LCC Longitudinal Care Planning A Vision of the Longitudinal Coordination of Care Workgroup June 10, 2012

LCC LCC Workgroup Leads/Co-authors Larry Garber, MD LTPAC Care Transitions Terry O’Malley, MDLTPAC Care Transitions Bill Russell, MDLongitudinal Care Plan Joanne Lynn, MDLongitudinal Care Plan Laura Heermann Langford,PhD,RN Longitudinal Care Plan Russ Leftwich, MDLongitudinal Care Plan Susan E. Campbell, PhD, RNLongitudinal Care Plan Jennie HarvellPt. Assessment Summary Sue Mitchell, RHIAPt. Assessment Summary 2

LCC Patients are evaluated with assessments (history, symptoms, physical exam, testing, etc…) to determine their status 3 Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Assessments

LCC Health Conditions/ Concerns Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Disease Progression Active Problems 4 Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Assessments Risks Side effects Patient Status helps define the patient’s current conditions, concerns, and risks for conditions Risks/concerns come from many sources Treatment

LCC Health Conditions/ Concerns Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Disease Progression Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) 5 Prioritize Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Assessments Risks Side effects Goals for treatment of health conditions and prevention of concerns are created collaboratively with patient taking into account their statuses and Care Plan Decision Modifiers Treatment

LCC Health Conditions/ Concerns Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Disease Progression Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) 6 Prioritize Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Assessments Risks Side effects Decision making is enhanced with evidence based medicine, clinical practice guidelines, and other medical knowledge Decision Support Treatment

LCC Health Conditions/ Concerns Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Disease Progression Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Decision Support Decision Support 7 Orders, etc.. Prioritize Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Assessments Risks Side effects Interventions and actions to achieve goals are identified collaboratively with patient taking into account their values, situation, statuses, risks & benefits, etc… Treatment

LCC Health Conditions/ Concerns Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Disease Progression Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Decision Support Decision Support 8 Orders, etc.. Care Plan Prioritize Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Assessments Risks Side effects The Care Plan is comprised of Modifiers, Conditions/Concerns, their Goals, Interventions/Actions/Instructions, Assessments and the Care Team members that actualize it

LCC Health Conditions/ Concerns Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Disease Progression Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Decision Support Decision Support 9 Orders, etc.. Care Plan Prioritize Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Assessments Outcomes Risks Side effects Interventions and actions achieve outcomes that make progress towards goals, cause interventions to be modified, and change health conditions

LCC Health Conditions/ Concerns Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Disease Progression Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Decision Support Decision Support 10 Orders, etc.. Care Plan Prioritize Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Assessments Outcomes Risks Side effects The Care Plan (Concerns, Goals, Interventions, and Care Team), along with Risk Factors and Decision Modifiers, iteratively evolve over time

LCC Health Conditions/ Concerns Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances 11 Care Plan A many-to-many-to-many relationship exists between Health Conditions/Concerns, Goals and Interventions/Actions 0… ∞

LCC Health Conditions/ Concerns Risks/Concerns: Atherosclerosis Hypoglycemia Diarrhea Myositis Hepatitis Risks/Concerns: Atherosclerosis Hypoglycemia Diarrhea Myositis Hepatitis Diabetes Mellitus Hyperlipidemia Diabetes Mellitus Hyperlipidemia Goals A1C < 7 LDL < 100 Exercise 3x per week Normal liver and muscle tests Goals A1C < 7 LDL < 100 Exercise 3x per week Normal liver and muscle tests Interventions/Actions Metformin Atorvastatin Walking Testing blood sugars Call MD if FSBS>300 Testing cholesterol Testing liver enzymes Testing muscle enzymes Interventions/Actions Metformin Atorvastatin Walking Testing blood sugars Call MD if FSBS>300 Testing cholesterol Testing liver enzymes Testing muscle enzymes Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances 12 Care Plan 0… ∞ Disease Progression Side effects Example:

LCC Health Conditions/ Concerns Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances 13 Orders, etc.. Care Plan Prioritize Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Assessments Outcomes Care Plan Process

LCC Health Conditions/ Concerns Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Care Team Members each have their own responsibilities 14

