Care Plan Insights

What is a “care plan” from our perspective as patients? We understand how care plans help health care teams coordinate patient care, but how do we create care plans that are meaningful to us in our everyday lives? A multidisciplinary team at the Mayo Clinic has been working with the Center for Innovation (CFI) to begin to answer this question.

The Care Coordination and Care Plan team began by sharing their observations from qualitative interviews and shadowing with clinic colleagues and patients. Representing a variety of disciplines and areas within the clinic – nursing, primary care, hospital staff, technologists, physicians, designers, systems analysts, content developers, and usability experts - they also each brought previous, related work from each of their areas. The CFI’s Community Health Transformation team synthesized the group’s knowledge and observations into a set of care plan insights. These 13 insights capture the team’s definition of an effective care plan with an emphasis on the patient perspective.

Most importantly, the care plan needs to be “real” to people for them to use it and act on it. Knowing the role that a strong social support network plays in health and well-being, a comprehensive care plan encourages people to think of their care team beyond just their health care providers. It enables care decisions to be made collaboratively with patients and among multiple, invited stakeholders, including remote family members and social service resources. An effective care plan acknowledges that people are part of families and it enables patients to engage their friends and family in supporting their plan.

An asset-based, rather than a deficit-based, care plan supports goal-setting by using the fundamentals of wellness coaching. It focuses on achievements and patient-important outcomes more than failures to meet clinical numbers. It is part of a learning system, which blends the Mayo Clinic shields (practice, education, and research) at the point of care to continuously increase and deliver knowledge about what works for individuals and what may work for people similar to those individuals.

A care plan is intelligent in the way it presents information to different users – patients, caregivers, nurses, physicians, hospitalists – knowing that they each have a different role to play, with different information needs. It serves this knowledge up, at a glance, and just-in-time; built from the ground up for present and future integration into databases both inside and outside of Mayo Clinic. Rather than driving workflows, it is a tool that is responsive to the emergent interactions between people and the service relationships that technology alone cannot fulfill.

These insights are the foundation for what kind of care plan the Care Coordination and Care Plan team will develop. True, this vision feels big, maybe even overwhelming. However, by starting with divergent thinking, acknowledging that the care plan is part of a larger, complex system, and by “thinking big” the team has set this project on a path to deliver not only the expected, but to potentially deliver an unexpected, higher impact breakthrough as well. The Center for Innovation approaches its work with this “think big, start small, move fast” philosophy. The Care Coordination and Care Plan team’s next step will be to “start small” by translating these insights into early, rapid prototypes created to learn and to test assumptions.