CARE

PLANS

PART 1: Overview

“Self-care in health is the new black.

We’re digitally DIY’ing life, scheduling our own travel and booking restaurant tables, curating our photographs and trading stocks. People are morphing into health consumers, and that requires health engagement which means getting smart about our bodies, our selves, our numbers, and our treatment options. CarePlans is an on-ramp to shared and sound decision-making for self-health.”

- Jane Sarasohn-Kahn, MA (Econ.), MHSA

Health Economist, Advisor, Trend Weaver

THINK-Health, Health Populi blog, Huffington Post

Healthy Living

Photo by COM SALUD

A care plan is a synthesis of all plans of care produced by you and your providers to manage your health day to day. It serves as a continuous, conceptual framework shared by all of your care team members to guide your care.1,2,3

What's in a Care Plan

Care plans usually consist of these universal components1,2:

Patient Summary

Summarized history includes basic information such as demographics (name, age, contact info, ethnic or religious beliefs), health metrics (weight, blood pressure, etc), allergies, or medications and therapies. It can also contain past health history such as past hospitalizations.1

Health Concerns

These can include a variety of issues such as medical, surgical, behavioral, cognition, mood, environmental factors, financial, and more.2,4

Goals

Goals are used to measure progress. They give a care plan direction and are the first indicator of what path a patient is taking to manage their health concerns. Care plans are typically made up of a few high level goals that consist of many smaller short-term goals.1,2

Instructions & Interventions

Information or directions given to you and your other providers make up the instructions of your care plan. This can include how to care for a condition, what to do at home, when to call for help, or changes to the medication. Interventions are actions taken, most often by you, to work toward achieving care plan goals. This can include symptom and medication management, community/social services, and removal of barriers to success.1,2,5

Review

You and your provider evaluate the effectiveness of the care plan, and make adjustments where appropriate.1

Care Team

Your care team is everyone who manages or provides care, including yourself. Medical practitioners, nurses, social workers, and caregivers are just a few examples.2,7

While a general consensus is being reached on the universal components of a care plan, the actual content that these components address is still largely unstandardized. In the future, there will be always-evolving care plan templates with evidence-based content for the full spectrum of human conditions. For now, we can categorize the areas of concern into commonly used categories.

View more at carecards.me

Nutrition

A nutrition plan must recognize the current problems in eating habits and consider chronic conditions/symptoms, food preparation capabilities, and dietary restrictions of the individual. The outer aisles of the supermarket are where the healthiest foods are: greens, fruits, poultry, nuts, grains, and dairy. Fill up the cart.
Meals at home and a brownbag lunch at work are more nutritious than eating out. Families who eat the evening meal together eat healthier.9

View more at carecards.me

Physical Activity

Regular physical activity is especially important for those with conditions like diabetes, high blood pressure, or high cholesterol. The goal is to get active and STAY doing enjoyable and, therefore, sustainable activities. Exercising regularly can lower your blood glucose, blood pressure, and cholesterol levels, and even reduce stress. An increase in light activity increases fitness, so fidget and putter and do housework. Make walking a daily habit — for your commute, errands, stairs, and fitness — and get that step count going up.9

View more at carecards.me

Sleep

The amount of sleep a patient gets is a significant factor on their overall wellbeing. Healthy adults need 7-8 hours of sleep a day for optimal performance, and children and teens need more. Prolonged inadequate sleep can cause high blood pressure, heart attack, obesity, stroke, depression, mental impairment, and generally poor quality of life. Maintaining a consistent sleep schedule helps keep your cycles regular and promotes better quality sleep. Create a relaxing bedtime ritual and keep laptops out of the bedroom. Beds are for sex and rest. Recognizing problems with sleep behaviors and outlining the steps to improvement are an important part of the care plan.9

View more at carecards.me

Mental Resilience

Management of stress and any mental, cognitive, or mood symptoms is another, very complex part of the care plan. Prolonged exposure to stress can be unhealthy, and cause or make it difficult to manage conditions like diabetes, high blood pressure, high cholesterol, and psychiatric illnesses. Chronic stress can negatively impact on your immune, digestive, renal (kidneys), and reproductive systems. It is essential to take the proper steps eliminate or cope with stressors in an effective way, as well as manage any symptoms of mental illness.9

View more at carecards.me

Medication Management

Recognizing a need for change in the medication regimen allows for the creation of a treatment plan. A vital part of incorporating this into the care plan is ensuring the adherence to the prescribed medication. Patients who stick to their medications have better outcomes. Quitting early means health suffers.9
It is important to ask and understand why a medication is necessary, how to properly take it, what side effects are causes for alarm, and who to talk to if issues arise.9

View more at carecards.me

Prioritize Sexual Health

Good health bolsters your sex life; your sex life bolsters your health. Regular sex — once a week or more — is associated with greater immunity, less stress, fewer heart attacks, longer life, and unleashes mood-boosting endorphins. If worries or physical challenges are hindering your enjoyment of sex, talk to your partner and possibly a doctor for reassurance and advice. To avoid HIV infection and sexually transmitted diseases (STDs), a condom is the first line of defense. It forms a barrier between the penis and anus, vagina, or mouth. Bodily fluids cannot get past it. For safer oral sex, there are dental dams.9

