INTERDISCIPLINARY CARE PLANNING PROCESS
Infusion & Ambulatory Care Policy & Procedure Manual
Policy & Procedure
SCS Internal Code:
Org, d
PROCEDURE NO.:
3.1-01
Approved By:
Date Effective:
Reviewed/
Date Reviewed/
Revised By: Roger S. Klotz, R.Ph., BCNSP, FASCP, Revised:
FACA, FCPhA, CDM
06/30/06
Drafted By:
Date Drafted:
12/16/90
Page:
1 of 9
K. Andrusko-Furphy, Pharm.D.
Supersedes Date:
12/31/05
06/21/06
PURPOSE:
The purpose of a patient plan of care (“Care Plan”) is to establish premeditated patient-specific outcome and
goals relating to the patient’s therapy or services being provided, the treatment diagnosis, any other secondary
diagnosis, the age, and the sex of the patient. This allows the clinician to develop patient-specific interventions
to address the state goals and to make any necessary modifications to their therapy (interventions) when the
goals of therapy are not being achieved. Ultimately, the patient’s “Care Plan” should attempt to maximize the
addressing of the patient's care needs while minimizing the potential for adverse reactions or outcomes due to
the therapy or services being provided. Care planning should be based on initial and ongoing patient
assessments.
NOTE: Plan of Treatment (POT) is sometimes used interchangeably or synonymously with Plan of Care
(POC), which can cause confusion. Plan of Treatment in context here is meant to refer to
Doctor's Orders. A Plan of Care or care plan is how those orders are going to be implemented
and monitored by the multi-disciplined team (nurses, pharmacists, respiratory therapists, social
workers, etc.). Unfortunately, to confuse the issue, Medicare refers to the Plan of Care as the
Plan of Treatment and the two are combined, (i.e., Medicare 485 form.).
Also, a newer format for care planning is the development of disease-specific clinical or critical
pathways care paths or care maps.
INTRODUCTION:
The goal of care planning is to minimize or prevent potential disease-related or therapy-related problems.
Regimens and/or care plans should be designed in order to achieve a specific outcome: (1) eradicate disease, (2)
prevent disease, (3) reduce symptomatology, or (4) cure disease. This requires that there be an organized,
proactive, coordinated and multi-disciplinary approach to a patient's medical management. This has been
referred to as a "Care Plan", "plan of care", "care planning", "plan for clinical monitoring" or "monitoring plan"
and requires "care coordination" and with increasing occurrence “Collaborative Practice”. More recently, there
is a trend towards "patient-focused care." This too requires "care coordination", but in addition the concept
embraces a decentralized, non-traditional, cross-trained, multi-disciplinary approach to patient care. It still
Infusion & Ambulatory Care Policy & Procedure Manual  Copyright 2006 Care Partners Consulting Pharmacists, LLC  All Rights Reserved
PROCEDURE TITLE:
INTERDISCIPLINARY CARE PLANNING PROCESS
PROCEDURE NO.:
3.1-01
Page
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Date Effective:
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embraces care planning, but takes a much more aggressive proactive approach versus a reactive approach to
patient problems. “Care Pathing” is more structured, pre-established protocol driven, and documentation "by
exception" oriented. It is synonymously referred to as "clinical pathways", "care maps", "critical paths",
"structured care plans", "procedure plan", or "Care Map". In hospital practice, “unit-based patient care teams”
are administering these critical pathways. Pathways are developed internally and include consultations, tests,
activities, treatments, medications (interventions), diet, teaching; discharge planning needs, and expected
outcomes. Interventions are assigned actual time lines (i.e. frequencies: on day 1, "x" times/day will occur;
during week 3, "x" times/week will occur, etc.). This information can later be compared on variance reports
relating the assigned protocol to actual individual patient-specific services and outcomes. The variances can be
used for continuous quality improvement and making improvements to critical pathways once individual results
of interventions are known. Currently, there are very few standardized inter-disciplinary pathways to compare
one organization to another. Critical pathway development research to date has concentrated primarily on
specific disease state management, usually chronic or costly, (i.e., asthma, hip replacement).
Note: Patient care outside of an organized health care facility requires a focus of health care professionals on
the coordination of the patient’s care. Thus, a strong “Collaborative Practice” focus is critical to maximizing
the benefits of the care plan while minimizing adverse events.
OBJECTIVES:
1.
To provide each patient with an individualized care plan and to provide Medication Therapy
Management (MTM) services that will meet the patient’s needs.
2.
To delineate from the organization's scope of services those patient needs that cannot be addressed
directly or through contracted services and arrange for those needs to be met.
3.
To obtain a complete medical history.
4.
To obtain pertinent baseline clinical information to be used in evaluating the patient as it relates to the
therapy that is being provided.
5.
To evaluate the therapies or treatments ordered for clinical appropriateness, therapeutic duplication,
drug interaction, or allergic reactions.
6.
To establish a structured care plan or clinical pathway/critical path with patient-specific goals of therapy
in conjunction with the physician, nurse, and any other health care professional that would attempt to
maximize the desire treatment outcome while minimizing any potential adverse effects or treatment
failures.
