Coordinated Care Plan (CCP) User Guide
Contents
1. contributed to this plan What is most important to me right now What concerns me most about my healthcare right now What I hope to achieve What we can do to achieve it Who will be responsible What it tries to capture The names of all the care team members who directly contributed to the care plan The single highest priority of the patient both within and outside the context of their health The single greatest concern of the patient within the context of their health The patient s articulation of his her key goals not limited to medicine or healthcare considering the advice of the care team The actions that the care team will take to accomplish those goals i e the follow up The names of care team members who will be responsible for completing the actions described How to fill it out Free text Free text Free text Free text Free text Free text Examples and key questions Me Donald Duck Mickey Mouse Homer Simpson Enjoying time with my family What parts of your day do you look forward to the most What is really important to you and your family Being able to afford my prescription medication What is most concerning about the state of your healthcare Walk my daughter down the aisle at her wedding on June 30 What are the top 3 things you want to be able to do What do you want to improve or work on Make an appointment with the physiotherapist and follow exercise regim2. feels he she has some difficulty travelling but it does not affect his her independence The patient feels he she has much difficulty travelling and this negatively affects his her independence The patient is unable to travel outside of his her home The patient is unable to get out of his her bed The patient declined to answer A measure of the patient s sense of how difficult it is for him her to understand written information about their health and or treatments Examples and key questions Choose from the drop down list Description The patient has no difficulty in understanding information about his her health The patient has some difficulty in understanding information about his her health but is able to cope The patient is extremely limited in his her capability to understand information about his her health The patient declined to answer An indication of whether or not the patient currently smokes products containing tobacco Choose from the drop down list Description The patient smokes products containing tobacco The patient does not smoke products containing tobacco The patient declined to answer The patient s estimate of the number of cigarettes per day he she smokes A number 5 22 HealthLink i Information Field What it tries to capture How to fill it out Examples and key questions of pack years The patient s estimate of the A number 3 number of pack years he she has smoked Pack years number of packs
3. for Personal Care know your healthcare wishes No Decline to answer My ACP is located here have a Power of Attorney POA for personal care Description The patient has a completed advanced care plan The patient does not have an advanced care plan The patient declined to answer The physical location of the patient s ACP The patient has a legal document that gives someone else the right to act on their behalf for care and medical treatment Free text Choose from the drop down list have a copy in my jewelry box and my daughter has a copy too No Decline to answer Description The patient has an Attorney for Personal Care The patient does not have an Attorney for Personal Care The patient declined to answer 18 HealthLink Information Field My POA document is located here POA for personal care s name Relationship to me Telephone As understand it my advanced care plan says My situation and lifestyle What it tries to capture The physical location of the patient s POA document The name of the Attorney for Personal Care The relationship of the Attorney for Personal Care to the patient The primary telephone number s for the Power of Attorney The patient s plain speak interpretation of what his her ACP entails How to fill it out Free text Free text Free text Telephone number as XXX XXX XXXX Free text v2 5 Examples and key questions In a drawer at home Ja
4. health status This section includes information about the use of equipment current self monitoring any coaching received and other interventions It is intended to capture primarily medical or clinical activities whereas the subsequent section is intended to capture activities more related to social health and well being Information Field Significant surgeries and or implanted devices e g pacemaker transplant stent Health education or counselling e g group counselling Next planned date Assistive devices e g oxygen cylinder wheelchair Self monitoring routines e g daily home blood pressure readings Other treatments What it tries to capture A list of surgical devices the patient depends on or significant surgical changes A list of the counselling or education services that the patient is currently receiving The date of the next planned health education or counselling session A list of the assistive devices that the patient uses A brief description of the self monitoring that the patient conducts A brief description of any treatments or interventions that the patient is undertaking or exposed to other than the ones listed How to fill it out Free text Free text A date in the format YYYY MM DD Free text Free text Free text Examples and key questions Pacemaker Peritoneal dialysis catheter Diabetes education program 2014 01 13 Uses a walker CPAP machine Blood
5. smoked per day multiplied by the number of years spent smoking e g half a pack per day X 20 years 10 pack years Quit date If applicable the date that the A date in the format 2013 09 23 patient quit smoking or the date YYYY MM DD of the most recent quit attempt I drink alcohol An indication of whether or not Choose from the drop down list the patient currently uses M LL A 11 5 Ze Option Description Yes The patient consumes products containing alcohol No The patient does not consume products containing alcohol Decline to answer The patient declined to answer of drinks in one sitting The patient s estimate of the A number 2 highest number of drinks beer 341ml drink wine 148ml drink spirits 44ml drink he she has had in one sitting in the last 14 days of drinks week The patient s estimate of the A number B number of drinks he she typically has in one week have ever used other An indication of whether the Choose from the drop down list substances patient has ever used other substances beyond alcohol tobacco and medications prescribed to him her 23 HealthLink Information Field Option Yes No Decline to answer Which Marijuana Cocaine Hallucinogens Stimulants Opiates Sedatives Solvents Other Decline to answer How Recently More than 6 months ago Within the last 6 months Decline to answer v2 5 What it tries to capture How to fill it out Description The patient h