View more at carecards.me

Kick Bad Habits

It’s important to identify and recognize the impact of bad habits such as smoking, alcohol over consumption, substance use, and even consumption of harmful foods. Care plans can outline the steps to stop these behaviors that can lead to a variety of poor health conditions.9

View more at carecards.me

Know Your Numbers

A few minutes of daily head-to-toe visual checks helps you notice changes, like a new freckle or unusual hair growth or loss. Monthly checks of skin and your male or female parts give you information to share with your doctor. Especially relevant to patients managing chronic conditions, monitoring of relevant vitals (such as weight, blood pressure, daily steps, blood sugar, etc.) is an essential part of a care plan and self care.9

View more at carecards.me

Manage Your Daily Activities

Any other problems that affect the patient’s general wellbeing can be relevant to the care plan. These can be things such as personal hygiene, functioning around the house, management of finances, transportation, safety behaviors, etc.9

How Care Plans Work

A care plan applies the different areas of concern (i.e. physical activity, nutrition, etc.) across the universal components (i.e. goals, instructions, etc.). There is a baseline care plan that exists for general healthy living, and this baseline becomes more customized to a person as more information is collected. Factors such as sex, age, ethnicity, activities, conditions, etc. influence what content goes in a care plan, and how important those areas are to the person.

Explore how the care plan changes these factors across the three individuals below.

Patient Summary
Isabella is a 13 year old, active 7th grader who plays the flute and is a defender on the girls soccer team. Isabella snacks throughout the day and she does not like meat very much.
Health Concerns (Choose 2)
Care Team

Mom, Dad, Pediatrician, Coach

Goals Instructions & Interventions Review
Nutrition

Develop and maintain healthy eating habits and routines.
Promote bone strength and growth.

Eat breakfast every day to boosts the body's metabolism, improve energy and alertness, and reduce risk of obesity.
Avoid junk and processed foods.
Get 4 servings of calcium every day for bone growth and strength.
Consume vitamin D enriched milk, eggs, and fatty fish like salmon to improve absorption of calcium.

Review eating habits next check-up.
Assess for any barriers to nutrition plan adherence.

Physical Activity

Maintain regular physical activity.
Strengthen bones and muscles.
Ensure adequate time for rest and relaxation.

Get at least 60 minutes of mostly aerobic exercise.
Get muscle and bone strengthening exercise 3 days a week.

Review weight trend and adjust plan accordingly.
Assess for barriers to exercise plan adherence.
Sleep

Get enough sleep.
Get on a regular sleep schedule.

Prioritize 8-10 hours of sleep for active, growing bodies.
Avoid sleeping in weekend to maintain a consistent routine.
Stop using computer, phone, and TV 1 hour before bed for a better quality sleep.

Assess general morning energy levels at next check-up.
Mental Resilience

Managing Medication

Ensure vaccinations are received.

Schedule next HPV vaccination in 3 months.
Get influenza vaccine in the fall.

Assess upcoming vaccinations.
Sexual Health

Cessation of Bad Habits

Get less screen time.
Reduce bad snacking behaviors.

Spend less than 2 hours of continuous time on screens - try timers, parental controls.
Keep only healthy snacks (fruits, vegetables, nuts, whole grains) in the house.

Assess for barriers to achieving goal screen time.
Review satisfaction/adherence to snacking goals.
Tracking Vitals

Track height and weight.

Track height and weight once a month with phone application or pencil and paper.

Schedule yearly physical exams with pediatrician.
Test regularly for anemia.
Managing ADLs

Remembering to brush teeth daily.

Leave a reminder on the bathroom sink, or set an alarm.

Isabella
Health Concern

Nutrition

Develop and maintain healthy eating habits and routines.
Promote bone strength and growth.

Eat breakfast every day to boosts the body's metabolism, improve energy and alertness, and reduce risk of obesity.
Avoid junk and processed foods.
Get 4 servings of calcium every day for bone growth and strength.
Consume vitamin D enriched milk, eggs, and fatty fish like salmon to improve absorption of calcium.

Review eating habits next check-up.
Assess for any barriers to nutrition plan adherence.

Physical Activity

Maintain regular physical activity.
Strengthen bones and muscles.
Ensure adequate time for rest and relaxation.

Get at least 60 minutes of mostly aerobic exercise.
Get muscle and bone strengthening exercise 3 days a week.

Review weight trend and adjust plan accordingly.
Assess for barriers to exercise plan adherence.

Sleep

Get enough sleep.
Get on a regular sleep schedule.

Prioritize 8-10 hours of sleep for active, growing bodies.
Avoid sleeping in weekend to maintain a consistent routine.
Stop using computer, phone, and TV 1 hour before bed for a better quality sleep.

Assess general morning energy levels at next check-up.

Mental Resilience

Managing Medication

Ensure vaccinations are received.

Schedule next HPV vaccination in 3 months.
Get influenza vaccine in the fall.

