Care Definitions

CARE DEFINITIONS: WHAT ARE WE TALKING ABOUT? 

[ This is a work-in-progress, your additions and feedback are welcome! ]

Care Plan

Care planning promotes person-centeredness, improves outcomes, and reduces the cost of care. By design, care plans take a patient-centered approach, both by making comprehensive health data available across providers and settings and through the incorporation of data elements that have not traditionally been included in health IT systems (e.g., social determinants of health [SDOH], patient health and life goals, patient preferences).

A patient-centered care plan describes in an easy, accessible way the patient’s needs, views, preferences, and choices, the resources available, and the actions taken by care team members (including the service user and caregiver(s)) to meet the patient’s needs. 

(Source: HL7 Multiple Chronic Conditions (MCC) eCare Plan)

Care Plans typically contain:

1. Assessments of the patient’s health status (in the source case above, assessment and management of suspected/confirmed hypertension), co-morbidities, ability to comply with a care plan, and additional relevant patient information such as: insurance coverage, availability of care giver(s) support, mobility/transportation, environment (home, community, access to care facilities, SDOH), and patient preferences. Recommend interview by social worker or case manager to obtain the non-clinical information.

2. Contributor(s) to the plan: patient, caregiver(s), primary care provider, specialty provider (cardiologist, nephrologist in the source case above), nursing staff, care manager, social worker, chaplain, etc.

3. Data liquidity within clinical information systems that capture and share pertinent patient data that is responsive to changes in data/documentation relevant to the patient’s status (e.g. healthcare data, discrete values, documents, laboratory and imaging reports etc.), social status (SDOH), and patient goals.

4. Ongoing updates on efforts to address the patient’s needs and improve health outcomes or delay a decline in health.

5. Documentation of outcomes based on care delivery over time (e.g. improved health/quality of life, reduced costs [due to fewer hospitalizations, Emergency Department (ED) visits, etc.] improvement in health markers over time [e.g. lower blood pressure, stable or improved health status, cardiac, renal, and vascular indicators]). 

Care Pathway

In 2007, Vanhaecht et al. defined the term ‘care pathway’ or ‘pathway’ as follows:

“A care pathway is a complex intervention for the mutual decision-making and organisation of care processes for a well-defined group of patients during a well-defined period.

Defining characteristics of care pathways include:

• an explicit statement of the goals and key elements of care based on evidence, best practice, and patients’ expectations and their characteristics;

• the facilitation of the communication among the team members and with patients and families;

• the coordination of the care process by coordinating the roles and sequencing the activities of the multidisciplinary care team, the patients and their relatives;

• the documentation, monitoring, and evaluation of variances and outcomes, and

• the identification of the appropriate resources.” 

(Source: International Journal of Integrated Care, 2012 Jan-Dec.)

Care Management

Care management is “a promising team-based, patient-centered approach designed to assist patients and their support systems in managing medical conditions more effectively.” It also encompasses those care coordination activities needed to help manage chronic illness.

Care management is a set of activities intended to improve patient care and reduce the need for medical services by enhancing coordination of care, eliminate duplication, and helping patients and caregivers more effectively manage health conditions.

(Source: Agency for Healthcare Research and Quality (AHRQ), Care Management Issue Brief, 2018 Aug.)

Care Coordination

There are over 40 definitions for the term “care coordination” throughout the industry. Figure 1 on the AHRQ Care Coordination Measures Atlas Update illustrates the many facets of care coordination with a triangle encircled by inner and outer rings. Inside the triangle, the central goal of care coordination is stated: 'Meet Patient Needs and Preferences in Delivery of High-Quality, High-Value Care.” The three sides of the triangle are labeled: “Patient/Family Perspective,” “Health Care Professional(s) Perspective,” and “System Representative(s) Perspective.” The outer ring contains a series of circles with various participants, settings, and kinds information. They include: primary care, specialty care, inpatient mental services, long-term medical history, test results, home informal givers, education support, medications/pharmacy, community resources. The blue ring that sits between the outer circles and inner triangle represents care coordination.

Care Management vs. Care Coordination

While “Care Management” and “Care Coordination” are sometimes used interchangeably and both focus on patient care, the two terms are different in their implications regarding billing, reimbursement, patient management tools, and patient outcomes. The AHRQ emphasizes that Care Coordination necessitates communicating the patient’s needs and preferences at “the right time to the right people.” The information must be shared and used in a secure manner that provides “effective care to the patient.” Care Management is a more episodic approach that has, according to AHRQ, “emerged as a leading practice-based strategy for managing the health of populations.”

(Sources: Agency for Healthcare Research and Quality (AHRQ), Care Management Issue Brief, 2018 Aug. and Agency for Healthcare Research and Quality (AHRQ), Care Coordination, 2018 Aug.)

Care Team

A clinical care team usually includes groups of physicians, nurses, physician assistants, clinical pharmacists, social workers, community service providers, and other health professionals that help to establish new lines of collaboration, communication, and cooperation to better serve their patient's needs. For patient-centered care, it is essential that the patient and his/her caregivers are also included as active participants in the care team.

(Source: ElationHealth, 2018 Oct 1.)

Footnotes

 [MJ2]At the Elation Health website, at https://www.elationhealth.com/healthcare-innovation-policy-news-blog/care-coordination-v-care-management/, it is noted that:

“The terms “care coordination” and “care management” are often used interchangeably. In reality, though, they are considerably different. While both are obviously focused on patient care, there are varying implications in regard to billing, reimbursement, patient management tools, and patient outcomes. Yet the two activities are interconnected.  The Agency for Healthcare Research and Quality (AHRQ) describes care coordination as:

deliberately organizing patient care activities and sharing information among all of the participants concerned with a patient’s care to achieve safer and more effective care.

The AHRQ emphasizes that care coordination necessitates communicating the patient’s needs and preferences at “the right time to the right people.” The information must be shared and used in a secure manner and in a way that provides “effective care to the patient.”

Further, the AHRQ describes care management as:

a promising team-based, patient-centered approach designed to assist patients and their support systems in managing medical conditions more effectively.

Care management is a more episodic approach that has, according to AHRQ, “emerged as a leading practice-based strategy for managing the health of populations.”