6. the pharmacy that provides the drugs and the prescriber s name The start dates and change dates create a chronology of the patient s medication usage and how they may have changed over time Information Field Date of last medication reconciliation Performed by What it tries to capture How to fill it out The date on which the most A date in the format recent medication reconciliation YYYY MM DD was performed by a qualified member of the care team The name of that qualified member of the care team Examples and key questions 2013 09 23 Free text Mickey Mouse 13 HealthLink Information Field My last medication change was It made me feel Better Worse About the same Aids use to take my medications Dosette Blister packs Other Challenges I have taking medications Drug name Dose v2 5 What it tries to capture How to fill it out A plain language description of Free text the most recent change addition deletion modification etc to the patient s medication A plain language description of Choose from the drop down list how that change made the patient feel Examples and key questions Increase ibuprofen Description The medication change made the patient feel better The medication change made the patient feel worse The medication change did not produce an effect that could be detected by the patient A description of the aids that the Choose from the drop down list patient use
7. to identify an organization e g a retail pharmacy Where HealthLink i care team members are listed elsewhere in the care plan e g primary contact their name and contact information should be the same as it is listed in this section Information Field What it tries to capture How to fill it out Examples and key questions Name The name of the particular care Free text Fred Flintstone team member Role or relationship The care team member s Free text Dietitian professional role or relationship Parent SDM to the patient if the care team Priest member has been designated to make decisions on the patient s behalf if the patient is incapable of making decisions by him or herself include the fact that they are a substitute decision maker SDM Organization If applicable the organization Free text Guelph FHT with which the care team member is affiliated Telephone The care team member s Telephone number as 613 555 1234 primary telephone number XXX XXX XXXX Regular care team member Whether or not the patient sees Choose from the drop down list the care team member at least once a year on a planned basis s Option Description Yes The patient sees the care team member at least once a year on a planned basis No The patient does not see the care team member at least once a year on a planned basis HealthLink Information Field Lead care coordinator I rely on most at home The peo
8. 3 kg since March 2013 What progress have you made toward accomplishing this goal 2013 10 17 Severe chest pain What are some future situations that we should plan for Call 911 Do not bathe independently or take Tylenol Donald Duck Who are some care team members who will be ready to help you if these things happen 17 HealthLink Information Field Telephone Review date have received information about advanced care planning What it tries to capture The primary telephone number s for the persons listed to help the patient in this situation A future date on which the patient s plan for future situations will be reviewed by the care team and the patient The patient has been informed by a member of their care team about advanced care planning How to fill it out Telephone number as XXX XXX XXXX A date in the format YYYY MM DD Choose from the drop down list v2 5 Examples and key questions 613 555 0173 2013 10 26 Is there someone whom you trust to care out your wishes if you are unable to speak for yourself No Decline to answer have a completed advanced care plan Description The patient has received information about advanced care planning The patient has not received information about advanced care planning The patient declined to answer Affirmation of whether the patient has an oral or written advance care plan Choose from the drop down list Does your Attorney
9. HealthLink Coordinated Care Plan CCP User Guide Guidelines and examples 2014 08 07 HealthLink i Table of Contents digeerfte e E SEEDS 3 Guiding Principles for COPS E MMOs oc ccessecccesssccccecsscccceesscecceesseccceesseccceessecceeesscccceesseccceessees 3 CCP template information fields esee ERR MES cocesssececeesscceceesssceceesscccceessececeessececeessececeesseccceessase 4 DECIMI Be EEUU dE ICT 4 NAI NU Ce E E 4 MY Care te atyi iue tere e ter alin OMBRE oo NP eese Ree 8 MY NO AltA RETE TEES O 0 u 10 My known current medications eeee c ES Eee Renee nemeenenernnnn ne nhmennen instans trs nasa sias arse r ans 13 My plan to achieve my goals for care 4E ee NEM coos ees Lu NER se ceesscoecececesaessssncesececesaessasneesneneessasscsneeseeeeaesasssansess 15 My situation and lifestyle 89N 98898 WEB 09 EB nnnnenn nennen nnn resa snnsn 19 My assessed health needs Re E terere nere teur ere oun eerie enne 26 My most recent hospital visir a WERE 26 My other treatments M O QR QN M 28 My current supports and Sehvices a MGM ssecsssessecsssonsecessossecsesassecsssassecsesansecsesassecseaasseceeaauseceeaauseceeaassecseaausececaanseceeanseceeaannecs 29 My ap
10. al Income System provides financial aid to qualifying seniors Special Services at Home provides services and financial aid to families caring for a disabled child Various benefits provided to qualifying military veterans Guaranteed Income Supplement a federal government supplement for individuals with low income An indication of the patient s Choose from the drop down list sense of compliance with his her recommended diet 20 HealthLink Information Field Option Yes No don t have one I don t know Decline to answer How adequate my food is for my health More than adequate Adequate Less than adequate Much less than adequate Decline to answer How travel Independently Dependently on friends or family Dependently on public transit Dependently on accessible transit Decline to answer Other How difficult it is to travel v2 5 What it tries to capture How to fill it out Description The patient follows his her recommended diet The patient does not follow his her recommended diet The patient does not possess a diet recommended by a medical authority The patient does not know if he she possesses a recommended diet or if he she possesses one whether he she follows the recommended diet The patient declined to answer A measure of the patient s sense of how his her food source impacts his her health Examples and key questions Choose from the drop down list Description The patient feels his he
11. as used the above described substances The patient has not used the above described substances The patient declined to answer A description of the other substances that the patient has used in the past Examples and key questions Choose from the drop down list Description The patient has used marijuana a plant that produces the psychoactive THC which may distort perception disrupt cognitive functions and cause loss of motor function The patient has used cocaine a stimulant commonly used in powdered and freebase crack forms The patient has used a hallucinogen a drug belonging to a class of psychoactive substances that include LSD ketamine etc which may cause hallucinations The patient has used a stimulant a drug belonging to a class of substances that increase alertness attention and energy The patient has used an opiate a drug belonging to a class of depressant painkillers derived from the opium poppy The patient has used a sedative a drug belonging to a class of substances that induces sedation by reducing irritability or excitement The patient has used a solvent a drug belonging to a class of substances that are inhaled by people for their psychoactive effects The patient has used any substances other than the ones listed e g non prescribed use of prescription drugs other people s prescription drugs The patient declined to answer An indication of how recently the patient has used the substances he or she indicate
12. be some common aspects of care coordination in place in order for the CCP to be a useful tool the user guide does suggest some guiding principles on using CCPs noted below These guiding principles may inform the development of coordinated care planning processes although for the most part they simply reflect the work that is underway in many Health Links already Guiding Principles for CCPs When potential users of coordinated care plans CCPs trust in their quality accuracy and reliability they are more likely to adopt and embed CCPs into their workflow This creates a positive feedback loop whereby the more CCPs are used the greater their value since more frequent use leads to more comprehensive and timely information being captured in CCPs Comprehensive and timely information furthers users trust in CCPs and the cycle continues Thus it is crucial that guiding principles that ensure the integrity of CCPs are agreed upon and shared by all users Adoption HealthLink i The following are five guiding principles to encourage the trust use and value of CCPs 1 The patient is informed of all information included in the CCP who has access to the information and how the information is intended to be used 2 Each CCP is developed with direct input from the patient CCPs reflect patients stated goals needs and preferences and are written in clear accessible language using patients own words where possible 3 CCPsare accessibl
13. contact Relationship to me primary contact Telephone primary contact Emergency contact Relationship to me emergency contact Telephone emergency contact My care team Those people who are dependent on the patient e g to whom patient is a caregiver The name of the patient s primary contact should match what is given in My care team The relationship to the patient of the primary contact The primary contact s primary telephone number The name of the patient s emergency contact who is to be contacted when primary contact cannot be reached The relationship to the patient of the emergency contact e g son The emergency contact s primary telephone number Free text Free text Free text Telephone number as XXX XXX XXXX Free text Free text Telephone number as XXX XXX XXXX My two children Donald Duck Who is your main go to person who you would want involved in your care Parent 416 555 1234 George Jetson In an emergency if Donald wasn t available who would you want us to call Cousin 519 555 1234 This section records the members of the patient s care team including both formal and informal caregivers and provides some information to describe each member s role in the care team This section also serves as a directory for anyone who may view the care plan Where possible individuals should be identified although in some cases it may be more appropriate
14. core services HealthLink Information Field No other coverage Decline to answer Health card Telephone Alternate telephone Email address Preferred contact by Telephone Email Translator Other Decline to answer Mother tongue Official language English French Neither Decline to answer Ethnicity culture v2 5 What it tries to capture How to fill it out The patient has non OHIP insurance for core services e g RCMP The patient declined to answer Examples and key questions The patient s health card Free text 0123456789VG number if they have one including the version code if applicable The patient s primary telephone Telephone number as 613 555 1234 number XXX XXX XXXX An alternate telephone number 613 555 4321 by which to contact the patient The patient s primary email address The method by which the patient prefers to be contacted Telephone number as XXX XXX XXXX Free text email provider ca Choose from the drop down list Description The patient prefers to be contacted by telephone The patient prefers to be contacted by email The patient prefers to be contacted via a translator The patient prefers to be contacted by a method other than the ones listed e g mail The patient declined to answer The patient s mother tongue The official language in which the patient is most comfortable Free text Arabic Choose from the drop down list Description English is the offic
15. d he or she has used in the past Choose from the drop down list Description The patient has used the above indicated substances at some point in time more than 6 months ago The patient has used the above indicated substances within the last 6 months The patient declined to answer 24 HealthLink Information Field gamble responsibly No Unsure Decline to answer More recent date gambled days in last 90 days get 30 minutes of physical activity 3x week Sometimes Never am unable to Never do not want to Decline to answer Other considerations e g sleep habits v2 5 How to fill it out Choose from the drop down list What it tries to capture An indication of whether the patient in his or her opinion has responsible gambling practices Examples and key questions Description The patient believes he or she is gambling responsibly see for example the Short Problem Gambling Screener available at www problemgambling ca The patient acknowledges that they do not gamble responsibly The patient is unsure whether they gamble responsibly The patient declined to answer The most recent date that the A date in the format 2013 05 13 patient has gambled YYYY MM DD The patient s estimate of how A number 4 many days in the last 90 days on which he gambled at least once The patient s estimate of whether or not he she gets the indicated amount of physical activity Choose from the drop
16. down list Description The patient always gets the above described amount of exercise The patient sometimes gets the above described amount of exercise The patient never gets the above described amount of exercise because they re unable to The patient never gets the above described amount of exercise because of lack of motivation The patient declined to answer Any issues that should be brought to the attention of the care team that have not been covered by any of the previous fields Free text Only able to get four hours of sleep a day 25 HealthLink or My assessed health needs This section lists the health needs that have been identified by the patient s providers This section attempts to capture a more quantitative assessment of the patient s health using the results obtained by various health assessments Assessment types will be detailed in the appendix Information Field What it tries to capture How to fill it out Examples and key questions Assessment name The name of the particular Free text LACE for Hospital re admission assessment that was conducted risk for the patient Completed An indication of whether or not Drop down list said assessment has ever been completed for the patient Option Description Yes Said assessment has been performed for the patient No Said assessment has not been performed for the patient Date Completed The date that the most recent A date in the format 2013 05 13 instance of said assess
17. e to patients and the circle of care in any setting where care may be delivered 4 CCPsare actively used and reliably maintained according to the clinical practices established in each Health Link by all in the circle of care 5 CCPsare based on current evidence and use generally accepted clinical guidelines CCP template information fields This guide applies to CCP template version 0 6 2F All sections Two information fields are common to all sections 1 Last verified and 2 Last verified by They help to establish the authorship of each section as well as the currency of the information in that section Information Field What it tries to capture How to fill it out Examples Last verified The most recent date on which A date in the format 2014 01 18 the information in this section YYYY MM DD was verified and or reviewed for accuracy Last verified by The name of the individual who Free text Fred Flintstone most recently verified and or Mickey Mouse reviewed this section My identifiers This section helps to establish the identity of the patient by providing both basic information about him her e g name date of birth address etc as well as other information that will help the care team understand the patient such as his her ethnicity religion marital status and living conditions HealthLink Information Field Given name Preferred name Surname Gender What it tries to capture The patient s given na
18. en What are some steps we can take to work toward this goal Me Who do you want to help you do this 16 HealthLink Information Field Expected outcome Barriers and challenges Results achieved so far Review date Future situations What I will do What I will not do Who will help me What it tries to capture A measurable articulation of the patient s goal Those barriers or challenges identified by any care team member that could prevent the patient from reaching his her goals A description of the patient s progress towards completing the goal A future date on which progress on the patient s goals will be assessed by the care team and the patient A situation that the patient may be faced with based on their current situation in the near future Actions that the care team has agreed the patient should do in this situation Actions that the care team has agreed the patient should not do in this situation Those people who will help the patient in this situation and are aware of their inclusion in the plan How to fill it out Free text Free text Free text A date in the format YYYY MM DD Free text Free text Free text Free text v2 5 Examples and key questions Weigh 80 kg How will you know when you ve achieved your goal Spouse unwilling to modify diet with me How confident are you that we can do this What do you think might stop you from getting there Lost
19. ence that provides care for seniors Residence that provides for persons with developmental disabilities Licensed home providing 24 hour nursing care or supervision Institution that provides treatment to injured or sick persons Home for end of life care Institution that houses offenders serving sentences from 60 days to 2 years Temporary residence for homeless persons Residence where inhabitants share a kitchen and bathroom Lacking stable permanent appropriate housing Residence other than the ones listed The patient declined to answer People who live with me Those people with whom the patient currently lives Choose from the drop down list Partner only Partner and others Description The patient lives alone The patient only lives with his her partner The patient lives with his her partner and others e g children HealthLink Information Field Children only Parent s or guardian s Sibling s Other relative s Others Decline to answer What it tries to capture How to fill it out The patient only lives with his her children The patient lives with his her parent s or guardian s The patient lives with one or more of his her siblings The patient lives with one or more relatives other than the ones listed e g cousin uncle The patient lives with one or more people other than the ones listed The patient declined to answer v2 5 Examples and key questions People who depend on me Primary
