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Care is proactive, evidence-based, personalized, patient-directed, and anchored by the patient-centered medical home (PCMH) (196). Sophisticated health IT tools enable these capabilities in a manner that is seamless and user-friendly for patients, care teams, and those who support them. Patients have access to tools that enable them to communicate easily and exchange information with providers and drive the development, implementation, monitoring, and updating of care plans aimed at achieving the patient’s health goals.Workflow enhancing, knowledge-based tools enable diverse healthcare professionals working in different settings to function efficiently as an integrated care team to optimize care and outcomes for individual patients and populations. For example, systems enable pertinent care team members to gather key information proactively from the patient and other sources before their visit to make encounters more productive and provide updates on new data and plans produced during the encounter to the entire team. Nonurgent updates are “on-demand” while more urgent developments are conveyed proactively.

Decision support tools, integrated with care planning and monitoring tools ensure that care is evidence-based, important information and interventions are not overlooked, and all members of the care team are informed about and understand their role in the care plan. Shared decision-making tools used in developing care plans ensure that the plan is optimized to achieve patient goals. Population management tools, mobile apps, EHRs, patient portals, and other health IT tools support care plan execution and ensure that patients get all the right care to support their goals—and no contraindicated care.

Health IT-enabled best practice workflows—adapted as needed to local and patient-specific circumstances—make “the right thing to do easy” and help ensure that potential gaps in care are proactively prevented. When this fails, the gaps are detected and addressed promptly. Telehealth tools enable care to be provided and monitored outside of care delivery settings and, when appropriate, with engagement by the patient’s caregivers and family members.

How Patients & Care Teams Experience This Future State

During a patient’s normal daily routines, they have convenient access to resources and tools, informed by the best evidence, to improve their health and their satisfaction with their care by:

  • Helping them address questions that arise about their health via portals that respond to the need and context 
  • Supporting shared decision making and information sharing with all those on their lay and professional care teams and easy communication with members of the care team (197)
  • Automatically showing patients the care they need in a personalized and understandable way, via links to educational materials and decision aids in a patient portal
  • Actively participating in the development of care plans that integrate and health management approaches across all of their providers and care settings
  • Supporting team-based care for proactive management, with key information readily available to all members of the team
  • Providing guidance and tools for managing health issues including pathways for step-by-step guidance to achieve health goals, links to social support systems and apps that pull data from the care plan and medical record and local support resources (e.g., regarding nutrition, exercise, community programs) to assist in making personalized health decisions and acting on them successfully
  • Making the process of care more patient focused
  • Sharing tools that enable them to find clinicians based on transparent pricing and quality of care metrics that matter to them

During a professional care team’s normal daily routines, they have convenient access to resources and tools, informed by the best evidence, that improve their work satisfaction and care processes and results for individual patients by:

  • Helping them gather, integrate, prioritize, and review critical patient data to enable proactive healthcare
  • Making the right decisions, actions, and documentation the easy thing to do—including supporting shared decision making with patients—in ways that fit smoothly into clinical workflow (198)
  • Providing requested clinical information and guidance via portals that deliver vetted, evidence-informed information that is responsive to the particular need and context 
  • Streamlining and optimizing communications and collaboration with patients and others on their care team, as well as with community-based resources
  • Optimizing care for individual patients and entire populations through a population management perspective that helps identify and close care gaps across all patients

The figures below shows a portal mockup that illustrates how patients and clinicians can access needed answers, guidance, and resources (not addressed by care plan templates) from AHRQ and others in a manner more sensitive to the users’ perspective then is typically available today. Notice the filters for patient, clinician, care resource developer, and QI team beneath search box and the search results organized into different categories. These figures are for illustration/discussion purposes only and are not a proposal or recommendation.

