Mar 242014

Two very different programs in Minnesota have been improving care plans for frail elderly clients. Coherent and effective care plans, so essential to good care for frail elders, are simply missing from most clinical practices.

Medicaid recently issued regulations requiring care plans in home-based primary care. Care plans are centrally important in the work of the few geriatric or palliative care teams,  hospice programs, and PACE. But in most care settings, no plan coordinates the half dozen specialist referrals, community-based services, and various care manager and discharge planner assessments. How can we improve that?

Geriatric Services of Minnesota (GSM) has teams of full-time primary care doctors and nurses working to create a safe system of care for frail elders in Minneapolis. They negotiate a written plan with patient and family within 2 months of an elder coming into their care. The plan characterizes the person’s life story, the current situation, and likely future course. It also lists the goals upon which all have agreed, the implications for any acute situation, and the plan for ongoing support. Virtually all patients have a POLST, which summarizes instructions and key decisions for an emergency and identifies the surrogate decision maker. For GSM, the responsible clinician documents the care plan and ensures continuity of care across time and setting by always being available to the on-call physician or nurse practitioner (NP). Dr. Nick Schneeman, the project’s lead physician, says, “Physicians, the NPs, and the entire clinical team are trained to think about and access the patient’s goals of care for every interaction and before any prescriptions, testing or referrals are even contemplated. Sounds simple, and in a way, it is; but it is transformational.”

The LifeCourse project at Allina Health System takes a different path to a similar end. That project builds a deep understanding of the patient’s life story and provides trained lay persons (community health workers known as “Care Guides”) who help inform and guide clients and their families through the experience of living with serious illness and progressive disability. They work with a team that includes nurses, pharmacists, and behavioral therapists. They have contact with the patient’s primary care physician, and, although the team includes a physician, its primary focus is to provide support for physical, emotional, spiritual, and social issues, along with a practical plan for daily needs. LifeCourse has enhanced its EPIC medical records system with a “What Matters Most” feature to record goals as the patient or family member says them. You can learn more about the LifeCourse project at

These are two very different approaches, but they share some important strategies.

  1. They ensure that the care team knows enough about the patient and family and the likely future course to help make workable plans that suit the situation and their priorities.
  2. They effectively integrate and implement the plans across time and settings.
  3. They are engaged with their community’s resources and are clever and thoughtful about creating a workable plan.

Of course, they are quite different from one another in emphasizing a physician coordinator or a layperson guide, and it will be very interesting to see how they affect the experience of elders and their families and the costs of care.

Where are the good models for care planning?

Do you know of a program that is doing a good job of care planning for frail elders? Who is working on these issues? What do you think, and what do you see happening? How could we measure the quality of care plans and care planning? What could encourage caregivers to demand good care plans? We are eager to hear from you.

Post a comment below or send email to [email protected].

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