20. g of a large number of the patient s care team members in a case conference where the draft care plan is developed discussed and or confirmed More detailed information could be provided about best practices in each of these stages should these be considered valuable additional training tools and as clear best practices begin to emerge from Health Links FILES Daisy Duck s Narrative DaisyDuckNarrative v2 docx Daisy Duck s Care Plan DaisyDuckCarePlan v5 docx Bruce Wayne s Narrative BruceWayneNarrative v4 docx Bruce Wayne s First Care Plan BruceWayneFirstCarePlan v5 docx Bruce Wayne s Second Care Plan BruceWayneSecondCarePlan v5 docx 32
21. glucose monitoring Acupuncture 28 HealthLink i My current supports and services This section describes all the formal and informal supports and services provided to the patient that are more related to the patient s social health and well being as opposed to the preceding section which was focused on medical or clinical activities This section includes basic information about who the primary contact is and contact information for each support or service and what and when services were provided Information Field What it tries to capture How to fill it out Examples and key questions Contact name The name of the patient s Free text Wily Coyote primary contact or support service provider for a particular support service Organization If applicable the name of the Free text YMCA organization with which said person is affiliated Services provided If applicable a description ofthe Free text Aerobics Class services provided Telephone The primary telephone number Telephone number as 613 555 9999 for the contact XXX XXX XXXX Email address The primary email address for Free text a3347140 drdrb net the contact Start date The date on which the patient A date in the format 2012 09 21 started using the particular YYYY MM DD support service My appointments and referrals The Appointments and referrals section lists the basic information on upcoming health related appointments These could include visits to or from formal or info
22. ial language in which the patient is most comfortable speaking French is the official language in which the patient is most comfortable speaking The patient is unable to speak in either official language neither English nor French The patient declined to answer The patient s self identified ethnicity or culture Free text Inuit HealthLink Information Field How to fill it out v2 5 Religion or social group What it tries to capture The patient s self identified religion or social group Examples and key questions Free text Hindu Freemason Marital status Said patient s marital status Choose from the drop down list Never married Married or common law Separated Divorced Widowed Decline to answer Description The patient has never been married The patient is currently married or in a common law relationship The patient is separated from his her spouse The patient is divorced from his her spouse The patient is widowed a widower The patient declined to answer Where I currently live The patient s current living arrangements Choose from the drop down list Private dwelling Assisted living home Retirement home Group home Long term care home Hospital Hospice Correction centre Shelter Rooming house Homeless Other Decline to answer Description Residence that is privately owned or leased by the patient Residence that provides support services but no medical monitoring Resid
23. mal employer and works 30 hours or more per week Patient has a formal employer and works less than 30 hours per week or only for part of the year Patient is performing services willingly and without pay Patient is without a job either by choice or by circumstance excepting retirement Patient has left ceased to work reasons may include age personal choice or legal reasons The patient declined to answer A measure of the patient s sense of whether or not his her income impacts his her health up to patient s discretion Choose from the drop down list Description The patient feels living and health related expenses are easily covered by his her income The patient feels living and health related expenses are covered by his her income The patient feels living and health related expenses are close to being met by his her income The patient feels living and health related expenses are not being met by his her income The patient declined to answer Identifies the supplementary benefits that the patient receives Choose from the drop down list Description Insurance plans that are arranged between the patient and a third party Ontario Drug Benefit pays most of the cost of prescription drugs for qualifying patients Ontario Disability Support provides financial support for qualifying disabled persons in financial need Program that provides financial aid and services for qualifying persons in temporary financial need Guaranteed Annu
24. me The name by which the patient prefers to be identified The patient s surname or family name The patient s identified gender How to fill it out Free text Free text Free text Choose from the drop down list v2 5 Examples and key questions Michael Mike Do you prefer to be called by a different name Jones Transgender male Transgender female Other Decline to answer Date of birth Health Link Address City Province Postal code OHIP insured Description The patient identifies as a male The patient identifies as a female The patient identifies as a transgender male The patient identifies as a transgender female The patient identifies as a gender other than the ones listed The patient declined to answer The patient s date of birth The name of the Health Link from which the patient s CCP was created The address of the patient s primary residence The city of the patient s primary residence The province of the patient s primary residence The postal code of the patient s primary residence Whether or not the patient has OHIP coverage A date in the format YYYY MM DD Free text Free text Free text Standard two letter format Standard six character format Choose from the drop down list 1965 10 15 Barrie Community 123 Main Street Ottawa ON A1A1A1 No uninsured Description The patient has OHIP insurance The patient does not have any insurance for