A key resource supporting proactive, patient-centered, evidence-informed care in this future vision is a tool for supporting care development that:

  • Supports collaborative care plan development and implementation by patients and all the care teams and caregivers that support them
  • Coordinates user input and activities across patient/caregiver, care teams, specialities, facilities, and organizations
  • Is accessible at any time by anyone with authorized access
  • Is interoperable across different systems and organizations (including those outside the organization where the patient’s care plan was originally developed)
  • Is based on evidence-based care plan templates for preventive care and for managing common and important acute and chronic clinical issues (gathered automatically based on patient’s active clinical problems)
  • Includes support for addressing the common situation where patients have multiple chronic conditions
  • Uses convenient, workflow-friendly shared decision-making tools that help patients and care teams adapt problem-specific care plan templates (individually and when aggregated to cover the patient’s conditions) to patient-specific goals, circumstances, and preferences based on data from the EHR, the care team, and the patient
  • Reconciles the combined set of problem-focused care plans into a unified/integrated care plan that provides a coherent and feasible evidence-informed set of actions and, ultimately, has development and implementation that will be enhanced by AI and machine learning (ML) approaches and tools (199) (200) (201) (202) (203) (204)
  • Provides workflow-friendly order sets, documentation templates, protocols, and other tools so that any care team members (including the patient) can initiate and track care as directed by the plan
  • Supports a care model that both increases preventive services and provides problem-based support both within and outside of traditional office encounters
  • Evolves the patient’s care plan as circumstances change based on input from the patient and the care team, data from information systems, and updated evidence and recommendations (which are automatically delivered to care plan templates and patient-specific care plans)

The figure below illustrates some of these features. It is a mockup to foster discussion and not a proposal or live system.

In this mockup, after all relevant data are input into the Care Plan Support Tool, the “Review CarePlan” function at the top right of the graphic generates a unified plan across the patient’s conditions.

The Care Journey

This section of the Future Vision Appendix outlines a highly desirable future vision for the health/care delivery journey. It makes concrete a core element of the destination targeted by the ACTS Roadmap deliverable—that is, improved information flow, workflow, and outcomes for those who give and receive healthcare. The future vision perspective illustrates steps where evidence-informed tools support patients and their care teams in making decisions and taking actions that will produce outcomes aligned with the Quintuple Aim.

The patient journey brings to life key interventions believed to provide the foundation for next-generation health IT and evidence-enabled care. The goal for this patient journey is to evoke from diverse stakeholders (especially patients and caregivers) reactions such as:

“If care were broadly delivered as illustrated in this future state, my constituency, organization, and I would be closer to achieving our goals and healthcare would move closer to the Quintuple Aim. This future vision is so compelling that we will work toward its realization.”

Current State of Care Delivery

Current care-related workflows, staffing, training, reimbursement, financial incentives, content development, and technologies do not support such a future state well. The ACTS Roadmap focuses on steps AHRQ and others can take to deliver information resources needed for this future vision. However, these other barriers and their implications will also be made explicit.

Clinical Perspective: Gaps to be addressed in achieving the future vision include:

  • Reduction in the number of portals patients must negotiate
  • Easy navigation to community support resources
  • Symptom evaluation tools and pre-visit questionnaires with automatic triggering of the appropriate tool based on presenting complaint or problem
  • Integration into clinical care of patient-generated data including automated devices
  • Care guidelines, appropriate to the patient and delivered at the point of care without interruption of workflow
  • SMART and flexible documentation templates
  • Shared decision-making tools, triggered automatically for appropriate decisions
  • Dashboards for the patient and members of the care team to determine the patient’s status and unaddressed needs
  • Dynamic links to knowledge sources integrated with the EHR
  • A care plan generator that is accessible to and allows input from all members of the care team, the patient, and non-professional caregivers

The current state of primary care doesn’t support the idealized model due to both internal (practice) and external (regulatory, payment) factors. Payment and technology enablers will need to support eliminating many time-consuming activities that don’t add value (198) and creating and nurturing the alternative high-value activities outlined in the desired future state. Patients and the lay and professional care teams will need ongoing support and coaching in order to move toward the idealized model. Workforce development and redeployment of existing personnel will be needed to fully achieve this vision. Additional personnel costs may be a perceived barrier in some settings but are likely to be offset by increases in efficiency.

A springboard for this care delivery future vision work was an AHRQ video (205) that outlines how care for a patient with multiple chronic conditions (“Mae”) would be much more efficient, effective, and patient-centered if it were driven by an evidence-based care plan. This care plan, developed with Mae and all those involved in her care, would coordinate and support the development and implementation of actions to optimize Mae’s health and wellbeing.

The ACTS Initiative’s work to articulate a care delivery future vision began with adding additional conditions to Mae’s problem list to leverage important pertinent work by AHRQ and others and laying out an idealized health journey for Mae that leverages next-generation approaches to using evidence informed tools and resources to support decisions and actions. The desire was to include detailed who, what, when, where, how information for this journey so that implementers in care delivery and resource developer organizations could provide input into realizing these desired details.