Assess upcoming vaccinations.

Sexual Health

Cessation of Bad Habits

Get less screen time.
Reduce bad snacking behaviors.

Spend less than 2 hours of continuous time on screens - try timers, parental controls.
Keep only healthy snacks (fruits, vegetables, nuts, whole grains) in the house.

Assess for barriers to achieving goal screen time.
Review satisfaction/adherence to snacking goals.

Tracking Vitals

Track height and weight.

Track height and weight once a month with phone application or pencil and paper.

Schedule yearly physical exams with pediatrician.
Test regularly for anemia.

Managing ADLs

Remembering to brush teeth daily.

Leave a reminder on the bathroom sink, or set an alarm.

Patient Summary
Reggie is a 35 year old, successful, driven accountant who works 8am-6pm in downtown Boston and commutes home to a nearby suburb. He enjoys gaming and occasionally going out to drink at bars or clubs with friends during the week. On the weekends, Reggie likes to swim at the local fitness center or go on walks with his labradoodle. Reggie is in long distance relationship, and sees his boyfriend about once every 2 weeks.
Health Concerns (Choose 2)
Care Team

Primary Care Physician, Boyfriend, Mother, Friends

Goals Instructions & Interventions Review
Nutrition

Eat a healthier, plant-based diet.

Eat more vegetables, fruit, nuts, beans, and whole grains, less meat.
Avoid red meats, processed meats, or cured meats.
Eat 2-3 servings to fish a week (for the fish oils).
Replace the fatty snacks consumed when gaming, with a fresh fruit.
Avoid the free high-fat snack foods at the accounting firm.
Meatless Mondays.

Review eating habits next check-up.
Assess for any barriers to nutrition plan adherence.

Physical Activity

Sit less and maintain current body weight by staying active.

Get 30 minutes of physical activity a day.
Join a local swim team that meets twice a week.
Use a bike for the 30 minute work commute.
Find alternate bike paths to stay motivated and interested in the exercise.

Review weight trend and adjust plan accordingly.
Assess for barriers to exercise plan adherence.
Sleep

Feel more awake in the mornings for work.

Turn the games/computer off at least an hour before bed.
Go to bed by midnight to sleep at least 8 hours for the 8am job.

Review general morning energy levels a month from now.
Mental Resilience

Reduce the stress from partner often being absent.

Call partner by next month, and communicate the reason for the stress.
If interest in hobbies are still lacking two weeks from now, seek appointment with specialized mental health professional.
Focus on meeting with friends more often.

Review mental stress condition with a care provider.
Managing Medication

Get vitamin D levels up to the normal range to lower the risk of depression.

Take 2000IUs of vitamin D3 every day.
Place daily vitamins by the coffee maker to incorporate them into daily routine.

Review vitamin D levels every 3 months.

Sexual Health

Have an understanding of personal sexual health status.
Understand how to avoid HIV infection and other sexually transmitted diseases (STDs).

Conduct monthly self-exams for testicular cancer.
Make appointment this month with primary provider for HIV screening.
Use condoms to form a barrier between the penis and anus, or mouth.

Review results from HIV screening.
Cessation of Bad Habits

Reduce alcohol intake by half of current consumption.

To limit alcohol consumption, drink water for every other friend meeting.

Review general alcohol consumption levels.
Tracking Vitals

Be able to consistently keep track of current body weight.

Place the bathroom scale in front of the counter as a daily reminder to check body weight.

Review trends in body weight with a primary care provider.
Managing ADLs

Manage time to bike to work in the mornings.

Set an alarm to wake up half an hour earlier than usual.

Review biking frequency in the commute.
Reggie
Health Concern

Nutrition

Eat a healthier, plant-based diet.

Eat more vegetables, fruit, nuts, beans, and whole grains, less meat.
Avoid red meats, processed meats, or cured meats.
Eat 2-3 servings to fish a week (for the fish oils).
Replace the fatty snacks consumed when gaming, with a fresh fruit.
Avoid the free high-fat snack foods at the accounting firm.
Meatless Mondays.

Review eating habits next check-up.
Assess for any barriers to nutrition plan adherence.

Physical Activity

Sit less and maintain current body weight by staying active.

Get 30 minutes of physical activity a day.
Join a local swim team that meets twice a week.
Use a bike for the 30 minute work commute.
Find alternate bike paths to stay motivated and interested in the exercise.

Review weight trend and adjust plan accordingly.
Assess for barriers to exercise plan adherence.

Sleep

Feel more awake in the mornings for work.

Turn the games/computer off at least an hour before bed.
Go to bed by midnight to sleep at least 8 hours for the 8am job.

Review general morning energy levels a month from now.

Mental Resilience

Reduce the stress from partner often being absent.

Call partner by next month, and communicate the reason for the stress.
If interest in hobbies are still lacking two weeks from now, seek appointment with specialized mental health professional.
Focus on meeting with friends more often.

Review mental stress condition with a care provider.

Managing Medication

Get vitamin D levels up to the normal range to lower the risk of depression.

