A personalized care plan can improve the quality of care provided for individuals with certain chronic conditions, but only if implemented properly.

Despite a 2015 mandate from the Centers for Medicare & Medicaid Services enforcing the creation of patient-centered care plans as part of an ongoing effort to improve chronic care management services, the definition of “care planning” remains hazy, according to a viewpoint published in the current issue of JAMA. That presents a problem, since a poorly defined mandate sets the stage for an ineffective administrative burden.

“Rather than improve care, mandates for care planning, if not done effectively, could create additional burden for primary care practices and patients, with no perceptible benefit,” write Samuel T. Edwards, M.D., David A. Dorr, M.D., and Bruce E. Landon, M.D.

They outline three steps for the development of a clinically effective care plan:

  • Create a central record. Since care for chronic conditions often involves cooperation among multiple providers, the authors stress the importance of a common repository, such as an electronic health record system incorporating detailed notes, in which all providers can get a sense for the full range of the plan.
  • Involve patients in setting treatment goals. Aligning medical care with the issues that matter most to patients plays a critical role in developing an effective care plan, according to the authors. They recommend the use of planning tools that elicit patients’ needs in terms of what matters to them specifically in terms of their general well-being, including “physical activity, sleep, diet, personal development, family, spirituality and personal surroundings.” This information provides a basis on which to define specific goals and build a medical plan to suit them.
  • Focus on efficient disease management. Patients with chronic conditions often have multiple issues that clinical teams need to juggle. Therefore, the authors recommend that clinical teams address barriers to care and ensure care plans are optimally suited to managing a patient’s diseases, including behavioral health interventions.