What is a Care Plan?

Holly F. Sox, RN, BSN, RAC-CT - Clinical Editor, Careplans.com defines care plans as an essential part of healthcare, but is often misunderstood or regarded as a waste of time. Without a specific document delineating the plan of care, important issues are likely to be neglected.

Ultimate Purpose The ultimate purpose of the CCMP is to provide the student with appropriate treatment for optimal outcome during his/her stay in Job Corps.

Goals of CCMPs Promote healthy living Prevent unnecessary complications Treat diseases effectively Provide appropriate care* *World Health Organization Department of Chronic Disease and Health Promotion (CHP)

Nursing Diagnosis A nursing diagnosis deals with human response to actual or potential health problems and life processes. Nursing diagnoses also direct nursing interventions to obtain patient-specific outcomes*. *

Nursing Process Assessment Diagnosis Planning Implementation Evaluation Subjective Objective Assessment Plan When initiating and updating a care plan, the five steps of the nursing process should be followed.

CCMPs Focus on actions which are designed to solve or minimize the existing problem Are a product of a deliberate systematic process Relate to the future Are based upon identifiable health and nursing problems* Are holistic Nursingcrib.com

Rationale and Goals of CCMPs Improvement at all levels of care Promote effective strategies Open and systematic handling of errors Provide incentives Facilitate care coordination within and across organizations/community * *Chronic Care Management PowerPoint Right Time. Chronic Care Management Model. 3. Self-Management. Support. 4. Delivery 5. Decision 6. Clinical. System Support Information. Design Systems.

Team Approach to Care Define roles and distribute task Planned interactions for evidence-based care Clinical case management services for chronic care patients Regular provider initiated follow-up Cultural sensitive care* *Chronic Care Management PowerPoint Right Time. Chronic Care Management Model. 3. Self-Management. Support. 4. Delivery 5. Decision 6. Clinical. System Support Information. Design Systems.

Self Management Student has a central role in managing health Self-management support strategies Community resources to support self-management* *Chronic Care Management PowerPoint Right Time. Chronic Care Management Model. 3. Self-Management. Support. 4. Delivery 5. Decision 6. Clinical. System Support Information. Design Systems. Retrieved online from

Community Resources Students participate in effective community programs Form partnerships to fill gaps in needed services and avoid duplicating efforts Advocate to improve patient care* *Chronic Care Management PowerPoint Right Time. Chronic Care Management Model. 3. Self-Management. Support. 4. Delivery 5. Decision 6. Clinical. System Support Information. Design Systems. Retrieved online from

Barriers to CCMPs Some barriers to managing chronic illnesses include: Rushed visit with medical provider Lack of care coordination Lack of follow up Patients inadequately trained to manage their illnesses Reference: Allweiss, Pam, MD, MPH. Consultant CDC Division of Diabetes Translation; Faculty at University of Kentucky. ppt. The Chronic Care Model: A fancy name for “team approach” Found on the docstock.com

Who updates a CCMP? Assign a nurse (or nurses) to case manage students with chronic problems. That person is responsible for: meeting with students monitoring compliance with treatment or medications case conferencing on students

Quiz A CCMP relates to the future and is focused on actions which are designed to solve or minimize the existing problem. a) True b) False

Let’s look at the Asthma CCMP.

Asthma Scenario MM on entry Mild intermittent asthma with minimal episodes of coughing/wheezing, SOB or chest tightness Peak flow greater than 80% (green zone) predicated Last ER visit was more than one year ago Smoker – 2 PPD Rescue inhaler occasionally Denies any symptoms of asthma with increase activity

Asthma Scenario Day 3 on center MM comes to H&W with increasing asthma symptoms PRN nurse tells MM to increase the use of his inhaler q 2-3 hours PRN Day 23 on center In the middle of the night, he had increasing symptoms of coughing and wheezing; RA called HWM at home

Asthma Scenario Day 24 on center Describes mild, persistent symptoms for past month Did not come to HWC because he didn’t want to be a burden and was afraid that he would be sent home Expiratory wheezing/peak flow was 260 (60% of predicated yellow zone) Two nebulizer treatments CP added Advair BID Follow-up appointment scheduled in one week

Asthma Scenario Recommendations? Given this scenario, when should the CCMP have been initiated? Could the situation been avoided? How?

Let’s complete the asthma CCMP.

Quiz Which is not the purpose of a care plan: a. Provide appropriate care b. So the HWM or on call nurse is not called on the weekend c. Prevent complications

Tracking System The tracking system should be used to: Manage a list or group of students Track care/progress Case conference Monitor compliance Provide education CQI

Sample Tracking Systems Logs Word Excel Spreadsheet Appointment Book Calendar (outlook)

CCMP Log StudentEntryDiagnosisReferralFollow upNext appt Susie Smith11/4/2009DiabeticEndocrinologist by PCP Monthly12/6/2009, 1/10/2010 Derrick James 11/6/2009BipolarCMHC, Psychiatrist, Center Physician Weekly 2 months As needed 11/22/2009 1/15/2010

How do we Manage?

Time Management and Care Management

Outlook Calendar

Where to Find CCMPs Job Corps Community Website Health and Wellness Chronic Illnesses Documents

Available Medical CCMPs Asthma Diabetes Hypertension Obesity Seizure Disorder Sleep Apnea Adherence Techniques

TUPP/OH CCMPs Tobacco Cessation Xerostomia (chronic dry mouth)

Available Mental Health CCMPs Attention Deficit/Hyperactivity Asperger’s Syndrome Bipolar Mood Disorder Borderline Personality Depressive Disorders Gender Identity Obsessive Compulsive Post-Traumatic Stress Disorder Schizophrenia Tourette’s

Information Systems & Summary Timely updates Identify reminders for providers and populations for proactive care Facilitate individualized student plan Share information- need to know Monitor outcomes* Continuous Quality Improvement *Chronic Care Management PowerPoint Right Time. Chronic Care Management Model. 3. Self- Management. Support. 4. Delivery 5. Decision 6. Clinical. System Support Information. Design Systems. Retrieved online