Take 2000IUs of vitamin D3 every day.
Place daily vitamins by the coffee maker to incorporate them into daily routine.

Review vitamin D levels every 3 months.

Sexual Health

Have an understanding of personal sexual health status.
Understand how to avoid HIV infection and other sexually transmitted diseases (STDs).

Conduct monthly self-exams for testicular cancer.
Make appointment this month with primary provider for HIV screening.
Use condoms to form a barrier between the penis and anus, or mouth.

Review results from HIV screening.

Cessation of Bad Habits

Reduce alcohol intake by half of current consumption.

To limit alcohol consumption, drink water for every other friend meeting.

Review general alcohol consumption levels.

Tracking Vitals

Be able to consistently keep track of current body weight.

Place the bathroom scale in front of the counter as a daily reminder to check body weight.

Review trends in body weight with a primary care provider.

Managing ADLs

Manage time to bike to work in the mornings.

Set an alarm to wake up half an hour earlier than usual.

Review biking frequency in the commute.

Patient Summary
Donna is a 68 year old, retired bank clerk living in downtown Chicago with her husband. She enjoys doing crossword puzzles and watching TV at night, and therefore doesn't leave the apartment much. Donna often feels isolated and lonely, and suffers from chronic neck pain from sitting for long periods of time.
Health Concerns (Choose 2)
Care Team

Primary Care Physician, Daughter, Husband, Neighbor

Goals Instructions & Interventions Review
Nutrition

Eat a healthier, plant-based diet.

Eat more vegetables, fruit, nuts, beans, and whole grains, less meat.
Avoid red meats, processed meats, or cured meats.
Avoid processed meals by signing up for Meals on Wheels delivery once a week to help deliver healthier groceries to cook with.

Review eating habits next month.
Review any barriers to nutrition plan adherence.

Physical Activity

Get more active.

Begin with a local community center that offers exercise classes for seniors and has sessions at least 3 times a week.

Review mobility and movement changes 4 months from now.
Sleep

Reduce the time it takes to get to sleep.

Buy soft earplugs for daily use to reduce noise coming from the windows.
Turn off all TV lighting at least an hour before sleeping.

Review quality of sleep next month and consider a sleep aid.
Mental Resilience

Increase social interaction and community involvement.

Join a local community organization to social engage with people around a hobby.

Review satisfaction with community involvement or barriers to social interaction.
Managing Medication

Improve vitamin B6, B12, and Folate deficiencies by taking supplements regularly.

Improve vitamin B6, B12, and Folate deficiencies by taking supplements regularly.

Test vitamin levels every 6 months and adjust dosage accordingly.
Sexual Health

Increase sexual activity with husband.

Consider having sex in the mornings, or at times of day when both parties are most rested.

Review satisfaction with sexual activity or barriers to satisfaction.
Cessation of Bad Habits

Reduce unhealthy snacking when bored.
Improve posture to reduce neck pain and stiffness.

Keep only health snacks (fruits, vegetables, nuts) in the house.
Find hobbies that occupy the hands to fill periods of boredom.
Purchase a chair with strong ergonomic back support to prevent hunching forward when watching TV at night.
Purchase neck support pillow for daily use when sleeping.

Review quality of neck posture in 6 months, refer to Orthopedic if no improvement.
Tracking Vitals

Track weight, blood pressure, cholesterol, and blood sugar levels to screen for common chronic conditions.

Schedule next annual check-up.

Review results from check-up with a care provider to determine additional steps that may be needed.
Managing ADLs

Prevent future dental problems by prioritizing regular dental hygiene.

Set a daily automatic alarm as a reminder to brush teeth. A digital device, a clock, or watch reminder may all be used.

Review dental health in 6 months.
Donna
Health Concern

Nutrition

Eat a healthier, plant-based diet.

Eat more vegetables, fruit, nuts, beans, and whole grains, less meat.
Avoid red meats, processed meats, or cured meats.
Avoid processed meals by signing up for Meals on Wheels delivery once a week to help deliver healthier groceries to cook with.

Review eating habits next month.
Review any barriers to nutrition plan adherence.

Physical Activity

Get more active.

Begin with a local community center that offers exercise classes for seniors and has sessions at least 3 times a week.

Review mobility and movement changes 4 months from now.

Sleep

Reduce the time it takes to get to sleep.

Buy soft earplugs for daily use to reduce noise coming from the windows.
Turn off all TV lighting at least an hour before sleeping.

Review quality of sleep next month and consider a sleep aid.

Mental Resilience

Increase social interaction and community involvement.

Join a local community organization to social engage with people around a hobby.

Review satisfaction with community involvement or barriers to social interaction.

Managing Medication

Improve vitamin B6, B12, and Folate deficiencies by taking supplements regularly.

Improve vitamin B6, B12, and Folate deficiencies by taking supplements regularly.

Test vitamin levels every 6 months and adjust dosage accordingly.

Sexual Health

Increase sexual activity with husband.

Consider having sex in the mornings, or at times of day when both parties are most rested.

Review satisfaction with sexual activity or barriers to satisfaction.

