Develop a Shared Care Plan

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.

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.

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.