CARE PLAN TERMS & PROPOSED DEFINITIONS

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LONGITUDINAL COORDINATION
OF CARE WORK GROUP




A Community Led Initiative



CARE PLAN TERMS &
PROPOSED
DEFINITIONS



December 2012

Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

1


Table of Contents

Introduction

................................
................................
................................
................................

2

The Importance of Care Plan

................................
................................
................................
.....

2

Th
e Evolution of Plans of Care to Care Plans

................................
................................
.....

2

The Importance of Terms Used to Describe Care Plan

................................
..............................

4

Policy Requirements and the Ambiguous
Use of Care Plans and Plans of Care

....................

4

Terms, Structure, Components and Processes of Care Plan to Support Coordination of Care

5

Glossary of Terms


Care Plan Components/Elements

................................
..........................

6

LCC Proposed Model o
f Care Plan:

................................
................................
........................

8

Appendix A: Meaningful Use Requirements for Care Plan

................................
.......................
10

Stage 2 Meaningful Use Requirements for Care Plan

................................
............................
10

Future Stages of Meaningful Use

................................
................................
..........................
10

Appendix B: Physician Fee Schedule Requirements for Coordinating Care

.............................
12

Appendix C: CMS Conditions of Participation Requirements for Care Plan

..............................
13

Appendix D: CMS Interpretive Guidelines for Care Plan

................................
..........................
16

Appendix E: References

................................
................................
................................
..........
18




Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

2


Introduction


The recent CMS
Meaningful Use Stage 2 Final Rule

and
CY 2013 Medicare
Physician Fee
Schedu
le (MPFS) Final Rule
, introduced requirements to exchange care plan content with
transitions of care and referrals, and to enhance physician reimbursement for services related to
Transitional Care Management. The Standards and Interoperability (S&I) Frame
work
Longitudinal Coordination of Care Workgroup (LCC WG) August 2012 white paper,
Meaningful
Use Requirements For: Transitions of Care & Care Plans for Medic
ally Complex and/or
Functionally Impaired Persons
, identified the need for a more robust description of care plan
content to be exchanged as part of Meaningful Use requirements and in support of medically
complex and/or functionally impaired persons. Buil
ding on these documents, this
Care Plan
Terms & Proposed Definitions,

prepared by the S&I LCC WG, proposes standardized definitions
for care plan components to support the changing dynamics of health care (e.g., ACOs, disease
management, diverse

settings of care). With this document, the LCC WG
proposes
descriptions of terms, structure, components and processes of care plan to support coordination
of care.

The document is focused on the CONTENT of a care plan and not the PROCESSES of
a care pla
n.


The Importance of Care Plan


Individuals of all ages are living longer with chronic illness and disability. As the number and
complexity of their health conditions increase over time and episodes of acute illness are
superimposed, the number of clini
cians contributing to the care of these individuals increases as
well. It becomes significantly more difficult to align and coordinate care among a growing
number of providers in multiple sites.


Without a process to reconcile potentially conflicting pl
ans created by multiple providers,
unnecessary and potentially harmful interventions

may occur
. Without such a
reconciliation
process, it is also difficult to shift the perspective of clinicians from the management of currently
active issues to considerat
ion of future goals and expectations.


The Care Plan represents the synthesis and reconciliation of the multiple plans of care
produced by each provider to address specific health concerns. It serves as a blueprint shared
by all participants to guide th
e individual’s care. As such, it provides the structure required to
coordinate care across multiple sites, providers and episodes of care.



The Evolution of Plans of Care to Care Plans


Each provider creates a plan of care with the individual that inclu
des instructions and a
treatment plan, often for a specific issue or for a limited number of issues. Plans of care
are usually problem focused. With increasing complexity of illness and interventions,
and with multiple providers of care, inherent contrad
ictions will arise between
Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

3

interventions and goals proposed. These issues are recognized and reconciled by the
provider and individual as part of the process of creating this plan of care. The provider
and individual continuously modify this plan of care

as they assess its effectiveness and
as other health concerns arise. In doing so, more immutable and long term goals will
emerge.


As these plans of care become more numerous and the high level goals which influence
decisions are crystalized and become t
he focus of the plan, the process evolves to
become more whole person oriented, interdisciplinary and goal directed. This process
results in the creation of a Care Plan. The Care Plan reconciles redundancies and
contradictions between Health Concerns, In
terventions and Goals and aligns the desired
outcomes with the overall goals of care. It identifies and fills gaps in care and
communicates the new parameters for interventions. The Care Plan serves as a
“master” or “blueprint” for coordination of all co
mponents of care, attained through the
negotiated, collaborative process with which the individual and his/her interdisciplinary
care team establish it. However, it is important to keep in mind that this model does not
generally acknowledge the myriad of
informal forces that make things both more difficult
and more possible.



Figure
1




Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

4


The Importance of Terms Used to Describe Care
Plan


The terms “care plan” and “plan of care” appear to be used interchangeably within and among
policy statements. Neither term is used precisely enough to convey the difference between a
treatment plan for a specific condition, a
plan of care proposed by an
individual clinician to
address several conditions or a care plan that integrates multiple interventions proposed by
multiple providers for multiple conditions
. The management of medically complex and/or
functionally impaired individuals requires all of t
hese different types of plans. In order for these
individuals to receive the care they need, policy statements should reflect the precision required
to provide complex care.

