and the integrated care team (e.g., any actions that may cause conflict and the patient’s views on how to resolve conflict most effectively).
  • Any further information that the patient wants his or her care team to know.

 

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It is helpful to have a patient’s shared care plan linked with the electronic health record (EHR) system when feasible. Many elements of the care plan can then be populated automatically with information from the EHR.

When possible, staff with care/case management expertise (i.e., those trained to assist and support patients in overcoming barriers to physical or behavioral health) can lead the coordination process and ensure that the care plan reflects the input of the patient and other team members. One strategy is to have the patient fill out a form on the practice’s online portal and have this information automatically populate parts of the care plan. Additional information for the care plan can be provided by staff who carry out care/case management functions.

How Others Are Doing It

  • Cherokee Health Systems in Tennessee, which is both a community mental health center and a federally qualified health center, embeds behavioral health care providers in its primary care clinics. Cherokee aims to maintain an EHR system and a unified workflow to facilitate integration. Read more at http://www.integrationacademy.ahrq.gov/node/3141.

  • Intermountain Healthcare in Salt Lake City promotes behavioral health integration through its own in-house ambulatory and hospital-based information technology systems. The EHR system, health information exchange system, and population registries are all linked. Read more at http://www.integrationacademy.ahrq.gov/node/3140.

  • The Behavioral Health Integration program at MaineHealth consists of approximately 30 providers working in nearly 40 practices within seven hospital systems across central and southern Maine. MaineHealth’s system promotes shared medical decisionmaking by allowing providers to easily store and transmit patient information. Read more at http://www.integrationacademy.ahrq.gov/node/3139.

  • Access Community Health Centers in Madison, WI, ensures that psychiatrists and other providers have access to a patient’s health records. Primary care providers, behavioral health specialists, and the consulting psychiatrist regularly interact and discuss patient care. Read more at https://innovations.ahrq.gov/profiles/integration-behavioral-health-team-and-consulting-psychiatrist-primary-care-enhances-access.

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Engaging patients in the creation of their care plan requires the participation of multiple members of the team. One or more members of the team should become skilled at introducing the process of developing health goals and creating an action plan. Getting patient permission to exchange information should become a standard practice in the setting. Developing a complete care plan commonly requires multiple visits. Discussion of the care plan should address the links between physical and behavioral health.

When patients are engaged in their care plan, they have control over communications that may go beyond the care team. For example, patients can indicate if they want to be notified when the practice or system communicates with the community network or family members. Providers should be prepared to talk with patients about information sharing and confidentiality. Once the care plan is in place, it provides a mechanism for review that is broader than a medication list. An annual review of care plans can be done face to face or through a patient portal.

How Others Are Doing It

  • The Community Health Plan of Washington has been administering the Mental Health Integration Program at federally qualified community health clinics statewide since 2009. As part of this program, onsite behavioral health care managers act as linkages between primary and behavioral health care. A Web-based registry known as the Care Management Tracking System supports behavioral health integration and patient engagement. Read more at http://www.integrationacademy.ahrq.gov/node/3138.

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What Not to Do

  • Don’t develop a care plan and consider the process complete. The shared care plan should function as a living document that members of the care team refer to and update on an ongoing basis.

Contribute

The Playbook includes many examples of how sites have implemented specific aspects of integration. If you would like to contribute, please send us your example of how your organization develops and engages patients in shared care plans.

Send Us Your Example

Resources

Examples of Shared Care Plans

This resource provides four examples of shared care plans.

Source: Patient Centered Primary Care Institute
Treatment Plan – Behavioral Health

This is an example of a behavioral health treatment plan from MaineHealth’s Behavioral Health Integration program.

Source: MaineHealth
Defining Clause #3- Using a Systematic Clinical Approach (and a System that Enables it to Function)

Read about engaging and involving patients and families in care, including the development of a shared care plan.

Source: AHRQ Lexicon for Behavioral Health and Primary Care Integration (page 18)
Fine Print: Rules for Exchanging Behavioral Health Information in California

A report that describes the legal boundaries related to information sharing in California.

Source: California Healthcare Foundation
Integrating Physical and Behavioral Health: Strategies for Overcoming Legal Barriers to Health Information Exchange

This brief reviews strategies to overcome barriers to information exchange between behavioral and medical health providers.

Source: Manatt Health Solutions
Achieving a Shared Plan of Care with Children and Youth with Special Health Care Needs

This report includes guidance on developing a shared care plan with children who have chronic or complex health conditions.

Source: Lucile Packard Foundation for Children’s Health
Cherokee Health Systems

Cherokee Health Systems embeds behavioral health care providers in its primary care clinics and aims to maintain an electronic health record system and a unified workflow to facilitate integration.

Source: AHRQ Academy
Intermountain Healthcare

Intermountain Healthcare promotes behavioral health integration through its own in-house ambulatory and hospital-based information technology systems.

Source: AHRQ Academy
MaineHealth

MaineHealth’s electronic health record system promotes shared decisionmaking by allowing providers to easily store and transmit patient information.

Source: AHRQ Academy
Integration of Behavioral Health Team and Consulting Psychiatrist Into Primary Care Enhances Access to Behavioral Health Care for Low-Income Patients

Access Community Health Centers ensures that psychiatrists and other providers have access to a patient’s health records. Primary care providers, behavioral health specialists, and the consulting psychiatrist regularly interact and discuss patient care.

Source: AHRQ Health Care Innovations Exchange
Patient Engagement: Practical Strategies to Engage Patients in Integrated Health Care

This report offers strategies, tips, and lessons learned for supporting patient engagement in integrated care settings.

Source: Maine Health Access Foundation
Supporting Patient Engagement in the Patient-Centered Medical Home

This report offers engagement strategies and outlines key responsibilities for both patients and providers.

Source: Center for Advancing Health
Shared Decision Making: A Model for Clinical Practice

This article reviews a model to achieve shared decision making in clinical settings.

Source: Journal of General Internal Medicine, Vol. 27, No. 10 (2012)
Dialogue With Patient on Information Sharing and Confidentiality

This section of the Lexicon reminds providers of their responsibility to initiate conversations about information sharing with patients.

Source: AHRQ Lexicon for Behavioral Health and Primary Care Integration (page 19)
Making Wiser Choices About Medicines

This guide for patients provides information on a variety of depression medications.

Source: Mayo Clinic
Shared Decision Making

This fact sheet for providers includes information and tips to improve shared decision making.

Source: National Learning Consortium
Community Health Plan of Washington

This case study reviews tools used by the Community Health Plan of Washington to support behavioral health integration and patient engagement.

Source: AHRQ Academy

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