Care Plan Terms & Proposed Definitions (DRAFT)
Table of Contents
Introduction 2
The Importance of a Care Plan 2
The Importance of Terms Used to Describe a Care Plan 3
Policy Requirements and the Ambiguous Use of Care Plans and Plans of Care 3
Terms, Structure, and Components of Care Plan to Support Coordination of Care 3
Appendix A: Meaningful Use Requirements for Care Plan 7
Stage 2 Meaningful Use Requirements for Care Plan 7
Future Stages of Meaningful Use 7
Appendix B: Physician Fee Schedule Requirements for Coordinating Care 10
Medicare Physician Fee Schedule Rule 10
Appendix C: CMS Conditions of Participation Requirements for Care Plan 11
Appendix D: CMS Interpretive Guidelines for Care Plan 14
Appendix E: References 16
Introduction
The recent Center for Medicare and Medicaid Services (CMS) Meaningful Use Stage 2 Final Rule and calendar year (CY) 2013 Medicare Physician Fee Schedule (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) Framework Longitudinal Coordination of Care Workgroup (LCC WG) August 2012 white paper, Meaningful Use Requirements For: Transitions of Care & Care Plans for Medically 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. To further build on these guidelines, the S&I LCC WG has developed the following document, Care Plan Terms & Proposed Definitions, to propose standardized definitions for care plan components in support of the changing dynamics of health care (e.g., Affordable Care Organizations (ACOs), disease management, diverse settings of care). This document describes key terms, structure, and components a care plan to support coordination of care. This document does not define the related processes of a care plan and/or roles and responsibilities associated with those individuals that develop, manage or use a care plan.
The Importance of a 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 clinicians 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 plans created by multiple providers, it is impossible to avoid unnecessary and potentially harmful interventions. Without such a process, it is also difficult to shift the perspective of clinicians from the management of currently active issues to consideration 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 the individual’s care. As such, it provides the structure required to coordinate care across multiple sites, providers and episodes of care.
The Importance of Terms Used to Describe a 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 these 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.
More recent policy requirements that have emerged which underscore both the importance of “care plan” for medically complex /functionally impaired persons and the need to unambiguously define these terms are listed in table 1. Within these regulations, the term ‘care plan’ and its components are not defined in a clear and precise manner.
Table 1: Policy Requirements With Ambiguous Care Plan Terminology
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 Stage 3 and future stages
Terms, Structure, and Components 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 and components needed to plan and coordinate care becomes critical. The LCC WG has developed this Care Plan Terms & Proposed Definitions document to catalog key terms and concepts so that it may serve as a vehicle to gather input toward consensus on the semantics, structure, and components of this foundational activity.
As part of it’s scope of work under the S&I Framework, the LCC WG has developed a set of data elements that the WG believes are required to create and exchange a “Care Plan” (CP) for medically complex and functionally impaired individuals[1]. To better normalize these data elements across healthcare settings and scenarios, the WG is proposing a set of definitions to help frame these data elements. These proposals comprise 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 growing 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 participants 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 interventions, and deviation from the individual’s goals of care.
In parallel, healthcare payment models that put a premium on coordination of care across multiple sites and providers are evolving. This is especially true for patients with complex medical and 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—the 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.
Individuals with more than one significant health problem may have specific care teams dedicated to their management. Currently, there are many different processes in place that create effective integrated CPs for different subgroups of complex individuals (e.g., PACE, Hospice, etc.). Depending on the complexity of the patient and the numbers of clinical disciplines involved and the patient’s preferences, it may be necessary to reconcile and align care plans across disciplines.
The following table lists LCC WG proposed definitions for key ‘care plan’ terms and components. For comparison, applicable terminologies from the Meaningful Use (MU) stage 2 rule are provided.
Further information on the stage 2 requirements for care plan and future stages for MU are provided in Appendix A.
Appendix B lists the Physician Fee Schedule requirements for coordinating care, Appendix C outlines the CMS conditions of participation requirements for Care Plan and Appendix D provides the CMS Interpretive Guidelines for Care Plan.
Table 2: LCC WG Proposed Definitions for Care Plan Terms/ Components
Term/Component / CARE PLANMU2 / Not defined
LCC Proposed Definition / The S&I LCC believes that the exchange of care plans is important to support collaboration across care settings and providers, and allows for and can encourage team based care.
The S&I LCC believes that a “care plan” considers the whole person and focuses on a number of health concerns to achieve high level goals related to healthy living.
In contrast, some clinicians use the concept of “plan of care” to focus on discrete problems, the specific interventions to address the problem, and achieve a certain goal related to the problem.
The S&I LCC WG believes that both the Care Plan and Plan of Care share the universal components: health concern, goals, instructions, interventions, and team member.
Term/Component / HEALTH CONCERN
MU2 / · Health concern is not defined.
· “Problem” is defined as “The focus of the care plan”
LCC Proposed Definition / Health concerns reflect the issues, current status and 'likely course' identified by the patient or team 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 issues 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)
Term/Component / GOALS
MU2 / 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 patient defined goals (e.g., prioritization of health concerns, interventions, longevity, function, comfort) and clinician specific goals to achieve desired and agreed upon outcomes.
Term/Component / INSTRUCTIONS
MU2 / “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 believe 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 separate 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 the individual’s condition, what to do at home, when to call for help, any additional appointments, testing, 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.
Term/Component / INTERVENTIONS
MU2 / Not defined
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.
Term/Component / OUTCOMES
MU2 / Target outcome; target or measure to be achieved in the process of patient care (an expected outcome).
LCC Proposed Definition / Status, at one or more points in time in the future, related to established care plan goals.
Term/Component / TEAM MEMBER
MU2 / Care team includes the primary care provider of record and any additional known care team members beyond the referring or transitioning provider and the receiving provider.
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.
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 transition 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 members 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).