Care Plans

A care plan is structured care that a patient follows over time: a checklist of tasks, such as taking a medication, and a set of goals, such as keeping blood pressure under a target. Plans are written centrally. Your organization offers its own plans and the shared plans made available to it.

A patient is enrolled in a plan for one episode, from the day it starts until it is completed, discontinued or abandoned. To follow the plan again later, enroll the patient again. Each episode keeps its own history.

The Care Plans card

The card is in the Monitoring section of an active visit. It lists the patient’s active plans, each with a summary such as “3/4 tasks · 1/2 goals on track”. A plan the patient enrolled in themselves is marked Patient. Goals are measured in the background: a vital sign, lab result, symptom, exercise, sleep, nutrition or emotional state entry you record reaches the summary within a few seconds, and a newly enrolled plan shows its goals once they are first measured. While a plan is being measured it shows Updating goals…; the summary updates on its own when it is done, with no need to reload the page.

• Enroll adds the patient to a plan. The patient must be monitored by your organization first. If they are not, Enroll asks you to monitor them: choose Monitor to turn monitoring on and continue, or Cancel to stop. If your role can’t monitor patients, it tells you to ask someone who can. Monitoring can’t be stopped while one of your plans is active for the patient. Pick the plan, the start date, and optionally a target end date. The list offers your organization’s own plans and the shared plans made available to it, in their latest published form; plans still being written or withdrawn are not offered. New organizations start with four ready-made plans: Weight Management, Type 2 Diabetes, Hypertension Control, and Cholesterol and Heart Health. Selecting a plan shows its description. Without one, the plan’s suggested duration is used. A plan with a goal measured over the whole plan needs a target end date.
• The expand icon opens every plan, including ended ones. There you can also show plans you have hidden, and choose whether to include the patient’s own plans.
• Click a plan to open its details.

On a read-only (closed) visit you can still open every plan and its details, but you can’t enroll, tick tasks, end or hide plans.

A plan’s details

Tasks are ticked off by hand, by you or by the patient. Each shows when it was ticked. Tasks marked Required are the essential ones.

Goals are measured automatically from the patient’s readings (vital signs, lab results, symptoms, and the exercise, sleep, nutrition and emotional state entries). Each goal is measured over periods, daily, weekly, every 30 days, or once for the whole plan, counted from the day the plan started. Each goal states its target in words, naming the reading it measures in your language, such as “average Systolic Blood Pressure under 130, weekly”. For each period you see:

• the measured value, such as the latest, average, lowest or highest reading, or how many readings there were;
• how many readings the period holds;
• On track or Off track against the target, or No readings.

Exercise, sleep, nutrition and emotional state entries are recorded per day, so they count as one reading per day: the day’s total exercise minutes, the day’s average nutrition score over its meals, and the day’s latest sleep or emotional state entry. A day belongs to the period it falls in (days end at midnight UTC).

Some goals count entries in chosen categories rather than measuring a number, such as “Number of Hours of sleep (7+ hours) ≥ 3, weekly”: nights with seven hours or more, at least three a week. Their value is how many entries were in those categories; the readings column still counts every entry of the period.

The period still running is marked In progress and is measured again a few seconds after each new, corrected or deleted reading. A finished period never changes, even if a reading inside it is corrected or deleted later. A plan that started in the past, or that changes its end date, has its periods measured in the background, so they can take a moment to appear.

A plan your organization enrolled the patient in is measured against readings recorded by your organization and by the patient. A plan the patient enrolled in themselves is measured against all of their readings.

End plan closes the episode as completed, discontinued or abandoned, as of now. An ended plan can’t be reopened, and its tasks can no longer be ticked. Only your organization’s own plans can be ended here.

The patient’s own plans

Patients can enroll themselves in shared plans. You see such a plan only if the patient shares it with your organization. You can follow it and hide it from your view, but only the patient can tick its tasks or end it.

Hiding a plan only removes it from your default view. It never removes anyone’s access, and the patient can hide your organization’s plans from their own view in the same way.

Who sees what

• Staff need permission to view the patient’s care plans. Enrolling, ticking tasks, ending and hiding need permission to assign care plans. Your organization’s licence must include care plans. Without the permission to view them, the card is not shown.
• Patients see all of their plans, from every organization and their own. They tick tasks on any active plan and run the plans they enrolled in themselves.