Standard 4.0

4.0

Establish a dynamic care plan that addresses all settings throughout the care continuum.

People, processes, and technology are in place to support the ongoing care plan, created with input from the patient, primary caregiver, and family. This care plan should be accessible to all care coordinators and remain with the patient’s regular ambulatory care provider, the patient, and the patient’s health care plan.

Organizations can meet this standard by demonstrating that the care plan includes the following elements:

Review of all available data, including patient self-report or from individuals within the patient’s support network.

Review of goals for care and potential transitions for settings and levels of care with patient/family/caregiver.

Tracking methodology for high-risk patients with an ongoing care plan.

Identification and documentation of:

• Regular ambulatory care provider
• Health plan benefits
• SDOH factors
• Designated caregivers
• Pharmacy(s) utilized
• Specialty care providers
• Home health/home care provider
• Community agencies

Identification and documentation of advance care planning documents.

Pharmacy consult as appropriate, with documentation of the outcome and evidence of patient/family/caregiver awareness, adherence, and understanding of the necessary course of action.

Evidence of timely reassessments as the patient moves across care settings.

Documentation of referrals and linkages to community resources and services.

Utilization of available technologies to maximize accuracy with the ability to efficiently transfer care plan information across the care continuum (patient, caregiver, provider), using secure data exchanges (HIE Health Information Exchange) and paperless systems when possible.

Identification and documentation of the personnel coordinating transitions across the care continuum.

Communication and sharing of the care plan to known care coordinators across the continuum.