Current State Patient Journey

Mae is a 63-year-old female for whom you have provided primary care for 10 years. She is widowed and lives in town by herself; although her adult daughter visits her frequently to see how she is doing. You have treated her for hypertension and osteoarthritis. Recently, you had to stop the use of nonsteroidal anti-inflammatory drugs (NSAIDs) for her osteoarthritis pain due to progression of stage 3 CKD. Acetaminophen has been ineffective, as has a recent trial of tramadol. You elected to start her on low doses of opiates (oxycodone, 5 mg every 4 hours). This was initially effective in that it reduced her pain, improved her function, and enhanced her overall quality of life. However, Mae told you after several months that it wasn’t working as well as it had at the start of treatment and requests a stronger dose via a phone message. You ask the patient to come in for a visit to review her pain control program.

Resulting Office Visit—Current State

You gather additional pertinent information. She shares that she sometimes takes more oxycodone than prescribed because of her pain. Your review of the prescription drug monitoring program (PDMP) confirms that she has run out of medication and requested renewals early the last two times. She also states that she is feeling depressed and attributes that to loneliness after the loss of her husband and having to deal with significant pain every day. She denies any thoughts of suicide but tends to stay at home most of the time due to the depression and chronic pain, even though her daughter tries to get her out to the mall or to a restaurant. You share with Mae that she may be developing a mild OUD and shows signs of depression—quite understandable given her loneliness and chronic pain. You suggest she start a new medication—duloxetine—which may help both her chronic pain and her depression and ask that she return for a visit to check on how she is doing in 3–4 weeks. You ask if her daughter can accompany her at that visit, only to learn that the daughter works full time and can’t come during your office hours.

Follow Up Visit—Current State

Mae reports reduced pain and somewhat better mood. Her blood pressure now catches your attention, and you realize that she may need an additional antihypertensive and that she is overdue for a check of her renal function. For the next several months, over a series of several office visits, you closely monitor her pain and overall function, her blood pressure, and her renal function. Although all those issues eventually seem to be responding to treatment, you realize that she is overdue for pneumococcal immunization, a mammogram, and some form of colorectal cancer screening. You recommend a colonoscopy because, if normal, it will buy you and Mae a full 10 years before you need to remember to repeat the procedure. You refer her to a gastroenterology group and tell her that “all the doctors in that group are great.” You also order a mammogram and ask her to schedule a visit soon to get her cervical cancer screening updated.

Problems With the Current State

Note that although this clinical team seems to have provided reasonable care, the care is reactive rather than planned. There is a delay in the identification and treatment of problems. The recommendation for colon cancer screening is not patient-centered because the patient’s preferences are not elicited for shared decision making. Care is done exclusively in the office, requiring several office visits for Mae and more time for history taking by the clinical team. All care is dependent on the doctor and not the broader care team. There is no effort to gather important information prior to office visits, which takes time away from the physician’s interaction with the patient. Care is not coordinated with Mae’s family nor is there any apparent attention to Mae’s social isolation. There is no mechanism to identify gaps in care (such as the overdue mammography) proactively, so closing them depends on an office visit which may not occur in a timely manner. Although Mae’s care might be considered appropriate given the current lack of effective technology and financial resources for most primary care offices, we can do much better.

This state of affairs is not entirely due to lack of awareness on the part of the clinical team. Clinicians know that evidence-based tools exist to personalize care and share decision making, but they are not practical to find and apply real-time in practice. Health IT supports for care planning and execution are not adequately available and those that are available are underused. Functionality needs to be re‑created in each system, which is costly and impractical. Lack of these tools results in a limited ability to personalize care to the person or setting and there is suboptimal patient engagement in defining and carrying out care. The concept of developing formal care plans is not universally (or even widely) known or practiced.