LCC Health Conditions/ Concerns Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances 15 Care Plan Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Patient Assessments and testing have many sources Patient Family Physicians Non-physician Providers NursingCoordinators

LCC Health Conditions/ Concerns Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Registries and Clinical Decision Support used by the Patient- Centered Medical Home identify when patient assessments, testing and/or interventions are overdue, or other deviations from the Care Plan exist Registries and Clinical Decision Support in Patient-Centered Medical Home 16

LCC Health Conditions/ Concerns Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Care Plan transporting, synchronizing and viewing Patient Family Physicians Non-physician Providers NursingCoordinators The Care Plan is filtered, translated and transported to meet the needs of each participant/setting in the patient’s care

LCC Health Conditions/ Concerns Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental How to represent many-to-many-to- many-to-many??? 18 0… ∞

LCC Health Conditions/ Concerns Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental The MAP Master All-care Plan 19 0… ∞ M aster A ll-care P lan Item #1 Item #2 Relationship (e.g. Goal-for-Problem, Intervention-for- Problem, Goal-for-Intervention, Performing Team Member- for-Intervention, Performing Team Member-for-Assessment, Team Member Responsible-for-Problem, Team Member Following-Problem, Problem-Problem Causality, etc…) M aster A ll-care P lan Item #1 Item #2 Relationship (e.g. Goal-for-Problem, Intervention-for- Problem, Goal-for-Intervention, Performing Team Member- for-Intervention, Performing Team Member-for-Assessment, Team Member Responsible-for-Problem, Team Member Following-Problem, Problem-Problem Causality, etc…)

LCC Health Conditions/ Concerns Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental The MAP Master All-care Plan enables many views 20 0… ∞ M aster A ll-care P lan Item #1 Item #2 Relationship (e.g. Goal-for-Problem, Intervention-for- Problem, Goal-for-Intervention, Performing Team Member- for-Intervention, Performing Team Member-for-Assessment, Team Member Responsible-for-Problem, Team Member Following-Problem, Problem-Problem Causality, etc…) M aster A ll-care P lan Item #1 Item #2 Relationship (e.g. Goal-for-Problem, Intervention-for- Problem, Goal-for-Intervention, Performing Team Member- for-Intervention, Performing Team Member-for-Assessment, Team Member Responsible-for-Problem, Team Member Following-Problem, Problem-Problem Causality, etc…) Patient Physicians NursingCoordinators Which problems am I responsible for? Who on my Care Team is taking care of my wound? What problems are treated by this intervention and what are the goals of treatment? What interventions are in place for this health concern? Family Non-physician Providers Patient Physicians NursingCoordinators

LCC Health Conditions/ Concerns Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risk Factors Age, gender Significant Past Medical/Surgical Hx Family Hx, Race/Ethnicity, Genetics Historical exposures/lifestyle (e.g. alcohol, smoke, radiation, diet, exercise, workplace, sexual…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Risks/Concerns: Wellness Barriers Injury (e.g. falls) Illness (e.g. ulcers, cancer, stroke, hypoglycemia, hepatitis, diarrhea, depression, etc…) Disease Progression Active Problems Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Goals Desired outcomes and milestones Readiness Prognosis Related Conditions Related Interventions Progress Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Interventions/Actions (e.g. medications, wound care, procedures, tests, diet, behavior changes, exercise, consults, rehab, calling MD for symptoms, education, anticipatory guidance, services, support, etc…) Start/stop date, interval Authorizing/responsible parties/roles/contact info Setting of care Instructions/parameters Supplies/Vendors Planned assessments Expected outcomes Related Conditions Status of intervention Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Care Plan Decision Modifiers Patient/family preferences (values, priorities, wishes, adv directives, expectations, etc…) Patient situation (access to care, support, resources, setting, transportation, etc…) Patient allergies/intolerances Decision Support Decision Support 21 Orders, etc.. Care Plan Prioritize Patient Status Functional Cognitive Physical Environmental Patient Status Functional Cognitive Physical Environmental Assessments Outcomes Risks Side effects Questions?