Coordination of Care Models

The composition of the care team is determined by jurisdictional, organizational, credentialing body policies, financing mechanism and may be varied by patient’s personal and/or family’s choice (often within the constraints of the various policies and financing mechanisms). This section simply assumes the existence of a Care Team with the goal of establishing the context of ongoing and incremental contribution to the Care Plan and associated care data. The patient and family are assumed to be parts of the Care Team.

This section describes the context of collaboration and interaction paths rather than a fixed process. Coordination of care is framed from the perspective of dynamic evolution of care driven by ongoing evaluation of the patient’s health status, care team interaction and collaboration. The Care Team is assumed to have a shared awareness changing care plan contents based on a synchronized Care Plan and care plan related activities from care coordination service notifications.

Synchronization of the Care Plan eliminates gaps in information and breakdowns due to missing change updates. Synchronization can also expose inconsistencies and help resolve conflict between specialty views of the plan; helping determine the need for expert clinical reconciliation.

The context of care team contribution starts with: Any Care Team member can “say” anything pertinent at any time resulting in change updates to the shared/synchronized content and resulting in raised awareness to other care team members who in turn can react to the changes. Contribution consist may result in changing structured elements of the plan, health concerns, health goals, care preferences, health risks, health barriers and the status and documentation of care activities and interventions. Care team contribution is controlled by the dynamic ongoing negotiation of care team members who may accept, reject and propose alternatives. There are other controls to care team contributions based on organization business rules and policies; business rules and policies are out of the scope of this specification. This specification focuses on the expert, autonomous decision making and negotiation of individuals interacting based on shared and synchronized content.

Central to collaboration is the concept of negotiation. Care Team negotiation consist of an emergent and dynamic flow of interactions between two or more individuals informing each other, making requests, making proposals and accepting, rejecting or countering the requests and proposals in order to reach agreement.

The diagram in figure 4 provides an organizing framework for coordination of care dynamic models. It may be viewed as a meta-model for coordination of care interaction and collaboration models. The organizing model establishes the relationships between Health Event, Care Management Activity, Care Collaboration and Shared Content. Shared Content consists of the Care Plan and other associated information content. Shared content is synchronized among care team participants. The main idea is to support shared care team awareness and transparency of the patient’s care to eliminate gaps in information. Shared content is updated at the various stagespoint of interaction (including synchronization, harmonization, post negotiation) leading to self-organizing and reconciled systems. Shared content is incrementally built as a result of ongoing interactions.

A Health Event is an recorded occurrence of a thing of importance to the health of the patient. The event may result from knowledge which is often/should be directly recorded, from care management activities or from care team collaboration and interactions. The event in turn may trigger new care management activities or new collaborations and interactions which in turn result in incremental updates to the shared content and context.

A Care Management Activities represent the performance of tasks and (which includes investigations, interventions and evaluations) in support of patient’s care by one or more care team members.

Care management activities are indicated in the Plan.

Care Team Collaboration emerges during the evolution of care based expert care team evaluation decision and autonomous direction within the constraints of professional standards, policies, business rules, care team working agreements and social contracts.

Business rules and policies are out of the scope of this specification. The meta-model simply acknowledges their existence and their relationship as a constraint in guiding care management activities and care team collaboration. Coordination of care systems would make available their model content and context to support decision making based on business rules and organization policies. The model content corresponds to the input and outputs defined in the capabilities defined in this document and the model detailed in the HL7 Care Plan DAM.

A view of the dynamic, ongoing and emergent Care Team contribution based on a shared Care Plan may look as follows:

1. A Care Team member looks up an existing Plan
   • A plan may be created if none exists or its existence is not known
2. The Plan changes based on the Care Team member’s assessment with the patient
   • Health Goals, Care Preferences, Health Concerns, Heath Risks, Care Barriers, Care Activities and Interventions are assessed, validated, added, changed or removed.
3. The Plan leads to a cycle of intervention, outcomes and review
4. The patient may be referred to a specialist or other health/social services providers
   • The Care Team member requests participation from the specialist or other providers and subsequently shares the Plan
5. As the patient transitions to the specialist or other health provider care settings… we can repeat these steps… with the specialists being generically referred as the care event steps can be repeated with the actors represented by the generic “Care Team member”
6. Communication may occur at any time between Care Team members as they react to synchronized change updates.