Development of Know-How Information Sharing System in Care Planning Processes – Mapping New Care Plan into Two-Dimensional Document Space

Abstract Assisted living (AL) communities are increasingly home to frail, chronically ill older adults who remain until death. State laws mandate that AL facilities request copies of any advance care planning documents residents have and make forms available upon request. Using secondary data from a larger study funded by the National Institute on Aging (R01AG047408) that focuses on end-of-life (EOL) care in AL, this project investigated barriers and facilitators to conducting advance care planning in AL. Data included in-depth interviews (of 86 minute average length) with 20 administrators from 7 facilities around the Atlanta metropolitan area and aggregate data collected from each facility regarding facility, staff, and resident characteristics. Findings from thematic analysis of qualitative data showed that key barriers to planning in AL included lack of staff training and reluctance among administrators and families to discuss advance care planning and EOL care. Important facilitators included periodic follow-up discussions of residents’ wishes, often during care plan meetings, educating families about the importance of planning, and external support for staff training and family education from agencies such as hospice and home health. Three study facilities exceeded state requirements to request and store documents by systematically encouraging residents to complete documentation. These facilities, whose administrators discuss advance care planning and residents’ EOL wishes with residents and families during regular care plan meetings, were more likely to have planning documents on file, demonstrating the potential of long-term care communities, such as AL, to successfully promote advance care planning among residents and their family members.

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‘It’s almost superstition: If I don’t think about it, it won’t happen’. Public knowledge and attitudes towards advance care planning: A sequential mixed methods study

Palliative Medicine ◽

10.1177/02692163211015838 ◽

2021 ◽

pp. 026921632110158

Author(s):

Sonja McIlfatrick ◽

Paul Slater ◽

Olufikayo Bamidele ◽

Deborah Muldrew ◽

Esther Beck ◽

...

Keyword(s):

Mixed Methods ◽

Focus Group ◽

Advance Care Planning ◽

Public Awareness ◽

Community Action ◽

Care Plan ◽

Care Planning ◽

Knowledge And Attitudes ◽

Sequential Mixed Methods ◽

Advance Care

Background: Internationally, participation in advance care planning is low. Whilst a community action approach is advocated, what the public know and understand about advance care planning is unknown. Aim: To assess public awareness, knowledge and attitudes towards advance care planning and identify strategies to raise awareness within a public health framework. Design: Sequential mixed methods comprising a cross-sectional survey and focus group/interviews. Setting/participants: A random representative sample of adults from one region of the United Kingdom ( n = 1201; response rate 56%) completed a face-to-face survey. Twenty-five participants consented to an additional focus group/interview held in a secure accessible location or via telephone. Results: Most participants (78.7%) acknowledged the benefits of advance care planning conversations, however, two thirds did not want to think about advance care planning or find out more at present. Respondents were reluctant to broach advance care planning as it was linked to end of life care and funeral plans, and they did not wish to cause distress to their loved one. Respondents trusted their family to respect their wishes and they considered having an advance care plan in place would be of assistance in the future. Top-down leadership, normalisation, and increased education were identified as potential approaches to overcome barriers. Conclusions: Advance care planning was recognised as important despite limited awareness, lack of knowledge and misperceptions. Whilst a community action approach to enhance understanding and engagement was supported, a ‘one size fits all’ approach will not work; rather bespoke targeting is required with educational and media messaging aligned.

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ІНФОРМАЦІЙНІ МОДЕЛІ ЗАГАЛЬНОГО ДОГЛЯДУ ЗА ХВОРИМИ З ПІДТРИМКОЮ АЛГОРИТМІВ ПРИЙНЯТТЯ РІШЕНЬ НА ОСНОВІ КЛАСИФІКАТОРА ICNP

Medical Informatics and Engineering ◽

10.11603/mie.1996-1960.2018.1.8892 ◽

2018 ◽

Author(s):

V. P. Matrtseniuk ◽

I. Ye. Andrushchak ◽

I. V. Tsikorska

Keyword(s):

Decision Trees ◽

Nursing Care ◽

Care Plan ◽

Care Planning ◽

Nursing Process ◽

Plan Implementation ◽

Physical Assessment ◽

Nursing Diagnosis ◽

Information Models

The paper presents information models of the nursing process through a conceptual presentation, including assessments of the patient's overall condition (nursing interviews, physical assessment, measurement, documentation analysis), nursing diagnosis, nursing care planning, determination of expected results, nursing manipulation, care plan implementation and care results evaluation. Particular attention is drawn to the possibility of using international terminology in describing nursing practices. Analysis of solutions is carried out using the terminology of decision trees.