Cessation of Bad Habits

Reduce unhealthy snacking when bored.
Improve posture to reduce neck pain and stiffness.

Keep only health snacks (fruits, vegetables, nuts) in the house.
Find hobbies that occupy the hands to fill periods of boredom.
Purchase a chair with strong ergonomic back support to prevent hunching forward when watching TV at night.
Purchase neck support pillow for daily use when sleeping.

Review quality of neck posture in 6 months, refer to Orthopedic if no improvement.

Tracking Vitals

Track weight, blood pressure, cholesterol, and blood sugar levels to screen for common chronic conditions.

Schedule next annual check-up.

Review results from check-up with a care provider to determine additional steps that may be needed.

Managing ADLs

Prevent future dental problems by prioritizing regular dental hygiene.

Set a daily automatic alarm as a reminder to brush teeth. A digital device, a clock, or watch reminder may all be used.

Review dental health in 6 months.

Patient Summary
Isabella is a 13 year old, active 7th grader who plays the flute and is a defender on the girls soccer team. Isabella snacks throughout the day and she does not like meat very much.
Health Concerns (Choose 2)
Care Team

Mom, Dad, Pediatrician, Coach

Goals Instructions & Interventions Review
Nutrition

Develop and maintain healthy eating habits and routines.
Promote bone strength and growth.

Eat breakfast every day to boosts the body's metabolism, improve energy and alertness, and reduce risk of obesity.
Avoid junk and processed foods.
Get 4 servings of calcium every day for bone growth and strength.
Consume vitamin D enriched milk, eggs, and fatty fish like salmon to improve absorption of calcium.

Review eating habits next check-up.
Assess for any barriers to nutrition plan adherence.

Physical Activity

Maintain regular physical activity.
Strengthen bones and muscles.
Ensure adequate time for rest and relaxation.

Get at least 60 minutes of mostly aerobic exercise.
Get muscle and bone strengthening exercise 3 days a week.

Review weight trend and adjust plan accordingly.
Assess for barriers to exercise plan adherence.
Sleep

Get enough sleep.
Get on a regular sleep schedule.

Prioritize 8-10 hours of sleep for active, growing bodies.
Avoid sleeping in weekend to maintain a consistent routine.
Stop using computer, phone, and TV 1 hour before bed for a better quality sleep.

Assess general morning energy levels at next check-up.
Mental Resilience

Managing Medication

Ensure vaccinations are received.

Schedule next HPV vaccination in 3 months.
Get influenza vaccine in the fall.

Assess upcoming vaccinations.
Sexual Health

Cessation of Bad Habits

Get less screen time.
Reduce bad snacking behaviors.

Spend less than 2 hours of continuous time on screens - try timers, parental controls.
Keep only healthy snacks (fruits, vegetables, nuts, whole grains) in the house.

Assess for barriers to achieving goal screen time.
Review satisfaction/adherence to snacking goals.
Tracking Vitals

Track height and weight.

Track height and weight once a month with phone application or pencil and paper.

Schedule yearly physical exams with pediatrician.
Test regularly for anemia.
Managing ADLs

Remembering to brush teeth daily.

Leave a reminder on the bathroom sink, or set an alarm.

Isabella
Health Concern

Nutrition

Develop and maintain healthy eating habits and routines.
Promote bone strength and growth.

Eat breakfast every day to boosts the body's metabolism, improve energy and alertness, and reduce risk of obesity.
Avoid junk and processed foods.
Get 4 servings of calcium every day for bone growth and strength.
Consume vitamin D enriched milk, eggs, and fatty fish like salmon to improve absorption of calcium.

Review eating habits next check-up.
Assess for any barriers to nutrition plan adherence.

Physical Activity

Maintain regular physical activity.
Strengthen bones and muscles.
Ensure adequate time for rest and relaxation.

Get at least 60 minutes of mostly aerobic exercise.
Get muscle and bone strengthening exercise 3 days a week.

Review weight trend and adjust plan accordingly.
Assess for barriers to exercise plan adherence.

Sleep

Get enough sleep.
Get on a regular sleep schedule.

Prioritize 8-10 hours of sleep for active, growing bodies.
Avoid sleeping in weekend to maintain a consistent routine.
Stop using computer, phone, and TV 1 hour before bed for a better quality sleep.

Assess general morning energy levels at next check-up.

Mental Resilience

Managing Medication

Ensure vaccinations are received.

Schedule next HPV vaccination in 3 months.
Get influenza vaccine in the fall.

Assess upcoming vaccinations.

Sexual Health

Cessation of Bad Habits

Get less screen time.
Reduce bad snacking behaviors.

Spend less than 2 hours of continuous time on screens - try timers, parental controls.
Keep only healthy snacks (fruits, vegetables, nuts, whole grains) in the house.

Assess for barriers to achieving goal screen time.
Review satisfaction/adherence to snacking goals.

Tracking Vitals

Track height and weight.

Track height and weight once a month with phone application or pencil and paper.

Schedule yearly physical exams with pediatrician.
Test regularly for anemia.

Managing ADLs

Remembering to brush teeth daily.