Policy Requirements and the Ambiguous
Use of Care Plans and Plans
of Care


There
are several policy provisions that require providers to establish “care plans”, “plans of
treatment” and “plans of care” including:



CMS Conditions of Participation,
Conditions of Participation: Home Health
Agencies
.( § 484
.18(a))



CMS Requirements for States and
Long Term Care Facilities

(§ 483.20 (k))



CMS
Conditions of Participation for Hospitals

(§ 482.61(c))



JCAHO Ambulatory Accreditation Program (RC.02.01.01)


These concepts are not defined in these regulations but appear to be used synonymously
and sometimes interchangeably across and even within various regulatory requirements.


R
ecent policy requirements have emerged
that

underscore both the importance of “care
plan”
, particularly

for medically complex /functionally impaired persons
,

and the need to
unambigu
ously define these terms
,
including
:


Regulation

Brief Description

MU Stage 2 Final Rule


Care plan content, if known, is required in the summary of
care for each transition of care or referral

CY2013 Medicare Physician Fee
Schedule Final Rule

Included payment provisions for Transitional Care
Management (TCM) and recognized the need for
communication and coordination across providers at
transitions of care

Request for Comment


Meaningful Use Stage 3

Proposes to build on Stage 2 care plan requirements for
MU St
age 3 and future stages

Table 1


Again, within these regulations, the term care plan and its components are not
defined in a
clea
r

and precise
manner
.


Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

5

The S&
I LCC believes that a
care plan

looks at the whole
person, cumulatively across a
number of health concerns, to
achieve high level goals
related to healthy living. In
contrast, the S&I LCC WG
believes that a
plan of care

(PoC) is more discretely
focused on

particular
prob
lems and

the specific
intervention to address the
problem and achieve a certain
goal related to the problem.
The S&I LCC WG believes
there

is currently no

clear
definition that differentiates
between
care plan

and
plan of
care
.

Terms, Structure, Components and Processes of Care Plan to Support
Coordination
of

Care


With the increased focus on communication and
coordination of care across providers, settings and
time, the need for clear, unambiguous terms to
express the structure, components and processes
needed to plan and coordinate care becomes critical.
The LCC W
G has prepared this
Care Plan Terms &
Proposed Definitions

document to catalog key terms
and concepts, and serve as a vehicle to gather input
toward consensus on the semantics, structure,
components and processes of this foundational
activity.


The
LCC
WG is proposing
components

that we
believe are required to create and exchange a “Care
Plan” (CP) for medically complex and functionally
impaired individuals. We are also proposing a set of
definitions to help frame these

components
. These
proposals comp
rise two small steps towards the
development of an unambiguous and shared view of
the complex processes involved in aligning the
interventions required to meet the health concerns of
these individuals. The ultimate goal is to identify the
information that

is required for the exchange of a CP
and standardize the content, format and definitions of
that information to support its interoperable exchange across all relevant sites and to all
involved parties.


The inability to create and exchange a CP is a growi
ng problem. As our population ages
and accumulates chronic conditions, there is an increase in the number and types of
interventions required to address acute illness and to restore and maintain health and
function. These interventions involve more parti
cipants and more sites of care putting a
premium on communication and integration. As complexity increases so does the
requirement to align interventions across multiple sites and participants in order to avoid
gaps in care, duplicate or conflicting inter
ventions, and deviation from the individual’s goals
of care.



In parallel, healthcare payment models are evolving that put a premium on coordination of
care across multiple sites and providers. This is especially true for patients with complex
medical a
nd functional needs who make up approximately 10% of patients and account for
70% of health care expenditures. For these individuals, the CP provides the blueprint for
aligning interventions to improve quality and efficiency of care. Most individuals, th
e other
90%, do not require this level of coordination or communication to receive efficient, high
quality care. They receive most of their care from one clinician or one team and their
plan of
care

is coordinated among
team members
,

including one or more

of
a small group of
collaborating providers
,

and

the patient
.

Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

6


Some individuals who have more than one significant health problem
may
have specific
care teams dedicated to
the

management

of the various conditions
.
Depending on the
complexity of the pat
ient, the numbers of clinical disciplines involved and the patient’s
preferences; it may be necessary to reconcile and align
plan
s of care

across disciplines and
providers.
Currently, there are many different processes in place that create effective
integ
rated CPs for different subgroups of complex individuals (e.g., PACE, Hospice,

etc.
).


T
o create either a plan of care or a care plan, the LCC WG believes the following items are
required:



Health concerns specific to the providers’ plans of care

o

Changes
to health concerns

o

Crosswalk of health concerns and goals

o

Prioritized health concerns



Goals of care

o

Provider and patient identified goals of care (including patient preferences)

o

Changes to goals of care

o

Prioritized goals of care



Interventions

o

Care
instructions

o

Changes to interventions

o

Prioritized interventions



Outcomes

grouped

by intervention



Team members
, including patients/family members





Crosswalk

(necessary for medically complex persons with care plans created with
multiple providers):

o

Care Pla
n

o

Health concerns and goals of care


Glossary of Terms


Care Plan Components/Elements


Term

Definition

Goals

CMS MU2 Final Rule, Page 54001, Column 2

The target outcome; target or measure to be achieved in the process of
patient care (an expected
outcome).


LCC Proposed Definition:

A defined outcome or condition to be achieved in the process of patient
care. Includes 1) patient defined goals (e.g., prioritization of health
concerns, interventions, longevity, function, comfort) and 2) clinician
spe
cific goals to achieve desired and a
greed upon outcomes.


