Valuing Patients with an Individual Plan of Care

Valuing Patients with an Individual Plan of Care

This is the third blog in a series of five from Dr. Jon Hart on value-based care.

When creating a value-based care model, you must consider the plan of care. This is the second pillar of three, which represents quality in the value equation I discussed in my first blog of this series. In all medical interactions, the provider must determine a plan for the patient, rooted in evidence-based, best practice medical concepts. These best practices range from the simple to the complex, from handwashing to the optimal choice of chemotherapy for a specific patient’s cancer.

We cannot stop there, though. The most effective plans also consider social, behavioral and mental forces at work in our patients’ lives. After we take a circumferential view of our patient in risk stratification, we must include in our plan actions to mitigate or eliminate all of the negative forces at play. Risk stratification told us “Who” needs our help the most, and a plan of care informs “How” to package that help.

Focusing on the Complex Needs of Higher Risk Patients

The plan could be simple, such as the case of an otherwise healthy person who develops a skin infection on the leg. The physician diagnoses cellulitis and prescribes an antibiotic, possibly with some followup scheduled. Simple. The situation is quite different for another skin infection on the leg of a patient with no transportation and poorly controlled diabetes complicated by a chronic skin ulcer on that leg. This person will potentially need diabetic teaching, help from a pharmacist, social work, a wound care specialist, physical therapy, hyperbaric oxygen therapy, intravenous antibiotics, and so on.

While the first case needs neither an elaborate, complex plan of care nor a large team to carry out the plan, the second scenario requires an Interdisciplinary Team (IDT) to help shape and deliver the care plan as envisioned by the provider. 

With input of the IDT, where all disciplines focus on optimizing the individual patient’s health and well-being, they can address the complex needs of the higher risk patient. The provider is accountable for the plan of care for the patient, but the IDT is responsible for carrying out the plan.

Care Plans for Patients Are Not Uniform

A key principle in value-based care is this: processes to render care are built based on populations, but plans of care are built based on individuals. We need to develop multiple standard processes for delivering various care to the population served, but the plans and paths for all patients are not uniform. This concept must be kept in the forefront or we will default to pushing patients through our own standard processes, whether or not they meet their needs effectively.

As an example of this principle at work, consider this chart, a hypothetical “menu” of programs and processes put in place in a health system to support a patient after hospitalization.

supporting the patient chart

[PCP = Primary Care Provider; CCC = Complex Care Center or “transitions clinic”; PT/OT = Physical and Occupational Therapy; Subspec = Subspecialist, e.g. Cardiologist or Pulmonologist; Med Rec = Medication Reconciliation]

For a patient being discharged from the hospital after a bout of pneumonia, providers must access individual needs as shown on the menu above. If they had been otherwise healthy prior to the hospitalization, they may simply need to finish their medication and see their PCP in a week. The more complex patient may need additional services offered on the “menu,” such as a home visit within 24 hours, a visit to the transition clinic on day three, a subspecialist visit within five days, remote patient monitoring for a few weeks, etc. 

We must build the programs and services to meet the needs of our population based on standard practices and processes, but we must deliver those services in a way tailored to a specific patient’s needs. Remember, these patient-specific needs include medical, social, psychological, emotional and logistical resources, at the very least.

Furthermore, the more complex the plan, the greater the need exists for effective communication and collaboration in carrying out that plan. Integration via communication and coordination is what patients need, not segmented care delivered in isolation. The best plan of care is useless if it is not communicated and coordinated between all the folks involved in delivering on that plan, including the patient.

Communication: A Key Component of Care Plans

Often experts say what we need are new and better treatments or software platforms, hyper-segmentation and specialization to have experts meeting patients’ needs, and/or multiple awe-inspiring efforts and initiatives to better care for our patients. 

What we and the patients really need, though, is better communication. In addition to facilitating effective plan execution, when the patient sees that all the medical players are on the same page in care delivery, the levels of patient confidence and comfort rise. This facilitates a sense of worth and being cared for while meeting the medical needs.

Technical advances and transcendent initiatives are great and can be lifesaving, no doubt, but if the right hand is unaware of the left hand’s actions and intent, we will fall short of our ultimate goal of each patient feeling cared for as we assist them in optimizing health and well-being. More on this next time as we look at the third pillar, longitudinal support.

More Articles in this Value-Based Care Blog Series by Dr. Jon Hart:

Creating a Value-Based Care Model

Risk Stratification for Population Health Management Teams

Building Better Relationships Key to Value-Based Healthcare Delivery

Value-Based Care Software to Support Your Population Health Strategy

Dr. Hart is a Board-Certified Family Medicine physician with over 20 years of clinical patient care experience creating a foundation for his over 11 years of experience as a healthcare executive.  He has practiced as a rural Family Physician, ED Physician and Hospitalist. Administrative experience includes CMO of payers and executive positions in hospital health systems, building and running value-based systems. Currently, Dr. Hart serves as the Medical Director of Value-based Programs for Millennium Physician Group in Florida. Visit his website: