Using the longitudinal plan of care to drive better outcomes [podcast]

Almost every healthcare organization struggles with achieving a 360-degree view of its patients’ healthcare experience.

Even if you have a full grasp on how patients interact with your system, it’s harder to see the hundreds of other interactions that impact their health – from access to transportation to pharmacy visits to experiences with providers outside your system.  

Enter the longitudinal plan of care, a shared care plan that aims to combine insights from all these interactions into a single, easy-to-view location. The longitudinal plan of care (LPOC) could drive immense improvements in holistic care, but most organizations haven’t fully committed to implementing and using it.

In this podcast, Nordic’s Director of Optimization Solutions Rick Shepardson and Manager of Optimization Solutions Jake Aleckson discuss the benefits of a fully optimized LPOC and the path to better engagement from providers and patients. If you’d prefer to read rather than listen, the transcript is below.





Rick:  Hi. My name's Rick Shepardson, and I'm director of Optimization Solutions here at Nordic. I am joined today by Jake Aleckson.

Jake: Thanks, Rick. Appreciate the introduction. I’m Jake Aleckson, the manager of Optimization Solutions here at Nordic, working very closely with Rick. I've been in the Epic space now for about 10 years, working primarily on the ambulatory side, and I’ve done quite a bit of Healthy Planet work. I think we're here to talk a little bit about the longitudinal plan of care today.

Rick: We are here to talk about the longitudinal plan of care, Jake. It's a piece of functionality that many organizations have implemented it in some way over the years, as far as I understand. However, they don't necessarily get as much bang for the buck out of it as they could. There are a lot of ways that I think you can optimize that area, and I want to talk a little bit about that today.

Let's start out by framing a little bit about what we mean by the longitudinal plan of care – the LPOC, as some people call it. People set expectations during implementation that, “We're going to have this full list of the patient’s needs and be able to track and monitor and manage them throughout the duration of their care needs.” This is something that got built early on, but as we have moved further into this population health world, it's more and more important to be able to track patients' progression, monitor care gaps, be able to ensure that you're able to reach out to the patients that are falling off course, that maybe are struggling to stay healthy.

The longitudinal plan of care becomes this integrated tool that supports the patient and their engagement, as well as the care coordination and management of that patient.

There are a lot of different tools and use cases, if you will, for the longitudinal plan of care, but a lot of it comes down to: How do you really build it out to optimize it, to make sure it's as useful as possible to these different people? How do we help drive patient health and outcomes using it? I want to dive more into that. Maybe we can take it bit-by-bit.

So Jake, what are typically the components of the longitudinal plan of care? What are the key pieces there?

Jake: Yeah, I think that there are a number of items on that plan of care. I think that the top four are that care coordination note, which is that summary of the patient's current situation, who's on the care team, and quick updates, so that if staff are looking at that patient's plan of care in the ED, in the inpatient, on the outpatient side, they know what’s going on with that patient.

The problem list is the other piece, where clinicians can get a quick snapshot of the patient's key problems and the most recent update on those problems.

Another area is the goals. This is an area that is newer to Epic within the last few years and newer to organizations around asking and tracking goals. Another piece that I think is important is who is on the patient's care team. It's important for everybody that's on the care team to know who else is caring for the patient, so keeping that accurate is important.

Rick: So four key pieces, who is on the care team for that patient, the notes that they're writing, the problems that they're trying to address for that patient, and the goals for that patient, how that patient can stay on track and stay healthy. Is that right?

Jake: Yes, I think those are the four key pieces. There are also medications, recent visits, upcoming or overdue tests within health maintenance on the recommended LPOC, but those are the four key pieces that clinicians and people on the care team should be concentrating on.

Rick: Yeah, and a lot of people are focusing on some of these health maintenance reminders now. That's a big area of opportunity because the health maintenance reminders are ways to make sure the patients are following up on some of their care needs. Maybe it's a foot exam for the diabetic, or an immunization, or some of these different medications that they need to be taking, or annual visits, right? These health maintenance reminders can be made visible to both the provider and the patient via the longitudinal plan of care, right?

Jake: Yeah. That's one of the pieces.

Rick: Yeah, and I think that the other really cool area that's being integrated now is social determinants, right? Can you talk a little bit about social determinants and how they fit in?

