Coordinated Care

Introduction

The CareplanCordinatedCareSe resource is used to communicate information about care plans created in COSMIC's Link module. COSMIC Link supports processes and routines regarding coordination between actors which provides health care as well as social services to ensure one uninterrupted care chain.

Participating actors collaborate and exchange messages and draw up various coordination plans. Coordination care plans consists of information about ongoing and planned activities based on the patient's needs. One plan can consist of several notes written by several different users.

COSMIC Link supports three different types of plans:

Samordnad Individuell Plan (SIP)

Used when coordination between different actors is needed, provided the patient has given its consent to coordinated individual planning. Those involved can document their separate parts in a new SIP version. Follow-ups and continued coordination is thus documented in a later version of that SIP.

A SIP ends when no other need for coordination of documentation is required. You can only have one SIP in progress at a time, but several plans of this type can be created within the same coordination matter.

Plan According to LPT/LRV

A plan according to LPT / LRV is documented when coordination is needed before discharge of a patient to open psychiatric compulsory care or open forensic psychiatric care (ÖPT/ÖRV). To create this plan, registration of consent is required for coordinated planning despite the fact that the regulations do not require the patient to give their consent. The actors involved can document their parts in this plan. When this is done, the plan is approved.

Discharge Plan

Used when discharging the patient. It requires no coordination between different parties and the plan can be used when a coordinated individual plan is not needed, or when a SIP will be created after printing. A discharge plan can only be created if the patient has agreed that information may be shared between social services and health care. The actors involved can document their parts in this plan. The plan can be printed.

Included Profiles

Use Cases