Scenario: Sequential Transitions of Care
This business scenario describes the transitioning of a patient’s care across several settings. At each
transition, a text box describes how the living, shared care plan is affected by the transition.
Patient Admitted to Inpatient Setting
Patient A admitted to inpatient setting. In order to provide care for Patient A, a plan is needed (Care
Plan). An Assessment Process and a planning process are conducted.
1. Inpatient provider(s) create an action plan for patient A
2. Patient A Care plan will contain multiple plans of care to deal with varying health concerns.
Goals are identified in order to determine if the plans of care needs are met
3. Inpatient provider(s) create plans of care for each health concern
a. Diabetic ketoacidosis plan of care include the following. Instructions are also embedded
in the plans of care.
i. Treatment plan for high glucose levels.
ii. Treatment plan for abnormal lab results (plan for frequency of lab results and
what should be done for abnormal results)
iii. …
b. Nursing plan of care may include getting the patient and family ready for the next level
of care. Instructions are also embedded in the plans of care.
c. Social service’s plan of care includes assisting the patient and family in identifying
resources for healthcare financial needs. Instructions are also embedded.
d. PT plan of care to evaluate and prevent complications related to immobility.
The various plans of care are implemented and goals are met. Patient A is ready to transition to the next
level of care. Discharge summary with plan and instructions for the next level of Care is generated and
shared. Transient plan content is flagged to expire from display after a settable number of days.
The discharge summary might deal with only those health concerns that the patient had at discharge.
However, since “the” care plan is shared among participants, the goals and plans of continuing relevance
are adjusted and retained. Transpired plan content is suppressed but can be displayed upon request.
Outpatient Setting (PCP)
Assessment and planning Processes are conducted for the outpatient setting.
1. Ambulatory provider(s) create an action plan for patient A
2. Patient A Care plan will contain multiple plans of care to deal with varying health concerns.
Goals are identified in order to determine if the plans of care needs are met.
3. Patient A health concerns may include
a. Medical diagnosis and severity = IDDM-new onset
b. Nursing issues = difficulty coping; knowledge deficit - patient A is legally blind and may
not be able to self-administer his insulin at home
c. Financial Issue = patient A is uninsured and may not be able to afford his needed care
4. Ambulatory provider(s) create plans of care for each health concern
a. New onset IDDM plan of care include the following. Instructions are also embedded in
the plans of care.
i. Treatment plan for high glucose levels.
ii. Treatment plan for abnormal lab results (plan for frequency of lab results and
what should be done for abnormal results)
iii. …
PCP involves other care providers in the patient care because serum glucose is not being adequately
controlled. A referral to an endocrinologist is made. Transient plan content is flagged to expire from
display after a settable number of days.
The referral document might deal with only those health concerns that are the reason for the referral.
However, since “the” care plan is shared among participants, the goals and plans of continuing relevance
are adjusted and retained.
Outpatient Setting (Specialist - Endocrinologist)
Assessment and planning processes are conducted once again.
1. Specialist provider(s) create an action plan for patient A
a. Action plan = Care Plan for Patient A
2. Patient A Care plan will contain multiple plans of care to deal with varying health concerns.
Goals are identified in order to determine if the plans of care needs are met.
3. Specialist provider(s) create plans of care for each health concern
a. IDDM plan of care include the following. Instructions are also embedded in the plans of
care.
i. Treatment plan for high glucose levels.
ii. Treatment plan for abnormal lab results (plan for frequency of lab results and
what should be done for abnormal results)
i. …
Specialist involves other care providers in the patient care because serum glucose is not being
adequately controlled even with changes in insulin prescription. Home health services are
ordered.Transient plan content is flagged to expire from display after a settable number of days.
Outpatient Setting (Homecare Services)
(The process repeats for life)
Going forward, the details of specialty and episodic plans of care are available on demand, but
otherwise are suppressed for the sake of noise reduction. All plan content is marked for appropriate
“aging” so that irrelevant items quietly disappear from the plan by default (suppressed from display but
fully audit-trailed).
In this manner the displayed care plan continuously retains the correct “horizon” of goals and planned
actions. It stays concise and manageable.