Jake: Yeah, so an example of a social determinant is the type of transportation – including if there are limitations on their transportation, if that patient has social or financial needs. This is an area that has maybe been documented before but always hasn't been called out. I know Epic is releasing new smart forms specific to capture this information during those care coordination visits. That information is obviously appropriate to be placed right on that plan of care, because they're key pieces of information for caring for that patient.

Rick: Yeah. You hit on another key point there, too, which is the smart forms. Ultimately, the reason you build smart forms is to make it as efficient as possible to document. In this area of care coordination, where these care coordinators are responsible for vast populations of patients, have you found the longitudinal plan of care to be something that allows them to efficiently view and care for and document patient care needs and know where to find it that it streamlines workflows?

Jake: I think that organizations that have successfully used the LPOC make sure that the areas of documentation are available to everybody and are well-educated, so that everybody on the care team are documenting in those areas that then populates this place of care. That's not always the case, though.

Rick: Yeah. So starting to hit on more of these different people that are using the plan of care, and really there's no end to who can use and benefit from this tool, is that fair?

Jake: Correct. I think the primary users are going to be the PCP and those care managers that are managing that patient's care. But there are also specialists that are able to go and see what else is going on with this patient and what other medications they’re on. And then clinical support staff. I think you touched on this earlier, but the patient also has access to this within My Chart so that they're able to be more part of the care team. But then also the community, as well, which I think we'll touch on this in a little bit.

Rick: When you bring up that community, one of the biggest challenges when understanding what care the patient has received comes down to interoperability. That patient can be seen at your clinic, and then they can go down and be seen or get their shot at Walgreens or CVS. And then they can go to a competing clinic down the street and see someone there. How has the longitudinal plan of care evolved to support some of this 360 view of the patient?

Jake: You mention the interop aspect. Really, it's all about data. It's grabbing that external data from whatever source that may be. It may be claims data, it may be the organization down the street, it may be that CVS. Gathering as much of that information, bringing it into your system, making sure that it's discrete, mapping it to the correct places, so then it displays in this longitudinal plan of care.

Rick: All that can be integrated in the data warehouse in Caboodle, right? There are a lot of different ways that you can integrate that data. And then once it's available, just will show up in the longitudinal plan of care. What are the options there?

Jake: There's actually an on/off switch as far as whether clinicians want to see that external data on that longitudinal plan of care. One example is the continuity of care documents – the CCD documents that are coming in through Care Everywhere. Organizations are able to map the data points of the goals, the care coordination notes, and the problem list. They’re able to map those pieces, and then that information is able to display and give the clinician the ability to turn it on and off.

Rick:  Yeah. They can turn it on and off or they can validate it. Once the patient comes in and sees them, they can ask, "Oh, did you get that vaccine when you were at CVS?" And it kind of fosters more of that communication.

Jake: Yeah, and I think what you're getting at is reconciling outside information – bringing it into the native EMR.

Rick: It also allows the clinicians to have a bigger picture view of what is happening in that patient's life and get that snapshot view, rather than digging all over the chart. I think this is one of the biggest wins of using the longitudinal plan of care and centralizing all of that information.

Jake: On this topic, I think this is one of our biggest optimization opportunities. How do we make this a more valuable tool for the care team? This is probably the number one way, to make it as complete as possible with as much data as is available to them.

Rick: Yeah. If that's the win, if that's the end stake, getting all this patient data from all these different organizations, consolidated in an easy-to-use view that helps drive problem improvement and patient goal attainment, that's a pretty lofty spot. What are the challenges? What are some of the things that catch organizations up along the way?

Jake: It’s making sure that all the users, all the clinicians, understand where to document so that it displays. That’s going to include that goal section and the overview note of the problem list. One of the problems is that it could be seen as double documentation in some situations. Trying to educate and foster and show the importance of that data in the longitudinal plan of care and adding value to that is a challenge and is an important piece.

Another is just access to the report. The snapshot is probably, at least on the ambulatory side, one of the most commonly used reports, and it's because the report comes up right when you open the patient's chart. I think one of Epic's recommendations is put this longitudinal plan of care right on the first tab of Chart Review. And I haven't seen a lot of organizations do that, and I think part of it is because they’re thinking, “Is there enough value, yet, in this plan of care?"

Rick: Well, and Chart Review has been around for a long time. People are scared to disrupt Chart Review. But also, who wants to go dig through Chart Review, and how do you find all the relevant information? I created custom searchers for Chart Review to help people find it. I spend validation sessions creating Chart Review tabs and views and reports. If there's an opportunity to sort of suck all the key information out of Chart Review and put it into a single view, I would imagine that, in a progressive organization, there might be a lot of value for physicians. They'd probably buy into that.