Health Concern

CMS MU2 Final Rule Definition:

None


LCC Proposed Definition:

Issues, current status and 'likely course' identified by the patient or team
Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

7

Term

Definition

members that require intervention(s) to achieve the patient's goals of
care, any issue of concern to the individual or team member.


“Problems” and “diagnoses” will capture medical/surgical diagnosis but
are insufficient to capture the full array of issue
s that are important to
individuals. Health concerns include:



Medical/
surgical diagnoses and severity



Nursing/Allied Health/Behavioral Health issues



Patient reported health concerns



Behavioral/Cognition/Mood issues



Functional status, including ADL issues



Environmental factors (e.g. housing and transportation)



Social factors including availability of support and relationships



Financial issues (e.g. insurance, eligibility for disability)


Instructions

CMS MU2 Final Rule, Page 54001, Column 1

By clinical instructions we mean care instructions for the patient that are
specific to the office visit. Although we recognize that these clinical
instructions at times may be identical to the instructions included as part
of the care plan, we also believ
e that care plans may include additional
instructions that are meant to address long
-
term or chronic care issues,
whereas clinical instructions specific to the office visit may be related to
acute patient care issues. Therefore, we maintain these as separa
te
items in the list of required elements later.


LCC Proposed Definition:

Information or directions to the patient and other providers including how
to care for their condition, what to do at home, when to call for help, any
additional appointments, testi
ng, and changes to the medication list or
medication instructions, clinical guidelines and a summary of best
practice.


Detailed list of actions required to achieve the patient's goals of care.


Example
:

A person sees their PCP for a cold and is
instructed to rest, consume
plenty of fluids, take an expectorant twice daily, and return if symptoms
do not abate in within 7 days and call if the person develops serious
symptoms such as high fever.


Interventions

CMS MU2 Final Rule Definition:

None


LCC Proposed Definition:

Actions taken to maximize the prospects of achieving the patient's or
providers' goals of care, including the removal of barriers to success.
Instructions are a subset of interventions.


Performance
Outcomes

CMS MU2 Final Rule De
finition:

None


LCC Proposed Definition:

Status
,

at
one or more
point
s

in
time in
the future
,

related to established
care plan goals
.


Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

8

Term

Definition

Problem

CMS MU2 Final Rule, Page 54001, Column 2

The focus of the care plan


LCC Proposed Definition:

The LCC WG
subsumed “problem” in the concept of “health concern”.


Team member

CMS MU2 Final Rule Definition:

None


LCC Proposed Definition:

Parties who manage and/or provide care or service as specified and
agreed to in the care plan, including: clinicians, other
paid and informal
caregivers, and the patient.



LCC Proposed Model of Care Plan:


In addition,
t
he LCC WG
proposes

a care planning

model

that recognizes that the
increasing
complexity of

care planning as complexity of the individuals’ care increases. For
example, as there is an increase in patient complexity
:



patient preferences may change,



the number of team members may change,



the number and nature of interventions may change.



We
believe that as the complexity of the individual’s
condition

increase

that
processes
are
needed to insure that the components of
the
care

plan

are aligned with the patient’s

preferences, conditions and
goals and

are

not in conflict with each other.


We b
elieve that care planning can be enhanced by
interdisciplinary care planning including
all involved clinicians, caregivers, patient/family member.
While a similar a process

more
granular care planning vocabulary that permits distinctions between the vari
ous levels of
coordination required. We propose the following concepts to clarify these levels of
complexity:




Instructions
: List of action steps provided to a team member or patient necessary to
address health concern.




Treatment Plan
: Developed by a p
rovider in collaboration with the individual to address
an individual health concern under the purview of a single provider.




Plan of Care
: Developed in a provider setting and individually
negotiated

with the patient
to address health concern(s).


A patie
nt may have multiple plans of care originating with
each of several providers.




Care Plan
: Assembled in close collaboration with the individual to take into account all
the existing barriers to care access as well as the individual’s goals, philosophies, and
values that may influence care. In this schema there is only one Care Plan.


Its pur
pose
is to coordinate two or more Plans of Care, recognize difference and fill gaps.


One
variant of the Care Plan, the Longitudinal Care Plan, is a forward looking document that
Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

9

establishes goals several years into the future, and may address issues such
as
prevention and risk avoidance.



Figure
2



Add inputs and outputs to graphic


Term

Definition

Care Plan

CMS MU2 Final Rule Definition, Page 54001, Column 2

For purposes of the clinical summary, we define a care plan as the
structure used to define

the management actions for the various
conditions, problems, or issues. A care plan must include at a minimum
the following components: problem (the focus of the care plan), goal (the
target outcome) and any instructions that the provider has given to the

patient. A goal is a defined target or measure to be achieved in the
process of patient care (an expected outcome).


LCC Proposed Definition
:


Longitudinal
Care Plan

CMS MU2 Final Rule Definition:

None


LCC Proposed Definition
:


Plan of Care

CMS MU2 Final Rule Definition:

None


LCC Proposed Definition
:


Treatment Plan

CMS MU2 Final Rule Definition:

None


LCC Proposed Definition
:




Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

10


Appendix A:
Meaningful Use

Requirements for
Care Plan

Stage 2 Meaningful Use Requirements for Care Plan


In support of the national health outcomes policy priority to improve care coordination,
the MU
Stage 2 Final Rule established objectives requiring the EP or EH/CAH who” transitions their
patient to another setting of care or provider of care, or refers their patient to another provider of
care, provides a summary care record for each transiti
on of care or referral” and set measures
requiring this information exchange to occur for more than 50% of these transactions (page
54047). The rule also specifies data elements that, if known, are to be included in the summary
of care. New for MU Stage
2 is the inclusion of the following care plan content among the data
elements required in the summary of care:



Care plan field, including goals and instructions.