25. ment was YYYY MM DD completed Score Where applicable the numerical A number 3 outcome of said assessment Actions taken Where applicable the actions Free text None that were taken by the care team in response to said assessment My most recent hospital visit This section provides some information about the patient s most recent hospital admission or ED visit The section tries to capture details about the visit such as any complications that may have arisen during the visit the attending physician at the time and any follow up appointments or advice that may have occurred or been given out respectively Information Field What it tries to capture How to fill it out Examples and key questions 26 HealthLink Information Field Hospital name Type of visit What it tries to capture The name of the hospital where the patient most recently visited the ED or was admitted not meant to capture outpatient visits The type of hospital visit e g ED visit admission etc How to fill it out Free text Choose from the drop down list v2 5 Examples and key questions The Ottawa Hospital Have you been to a hospital or an ED in the past 6 months ED visit only Scheduled admission ED visit then admission Date of visit Date of discharge if applicable Reason for visit Complications Name of hospital physician Telephone Key advice from hospital physician Follow up appointment made with Descrip
26. mmune system dependant hypersensitivity reaction to said substance Inability to digest or dispose of said substance A description of which bodily Choose from the drop down list system is most affected by exposure to the substance Description 12 HealthLink Information Field Skin Respiratory Gastrointestinal Behavioural Blood Others Severity Moderate Severe Life threatening v2 5 What it tries to capture How to fill it out The skin is primarily affected by said substance The respiratory system is primarily affected by said substance The stomach and intestines are primarily affected by said substance The mental or motor response of the patient is primarily affected by said substance The blood is primarily affected by said substance The parts of the body that are primarily affected do not fall under the ones listed The level of danger in regards to Choose from the drop down list the substance allergy or intolerance as perceived by the care team Examples and key questions Description Symptoms could be ignored by patient with minimal effort Symptoms cannot be ignored by patient but do not limit his her daily activities Symptoms cannot be ignored by patient limit his her daily activities and require extensive treatment Symptoms endanger patient s life without treatment My known current medications This section lists current and past medications providing details such as drug name method of drug delivery
27. ne Porter Father 202 555 0163 want my life to be prolonged and that am provided with all life sustaining treatments applicable to my condition What is your advanced care plan This section begins to capture some of the social determinants of health about the patient that will likely impact health and care Where possible the impact of the information on the patient s health and care is the focus of the data rather than the information itself e g impact of income rather than the magnitude of income How to fill it out Information Field How work What it tries to capture A description of the patient s involvement or not with the labour force Description Choose from the drop down list Examples and key questions 19 HealthLink Information Field Student Self employed Full time Part time seasonal Volunteer unpaid Unemployed Retired Decline to answer How adequate my income is for my health More than adequate Adequate Less than adequate Much less than adequate Decline to answer Supplementary benefits I receive select all that apply Private insurance ODB ODSP Ontario Works GAINS SSAH Veteran s Benefits GIS I follow my recommended diet v2 5 What it tries to capture How to fill it out Examples and key questions Patient is enrolled in a school or college full time or is home schooled Patient s income comes directly from own profession or business Patient has a for
28. particular medication The date of the most recent change to any aspect of this particular medication The care team member who prescribed directed the patient to take this particular medication Any other notes that do not fall into previous categories pertaining to the patient s medications and their use My plan to achieve my goals for care Free text Free text Free text A date in the format YYYY MM DD A date in the format YYYY MM DD Free text Free text v2 5 Examples and key questions Daily Pain arthritis Rexall Oak St 2005 02 13 2013 05 14 Homer Simpson Do not take with aspirin or alcohol This section describes the analysis of the current situation and the care plan for the patient The patient informs the plan generally by communicating his or her priorities and concerns about his or her health More specific goals are articulated below which should represent the agreed upon goals for the patient and care team Several specific actions to achieve the goals are listed each with a person responsible for 15 HealthLink v2 5 ensuring the completion of the goal identified The My plan for future situations subsection describes what the patient should do in certain situations such as a sudden decline in health or function Finally there is a sub section to provide process related information about the patient s advanced care planning Information Field Care team members who
29. ple rely on most at home are feeling Able to continue Not satisfied Angry or distrustful Unable to continue My health v2 5 What it tries to capture How to fill it out Examples and key questions A flag to identify which member Check box of the care team is the lead care coordinator and primary author of the coordinated care plan A flag to identify which member Check box of the care team the patient relies on the most at home or informally up to patient s discretion An indication of caregiver burnout the ability of informal members of the care team to continue to provide support to the patient Choose from the drop down list Description The care team members have no difficulty in continuing to provide care for the patient The care team members are dissatisfied with some aspect of the situation but are able to continue providing care The care team members are angry or distrustful due to some aspect of the situation but are able to continue providing care The care team members cannot continue providing care to the patient without new supports This section records the various factors that may negatively affect the patient s health ranging from physical and mental conditions to social conditions This section serves to provide a holistic assessment of the patient s health by giving brief descriptions of each aspect of their health as well as some chronology by providing dates of health issue onset Ent