Future Vision for Care Delivery

In proposing a future state of care delivery, we consider seven phases of a patient’s[1] journey through the healthcare system. These are:

  1. At home when symptoms develop
  2. Pre-appointment planning for an office visit
  3. Primary care visit and initiation of integrated care plan
  4. Post-encounter care and implementation of care plan
  5. Additional encounters with providers and modifying the care plan
  6. Selecting a primary or referral clinician
  7. Population management

The ideal future state assumes the existence of a PCMH that provides comprehensive, patient-centered care coordinated with an emphasis on quality, safety, and easily accessible services. It also assumes the availability of a multidisciplinary care team that includes, in addition to a health provider (e.g., physician, advanced-practice nurse, or physician assistant), care coordinators and navigators who can:

  • Gather data from the patient and other care providers
  • Assist with arranging appointments with other providers and for diagnostic testing
  • Locate and connect the patient with social services and community resources
  • Provide monitoring outside of the office setting to enable early intervention and close gaps in care through a population health approach

This future vision is articulated with the realization that it involves a wealth of resources that may not be rapidly achievable in many practice settings, but it provides a goal toward which long-range planning should aspire.

Interventions[2] Underlying Care Delivery Future Vision

Table B-1. Interventions Underlying the Future Vision lists the health IT-enabled interventions that provide the building blocks for the highly desirable future vision for care delivery—and otherwise supporting patients’ health journeys—with evidence-informed tools and resources.

#

Intervention Name

Clinical Need Addressed / Description

1

Patient Portal

Online system (accessible via computer, smartphone, or tablet) that connects patients (and their caregivers) to the patient’s care team(s) and to self-management information, tools and resources, and the patient's health data (displayed in easy to understand formats, with visual components to aid understanding). Used to address nonurgent, care-related communications and questions from patients/caregivers and care teams outside of office visits. Provides a platform to deliver patient-facing interventions and allows for appointment scheduling. Ideally, all those participating in a patient’s care use the same portal. Key information such as the care plan is interoperable across portals and data can move between applications with appropriate permissions (e.g., via APIs).

2

Patient Education / Self-Management Tool

Helps patients understand their health conditions and how they are best managed (e.g., via details of different treatment approaches and the benefits, risks, and costs of each). Guides and supports patient self-care actions and addressing changing health status including when and how best to seek professional care team support. May be offered through an automated virtual assistant. Information should be geared to the patient’s language and reading level.

3

Community Support Resources

Guide to local, regional, and national resources that can help address SDOH (206) (e.g., related to food/nutrition, housing, education, safety, physical environment) and provide other support from resources in the community and beyond (e.g., in-person and online peer support, condition advocacy sites).

4

Symptom Evaluation Tool

Patient enters information about symptoms. Tool offers information about possible causes and interim management pending further evaluation and treatment by care team. Results are ideally available to the provider(s)’ EHR system.

5

Patient Data Tracking Journal

Allows the patient to document and track key health parameters of interest to them over time, setting, circumstances, and parameters important to the patient’s specific condition. Examples include functional status, pain quality, duration, intensity and location, and specific symptom inventories, such as the Epworth Sleepiness Scale. Results are used to monitor and fine-tune the care plan and are available to the provider(s)’ EHR system.

6

Screening/ Assessment Tool

Identifies patients who might have or are at risk for a particular condition (e.g., who have high cardiovascular disease [CVD] risk or who might have an OUD). Results are available to the provider(s)’ EHR system.

7

Pre-visit Questionnaire

Allows patient (or proxy) to summarize and share key data and goals/priorities before a clinical encounter in order to make the encounter more efficient, patient-centered, and results focused. Results should be available to the provider(s)’ EHR system.

8

Care Guideline

Provides evidence-informed, trusted guidance (e.g., from a Federal agency such as CDC or a clinical specialty society) for managing specific clinical conditions. Care guidelines inform other interventions in this table that help implement the guidance through support for making the right action/decision easy and safe for individual patients.

9

Telehealth

Remote delivery of healthcare services, such as health assessments or consultations, over the telecommunications infrastructure.

10

Documentation Template

Supports care teams in gathering and documenting key patient data related to their specific conditions and situation to support effective shared decisions and actions.

11

Shared Decision-Making Tool

Promotes shared patient/caregiver–clinician decisions for patient-centered condition management and health optimization. Addresses patient preferences and values, and ideally, helps patients/caregivers and providers select treatments authorized by their payer.

12

Patient Monitoring/ Management Dashboard

Provides an overview and timeline of treatments and results for a patient’s condition(s); used to inform, monitor, and optimize care plan and outcomes.