Care team including the primary care provider of record and any additional known
care team m
embers beyond the referring or transitioning provider and the receiving
provider (page 54016).



The MU Stage 2 Final Rule also provided the following definition of “care plan”:

For purposes of the clinical summary, we define a care plan as the structure
used to
define the management actions for the various s conditions, problems, or issues. A care
plan must include at a minimum the following components: problem (the focus of the
care plan), goal (the target outcome) and any instructions that the provider
has given to
the patient. A goal is a defined target or measure to be achieved in the process of
patient care (an expected outcome) (page 54001).


The MU2 requirements do not adequately define the concept of care plan nor its component
parts.


Future Stage
s of Meaningful Use


Proposals for future stages of Meaningful Use

presented at the October 25, 2012 Health IT
Policy Committee (HITPC) Meaningful Use Work Group

expand on the care plan requirements
described above and include:
UPDATE THIS LANGUAGE TO RFC


MU Stage 3

EP/ EH / CAH Objective:

EP/EH/CAH who transitions their patient to another setting of care or
refers their patient to another provider of care

Provide a summary of care record for each site transition or referral when transition or referral
occurs with available information

Must include the following four for transitions of site of care, and the first for referrals (with the
others as clinically
relevant):

1.

Concise narrative in support of care transitions (free text that captures current care synopsis
and expectations for transitions and / or referral)

Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

11

2.

Setting
-
specific goals

3.

Instructions for care during transition and for 48 hours afterwards

4.

Care
team members, including primary care provider and caregiver name, role and contact
info (using DECAF)


Measure
:
The EP, eligible hospital, or CAH that site transitions or refers their patient to another
setting of care (including home) or provider of care
provides a summary of care record for 65%
of transitions of care and referrals (and at least 30% electronically).


Certification Criteria
:
EHR is able to set aside a concise narrative section in the summary of
care document that allows the provider to pri
oritize clinically relevant information such as reason
for transition and/or referral.


Certification Criteria
:
Inclusion of data sets being defined by S&I Longitudinal Coordination of
Care WG, which and are expected to complete HL7 balloting for inclusion

in the C
-
CDA by
Summer 2013:

1.

Consultation Request (Referral to a consultant or the ED)

2.

Transfer of Care (Permanent or long
-
term transfer to a different facility, different care team,
or Home Health Agency)


Undetermined Stage

EP/ EH / CAH Objective:

EP/

EH/CAH who transitions their patient to another site of care or
refers their patient to another provider of care.


For each transition of site of care, provide the care plan information, including the following
elements
as applicable:

•Medical diagnoses and stages

•Functional status, including ADLs

•Relevant social and financial information (free text)

•Relevant environmental factors impacting patient’s health (free text)

•Most likely course of illness or condition, in broad terms (fre
e text)

•Cross
-
setting care team member list, including the primary contact from each active provider
setting, including primary care, relevant specialists, and caregiver

•The patient’s long
-
term goal(s) for care, including time frame (not specific to sett
ing) and initial
steps toward meeting these goals

•Specific advance care plan (POLST) and the care setting in which it was executed

For each referral, provide a care plan if one exists


Measure
:
The EP, eligible hospital, or CAH that transitions or refers

their patient to another site
of care or provider of care provides the electronic care plan information for 10% of transitions of
care to receiving provider and patient/caregiver.


Certification Criteria
:
Develop standards for a shared care plan, as being

defined by S&I
Longitudinal Coordination of Care WG. Some of the data elements in the shared care plan
overlap content represented in the CDA. Adopt standards for the structured recording of other
data elements, such as patient goals and related interven
tions.




Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

12

Appendix
B
:
Physician Fee Schedule

Requirements
for
Coordinating Care


Medicare Physician Fee Schedule Rule


The CY2013 Medicare Physician Fee Schedule Final Rule included payment provisions for
Transitional Care Management (TCM). It
recognizes the need for communication and
coordination across providers at transitions of care. The TCM codes cover face
-
to
-
face and
non
-
face
-
to
-
face post discharge services such as communication with the patient, caregiver,
home health agency or other co
mmunity services; education to support self
-
management,
independent living, and activities of daily living; identification of available community and health
resources; obtaining and reviewing discharge information, reviewing need for or follow
-
up on
pendin
g diagnostic tests and treatments; establishing referrals and arranging community
resources; etc.



Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

13

Appendix
C
:
CMS Conditions of Participation
Requirements for
Care Plan


Title 42
-

Public Health.
-

.

SUBCHAPTER E
-

STANDARDS AND CERTIFICATION.

PART 48
4
-

CONDITIONS OF PARTICIPATION:
HOME HEALTH AGENCIES
.


Subpart B
-

Administration.

§ 484.18 Condition of participation: Acceptance of patients, plan of care, and medical supervision.

Patients are accepted for treatment on the basis of a reasonable
expectation that the patient's medical,
nursing, and social needs can be met adequately by the agency in the patient's place of residence. Care
follows a written plan of care established and periodically reviewed by a doctor of medicine, osteopathy,
or pod
iatric medicine.



