Care Plan/Plan of Care: Joint Commission Perspective

The Joint Commission uses the care plan and plan of care interchangeably. The following is from 2013 TJC Hospital Accreditation Standards (which only focuses on inpatient care):

Care plan (or plan of care) – A written plan based on data gathered during assessment that identifies care needs and treatment goals, describes the strategy for meeting those needs and goals, outlines the criteria for terminating any interventions, and documents progress toward meeting the plan’s objectives. The plan may include care, treatment, and rehabilitation.

Care planning (or planning for care) – Individualized planning and provision of care, treatment, or services that address the needs, safety, and well-being of the patient or individual served. The plan, which formulates strategies, goals, and objectives, may include narratives, policies and procedures, protocols, practice guidelines, clinical paths, care maps, or a combination of these.

Standard PC.01.03.01 – The hospital plans the patient’s care. Elements of Performance for PC.01.03.01

-The hospital plans the patient’s care, treatment, and services based on needs identified by the patient’s assessment, reassessment, and results of diagnostic testing. (M)

-The written plan of care is based on the patient’s goals and the time frames, settings, and services required to meet those goals.

-Based on the goals established in the patient’s plan of care, staff evaluate the patient’s progress. (M)

-The hospital revises plans and goals for care, treatment, and services based on the patient’s needs. (M)

The (M) signifies “Measure of Success” which they define as “a quantifiable measure, usually related to an audit, that determines whether an action has been effective and is being sustained”.

Here is a simply patient journey my colleagues created recently. You can imagine that a care plan/plan of care/treatment plan or other type of plans would need to be associated with every episode/encounter of care in every care setting.

In the patient journey below, I used the following terms which are derived from the ONC Longitudinal Coordination of Care initiative:

  • Treatment plan: specific focus on solving defined specific problem(s)
  • Plan of Care: specific for a care setting (eg, inpatient, rehab, SNF)
  • Care plan: overarching, longitudinal plan of care

Mr. S is a 68 year old African American male under care of PCP. He has family history of CAD, is diagnosed with dyslipidemia and hypertension, and is also a smoker.

  • Care plan on dyslipidemia, hypertension, and smoking cessation counseling

Patient presents to the ED with Dyspnea. He doesn’t have any chest pain or dizziness. In the ED, he is diagnosed with new onset of heart failure. He is treated in the ED and discharged home after symptoms improved, and he is asked to follow up with his PCP within 1 week.

  • ED treatment plan on dyspnea and/or new onset of heart failure

Mr. S didn’t follow the ED discharge instruction on following up with his PCP. One month later, the patient presents to ED with severe dyspnea and peripheral edema. The patient is admitted to ICU in the hospital. Then, transitioned to med/surg after symptoms improved and condition is stabilized. After 2 days in med/surg, patient is discharged home.

  • Plan of care on heart failure. This can be specific to one discipline (eg, nursing); can also be interdisciplinary (eg, a plan of care of nurses, PT, OT, nutritionist, and social workers to follow)

1 week after discharge, the patient follows up with his PCP and cardiologist.

  • Care plan on heart failure, dyslipidemia, and hypertension.

The patient lives alone; he is not able to completely follow his treatment regimen. His physical functioning level significantly decreased since the diagnosis of heart failure. Home care support is required.

  • Care plan on heart failure, dyslipidemia, and hypertension focusing on restoring patient self-care ability and physical function from home care agency.