What is the plan of care?

From the Guidelines

The plan of care should be collaborative, patient-centered, and tailored to the individual's specific circumstances and goals, with a focus on prioritizing and sequencing care to address identified problems and promote optimal patient outcomes. When developing a plan of care, it is essential to conduct a thorough assessment of the patient's physical, psychological, and social needs, and establish clear, measurable goals based on the assessment findings 1. The plan should incorporate patient education about their condition, treatment options, and self-management strategies, as well as schedule regular follow-up appointments to evaluate progress toward goals and adjust the plan as needed. Some key considerations in developing a plan of care include:

• Collaborating with the patient to identify and prioritize problems, such as high blood pressure or shoulder pain, and developing action plans to address these issues 1
• Incorporating advance care planning, which involves making pre-determined decisions regarding healthcare in the event the patient becomes incapable of participating in decision making at a later time 1
• Using shared decision-making, which involves eliciting patient values and priorities, sharing medical information, and assisting the patient in making treatment choices 1
• Documenting all aspects of care thoroughly, including the patient's response to interventions, to ensure continuity of care and promote optimal patient outcomes. By taking a collaborative, patient-centered approach to care, and prioritizing and sequencing care to address identified problems, healthcare providers can promote optimal patient outcomes and improve quality of life. For example, if managing hypertension, a regimen might include Lisinopril 10mg orally once daily, with instructions to monitor blood pressure twice daily and maintain a blood pressure log, and regular follow-up appointments to evaluate progress and adjust the plan as needed 1.

From the FDA Drug Label

5 WARNINGS AND PRECAUTIONS

1. 1 Myopathy and Rhabdomyolysis Atorvastatin calcium may cause myopathy (muscle pain, tenderness, or weakness associated with elevated creatine kinase [CK]) and rhabdomyolysis. Steps to Prevent or Reduce the Risk of Myopathy and Rhabdomyolysis Atorvastatin calcium exposure may be increased by drug interactions due to inhibition of cytochrome P450 enzyme 3A4 (CYP3A4) and/or transporters (e.g., breast cancer resistant protein [BCRP], organic anion-transporting polypeptide [OATP1B1/OATP1B3] and P-glycoprotein [P-gp]), resulting in an increased risk of myopathy and rhabdomyolysis. Concomitant use of cyclosporine, gemfibrozil, tipranavir plus ritonavir, or glecaprevir plus pibrentasvir with atorvastatin is not recommended Atorvastatin calcium dosage modifications are recommended for patients taking certain anti-viral, azole antifungals, or macrolide antibiotic medications [see Dosage and Administration ( 2. 5)] . Discontinue atorvastatin calcium tablets if markedly elevated CK levels occur or if myopathy is either diagnosed or suspected. Temporarily discontinue atorvastatin calcium tablets in patients experiencing an acute or serious condition at high risk of developing renal failure secondary to rhabdomyolysis (e.g., sepsis; shock; severe hypovolemia; major surgery; trauma; severe metabolic, endocrine, or electrolyte disorders; or uncontrolled epilepsy). Inform patients of the risk of myopathy and rhabdomyolysis when starting or increasing the atorvastatin dosage. Instruct patients to promptly report any unexplained muscle pain, tenderness or weakness, particularly if accompanied by malaise or fever.

The plan of care includes:

• Monitoring for myopathy and rhabdomyolysis
• Avoiding concomitant use of certain medications
• Dosage modifications for patients taking certain medications
• Discontinuing atorvastatin calcium tablets if markedly elevated CK levels occur or if myopathy is diagnosed or suspected
• Temporarily discontinuing atorvastatin calcium tablets in patients at high risk of developing renal failure secondary to rhabdomyolysis
• Informing patients of the risk of myopathy and rhabdomyolysis and instructing them to report any unexplained muscle pain, tenderness, or weakness 2

From the Research

Plan of Care

The plan of care is a comprehensive and patient-centered approach that involves multiple disciplines and settings. Key components of the plan of care include:

• A dynamic document maintained by an interdisciplinary team that contains specific, actionable information for clinicians and staff across multiple care settings 3
• Communication strategies, medical plans, and psychosocial resources to promote communication and continuity of care 3
• Identification of patients for care coordination based on claim-driven risk assessments and social determinants of health (SDOH) 4
• Customized engagement in intensive care coordination to address SDOH risks and promote optimal health 4

Effective Interventions

Effective interventions for improving patient outcomes and healthcare system return on investment include:

• Evidence-based practices (EBPs) such as infection prevention, case management, and self-management 5, 6
• Integrated care interventions such as chronic care model (CCM), discharge management, and multidisciplinary teams (MDT) 5
• Care coordination interventions informed by SDOH to mitigate risks and promote optimal health 4

Implementation and Evaluation

Implementation and evaluation of the plan of care involve:

• A systematic, transparent, and stakeholder-driven process to identify, evaluate, and prioritize evidence-based interventions for broad dissemination and implementation 7
• Coordinated and consistent use of established nomenclature and methods to evaluate EBPs and patient outcomes 6
• Measurement of return on investment (ROI) and patient outcomes such as length of stay and mortality 6