Jake: Yeah. We would hope.

Rick: Yeah. In this new world, they kind of have to, right? In this whole value-based world?

Jake: Correct. But, yes. I think that first, right when you open Chart Review, if the plan of care is available, that has to increase adoption a little bit.

Rick: Yeah. So getting the clinicians to document in the right places so that it can be made available in the longitudinal plan of care, and then making the longitudinal plan of care available as accessibly as possible?

Jake: Yep. Those are the first two. I think another one is responsibilities. Whose responsibility is it to update these certain areas? It’s about making sure that there's clear guidelines, and one of the big decisions right on the Epic recommended LPOC decision tracker is, should nurses be able to document in the problem list? Again, the problem list is a key piece. The overview note needs to be populated, it needs to be up-to-date, and if we can't get clinicians, maybe the care coordinators or the RN's need to be able to offer that value. Now that's a big debate and we're not going to get into it today.

Rick: No. I had a client ask me about that a couple months ago, and I didn't want to touch that one, really. But you have too, right? So maybe we'll save that. Maybe we'll have a future podcast and talk about the warrants and considerations around nurse documentation on the problem list because that, I think, deserves its own time.

Jake: Problem lists in general. Problem list cleanliness.

Rick: Right. So we could probably riff on that for a while, but as we bring it back to the longitudinal plan of care, I think that taking some steps to get this integrated into an organization's EHR, being able to leverage it to consolidate data for external organizations and support interoperability needs, and being able to allow the clinicians to provide more accurate care and more timely care, right? Keeping the right care team members involved. Those are really powerful things, in this world where organizations are taking on more risk and more accountability for the patient's health.

There's the ability to use some decision support to help guide the clinicians along the way, right, with health maintenance reminders?

Jake: Yeah, definitely. I think at the point of care, there's the ability for health maintenance. There's various care gaps, quality measures that need to be met, and using health maintenance as a tool that's available to the patient usually and just from a tracking standpoint is important.

Rick: Yeah. So, being able to use some of that decision support, some of those health maintenance reminders correctly, allows it to kind of consolidate everything.

And what about some of the external groups? What about that care team down the road that you're affiliated with? Is there a tool to support that?

Jake: That's newer functionality, Healthy Planet Link. That is an add-on, an additional functionality to EpicCare Link. It’s about giving access to the community and giving access to other organizations to your EMR, but through a web-based portal. Healthy Planet Link gives the ability to give reporting workbench lists to partners. It’s the first step right now in giving access to this patient's record, giving the ability to view and, in some cases, to document. They are able to close care gaps. That will then feed back into the EMR, but I see that progressing and ultimately having a shared record without giving them access to your EMR.

Rick: Yeah, absolutely. I mean, it's a snapshot of the critical components of the EMR and the patient's condition and continuation, right?

Jake: And it's going to add more value because there's going to be more information on the plan of care.

Rick: So, we've got the benefit for these external care coordinator groups. We've talked about the benefit for your internal care coordinators. We've talking about internally the physicians, the clinicians during the visits, during the ED visits, right? It's a little bit for everyone. It's also for the patient, too. You can put it in My Chart?

Jake: Yep. It's available in My Chart, and with some of the recent upgrades, the pictures of the clinicians, the people on the care team. That can be very powerful for patients to be able to see, "Oh, yes. Those are the providers I've seen, and it's great to see that they've teamed up to provide better care for me." Versus, "Oh, I see this specialist once a year." But really, they are part of your care team.

Rick: So it's a great engagement tool, too. And tying this all together, as this patient is going though these care episodes, they know they have a chronic disease. They know that they need to improve their health and wellness. Having a single pane of glass, so to speak, to be able to pull the critical parts, components out of the patient chart, be able to demonstrate the care team, be able to help target the patient, or help the patient stay targeted on their own goals and their own outcomes, and be able to consolidate all of this into a single tool that supports all of these people on this patient care progression. That's really what the longitudinal plan of care is all about.

Jake: Excellent summary.

Rick: So really, I hope that you guys enjoyed this, learned a little bit about pop health along the way, and longitudinal plan of care.

If you have any questions, we would love to talk to you about it We're happy to riff and see what's on your mind. Feel free to reach out.

Jake: Thanks, Rick.

Rick: Thank you, Jake.



Topics: improved outcomes, population health

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