13

Condition Management Policy/ Procedure/ Protocol

A formal, explicit, CDO-specific description of how care should be delivered (e.g., for specific clinical conditions and situations). These are informed by care guidelines and other evidence and local experts and, in turn, drive other interventions in this table such as care plans and order sets.

14

Integrated Care Plan (Tool for developing, maintaining, and executing)

Documents and guides shared care goals, actions, and monitoring for the patient’s condition(s). Care plan addresses considerations related to the patient’s unique situation (e.g., SDOH, insurance details, preferences, etc.). Ideally a single unified, integrated, and patient-centered care plan is used by the patient and all authorized providers, teams, and caregivers connected to them. This care plan includes capabilities to notify appropriate care team members when there are changes, clarify required actions for specific members, and synchronize plans and activities across everyone involved in the patient’s care. (Critical details concerning policies and governance around care plan ownership, reconciliation, control, etc. are beyond the scope of the ACTS Roadmap, and will hopefully be addressed by related roadmaps.)

15

Clinical Calculator

Computes key parameters for clinical attention and decision making (e.g., a Morphine Equivalent Daily Dose [MEDD] calculator that helps ensure that prescribed opioid doses are appropriate for a patient and within safe daily and cumulative limits). Such calculators are ideally integrated efficiently into workflow. For example, a MEDD calculator linked to an e-prescribing / order entry system provides results prior to order signing and transmission.

16

PDMP Tool

Prescription Drug Monitoring Program tools support review of all past and currently prescribed controlled substances for the patient to help avoid and detect opioid misuse; ideally, this review is smoothly integrated into clinical systems and workflow. Data from this tool should interface seamlessly with the EHR.

17

Order Set

Ensures safe, effective, evidence and patient data-informed ordering of primary management interventions for patient condition(s)/situation. Also includes key associated corollary orders and safety checks. Could be used in outpatient, inpatient, and discharge settings, and includes preloaded, standardized ePrescriptions when needed.

18

Patient Registry

Tracks data about groups of patients over time (e.g., all patients cared for by an organization with a particular clinical condition). Can be used to identify patients due for indicated clinical services or with gaps in evidence-based care. (see Intervention 19, Care Gap, Need, or Issue Detection and Notification Tool)

19

Care Gap, Need, or Issue Detection and Notification Tool

Detect high-priority unmet or upcoming health needs such as indicated preventive service coming due or possible OUD, or condition (e.g., out of range clinical parameter) or return notifications (e.g., to care team and/or patient/caregiver) for clinical attention and/or action via workflow-friendly mechanisms.

20

Provider Selection Tool

Allows patients to access clear and useful information about clinicians that will allow for patients to make choices based on how much they will pay and what quality of service they might expect based on clinical outcomes received by other patients. Measures of patient experience collected through validated instruments should also be available to help patients choose clinicians who provide a good care experience. This is not an easy task, but it is crucial to achieve better outcomes at lower costs.

[1] Where “patient” is mentioned throughout this scenario, it broadly includes patient and any caregivers supporting them.

[2] Interventions that are patient-facing (e.g., activation/self-management tools, questionnaires, shared decision-making tools), are tailored to optimize patient comprehension and engagement (e.g., have appropriate, reading level, language, cultural sensitivity).

Future State Patient Journey: Details Through Seven Stages/Settings

Mae has contacted your office via the patient portal about her need for stronger pain medication. Care team members respond and ask her to provide some additional information prior to her visit (i.e., tools that screen for possible OUD and depression and assess her level of pain and function). Results of the screening tools reveal mild OUD, mild-to-moderate depression with no suicidality, and that Mae is having more trouble with housekeeping and meal preparation and has very few activities outside the home. All of this is communicated to the professional care team via the portal before her visit.

By the time Mae arrives for her office visit, you and the care team are well into creating an integrated care plan since you have the benefit of important relevant information gathered in advance, shared via the portal, and integrated into Mae’s EHR. This information helps populate a dashboard with the latest function/pain information and opioid use history, including a PDMP report. You tell Mae that the screening tools she completed confirm a significant loss of function and overall quality of life, as well as mild OUD and mild-to-moderate depression. You suggest the addition of duloxetine, and because so much time has been saved by data gathering and reporting in advance, you are able to spend more time discussing the diagnoses and treatment recommendations and jointly creating a care plan that Mae understands and agrees with.