Leave a reminder on the bathroom sink, or set an alarm.

Patient Summary
Reggie is a 35 year old, successful, driven accountant who works 8am-6pm in downtown Boston and commutes home to a nearby suburb. He enjoys gaming and occasionally going out to drink at bars or clubs with friends during the week. On the weekends, Reggie likes to swim at the local fitness center or go on walks with his labradoodle. Reggie is in long distance relationship, and sees his boyfriend about once every 2 weeks.
Health Concerns (Choose 2)
Care Team

Primary Care Physician, Boyfriend, Mother, Friends

Goals Instructions & Interventions Review
Nutrition

Eat a healthier, plant-based diet.

Eat more vegetables, fruit, nuts, beans, and whole grains, less meat.
Avoid red meats, processed meats, or cured meats.
Eat 2-3 servings to fish a week (for the fish oils).
Replace the fatty snacks consumed when gaming, with a fresh fruit.
Avoid the free high-fat snack foods at the accounting firm.
Meatless Mondays.

Review eating habits next check-up.
Assess for any barriers to nutrition plan adherence.

Physical Activity

Sit less and maintain current body weight by staying active.

Get 30 minutes of physical activity a day.
Join a local swim team that meets twice a week.
Use a bike for the 30 minute work commute.
Find alternate bike paths to stay motivated and interested in the exercise.

Review weight trend and adjust plan accordingly.
Assess for barriers to exercise plan adherence.
Sleep

Feel more awake in the mornings for work.

Turn the games/computer off at least an hour before bed.
Go to bed by midnight to sleep at least 8 hours for the 8am job.

Review general morning energy levels a month from now.
Mental Resilience

Reduce the stress from partner often being absent.

Call partner by next month, and communicate the reason for the stress.
If interest in hobbies are still lacking two weeks from now, seek appointment with specialized mental health professional.
Focus on meeting with friends more often.

Review mental stress condition with a care provider.
Managing Medication

Get vitamin D levels up to the normal range to lower the risk of depression.

Take 2000IUs of vitamin D3 every day.
Place daily vitamins by the coffee maker to incorporate them into daily routine.

Review vitamin D levels every 3 months.

Sexual Health

Have an understanding of personal sexual health status.
Understand how to avoid HIV infection and other sexually transmitted diseases (STDs).

Conduct monthly self-exams for testicular cancer.
Make appointment this month with primary provider for HIV screening.
Use condoms to form a barrier between the penis and anus, or mouth.

Review results from HIV screening.
Cessation of Bad Habits

Reduce alcohol intake by half of current consumption.

To limit alcohol consumption, drink water for every other friend meeting.

Review general alcohol consumption levels.
Tracking Vitals

Be able to consistently keep track of current body weight.

Place the bathroom scale in front of the counter as a daily reminder to check body weight.

Review trends in body weight with a primary care provider.
Managing ADLs

Manage time to bike to work in the mornings.

Set an alarm to wake up half an hour earlier than usual.

Review biking frequency in the commute.
Reggie
Health Concern

Nutrition

Eat a healthier, plant-based diet.

Eat more vegetables, fruit, nuts, beans, and whole grains, less meat.
Avoid red meats, processed meats, or cured meats.
Eat 2-3 servings to fish a week (for the fish oils).
Replace the fatty snacks consumed when gaming, with a fresh fruit.
Avoid the free high-fat snack foods at the accounting firm.
Meatless Mondays.

Review eating habits next check-up.
Assess for any barriers to nutrition plan adherence.

Physical Activity

Sit less and maintain current body weight by staying active.

Get 30 minutes of physical activity a day.
Join a local swim team that meets twice a week.
Use a bike for the 30 minute work commute.
Find alternate bike paths to stay motivated and interested in the exercise.

Review weight trend and adjust plan accordingly.
Assess for barriers to exercise plan adherence.

Sleep

Feel more awake in the mornings for work.

Turn the games/computer off at least an hour before bed.
Go to bed by midnight to sleep at least 8 hours for the 8am job.

Review general morning energy levels a month from now.

Mental Resilience

Reduce the stress from partner often being absent.

Call partner by next month, and communicate the reason for the stress.
If interest in hobbies are still lacking two weeks from now, seek appointment with specialized mental health professional.
Focus on meeting with friends more often.

Review mental stress condition with a care provider.

Managing Medication

Get vitamin D levels up to the normal range to lower the risk of depression.

Take 2000IUs of vitamin D3 every day.
Place daily vitamins by the coffee maker to incorporate them into daily routine.

Review vitamin D levels every 3 months.

Sexual Health

Have an understanding of personal sexual health status.
Understand how to avoid HIV infection and other sexually transmitted diseases (STDs).

Conduct monthly self-exams for testicular cancer.
Make appointment this month with primary provider for HIV screening.
Use condoms to form a barrier between the penis and anus, or mouth.

Review results from HIV screening.

Cessation of Bad Habits

Reduce alcohol intake by half of current consumption.

To limit alcohol consumption, drink water for every other friend meeting.

Review general alcohol consumption levels.

