Kathy Duckett, Director of Population Health at VNA Care Network Foundation & Subsidiaries in Massachusetts, was selected to participate in a Department of Health and Human Services (HHS) listening session titled "Accelerating Use of e-Care Plans for Delivery System Reform." HHS and the Office of the National Coordinator (ONC) sought input on the needs and issues of various stakeholders regarding e-Care Plans across the continuum of care. Their goal is to accelerate the expectation for comprehensive e-Care Plan usage across care delivery systems within the next few years and they sought input on how to make this reform occur more rapidly. They were particularly interested in understanding what role the government should play.
Several themes emerged from the discussion including:
- The current system is inadequate for meeting the expectations of an integrated e-Care Plan. Changes are needed in every care delivery arena if the goal of patient-centered, integrated care is to be realized.
- Home health will have an increasingly prominent role in health care delivery as health care moves toward care provided outside of the acute care arenas.
- Interoperability of all EMR systems across all care delivery arenas is key: hospitals, rehab centers, physician offices, skilled nursing, home health.
- Patients should be collaborators in the development and execution of the care plan. Care plans design and content must account for health literacy.
- Providers need dynamic, goal-oriented tools, such as dashboards, guidelines, and checklists, to facilitate communication. Actionable information should be delivered in a clear and concise way that accounts for the patient needs. Clinicians must also be clear about their role and responsibility as part of the care team.
- We must find ways to break down cross-institutional silos and create a shared care plan that is accurate, appropriate across all providers, and includes the patient.