(a) Standard:
Plan of care
. The plan of care developed in consultation with the agency staff covers all
pertinent diagnoses, including mental status, types of services and equipment required, frequency of
visits, prognosis, rehabilitatio
n potential, functional limitations, activities permitted, nutritional
requirements, medications and treatments, any safety measures to protect against injury, instructions for
timely discharge or referral, and any other appropriate items. If a physician r
efers a patient under a plan
of care that cannot be completed until after an evaluation visit, the physician is consulted to approve
additions or modifications to the original plan. Orders for therapy services include the specific procedures
and modalities

to be used and the amount, frequency, and duration. The therapist and other agency
personnel participate in developing the plan of care.



(b) Standard: Periodic review of plan of care. The total plan of care is reviewed by the attending physician
and HHA

personnel as often as the severity of the patient's condition requires, but at least once every 62
days. Agency professional staff promptly alert the physician to any changes that suggest a need to alter
the plan of care.



(c) Standard: Conformance with
physician orders. Drugs and treatments are administered by agency staff
only as ordered by the physician. Verbal orders are put in writing and signed and dated with the date of
receipt by the registered nurse or qualified therapist (as defined in § 484.4 o
f this chapter) responsible for
furnishing or supervising the ordered services. Verbal orders are only accepted by personnel authorized
to do so by applicable State and Federal laws and regulations as well as by the HHA's internal policies.


[54 FR 33367,
August 14, 1989, as amended at 56 FR 32974, July 18, 1991; 64 FR 3784, Jan. 25, 1999]


Title 42
-

Public Health.
-

.

SUBCHAPTER E
-

STANDARDS AND CERTIFICATION.

PART 483
-

REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES.

Subpart B
-

Requirements for
Long Term Care Facilities
.

§ 483.20 Resident Assessment

(k)
Comprehensive care plans.


(1) The facility must develop a comprehensive care plan for each resident that includes measurable
objectives and timetables to meet a res
ident's medical, nursing, and mental and psychosocial needs that
are identified in the comprehensive assessment. The care plan must describer the following


(i) The services that are to be furnished to attain or maintain the resident's highest practicable
physical,
mental, and psychosocial well
-
being as required under § 483.25; and

(ii) Any services that would otherwise be required under § 483.25 but are not provided due to the
resident's exercise of rights under § 483.10, including the right to refuse trea
tment under § 483.10(b)(4).



(2) A comprehensive care plan must be


(i) Developed within 7 days after completion of the comprehensive assessment;

(ii) Prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with
re
sponsibility for the resident, and other appropriate staff in disciplines as determined by the resident's
Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

14

needs, and, to the extent practicable, the participation of the resident, the resident's family or the
resident's legal representative; and

(iii) Peri
odically reviewed and revised by a team of qualified persons after each assessment.



(3) The services provided or arranged by the facility must


(i) Meet professional standards of quality; and

(ii) Be provided by qualified persons in accordance with each
resident's written
plan of care
.


Title 42
-

Public Health.
-

.

SUBCHAPTER E
-

STANDARDS AND CERTIFICATION.

PART 482
-

CONDITIONS OF PARTICIPATION FOR HOSPITALS.

Subpart E
-

Requirements for
Specialty Hospitals
.

§ 482.61 Condition of participation: S
pecial medical record requirements for psychiatric
hospitals.

(c) Standard:
Treatment plan
.

(1) Each patient must have an individual comprehensive treatment plan that must be based on an
inventory of the patient's strengths and disabilities. The written
plan must include


(i) A substantiated diagnosis;

(ii) Short
-
term and long
-
range goals;

(iii) The specific treatment modalities utilized;

(iv) The responsibilities of each member of the treatment team; and

(v) Adequate documentation to justify the diagnosi
s and the treatment and rehabilitation activities carried
out.



(2) The treatment received by the patient must be documented in such a way to assure that all active
therapeutic efforts are included.


Title 42
-

Public Health.
-

.

SUBCHAPTER E
-

STANDARD
S AND CERTIFICATION.

PART 485
-

CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS.

Subpart B
-

Conditions of Participation:
Comprehensive Outpatient Rehabilitation
Facilities
.

§ 485.60 Condition of participation: Clinical records

(a) Standard:
Content. . . .

(2) Current
plan of treatment;


Title 42
-

Public Health.
-

.

SUBCHAPTER E
-

STANDARDS AND CERTIFICATION.

PART 485
-

CONDITIONS OF PARTICIPATION: SPECIALIZED PROVIDERS.

Subpart H

Conditions of Participation for
Clinics, Rehabilitation A
gencies, and Public
Health Agencies as Providers of Outpatient Physical Therapy and Speech
-
Language
Pathology Services

§ 485.711 Condition of participation: Plan of care and physician involvement.

For each patient in need of outpatient physical therapy o
r speech pathology services there is a written
plan of care

established and periodically reviewed by a physician, or by a physical therapist or speech
pathologist respectively. The organization has a physician available to furnish necessary medical care in

case of emergency.

. . .

(b) Standard:
Plan of care
.

(1) For each patient there is a written plan of care established by the physician or by the physical
therapist or speech
-
language pathologist who furnishes the services.



(2) The plan of care for phys
ical therapy or speech pathology services indicates anticipated goals and
specifies for those services the


Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

15

(i) Type;

(ii) Amount;

(iii) Frequency; and

(iv) Duration.


(3) The plan of care and results of treatment are reviewed by the physician or by the i
ndividual who
established the plan at least as often as the patient's condition requires, and the indicated action is taken.
(For Medicare patients, the plan must be reviewed by a physician, nurse practitioner, clinical nurse
specialist, or physician assis
tant at least every 30 days, in accordance with § 410.61(e) of this chapter.)