7.
To provide inter-disciplinary cooperative care planning process to include all disciplines and the
patient/caregiver.
EQUIPMENT:
-
Attachment IA-IF - Sample Disease-Specific Care Plans - An Inter-Disciplinary Approach
Attachment II - Sample Clinical Pathway/Critical Path
Attachment III - Directions for Completing Attachment IV
Attachment IV - Patient Care Plan - Format B
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PROCEDURE TITLE:
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PROCEDURE NO.:
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Date Effective:
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- Attachment V - Patient Care Plan/Kardex
- Attachment VI - Directions for Completing a Patient Kardex
POLICY:
1.
The patient is to receive an initial assessment by the appropriate health professionals (i.e., nurse,
pharmacist, dietician, respiratory therapist) within 24 hours of the start of care.
2.
Care planning is to use information from the initial patient assessments.
3.
Care planning is to be multi-disciplinary/inter-disciplinary (as appropriate) and patient-specific.
4.
Care planning process must include the patient and their caregiver.
5.
Organizational limitations (needs unmet) are to be identified and the appropriate coordinated
arrangements made, (i.e., OT, PT, MSW, rehab).
6.
For patients receiving medications/therapies, the pharmacist will review the therapy for clinical
appropriateness particularly as it relates to the patient’s diagnosis, appropriate dosing, drug interactions,
and adverse effects.
7.
The pharmacist will discuss the goals of therapy with the nurse and any other health care professionals
involved in the patient's case. In conjunction with the physician, a plan for clinical monitoring/clinical
pathway/critical path/structured care plan will begin to be developed at the start of care and an initial
pathway/plan will be completed within five (5) days of the patient's admission to service. The
pathway/plan will be documented in the patient's clinical record.
8.
The pharmacist will review the medication therapy including side effects and potential drug interactions
with the patient/caregiver initially and recurrently whenever there is a significant change in therapy. This
discussion must include an explanation of therapy as it relates to the patient’s diagnosis to assure the
patient/caregiver is educated as to the need for the therapy.
9.
The multi-disciplinary team will develop an inter-disciplinary plan of action for clinical monitoring
(interventions) that address a patient-specific problem list based on real or potential identified problems
(i.e., drug-related, physical, emotional, psychosocial, spiritual) that will minimize adverse effects and
maximize desirable anticipated patient outcomes within five (5) days from the start of care.
10. A standard format for documenting the care planning process is to be chosen and used for all patients
requiring care planning (see example form types, Attachments I-IV, this procedure).
11. The pathway/plan is to be documented in the database, (i.e., paper or electronic medical record).
12. Minimally, the pathway/plan is to be reviewed every 30 days on long-term patients. Long-term patients
are defined as patients on service for greater than 30 days. Short-term patients, defined as patients on
service less than 30 days, will be reviewed minimally every two weeks or more frequently as needed.
The plan/pathway is to be updated as needed based upon the acuity level of the patient's
therapies/problems and individualized as needed (i.e., changes in clinical status, new problems)
minimally once a month.
13. The pathway/plan will be evaluated on a continued basis to assure that the patient-specific goals and
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PROCEDURE TITLE:
INTERDISCIPLINARY CARE PLANNING PROCESS
PROCEDURE NO.:
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Page
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Date Effective:
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outcomes of treatment are occurring. If not, appropriate adjustments/interventions will occur.
14. Care or services provided will be in accordance with the physician's, or other authorized individual's,
orders as required by law and regulation.
15. Any changes or modifications to the pathway/plan are to be documented for all appropriate patients
using a consistent organizational-wide format in the database.
NOTE: This does not necessarily mean maintaining one document for all disciplines. For
example, the pharmacists can document their care planning process on a Medication Care
Plan Template that has been individualized. Modifications or updates as potential drugrelated problems occur will be documented in the progress notes. Nurses can have a
separate disease-specific critical pathway document. All patient-specific changes or
modifications are to be made on this document.
The respiratory therapists can also use their own document format. Updates to their care
plans can be found on their visit records.
Minimally, once a month, all disciplines will meet to discuss the patient’s goals,
progression towards the established goals, need for changes in interventions/actions, or
need for new physician orders, as well as any changes in medications, therapies, or
services. An over all Medical Record for each patient must be made available to all
healthcare professionals involved in the patient’s care.
PROCEDURE:
1.
The multi-disciplinary patient care team will be involved in accepting a patient to home care services
based on the following questions: Is the patient and therapy and/or service prescribed for this patient
appropriate for home care? Is the organization qualified and trained to service the patient? Are this
patient’s care needs within the organization’s stated mission and scope of services?
2.
The need to refer to another organization and/or coordinate care with another organization should be
reconsidered if necessary.
3.
The pharmacist or nurse will obtain a complete medical history including other medications and
allergies, including the symptoms associated with the reported allergies, prior to dispensing the
prescribed medication (as appropriate).
4.
The pharmacist or nurse will do an initial pain assessment as well as periodic reassessments.
5.
If a pharmacist is involved in the care of the patient, he/she will evaluate the prescribed therapy and
therapies against any other medications and therapies for duplications, potential side effects, adverse
reactions, and/or drug interactions. These will be documented in the patient's clinical record.