30. pointments and referrals 9998 RGM eocecosccesssscessceessnsessssussaceesccesesnsussuseusueesesceessassussassueaeesssnsesssstucsseasoeecssntersanstascess 29 Appendix A Assessment Types and Examples sss sese nnns enne nnn sense tnss esee tn sess ee th sess se tn sisse tn siis se tn sisse tna s ESSEE ESSEE EnEn 31 Appendix B Sample CCP Scenarios O MM a cscccecssascccecececsasssanccseceeaesenscasceeecesaessnscaseeeecetsassuscasseeecatsussnanesseeueaesassaanecsecesaesenscaneeseceeaeseass 32 HealthLink in Purpose This document describes how the coordinated care plan CCP template is intended to be used and the purpose of each individual information field that is part of the CCP A user of the CCP could be a care coordinator authoring the plan a clinician viewing the plan the patient for whom the plan was made or an informal caregiver The descriptions in this guide allow users to have a common understanding of the information contained therein so that these clinical documents can be used consistently and reliably Many Health Links continue to develop coordinated care planning processes that define how providers patients and their families work together to coordinate and deliver care for Health Link patients The CCP user guide is not meant to impose any particular processes on Health Links nor be a substantive tool to help Health Links develop those processes However recognizing that there should
31. r nutrition requirements are being easily met The patient feels his her nutrition requirements are being met The patients feels his her nutrition requirements are close to being met The patient feels his her nutrition requirements are not being met at all The patient declined to answer A description of the primary day to day mode of transportation for the patient Choose from the drop down list Description The patient is able to travel independently without the aid of another person The patient is able to travel with the help of friends or family The patient is able to travel with the help of public transportation services or a taxi The patient is able to travel with the help of accessible transit e g Wheel Trans The patient declined to answer Some mode of transportation or way of travelling other than the ones listed A measure of the patient s sense of how difficult it is for him her to travel e g to appointments Choose from the drop down list Description 21 HealthLink Information Field Not at all difficult Somewhat difficult Very difficult Homebound Bedbound Decline to answer How difficult it is to read and understand information about my health Not at all difficult Somewhat difficult Very difficult Decline to answer I smoke tobacco No Decline to answer of cigarettes day v2 5 What it tries to capture How to fill it out The patient feels he she has no difficulty travelling The patient
32. re plan Bruce Wayne contains two representing a failed first attempt and how the care plan was revised for the subsequent second try Each scenario includes a narrative and a care plan The narrative s purpose is to allow readers to quickly form a general impression of the patient so that they are able to see how said scenario was mapped to a care plan template These sample CCP scenarios were created in response to our clinical focus group s demand for a clearer picture of how a CCP might look like They are an attempt at approximating real life scenarios so that they can be valuable to the care coordinator while not intending to guide actual care decisions These scenarios are fictitious cases and are not intended to represent any patient provider or organization The scenarios and care plans do not describe all of the detailed steps required to create the care plans We expect that these steps will vary greatly between Health Links However it has been noted that there are several common stages involved in the creation of a care plan for example e Initially care plans tend to be pre populated with demographic and basic health and treatment information often by a nurse case manager or administrative assistant e One or more interviews with the patient are held to try to understand the patient s goals for care and develop a draft care plan e These patient interviews usually occur before and or after a more comprehensive gatherin
33. ries in the physical health row should pertain to problems issues or concerns of the body as should entries in the mental health row pertain to problems issues or concerns of the mind Social health relates to social determinants of health such as relative income level relationships with others or any aspect of a patient s social history that may indirectly affect impact their health Information Field What it tries to capture How to fill it out Examples and key questions 10 HealthLink Information Field Description Clinical description Date of onset Stability What it tries to capture A plain language description of one of the patient s health issues it can be related to physical mental or social health A clinical description of the patient s health issues The approximate month and year the patient first became aware of the issue or was diagnosed with the issue An indication of whether the issue is stable or not note that this is at the discretion of the care team considering likelihood of deterioration disease flare crisis or other relevant factors How to fill it out Free text Free text A date in the format YYYY MM Choose from the drop down list v2 5 Examples and key questions Arthritis Osteoarthritis 1995 11 Option Stable Unstable Notes Height Height unit of measure Opion m Description The patient is stable in regards to the particular heal
