Patient-Centered Care Plans

Practices need to actively engage their patients in developing treatment or care plans and monitor progress regularly to guide revisions. Plans should specify the type and intensity of services to be delivered. Care plans should be made through a collaborative, shared decision-making process between patient and provider.

North Star

Patients are routinely part of creating care plans and making decisions with providers about their treatment. Progress is monitored and plans are changed as needed.

How Do You Do It?

Develop a Shared Care Plan

A care plan is a patient-centered health document designed to facilitate communication among members of the care team and with the patient. All care team members should refer to the care plan when managing and treating patients and record any changes in treatment or patient status.

Rather than relying on separate medical and behavioral health care treatment plans, a shared plan of care will help encourage a team-based approach. It can be used as a tool to exchange clinical information, communications, and other forms of coordination between primary care providers, behavioral health providers, and other care team members.

A medication-assisted treatment (MAT) patient’s care plan may include some or all of 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 opioid use disorder—Describes the medications prescribed, including the formulation, dosage, frequency, and other relevant information.
    • Behavioral therapies—Notes whether patients are 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 the MAT program, 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. Practices should document 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 Federal and State privacy requirements and use a standardized, compliant form for the release of information.
  • Patient Education: Highlights psychoeducation delivered about the treatment and self-management of opioid use disorder.
  • 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 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.

Engage Patients in Creating Their Care Plan

It is essential to make the patient a full, active participant in developing and monitoring the care plan. Medical and behavioral health providers both need to be involved with the patient, and family as appropriate, to help develop the patient-centered care plan.

Shared decision making builds patient engagement. Giving patients the opportunity to help develop and negotiate their care plans strengthens the relationship between patients and providers. Providers can better understand patients’ preferences and values in relation to their lives, health, and health care.

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. Getting patient permission to exchange information should also become a standard practice in the setting. Providers should 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, patients’ 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.

Tailor the Care Team

To the extent possible, the practice should consider patients’ 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.

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.
  • Don’t develop a care plan without input from the patient.