Person-Centered Care Plans

A shared care plan is a person-centered health document designed to facilitate communication among members of the care team with the patient. Rather than relying on separate medical and behavioral health care treatment plans, a shared plan of care encourages a team-based approach. Every professional who is part of the patient's care should be familiar with the patient's care plan.

Make sure that information sharing is in alignment with documented patient consent.

A patient's care plan for OUD treatment may include some or all the following elements:

• Goals: Includes the patient's self-defined short- and long-term health and life goals and the action plan to achieve them.
• Treatments and Supports:
  • Medications to treat OUD — Describes the medications prescribed, including the formulation, dosage, frequency, and other relevant information.
  • Behavioral therapies — Notes whether patients are appropriate for and willing to engage in counseling or other behavioral therapies. If so, describes the types and frequency of behavioral therapies they will receive and from whom.
  • Recovery supports — Includes the names and roles of community-based supports or services outside of your practice, such as peer supports, self-help groups, or other recovery supports, and the status of permission to exchange information with each of them.
  • Other medical care — Describes other medical conditions for which the patient is receiving treatment, including pharmacologic treatment.
• Care Team:
  • Team roles and responsibilities — Identifies the members of the patient's care team and notes who is responsible for specific goals or tasks.
  • Release of information — Includes a list of other providers internal or external to the health system who have standing permission to exchange information. Documents discussions with the patient about the risks and benefits of having a shared record and the precautions taken to protect patient privacy and confidentiality. The care team needs to understand all relevant state and federal privacy requirements and use a standardized, compliant form for the release of information.
  • Tailor the care team — To the extent possible, the practice should consider patient's unique needs and situation when identifying a care team to help in their treatment and recovery. When taking a team-based approach to care, practices need to be thoughtful and explicit in developing care teams and assigning roles.
• Patient Education: Highlights psychoeducation delivered about the treatment and self-management of OUD.
• Additional Information: Includes any other information the patient wants his or her care team to know, such as information related to the patient's history, family context, and other psychosocial factors or life circumstances.

Developing, using, and maintaining a person-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.

Shared decision-making builds patient engagement. Make the patient a full, active participant in developing and monitoring their person-centered care plan. This will strengthen the patient's relationship with providers and give them more ownership over their treatment. Patients are in the best position to express their preferences and values in relation to their lives, health, and health care. In addition, one or more members of the team should become skilled at introducing the process of developing life and health goals and creating an action plan.

The following quotes illuminate patients' feelings about shared decision-making (when given the choice between three different buprenorphine initiation protocols):¹

Getting patient permission to exchange information between providers should become a standard practice. Be prepared to talk with patients about the risks and benefits of information sharing and confidentiality. Except for emergency situations and mandated reporting of certain behaviors, patient's right to privacy is assured by state and federal laws. Standard procedures should include the use of consent forms to be signed before information is released.