WARNING
This guidance is under active development by NHS England and content may be added or updated on a regular basis.Care Plan Management
See also https://dsf.dev/intro/info/basics.html a similar concept, they may be open for a discussion. (Germany)
Care Planning plans how care is implemented using a combination of clinical pathways and processes.
The following pages provide background information:
- Clinical Pathways and Workflow
- Patient Pathway Example Diabetes
- US Physical Activity A US example of a complete Implementation Guide including Care Plan and Goals.
To store, share and collaborate on an assesment please see Structured Data Capture
The following frameworks have been identified as supporting Care Plan Managment:
Care Team
IHE Dynamic Care Team Management (DCTM) The Dynamic Care Team Management (DCTM) Profile will provide a mechanism to facilitate system interactions to support care team membership such as:
- Discovering Care Teams
- Creating/updating Care Teams
- Listing Care Teams
DCTM Profile provides the structures and transactions for care team management and sharing information about Care Teams that meet the needs of many, such as providers, patients and payers. Care Teams can be dynamically updated as the patient interacts with the healthcare system. A patient and providers may be associated with multiple types of care teams at any given time. This profile depicts how information about multiple care teams can be shared and used to coordinate care. The care team concepts described in this profile are patient centered with the overarching goal to support collaborative care. Care teams have many different meanings to many different people.
Care Plan
- IHE Dynamic Care Planning (DCP) The Dynamic Care Planning (DCP) Profile provides the structures and transactions for care planning, creating, updating and sharing Care Plans that meet the needs of many, such as providers, patients and payers. Care Plans can be dynamically updated as the patient interacts with the healthcare system. FHIR® resources and transactions are used by this profile. This profile does not define, nor assume, a single Care Plan for a patient.