Focus on what you can do, not on what you are unable to do. Meet the more than 350 customers we serve, including ACOs, health systems, insurers and more. One way a care manager can practice cultural competence is by asking the right questions to understand the patient's real circumstances, rather than jumping to conclusions or making assumptions based on past experiences or first impressions. A high-level care manager will take the time necessary to get to know the patient and approach the care plan from a holistic point of view.
Another influence may be the use of standardized care plan templates, which could limit the recording of an exhaustive and personalized debate about care planning. Writing a care plan allows a team of nurses (as well as doctors, assistants, and other care providers) to access the same information, share opinions and collaborate to provide the best possible patient care. Even regulatory bodies, such as the United Kingdom's CQC, receive government support for the advancement of technology in the care industry. This involves consulting patients frequently and recording data on the patient's progress toward their goals, which will be important in the evaluation stage of the care plan.
Sometimes, a patient must be assigned to a nurse with specific skills and experience; a care plan makes that process easier. It remains a key research question whether the effectiveness of care plans will be lower in groups that usually prefer professionals to lead, or if intervention in these groups will lead to better outcomes, since they have the greatest capacity to benefit. At the core of the care delivery process, care managers address the true complexities of each individual and must bring together all actors in a care plan to help the patient achieve optimal health. The measurable outcomes of care planning in this area could include patients' perceptions of the degree to which their health professional “supports autonomy” rather than “controls”.
Successful care management is achieved when care managers are as agile as the ever-changing human beings they care for. A good care manager also understands that these barriers affect a patient's ability to change behavior. This highlights that the chronic care model requires a careful design of the delivery system, including a clear definition of functions and the distribution of tasks among team members (including the patient), and regular monitoring by the healthcare team. The planning aspect of care plans can facilitate follow-up, and including values and preferences can make care more responsive to the patient's background and preferences.
The proposed typology of care planning and care plans offered here, together with the model of the process by which care planning can influence outcomes, provide a useful framework for future policy developments and evaluations. First, it is important to make the distinction between care planning for diseases and planning care for people. The support of leaders is critical to successful care management, but lack of participation at higher levels is a common obstacle for many care managers. The care manager's job is to guide patients through the process and to advocate for them throughout the process.
