Care Plan Storyboards with care coordination services scenarios

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Notice.png This content is based on an early draft and requires many updates to reflect changes for in progress ballot reconciliation.


The following are a set of Care Plan Storyboards under development. These storyboards extend on the approved care plan to include scenarios to support care activities planning, resources scheduling, and orchestration. The extensions are intended to provide sufficient details to support the definition of care coordination services and policy.

Acute/Emergency Condition Care Plan Storyboard

Chronic Condition Care Plan Storyboard

CCS Functional Profiles

The following set of profiles is in-process, to be included into the S-FM when stabilized.

Plan Reading

- Read a care plan and its (possibly distributed) related plans of care and treatment plans - Support on-demand reads (pull) as well as pub-subscribe (push) modes - In push mode, can subscribe to updates to some parts or to the plan as a whole

Plan Template Authoring

Note: Plan templates are also called "Order Sets"

- Initialize and maintain a plan, apply reusable parts (e.g. a protocol); individualize goals and interventions, etc.

- Save plans or portions of plans as named reusable components for later reuse

- Support online discussions of specified topics; allow for participants to propose, accept, reject changes

- Use concept codes for all clinical concepts, but also collect narrative version for human consumption

Care Planning

- as opposed to authoring

- instantiate a plan from a template

- individualize for the case at hand

- review

- make changes during the course of implementation/Execution

Execution Support

- Support assignment of resources and services required for execution

- Support "unplanned but needed actions" medical nursing and other professional caregiver actions. Examples of such unpredictability: Condition of patient changes in response to treatments, requiring changes to plan; patient is difficult to stabilize, e.g. brittle diabetic with cardiovascular risks - requires direct urgent interventions that are not even on the plan.

- Plan actions may hold their starting criteria that make an action eligible for starting, but users must still explicitly (to support automated start) users start actions that are due, suspend, and stop actions that become due.

- We expect workflow to be “emergent”; that is, plan templates serve as an initial plan, but the next actions may also be entered into place as deemed appropriate by duly authorized team members. Decisions may be prompted by a "Decision" that is connected to an action. plan item that may provide alternatives for consideration. Care team members activate planned actions that are already in place, and they maintain the "horizon" of new planned actions.

- Actions include their preconditions and postconditions, no testing and branching.

- Order entry: Place orders from predefined order sets; order attributes are limited to those included in CP DAM, so additional detail must be collected by order entry system. The CSS can accept a start command from the user, and the server implementation can trigger the interaction.

- Resource scheduling - seek simple case in first version; query availability (just resource type, time slots request, server seeks to avoid collisions), Then the client can choose a candidate and issue the ‘assign” operation. Out of scope: ability to refine search providers subject to environment, credentialing distance, financial constraints.

Progress Tracking

- Query for progress data

- Subscribe to alerts upon unmet incremental milestones/goals, planned but overdue actions.

- As a principle, we support detection and recording of events by humans or by machine. the API will support but not require the automatic detection of events by the server.

Plan Reconciliation

- produce list to support gap/overlap analysis and can record an overlap flag, but the users must decide what to delete

- Support analysis and clean-up disjoint, redundant, or conflicting plans; Can be invoked over a single plan or multiple plans.

- Automatically organize plans of care under care plans; combine plans of care for the same specialty

- Any generated suggestions are "proposed" - not automatically accepted.

- Care team members can propose alternatives

- In addition to on-demand invocations, an implementation could provide that an agent process suggests gaps and overlaps asynchronously (upon some change, or evaluated periodically)

Clinical Decision Support Integration

- Include operations from the CDS swim lane of the generic Car Plan process model (recommend goals; planned actions, etc.)

- Connect the CDS agent as a collaboration participant, so that CDS output is delivered as correspondence inside the CCS "collaboration" framework. the responses may attached suggested plan items in a "proposed" status.

- a care team member can request advice on some selected plan components (some or all of the plan)

- As an implementation opportunity, if the care plan data is exposed as vMR constructs, then third-party HL7-standard knowledge modules could be invoked on those plans.

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