Tracking Vitals

Be able to consistently keep track of current body weight.

Place the bathroom scale in front of the counter as a daily reminder to check body weight.

Review trends in body weight with a primary care provider.

Managing ADLs

Manage time to bike to work in the mornings.

Set an alarm to wake up half an hour earlier than usual.

Review biking frequency in the commute.

Patient Summary
Donna is a 68 year old, retired bank clerk living in downtown Chicago with her husband. She enjoys doing crossword puzzles and watching TV at night, and therefore doesn't leave the apartment much. Donna often feels isolated and lonely, and suffers from chronic neck pain from sitting for long periods of time.
Health Concerns (Choose 2)
Care Team

Primary Care Physician, Daughter, Husband, Neighbor

Goals Instructions & Interventions Review
Nutrition

Eat a healthier, plant-based diet.

Eat more vegetables, fruit, nuts, beans, and whole grains, less meat.
Avoid red meats, processed meats, or cured meats.
Avoid processed meals by signing up for Meals on Wheels delivery once a week to help deliver healthier groceries to cook with.

Review eating habits next month.
Review any barriers to nutrition plan adherence.

Physical Activity

Get more active.

Begin with a local community center that offers exercise classes for seniors and has sessions at least 3 times a week.

Review mobility and movement changes 4 months from now.
Sleep

Reduce the time it takes to get to sleep.

Buy soft earplugs for daily use to reduce noise coming from the windows.
Turn off all TV lighting at least an hour before sleeping.

Review quality of sleep next month and consider a sleep aid.
Mental Resilience

Increase social interaction and community involvement.

Join a local community organization to social engage with people around a hobby.

Review satisfaction with community involvement or barriers to social interaction.
Managing Medication

Improve vitamin B6, B12, and Folate deficiencies by taking supplements regularly.

Improve vitamin B6, B12, and Folate deficiencies by taking supplements regularly.

Test vitamin levels every 6 months and adjust dosage accordingly.
Sexual Health

Increase sexual activity with husband.

Consider having sex in the mornings, or at times of day when both parties are most rested.

Review satisfaction with sexual activity or barriers to satisfaction.
Cessation of Bad Habits

Reduce unhealthy snacking when bored.
Improve posture to reduce neck pain and stiffness.

Keep only health snacks (fruits, vegetables, nuts) in the house.
Find hobbies that occupy the hands to fill periods of boredom.
Purchase a chair with strong ergonomic back support to prevent hunching forward when watching TV at night.
Purchase neck support pillow for daily use when sleeping.

Review quality of neck posture in 6 months, refer to Orthopedic if no improvement.
Tracking Vitals

Track weight, blood pressure, cholesterol, and blood sugar levels to screen for common chronic conditions.

Schedule next annual check-up.

Review results from check-up with a care provider to determine additional steps that may be needed.
Managing ADLs

Prevent future dental problems by prioritizing regular dental hygiene.

Set a daily automatic alarm as a reminder to brush teeth. A digital device, a clock, or watch reminder may all be used.

Review dental health in 6 months.
Donna
Health Concern

Nutrition

Eat a healthier, plant-based diet.

Eat more vegetables, fruit, nuts, beans, and whole grains, less meat.
Avoid red meats, processed meats, or cured meats.
Avoid processed meals by signing up for Meals on Wheels delivery once a week to help deliver healthier groceries to cook with.

Review eating habits next month.
Review any barriers to nutrition plan adherence.

Physical Activity

Get more active.

Begin with a local community center that offers exercise classes for seniors and has sessions at least 3 times a week.

Review mobility and movement changes 4 months from now.

Sleep

Reduce the time it takes to get to sleep.

Buy soft earplugs for daily use to reduce noise coming from the windows.
Turn off all TV lighting at least an hour before sleeping.

Review quality of sleep next month and consider a sleep aid.

Mental Resilience

Increase social interaction and community involvement.

Join a local community organization to social engage with people around a hobby.

Review satisfaction with community involvement or barriers to social interaction.

Managing Medication

Improve vitamin B6, B12, and Folate deficiencies by taking supplements regularly.

Improve vitamin B6, B12, and Folate deficiencies by taking supplements regularly.

Test vitamin levels every 6 months and adjust dosage accordingly.

Sexual Health

Increase sexual activity with husband.

Consider having sex in the mornings, or at times of day when both parties are most rested.

Review satisfaction with sexual activity or barriers to satisfaction.

Cessation of Bad Habits

Reduce unhealthy snacking when bored.
Improve posture to reduce neck pain and stiffness.

Keep only health snacks (fruits, vegetables, nuts) in the house.
Find hobbies that occupy the hands to fill periods of boredom.
Purchase a chair with strong ergonomic back support to prevent hunching forward when watching TV at night.
Purchase neck support pillow for daily use when sleeping.

Review quality of neck posture in 6 months, refer to Orthopedic if no improvement.

Tracking Vitals

Track weight, blood pressure, cholesterol, and blood sugar levels to screen for common chronic conditions.

Schedule next annual check-up.

Review results from check-up with a care provider to determine additional steps that may be needed.

