My Shared Care Plan facilitates communication between patients/clients and health care professionals to support long-term planned care for patients with chronic illnesses, such as HIV/AIDS disease. It gives patients a tool to learn about and practice principles of self-management, producing activated and engaged patients. In addition, it gives health care professionals a communication tool to provide timely information that supports planned care and patient self-management.
The existing health care system also does not support the practice of patient self-management. The current system adheres to the traditional model of patients following "doctor's orders" and does not encourage a patient to perform such activated behavior as seeking information, defining problems, setting priorities, establishing goals, creating treatment plans, and solving problems along the way. Patients currently do not have a central role in determining their care, one that fosters a sense of responsibility for their own health.
Finally, patients face significant difficulty effectively communicating with their health care professionals. Gatekeeping is one aspect of this problem, as well as patients constantly having to repeat their stories every time a new health care professional becomes involved in their care (which is a frequent occurrence, particularly with chronic illness).
Development
My Shared Care Plan was trialed on paper with real patients for several months to inform the design of the electronic version. The web-based My Shared Care Plan was designed by a work group that included both clinicians and patients.
Over 100 Shared Care Plans have been created for adult patients living with congestive heart failure and/or diabetes since the electronic version was implemented in December 2002. We are working with several diverse community pilot sites to integrate usage of the My Shared Care Plan tool into the clinical setting. Pilot sites include a geriatric clinic, two family practices, a clinic for medically underserved minorities, a specialist group (cardiology), and the hospital.