6.
The pharmacist will review therapies as to their clinical appropriateness. The nurse will review the IV
line, home environment, and patient/caregiver trainability for clinical appropriateness. The appropriate
clinician will evaluate home medical equipment needs for clinical appropriateness, as required.
7.
The care planning process will begin at the start of care and use information obtained from the initial
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PROCEDURE TITLE:
INTERDISCIPLINARY CARE PLANNING PROCESS
PROCEDURE NO.:
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Date Effective:
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patient assessments. Information obtained by the appropriate health care professional’s initial
assessments is to be integrated. A care plan or critical pathway that is patient specific is to be
established within five (5) working days of the patient's start on service (Attachments I through VI).
8.
A standardized, consistent format for developing a care plan or pathway is to be chosen. Be consistent
(see examples of different styles, Attachments I-VI).
9.
For patients receiving medications/therapies and/or parenteral therapies (i.e. fluid and electrolytes,
TPN), the pharmacist admit note/initial plan for clinical monitoring/ clinical pathway/critical
path/structured care plan is to include:
a. Documentation of the review of the initial therapy as to its clinical appropriateness for that specific
patient based on medical history, other medications, age, sex, dose, dosing interval, and any physical
limitations the patient may or may not have that could impede the delivery of therapy, (i.e., problems
with eye sight, arthritis, patient training issues).
NOTE: The medical history can be summarized. If the nurse did a complete assessment, it is
appropriate to state "refer to nursing physical assessment and medical history dated
XX/XX/XX in the nurse's chart.
b. Documentation of baseline laboratories appropriate to the patient’s therapy/therapies prescribed.
(Monitoring is critically important to provide information need to evaluate all therapies and any
changes to the therapy prescribed).
c. If an admit note format is used, document in the patient's progress notes section of the patient’s
medical record.
10.
Regardless of the database format chosen for the care plan/pathway, it is to include the following:
a. Documentation of the chief diagnosis, (i.e., patient's primary medical problem).
b. Documentation of the patient-specific goal(s) of therapy with anticipated or expected outcomes.
c. Documentation of patient-specific potential problems, including drug or therapy/treatment-related
problems and patient’s symptoms.
d. Documentation of the patient-specific inter-disciplinary plan for monitoring follow-up.
NOTE: Include appropriate actions/interventions to be taken to prevent, solve, or intervene in
the identified problems. Also include which discipline is responsible for the
intervention(s) (i.e., nurse, physician, pharmacist, and dietitian). Responsibilities will
be partially based the plan of treatment/physician's orders, the plan of care, and input from
other health care professionals (i.e., physical therapist, respiratory therapist). The
monitoring should be reasonable and measurable (i.e., CBC with differential weekly on
Monday; blood chemistries every other week on Wednesdays, maintain current weight of
____________________).
NOTE: Care Plan or Critical Pathway "templates" can be utilized as a tool or as a starting
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point. However, care planning MUST be patient-specific.
11.
The patient is to be monitored for progress towards established goals. Communications are to be
documented in the patient's database, (i.e., paper chart, computer). An inter-disciplinary approach
should be utilized, (i.e., including the physician).
NOTE: Inter-disciplinary implies that the goals and actions of each discipline (multi-disciplinary)
are cooperative. It does not necessarily require that one document or care plan format be
used. Although, one document would streamline the process; pharmacy can have
separate care plans from nursing. If each discipline maintains separate documentation
there must be a means of sharing documentation to assure that coordination of care is
fully implemented.
12. Patient-specific actions/interventions taken as a result of treatments or administration of medications are
to be documented in the database (i.e., progress notes) or in a structured format (i.e., Attachments I-VI) as
they relate to the care plan/pathway (i.e., dosage adjustments, lab draws, adverse effects).
13. Interventions that may cause a change in the initial goal of therapy are to be documented as new goals.
14. If a goal is achieved, it is to be documented as such.
15. If an outside organization is involved in additional components of the patient's care, (i.e., outside nursing
agency, respiratory therapist, dietician) care planning and monitoring is to be cooperative.
NOTE: It is not necessary to have an actual copy of an outside agency's plan of care. However,
care coordination should be documented in the database as part of the interdisciplinary
care planning process.
16.
The patient should be reassessed as care needs require. Orders, problems, needs, and goals must be reevaluated, dated, and signed:
- once a month at a minimum and/or as indicated by changes in patient status (acuity) for long-term
patients (on service 30 days or more)
- every two (2) weeks for short-term patients (on service less than 30 days)
- per state or federal regulations
- as patient’s problems/needs dictate
17.
The patient's physician is to be notified of any necessary changes in the patient's care.
18. Nurses may utilize a "working" Care Plan/Kardex (see Attachment V). If kept separate from the
patient's chart, the Kardex may be used for scheduling, report, and case conference purposes.
19. At the end of service, a transfer/discharge summary is to be written that summarizes the therapy
outcome.
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PROCEDURE TITLE:
INTERDISCIPLINARY CARE PLANNING PROCESS
1.
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