The EHR makes it easy for you to arrange for a follow up contact in 2–3 weeks via a telehealth visit, with both Mae and her daughter via a secure video link. Once again, data gathered and organized by protocol before the visit sets up a productive virtual encounter. During the virtual visit, Mae’s affect and functional state are improved as indicated on the pre-visit data forms, and her daughter (seated at a computer terminal in her private office at work) provides additional examples of this improvement and asks what more could be done to help with her arthritis. The integrated care plan automatically suggests having Mae see a physical therapist and an occupational therapist to help with her arthritis. Because the therapists are linked with your EHR via a health information exchange (HIE), they have a more complete picture of her circumstances than they typically had before they were linked. With Mae’s permission and her daughter’s knowledge, you make a proactive referral to the local area Agency on Aging to develop options to reduce Mae’s social isolation. You send Mae’s information to the agency, and they contact her to offer options for meeting other community members in the context of entertainment or games, but also suggest Mae reconnect with her faith community, rediscover her love of gardening, consider a pet dog, or start mindfulness-based therapy.

While not the focus of the original call from Mae or the initial visit, the care plan supports attention to condition management and preventive services through workflow-friendly order sets, protocols, and other tools for any care team member to initiate and track care. The patient portal automatically shows patients the care they need and integrates into your population health tools so some of these items can be addressed by care coordinators outside of office visits. As a result, Mae is up to date with her breast cancer screening and all recommended immunizations prior to this care episode. She and her daughter know that she is due to update her colon cancer screening. She has used a shared decision-making tool and decided she wants a FIT test and not a colonoscopy. This can be arranged with a single-click order. She also has a home blood pressure monitor that links to your practice portal and you see that despite somewhat elevated readings at office visits, her home readings are on target and there is no need for additional antihypertensive medications.

The FIT test is positive, so despite her preference, Mae now needs a colonoscopy. She finds the provider comparison tool on the HHS website. Using the list of gastroenterologists you recommended, Mae enters her zip code, specifies a distance she is willing to travel, and the gastroenterologists who are accepting new patients within those parameters are listed. She can rank them based on cost and key quality parameters, including colonoscopy time to completion and perforation rate. She selects the gastroenterologist who best matches her quality priorities and clicks on the "Request Referral" button in her portal that informs you of her choice.

Patient's Symptoms Deteriorate at Home (Before an Integrated Care Plan is in Place)

Ideally, the patient should have an established connection with their medical home (196) through a patient portal. The patient consults the portal or an app at home for information to better understand what is happening and to get guidance on helpful next steps (Table B-1, Intervention 1)[1]. This connection should provide:

  • Explanations for possible symptoms and causes of deterioration (Table B-1, Intervention 4)
  • Immediate steps to manage deterioration, including listing “alarm conditions” that warrant urgent attention such as engaging the lay and/or professional care team or seeking emergency care (Table B-1, Intervention 2) (e.g., by activating an immediate phone or telehealth consultation (Table B-1, Intervention 9))
  • Guidance on when and how to contact the care team (Table B-1, Intervention 2)
  • Other self-care activities to better manage symptoms before the clinical encounter, and additional information about underlying clinical conditions to better understand their natural history and best overall management strategies (Table B-1, Intervention 2)
  • Tools to document symptoms and condition severity including influencing factors to guide self-care and to share with clinicians to support diagnosis/management plan (Table B-1, Intervention 5)
  • Pre-visit questionnaire to elicit the patient's goals, priorities, and concerns for the next visit (Table B-1, Intervention 7)
  • Transmission to the primary care team of data from the self-assessment tools before the visit (Table B-1, Interventions 1, 2, 4, 5, 7)
  • Patient (or proxy) books appointment as recommended by the self-management tools (Table B-1, Intervention 2) using the patient portal or app

Care Team Prepares for Productive Patient Visit (Pre-Appointment Planning by Team)

Pre-visit Planning at Medical Home. Before the patient comes in for the visit, the primary care team reviews patient-generated data (Table B-1, Interventions 1, 2 ,4, 5, 7) and gathers tools, questions, and interventions that will likely be needed during the visit. Additional activities that might occur prior to the visit include:

  • Sending the patient additional data collection forms. Questions (e.g., extensions of Table B-1, Interventions 4, 5, 6, 7) are sent by the care team via text or portal (Table B-1, Intervention 1) to gather additional data needed to inform shared decision making and care planning related to the patient's problems and their goals for the visit; patient responses are automatically imported into the appropriate place in their EHR.
  • Querying a HIE for key data from other sources to help with care (Table B-1, Intervention 16). Currently, most HIEs require manual search and retrieval of information. In the future, this is likely to be automated as a “push” process to the EHR. However, reconciliation of the incoming information will likely always require manual confirmation.
  • Populating the care plan. Because the patient doesn't have an integrated care plan, the care team activates an EHR function that creates a care plan template (Table B-1, Intervention 14), and then directs the EHR to populate that template with each patient problem and with relevant pre-visit data obtained from the patient. The template includes links to evidence-based tools that support problem management (e.g., Table B-1, Interventions 2–8, 14–15, 19)
  • Huddling to review data. On the morning of the patient visit, the professional care team huddles to review data (Table B-1, Interventions 2, 4, 5, 6, 7) and the care plan template (Table B-1, Intervention 14) and determine what additional data gathering, shared decision making, and further care planning and execution is needed. Since this patient has multiple providers, there are mechanisms connected to the care plan tool (Table B-1, Intervention 14) for the primary care team (including the patient) to communicate with other care team members that aren’t in the same place to inform them and give them an opportunity to collaborate on care planning.

Patient Has Primary Care Visit (to Develop and Implement Integrated Care Plan)

Care Plan Developed with Medical Home. Prior data gathering and tool setup sets the stage for a highly productive visit to better manage the patient's immediate concerns and provide more integrated, evidence-based, patient-centered care going forward. An integrated care plan (Table B-1, Intervention 14) developed and initially executed during this visit is the key resource for making this happen. During the visit, the team will:

  • Review prior data. During medical assistant (MA) intake, prior data are reviewed and validated (including the patient’s agenda for the visit) and new data are gathered (Table B-1, Interventions 2, 4, 5, 6, 7) per protocol from the care plan template (Table B-1, Intervention 14). This may include, for example, a problem-specific questionnaire or instrument to assess symptoms or severity of a condition.
  • Support history/physical exam documentation and additional data gathering. The provider and the patient use the patient’s data (Table B-1, Interventions 2, 4, 5, 6, 7) and template-generated documentation tools (Table B-1, Intervention 10) activated by the care plan, to support additional data gathering and documentation to inform decision making and care planning and execution.
  • Use shared decision-making tools. The patient and provider use shared decision-making tools (Table B-1, Intervention 11) to determine specific actions for further diagnostic, therapeutic, and monitoring activities for each problem (including preventive care). For this patient, an example would include a discussion of different options for colorectal cancer screening.
  • Establish and initiate care plan (see Figure B-3. Care Plan Support Tool Mockup Interface). The care plan is the best approach based on organizational care protocols (Table B-1, Intervention 13), which are in turn informed by evidence-based guidelines (8) but tempered by the patient's insurance specifics, preferences, priorities, and SDOH and other considerations. The care plan defines goals and success criteria, timelines, roles, and responsibilities and anticipates risks and barriers to successful implementation of the care plan and strategies to mitigate these barriers (Table B-1, Intervention 14).
    • Initial care plan execution by the provider is supported by evidence-informed order sets (Table B-1, Intervention 17) generated in response to care plan details. Order sets cover tests, treatments, and referrals in ways that address the patient’s preferences.
    • The care plan includes education and self-management information and tools for the patient (Table B-1, Intervention 2), which the care team reviews with the patient before the end of the visit.
    • The care plan lists everyone on patient's current care team in order to share the care plan (including underlying evidence and other drivers) to all team members to help optimize and coordinate care (Table B-1, Intervention 14). This care team member list is available via the EHR, patient portal, regional HIE, and other health IT channels as appropriate.
    • Governance procedures are in place to ensure that all members of the care team are contributing as expected.