34. rmal supports or services or visits to or from care team members Information Field What it tries to capture How to fill it out Examples and key questions 29 HealthLink Information Field Date Time Provider name Purpose Notes What it tries to capture The date of an upcoming appointment with a member of the care team The time of said upcoming appointment The name of said member of the care team A brief description of the purpose of said appointment A brief description of any other important context related to said appointment e g information to bring travel plans etc How to fill it out A date in the format YYYY MM DD 24 hour time in the format hh mm Free text Free text Free text v2 5 Examples and key questions 2013 10 24 10 15 Mickey Mouse weight loss follow up Delilah here at 0900 30 HealthLink i Appendix A Assessment Types and Examples Frailty A measure of the patient s capability of recovering after stress events Example Rockwood Frailty Scale Health Literacy A measure of the patient s desire and ability to make use of information that promotes and maintains good health Example Test of Function Health Literacy in Adults TOFHLA Rapid Estimate of Adult Literacy in Medicine REALM SF ADL A measure of the patient s ability to perform basic tasks of everyday living like dressing and eating Example InterRAI ADL Hierarchy Scale IADL A measure of the patient s ability
35. s to take his her medications Description A container intended for the storage and organization of a patient s medication Packaging used for storing and protecting a patient s medication Any aids other than the ones listed A plain language description of Free text the challenges the patient has in taking his her medications The generic name of the Free text Ibuprofen particular medication that the patient is currently taking The quantity of the particular medication that the patient is currently taking The route by which the patient Choose from the drop down list takes the particular medication have difficulty remembering to take my medication Number unit of measurement 20 mg Description 14 HealthLink Information Field Oral Topical Inhaled Injection Direction Reason Pharmacy Start date Change date Prescriber Special notes or instructions What it tries to capture How to fill it out The patient takes the medication by oral means The patient takes the medication by application to a body surface The patient takes the indication by inhalation The patient takes the medication by injection The prescribed method or frequency at which the patient takes the particular medication The reason that the patient was prescribed directed to take the particular medication The pharmacy from which the patient acquired this particular medication The date that the patient started taking this
36. th issue The patient is unstable in regards to the particular health issue Any other notes to explain or contextualize the issue Height of patient using the specified unit of measure The unit of measure of the Description Metres Free text A number Highlight one unit of measure ED visits due to pain How severe are your symptoms What triggers tend to cause your disease to flare 1 65 BEL height H vee On neE 11 HealthLink Information Field in Weight v2 5 What it tries to capture How to fill it out Examples and key questions Inches eee Weight of patient using either A number 92 the imperial or metric system up to provider discretion to pick one and ensure it s noted Weight unit of measure Opion kg Ib HbA1c Substance Allergy or intolerance Option Allergy Intolerance Symptoms patients weight i The unit of measure of the Highlight one unit of measure Description Kilograms Pounds Most recent HbA1c test result a A number 6 6 proxy for the average level of blood sugar over time reported in percent Name of the compound or Free text Corn factor which elicits a reaction Aspirin if it s a medication follow the naming guidelines in the medication section Whether the reaction between Choose from the drop down list the patient and the substance is that of allergy or intolerance Description I
37. tion The patient only visited the ED The patient was directly admitted into the hospital The patient visited the ED and then was admitted to the hospital The date that the visit started The date that the patient left the hospital A plain language description of the reason for the visit A plain language description of the complicating issues that may have exacerbated the visit The name of the physician most responsible for the patient during the visit The telephone number for said physician A plain language description of the key advice from said physician or a summary of the discharge order The name of the primary care provider with whom a follow up appointment has been made A date in the format YYYY MM DD A date in the format YYYY MM DD Free text Free text Free text Telephone number as XXX XXX XXXX Free text Free text 2013 04 13 2013 02 19 Severe shoulder pain couldn t move my arm Homer Simpson 613 555 9284 Increase ibuprofen to 400 mg 3x daily and start physiotherapy Mickey Mouse 27 HealthLink Information Field Date of follow up appointment My other treatments What it tries to capture How to fill it out The date on which said follow up A date in the format appointment is scheduled YYYY MM DD v2 5 Examples and key questions 2013 05 26 This section lists common interventions that are related to or may influence the patient s current
38. to perform activities related to independent living like housework and shopping Example InterRAI IADL Involvement Scale Pain A measure of the amount of pain felt by the patient Example InterRAI Pain Scale Hospital re admission risk A measure of the possibility that patients will be readmitted into a hospital within a specified time interval after hospital discharge Example LACE MAPLe Cognition A measure of the patient s cognitive ability or impairment Example InterRAI Cognitive Performance Scale CPS General Practitioner Assessment of Cognition GPCOG Aggressive Behaviour A measure of the patient s propensity for causing physical or emotional harm to others Example Aggressive Behaviour Risk Assessment Tool ABRAT Risk of self harm A measure of the patient s likelihood of hurting him or herself Example InterRAI Severity of Self harm SOS OCAN Safety to Self Mood A measure of the patient s emotional state Example InterRAI Depression Rating Scale DRS Positive and Negative Affect Schedule PANAS 31 HealthLink or Appendix B Sample CCP Scenarios This care plan guide package also includes two hypothetical scenarios Daisy Duck and Bruce Wayne These two try to exemplify two different but likely scenarios where the first shows a patient with a common chronic disease and the second shows a patient whose care is more focused on treating his mental health While the Daisy Duck scenario includes only one ca
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