Managing ADLs

Prevent future dental problems by prioritizing regular dental hygiene.

Set a daily automatic alarm as a reminder to brush teeth. A digital device, a clock, or watch reminder may all be used.

Review dental health in 6 months.

How Care Plans Started

  • 31st BC-15th Century

    Much of medical history was focused in reactive care, rather than taking preventative measures for the individual’s health. In the middle ages especially, the idea of preventative care could also have been stunted by the explanations of medical phenomena connected to spirituality and religious belief systems. Preceding modern medicine, most of the care regimens provided to patients were focused on either external symptoms, or a spiritual or magical basis.54

  • 6th-19th Century

    The 16th to 19th century was a period of heavy scientific discovery, leading to the transition of supernatural explanations to natural explanations for disease and illness.55 People began to see illness as something that could eventually be eradicated, and saw health as a natural state of the body that should be maintained and protected, further stepping away from traditional notions of supernatural explanations or divine punishment.56,57

  • 1930s

    The 1930s marked the entry of clinically driven care plans into the nursing field. When stays in the hospital were longer, there was time to implement written plans.58 Nursing team leads would also use care plans as a guide for the less-educated members of the team.59

  • 1970s

    There were many fields involved in the emergence oflife care planningduring this time. The converging principles of the fields of experimental analysis of behavior(EAB),developmental psychology, andcase managementestablished life care planning factors: a summative statement, communication tool, preventative planning, basic components, individualized plans, and needs come first ideology.60

  • 1980s

    Starting in the 1980s and in the following decades, life care planners were involved in consultations with insurance carriers and also with attorneys involved in litigation. Life care planning played a huge initial role in the field of litigation. It has since expanded into elder care, chronic illness and discharge planning. It has also expanded the number and types of professions who can each be involved in a part of care planning.61

  • 2000s

    The breadth of professionals and care providers within life care planning expanded, with individuals coming from rehabilitation counseling, rehabilitation nursing, physiatry, and case management professions. Both paper based and digital technology based care plans were regularly being used by patients and their care providers. A proliferation of digital technology based care plans also began to take hold in later years. Healthtap, Amwell, Better., HelloDoctor, HealthKit, My Chart, Practice Fusion, Health Vault, AskMD, Happify, and Healarium are all more well known examples.61

  • Current

    As of January 2015, CMS transitioned Medicare to the more quality-based practice of reinbursing for care management of eligible patients with 2 or more chronic conditions. Other private insurance companies are beginning to follow suit to prioritize consistent, preventative care facilitated by patient-accessible care plans. is has encouraged the growth of digital care planning services that aid chronic care management, such as CareSync, Wellframe, Bridge Patient Portal, and others. Many providers also utilize physical care planning materials like handouts and pamphlets for specific conditions. e pamphlet example below is a care plan for controlling high cholesterol. Inside are education about the diagnosis, room for high-level goal setting, slots to insert Care Cards for individal step goals, and the contractual agreement of the care team to better the patient’s health.5

Care Plans

Part 2: Current Landscape

In the second of this three part series, the Care Planning process and who is involved will be seen in detail. Barriers still exist in it’s implementation and current form, and a range of digital products will be compared to gain a general view of the current state of care planning.

Authors

GoInvo

Beckett Rucker, MPD
@beckettrucker

Beckett is designer, product strategist, and researcher. She concentrates on designing beautiful and surprising health services and systems from the skintop to celltop to desktop. She holds bachelors of arts in psychology and studio art from Rice University and a master of product development from Carnegie Mellon University. She has worked on design and service strategy for companies such as Seniorlink, Johnson & Johnson, and Updox Patient Portals.

GoInvo

Edwin Choi, MA

Edwin is a biologist turned designer. Combining the sciences and art, he orchestrates healthcare software experiences to be beautiful and clinically refined. Edwin is a graduate of Washington University, and has a masters in biomedical design from Johns Hopkins University. He has worked on projects for companies including Partners Healthcare and Notovox.

Health Hats

Danny van Leeuwen, RN, MPH, CPHQ
@HealthHats

Danny is an action catalyst empowering people traveling together toward best health (patients, caregivers, clinicians). He wears many hats in healthcare: patient with MS, care partner for several family members’ end-of-life journeys, a nurse for 40+ years, an informaticist and a QI leader. Danny’s current work focuses on communication at transitions of care, person-centered health planning, informed decision-making, and technology supporting solutions created with and for people at the center. He has collaborated with PCORI, AHRQ, and MassHealth among others.

Contributors

Web Designer & Developer

Yanyang Zhou

Web Designer & Developer

Jennifer Patel
@catamariface

GoInvo, MIT

Juhan Sonin
@jsonin

University of Missouri | toomanyclicks.com

Jeff Belden, MD
@jeffbelden

University of Michigan

​​Joyce Lee, MD, MPH
@joyclee

THINK-Health | Health Populi blog | Huffington Post

​​Jane Sarasohn-Kahn, MA, MHSA
@healthythinker

Healthcare Provocateur

​​Harry Sleeper
@harrysleeper

References