(4) Changes in the plan of care are noted in the clinical record. If the patient has an attending physician,
the therapist or speech
-
language pathologist who furnishes the servi
ces promptly notifies him or her of
any change in the patient's condition or in the plan of care.


Title 42
-

Public Health.
-

.

SUBCHAPTER E
-

STANDARDS AND CERTIFICATION.

PART 486
-

CONDITIONS FOR COVERAGE OF SPECIALIZED SERVICES FURNISHED BY
SUPPLIERS

Subpart D

Conditions for Coverage:
Outpatient Physical Therapy Services Furnished by
Physical Therapists in Independent Practice

§ 486.155 Condition for coverage: Plan of care

For each patient, a written plan of care is established and periodically revi
ewed by the individual who
established it.

. . .

(b) Standard:
Plan of care
.

(1) For each patient there is a written plan of care that is established by the physician or by the physical
therapist who furnishes the services.



(2) The plan indicates antici
pated goals and specifies for physical therapy services the


(i) Type;

(ii) Amount;

(iii) Frequency; and

(iv) Duration.



(3) The plan of care and results of treatment are reviewed by the physician or by the therapist at least as
often as the patient's con
dition requires, and the indicated action is taken.



(4) Changes in the plan of care are noted in the clinical record. If the patient has an attending physician,
the therapist who furnishes the services promptly notifies him or her of any change in the pa
tient's
condition or in the plan of care. (For Medicare patients, the plan must be reviewed by a physician in
accordance with § 410.61(e).)





Care
Plan Terms & Proposed Definitions (
DRAFT
)

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Longitudinal Coordination of Care WG


December

2012

16

Appendix
D
:
CMS Interpretive Guidelines
for
Care
Plan


State Operations Manual

Appendix B
-

Guidance to Surveyors:
Home Health Agencies

§484.18(a) Standard:
Plan of Care


G159

The plan of care developed in consultation with the agency staff covers all pertinent diagnoses, including
mental status, types of services and equipment requ
ired, frequency of visits, prognosis, rehabilitation
potential, functional limitations, activities permitted, nutritional requirements, medications and treatments,
any safety measures to protect against injury, instructions for timely discharge or referral
, and any other
appropriate items.

G162

(Rev. 11, Issued: 08
-
12
-
05; Effective/Implementation: 08
-
12
-
05)

The therapist and other agency personnel participate in developing the
plan of care
.


Interpretive Guidelines §484.18(a)

A statutory change renamed the

“plan of treatment” to “the plan of care.” These terms are synonymous.
Neither is to be confused with a nursing care plan.


The conditions do not require an HHA to either develop or maintain a nursing care plan as opposed to a
medical plan of care. This d
oes not preclude an HHA from using nursing care plans if it believes that such
plans strengthen patient care management, the organization and delivery of services, and the ability to
evaluate patient outcomes.

. . .

Written HHA policies and procedures shou
ld specify that all clinical services are implemented only in
accordance with a plan of care established by a physician’s written orders.

. . .

The plan of care must be established and authorized in writing by the physician based on an evaluation of
the pa
tient’s immediate and long term needs. The HHA staff, and if appropriate, other professional
personnel, shall have a substantial role in assessing patient needs, consulting with the physician, and
helping to develop the overall plan of care.

. . .

The pati
ent has the right, and should be encouraged, to participate in the development of the plan of care
before care is started and when changes in the established plan of care are implemented.

"Care Plan"

Pg. 75
-

"When corrections are made to an assessment already submitted to the state system, the HHA
must determine if there is an impact on the patient’s current
care plan
."

Pg. 91
-

"Drugs and treatments ordered by the patient’s physician and not documented on the
care plan

should be recorded in the clinical record."

State Operations Manual

Appendix PP
-

Guidance to Surveyors for
Long Term Care Facilities

F279

§483.20(k)
Co
mprehensive Care Plans

(1) The facility must develop a comprehensive care plan for each resident that includes measurable
objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that
are identified in the comprehe
nsive assessment. The care plan must describe the following:

(i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical,
mental, and psychosocial well
-
being as required under §483.25; and

(ii) Any services t
hat would otherwise be required under §483.25 but are not provided due to the
resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).


Care
Plan Terms & Proposed Definitions (
DRAFT
)

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2012

17

Interpretive Guidelines §483.20(k):

An interdisciplinary team, in conju
nction with the resident, resident’s family, surrogate, or representative,
as appropriate, should develop quantifiable objectives for the highest level of functioning the resident may
be expected to attain, based on the comprehensive assessment.

. . .

The
care plan must reflect intermediate steps for each outcome objective if identification of those steps
will enhance the resident’s ability to meet his/her objectives. Facility staff will use these objectives to
monitor resident progress. Facilities may, for

some residents, need to prioritize their care plan
interventions. This should be noted in the clinical record or on the
plan or care
.

F280

. . .

§483.20(k)(2) A
comprehensive care plan

must be
--

(i) Developed within 7 days after the completion of the
comprehensive assessment;

(ii) Prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with
responsibility for the resident, and other appropriate staff in disciplines as determined by the resident’s
needs, and, to
the extent practicable, the participation of the resident, the resident’s family or the
resident’s legal representative; and

(iii) Periodically reviewed and revised by a team of qualified persons after each assessment.


