Comprehensive Care Plans

A Care Plan provides a roadmap to ensure your goals are the focus. The plan is tailored to the specific needs of the client. The plan is developed with all involved parties and is used as the tool to insure that all agreed upon aspects of the plan are occurring as outlined. Comprehensive care is an approach that cares for the whole patient and all his or her needs, not just the medical and physical ones. Care coordination is a key feature of evolving care models designed to avoid issues regarding the care of patients. Currently, various federal programs that pay for health care services require a care plan as a component of care coordination. For example, care plans must be established for patients receiving certain Medicare benefits (e.g., home health care) and Medicare makes payment for certain primary care and care management services with a care plan element (e.g., chronic care management services).

Medicaid also provides coverage of Nursing Facility Services in licensed and certified Medicaid Nursing Facilities. Since unique resident needs may require particular care or services, the services needed to attain this level of well-being are established in the individual’s plan of care. These care plans must be interdisciplinary and longitudinal, or working across the entire care continuum. Current calls for care planning have been inconsistent. Therefore we must move towards a consistent understanding of both team-based care models and the resulting documentation that will empower data to move with the patients through the health care system.