After Office Encounter (Patient/Care Team Implement the Care Plan)

Care Plan Implemented

The integrated care plan addresses the patient’s clinical problems and concerns as well as preventive care, and guides the patient and their lay and professional care teams in coordinated actions that optimize the patient’s health and satisfaction, as well as other Quintuple Aim outcomes. The care plan is accessible on the portal, smartphone app, and/or paper. It has been agreed to by all those affected and is used and contributed to by all those authorized by the patient on their lay and professional care team. Defining who may contribute to overall care plan management will be determined by organizational policy and patient input. The patient follows the steps specified in the care plan (Table B-1, Intervention 14). The patient uses self-management support tools (Table B-1, Intervention 2), documentation tools (e.g., to capture/track information about pain and function, self-measured blood pressure readings) (Table B-1, Intervention 5), wearable devices and others that are further customized based on their individualized care plan (Table B-1, Intervention 14) as the foundation for self-management efforts.

  • Uses information about pertinent/helpful community-based resources (Table B-1, Intervention 3) to help make agreed-upon lifestyle changes and otherwise address social determinants and other factors influencing health.
  • Communicates with the care team with questions or concerns not addressed by care plan through the patient portal or app (Table B-1, Intervention 1), telehealth application (Table B-1, Intervention 9), encrypted phone or other route.

Additional Encounters (Monitoring & Modifying the Care Plan & Synchronizing Efforts Across Providers)

Care Plan Used & Modified Across Providers/Settings

As the patient’s health journey unfolds, they encounter different providers (e.g., medical home team, specialists, physical therapists) and different settings (e.g., office, urgent care, or ED visits, hospitalizations, long-term care). In each case, the integrated care plan is the foundation for decision making and action based on patient preferences and pertinent data/history, clinical evidence, and proactive planning by all care team members.

  • During subsequent encounters, the care plan is used and modified as appropriate based on circumstances and patient preferences, as well as guideline-informed (Table B-1, Intervention 8) care protocols (Table B-1, Intervention 13). Technology and governance are in place to support care plan access, use, and evolution, including details such as who may modify the care plan. Patient monitoring/management dashboards (Table B-1, Intervention 12) provide an overview of condition-specific actions and results to help track progress and identify helpful changes to the care plan when needed.
  • Shared decision making tools (Table B-1, Intervention 11), clinical calculators (Table B-1, Intervention 15), and any other of the applicable tools are leveraged as appropriate to support effective, evidence-informed, patient-centered decisions, actions, data gathering, and documentation.
  • All those authorized, receive updates to the care plan and related events as appropriate, and communications are facilitated as needed to ensure that the care plan remains an integrated tool. To accomplish this, it must be capable of exchanging data with various EHRs covering the patient and the patient’s portal(s) and/or APIs (Table B-1, Intervention 14).

Clinician Selection

Transparency is sorely needed in healthcare so that patients have information about the cost of care and the quality of service they might receive from a clinician, clinic, hospital, or health system. As we work toward the Quintuple Aim, reducing costs and improving quality, the definition of improving value requires much greater participation by patients in the selection of where and how to receive clinical care. There is a compelling argument to be made that if we do not enable patients to make cost comparisons based on the quality of services that matter to them, we will never get to true value-based healthcare. “Value” should not be defined solely by health plans and health systems; it must reflect patients’ views of value. As a result, the issues that matter most to them will not drive the system toward the value defined by others unless the two definitions of value coincidentally align. In transparent healthcare:

  • Patients define the quality metrics that matter to them. Likely to be at the top of the list: chance of survival, quality of life, risk of complication, durability of resource or intervention, and quality of the patient experience. For a patient considering a colonoscopy, this might be mortality rate, risk of perforation or post-procedure hospitalization, and time to next colonoscopy or identification of colon cancer with subsequent care by this specific clinician or team. They are also likely to consider whether a provider treats them respectfully, provides necessary information, is accessible for communication, and makes it easy to arrange the procedure.
  • Patients access tools that benefit from standardized definitions of services so that a colonoscopy at health system A covers all of the same care as a colonoscopy at health system B. There must be standard definitions of numerators and denominators for mortality, complications, and time interval to either return for service or diagnosis of cancer (as a missed diagnosis). These tools can then accept the quality metrics that matter to the patient to rank available clinical service options.
  • Patients generate accurate estimates of their out-of-pocket costs (within 5%) by inputting a few pieces of demographic data, the procedure code, and their insurance policy number into cost generators that provide price transparency for “shoppable” healthcare services and procedures. (207)


[1] Numbers in parentheses refer to interventions outlined in B.3.8 Assets Currently Available Related to the Future Vision.

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