Interpretive Guidelines §483.20(k)(2
)
:

As used in this requirement, “Interdisciplinary” means that professional disciplines, as appropriate, will
work together to provide the greatest benefit to the resident. It does not mean that every goal must have
an interdisciplinary approach. The mecha
nics of how the interdisciplinary team meets its responsibilities in
developing an interdisciplinary care plan (e.g., a face
-
to
-
face meeting, teleconference, written
communication) is at the discretion of the facility.

. . .

"Plan of Care"

Pg. 34
-

"The r
esident has the right to . . . Perform services for the facility, if he or she chooses, when
--
(i)
The facility has documented the need or desire for work in the
plan of care
;"

Pg. 60
-

"Also determine if the
plan of care

was consistently implemented."

Pg.
84
-

"This information should be noted in the assessment and identified in the
plan of care
."

Pg. 94
-

"Observe during various shifts in order to determine if staff are consistently implementing those
portions of the comprehensive
plan of care

related to a
ctivities."

Pg. 99
-

"If
care plan

concerns are noted, interview staff responsible for care planning regarding the
rationale for the current
plan of care
."




Care
Plan Terms & Proposed Definitions (
DRAFT
)

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Longitudinal Coordination of Care WG


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2012

18

Appendix
E
:
References


Medicare and Medicaid Programs; Electronic Health Record Incentive
Program

Stage 2;
Health Information Technology: Standards, Implementation Specifications, and Certification
Criteria for Electronic Health Record Technology, 2014 Edition; Revisions to the Permanent
Certification Program for Health Information Technology;
Final Rules, 77 Fed. Reg. (2012) (to
be codified at 42 C.F.R. Parts 412, 413, and 495)


Add CMS Online Manuals for CoP and Interpretive Guidelines



Care
Plan Terms & Proposed Definitions (
DRAFT
)

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Longitudinal Coordination of Care WG


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2012

19

PROPOSED DEFINITIONS & COMMENTS FROM SPREADSHEET


Term

Plan of Care

Definition from Draft
Glossary
(11/25/2012)

LCC Proposed Definition
:

A plan of care typically reflects a specific disciplinary approach to a given health concern
(e.g., physical therapy approach to gait deficit), integrates patient preferences, and
identifies:

• Prioritized health
concerns,

• Agreed upon desired or expected outcomes,

• Prioritized interventions,

• Provider care and patient instructions,

• Outcomes by Intervention


This set of instructions is from one or more providers to another provider or to the patient
and addre
sses a specific Health Concern. Within a Plan of Care (POC), reconciliation
occurs between the originator and recipient as the plan is being made or implemented


Applies to all patients and all sites of care. Plans of care all have self
-
contained
process
es for negotiation between clinician and patient, clarification, reconciliation of
conflicts, updating based on new information, identification and filling of gaps. The
simplest plan between one clinician and one patient has all of these attributes embodie
d
within the dialog. In a plan of care involving two clinicians and one patient, there is a small
added burden to reconcile three relationships or arms of the plan of care (C1 to P, C2 to P
and C1 to C2) to create one common plan of care.


Example:

Physica
l Therapy
-

CVA with left hemiparesis and gait disorder. Within 4 weeks, patient
will be able to ambulate 100 feet with a rolling walker. PT and PT aide to provide active
and passive range of motion three times daily and instruct staff in techniques.
St
rengthening exercises will begin and continue six times a week on the affected side.
Balance training and posture awareness will be done twice daily, six times a week. Gait
training and assessment for appropriate use of assistive devices will begin in on
e week
and will be done twice daily, six times a week until goal is reached.



Revised Definition
per WG calls

Problem focused, specific disciplines

HL7 Definitions

A plan of care (POC) is written by an individual provider in discussion with the patient. It
includes the list of current diagnoses and any chronic problem list in context of the
patient's overall health concerns and life goals. It describes the situatio
n and
management actions for the applicable conditions, problems or issues identified. The
POC encompasses social, financial, and cultural factors that impact care for individual
condition(s) under the provider/practice's care. Actors such as timing and

course, target
outcomes, and instructions, encompassing medical management objectives (treatment
plan), patient needs and preferences, and lists team members, and relevant or required
process and outcome
-
oriented quality measures.


From bulleted list in d
efinition: "Outcomes by Intervention"
-

Let's talk about what this
means. It's not clear to me...examples?

Recommended
Definitions
-


Susan Campbell

I don't have any objection to this specification, except that selling it adds a burden that
may reduce
the chances of success. Most people I know use plans of care and care
plans interchangeably
-

and most medical clinicians actually implement a very inadequate
version.

Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

20

Recommended
Definitions
-


Joanne Lynn

A plan of care typically reflects a
discipline
-
specific approach to a given health concern
(e.g., physical therapy approach to gait deficit), integrates patient preferences, and
identifies: Prioritized health concerns,

• Agreed upon desired or expected outcomes,

• Prior
itized interventions,

• Provider and patient instructions,

• Anticipated outcomes by Intervention


Example:

Physical Therapy
-

CVA with left hemiparesis and gait disorder. Within 4 weeks, patient
will be able to ambulate 100 feet with a rolling walker. P
T and PT aide to provide active
and passive range of motion three times daily and instruct staff in techniques.
Strengthening exercises will begin and continue six times a week on the affected side.
Balance training and posture awareness will be done twi
ce daily, six times a week. Gait
training and assessment for appropriate use of assistive devices will begin in one week
and will be done twice daily, six times a week until goal is reached.