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Care planning and adherence to diabetes process guidelines: Medicare data analysis

Australian Health Review ◽

10.1071/ah11136 ◽

2013 ◽

Vol 37 (1) ◽

pp. 83 ◽

Cited By ~ 2

Author(s):

Akuh Adaji ◽

Peter Schattner ◽

Kay Margaret Jones ◽

Bronwyn Beovich ◽

Leon Piterman

Keyword(s):

General Practice ◽

Strong Association ◽

Hdl Cholesterol ◽

Practice Management ◽

Care Plan ◽

Care Planning ◽

Process Measures ◽

Care Plans ◽

Management Plans ◽

Chi Square Analysis

Objective. To test the association, in patients with a diagnosis of diabetes I and II, between having or not having a care plan, (i.e. General Practice Management Plans (GPMPs),Team Care Arrangements (TCAs)), and having the recommended number of biochemical checks according to the diabetes Annual Cycle of Care guideline. The checks comprised HbA1c, HDL cholesterol and urinary microalbumin. Methods. Chi-square analysis of retrospective group data obtained from the Medicare database (from ‘billing’ patterns only). Results. The creation of GPMPs was associated with general practitioners (GPs) requesting checks for HbA1c (59.7%), HDL cholesterol (36.9%) and microalbumin (50.8%) for diabetes patients in accordance with guideline recommendations. Although the introduction of multidisciplinary care via a TCA was associated with an increase in the frequency of HbA1c checks (61.3%) in accordance with the guidelines, there was a reduction in the number of HDL cholesterol (23.7%) and microalbumin (36.8%) checks. The group with no care plans had the lowest association with HbA1c (47.8%), HDL cholesterol (19.7%) and microalbumin (29.3%) checks that met guideline requirements for diabetes. Conclusions. The use of GPMPs showed strong association with increased testing of process measures that met guideline requirements for diabetes. Further research is needed to understand the value and benefits of TCAs in promoting adherence to diabetes guidelines. What is known about the topic? Research suggests that care planning is associated with increased adherence by GPs to some of the processes of care stipulated in diabetes guidelines. What does the paper add? This study examines Australia-wide data obtained from Medicare. The findings demonstrated strong association between care planning and the process measures examined in this study. In contrast to previous studies, multidisciplinary team involvement via a TCA appeared to be less important than a GPMP in promoting adherence to process measures. What are the implications for practitioners? GPs should continue to provide structure care to patients via General Practice Management Plans.

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Can't See the Forest for the Care Plan: A Call to Revisit the Context of Care Planning

Journal of Clinical Oncology ◽

10.1200/jco.2012.48.4618 ◽

2013 ◽

Vol 31 (21) ◽

pp. 2651-2653 ◽

Cited By ~ 76

Author(s):

Carla Parry ◽

Erin E. Kent ◽

Laura P. Forsythe ◽

Catherine M. Alfano ◽

Julia H. Rowland

Keyword(s):

Care Plan ◽

Care Planning

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Prevalence and Benefits of Care Plans and Care Planning for People with Long-Term Conditions in England

Journal of Health Services Research & Policy ◽

10.1258/jhsrp.2011.010172 ◽

2012 ◽

Vol 17 (1_suppl) ◽

pp. 64-71 ◽

Cited By ~ 30

Author(s):

Jenni Burt ◽

Martin Roland ◽

Charlotte Paddison ◽

David Reeves ◽

John Campbell ◽

...

Keyword(s):

Patient Survey ◽

Care Plan ◽

Care Planning ◽

Cross Sectional Survey ◽

Cross Sectional ◽

Long Term Conditions ◽

Patient Reports ◽

Care Plans ◽

Interpersonal Care

Objectives Among patients with long-term conditions, to determine the prevalence and benefits of care planning discussions and of care plans. Methods Data from the 2009/10 General Practice Patient Survey, a cross sectional survey of 5.5 million patients in England. Outcomes were patient reports of: care planning discussions; perceived benefit from care planning discussions and resultant care plans. Patient and practice variables were included in multilevel logistic regression to investigate predictors of each outcome. Results Half the respondents (49%) reported a long-term condition and were eligible to answer the care planning questions. Of these, 84% reported having a care planning discussion during the last 12 months and most reported some benefit. Only 12% who reported a care planning discussion also reported being told they had a care plan. Patients who reported having a care plan were more likely to report benefits from care planning discussions. Several factors predicted the reporting of care planning and care plans of which the most important was patients' reports of the quality of interpersonal care. Conclusions There is a gap between policy and current practice which might reflect uncertainty as to the benefits of care plans. There is, therefore, a need for rigorous evaluation of care plans.

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