My Shared Care Plan

Whatcom County Pursuing Perfection Project
Bellingham, Washington, USA
 
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 diabetes or congestive heart failure. 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.

Background
In April 2002 the community of Whatcom County received a Pursuing Perfection grant from The Robert Wood Johnson Foundation to transform health care delivery. Using the Institute of Medicine report Crossing the Quality Chasm: A New Health System for the 21st Century as a guide, the Pursuing Perfection team identified numerous interventions that will be made to significantly improve the system of care. Phase II of this grant, in part, involves developing a strategy to explore the following questions:
  • How can we build the information technology (IT) to support planned care or open access?
  • What supports can IT give the multidisciplinary team?
  • How can we use IT to engage patients in their own care and make communication easier between patient and health care professional?
 
Problem
To address the above questions, the team is focusing on these specific problems:
The current health care system does not adequately support the needs of patients with chronic illnesses such as diabetes or congestive heart failure. Long-term, patient-centered planned care is very difficult to coordinate for patients who have complex conditions and, as a result, gaps in care often occur. One such gap is medications: every health care professional has a separate record for each patient and whenever one health care professional changes a medication either the other medication lists become inaccurate or the burden is placed upon the patient to make sure every health care professional's list is also updated.
 
Planned care is also hard to achieve given the multidisciplinary nature of a care team working with a chronically ill patient. With the absence of a community-wide electronic medical record, there are minimal supports for effective care team communication, with the end result of patients being burdened with filling in the communication gaps themselves.
 
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.

Directions
Download the form for complete instructions. You may also login to the web-based My Shared Care Plan as a guest to view John Doe's fictional Shared Care Plan, explore the functionality, and see sample content.

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