Recommended
Definition

Terry O'Malley





Term

Care Plan

Definition from Draft
Glossary
(11/25/2012)

CMS MU2 Final Rule Definition, Page 54001, Column 2

For purposes of the clinical summary, we define a care plan as the structure used to
define the management actions for the various conditions, problems, or issu
es. A care
plan must include at a minimum the following components: problem (the focus of the care
plan), goal (the target outcome) and any instructions that the provider has given to the
patient. A goal is a defined target or measure to be achieved in the

process of patient care
(an expected outcome).

LCC Proposed Definition
:

Applies to patients with care in multiple sites and/or with multiple providers over time. At
some point the multiple plans of care need to be negotiated, clarified, reconciled, updated
and expanded as needed. At this point, a new structure is needed to su
pport these
processes because they can no longer be done within the confines of each plan of care.
The Care Plan provides the "collaborative care platform" where, through an iterative
process, all of the plans of care are reconciled
under the direction
of

the "steward" and
communicated back to the participants.


The unified care plan document emerges through a process of:

• Considering multiple discipline
-
specific plans of care,

• Receiving input from the patient/ caregiver and all disciplines,

• Resolv
ing conflicts between plans of care,

• Identifying gaps,

• Assigning responsibilities and

• Clarifying ambiguities


See also Collaborative Care Plan” and “Longitudinal Care Plan”


Example:

Revised Definition
per WG calls

Addresses needs of whole person
, has high
-
level goals of living, brings in plans of care

Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

21

HL7 Definitions



Recommended
Definitions
-


Susan Campbell



Recommended
Definitions
-


Joanne Lynn

I have always fundamentally disagreed with having the care plan turn on multiple
providers and

sites. It has seemed to me that it arises from the complexity of the patient's
situation, not the multiplicity of people and places, though they often correlate. A person
with a dozen problems living at home with one family caregiver and one doctor need
s a
care plan. And that one poor doc may have to deal with a bunch of things that are not
"discipline specific"
-

like caregivers, finance, and safety. Also
-

can we acknowledge that
there is nothing more important than that the care plan reflect the pat
ient's priorities and
preferences and that the patient agree with (and own) the plan.


From the draft glossary definition: ". . . The Care Plan provides the "collaborative care
platform" where, through an iterative process, all of the plans of care are re
conciled
under
the direction (replace "under direction of" with "through facilitation and guidance")

of the
"steward" and communicated back to the participants."

Recommended
Definition

Terry O'Malley

For purposes of the clinical summary, we define a care plan as the structure used to
define the management actions for the various conditions, problems, or issues. A care
plan must include at a minimum the following components: problem or health concern (t
he
focus of the care plan), goal (the target outcome) and any instructions that the provider
has given to the patient. A goal is a defined target or measure to be achieved in the
process of patient care (an expected outcome). Conflicting goals and interve
ntions are
reconciled to provide consistent direction to all team members through a process that
includes:

• Consideration of all discipline
-
specific plans of care,

• Merge input from the patient/ caregiver and all disciplines,

• Resolve conflicts bet
ween plans of care,

• Identify gaps in plan,

• Assign responsibilities to specific team members and Clarify ambiguities


Term

Longitudinal Care Plan

Definition from Draft
Glossary
(11/25/2012)

CMS MU2 Final Rule Definition
: None

LCC Proposed
Definition:

Applies to patients with care in multiple sites and/or with multiple providers over time.
Multiple plans of care are negotiated, clarified, reconciled, updated and expanded as
needed. At this point, a new structure is needed to support these p
rocesses because they
can no longer be done within the confines of each plan of care. The Longitudinal Care
Plan provides the "collaborative care platform" where, through an iterative process, all of
the plans of care are reconciled through advice or direc
tion of the "steward" and
communicated back to the participants .


Applies to the approximate 20% of patients who receive care in multiple sites from
multiple providers over time.

Revised Definition
per WG calls



HL7 Definitions



Recommended
Definitions
-


Susan Campbell

A Care Plan becomes Longitudinal when its component POCs, disease states, or
interventions are ongoing, interdependent, and/or require periodic or continuous
monitoring.

Recommended
Definitions
-


Joanne Lynn

I
am not at all sure of the 20%, or of this trigger. I would make complexity (problem in
more than one domain) the trigger, and then virtually all frail elders and disabled persons,
and many people living in poverty, need care plans.

Care
Plan Terms & Proposed Definitions (
DRAFT
)

S&I
Longitudinal Coordination of Care WG


December

2012

22

Recommended
Definition

Terry O'Malley

Applies to Care Plans that define goals of care and prioritized interventions across
multiple site of care and teams of care takers over extended periods of time.



Term

Treatment Plan

Definition from Draft
Glossary
(11/25/2012)

CMS MU2

Final Rule Definition
: None

LCC Proposed Definition
:

A detailed statement applying to a specific health concern that specifies interventions,
anticipated outcomes, timelines and the team member(s) responsible for implementing
the intervention(s).



Example:


Hypertension: Lisinopril 5 mg daily. Low Sodium Diet. Exercise Regularly. Measure
Blood pressure weekly at local pharmacy. Report any elevations over 150 systolic or 100
diastolic. Target blood pressure is 130 over 80.

Revised Definition
per WG calls



HL7 Definitions



Recommended
Definitions
-


Susan Campbell

Question: How is this different from a protocol or order set (or does the concept of
treatment plan include them?)

Recommended
Definitions
-


Joanne Lynn



Recommended
Definition

Terry O'Malley

Detailed interventions that apply to a specific health concern listing interventions,
anticipated outcomes, timelines and team member(s) responsible for implementing the
intervention(s).