A roadmap to the future of person-centered care planning.

ABOUT THE PRINCIPLES

Much of current care planning is composed of pen and paper based legacy processes that are isolated within the hospital walls and medical professionals. There is limited co-design and coordination of care plans involving all care team members and the care recipient. The result is a lack of guidance and an overwhelming firehose of medical information, resulting in poorer health outcomes and reduced care plans adherence.

Our team of healthcare designers and nursing domain experts have evaluated the latest and emerging ideas in person-centered care planning within the healthcare space with an emphasis on the care recipient.

Our goal is to communicate a product based conceptual manifestation of a future facing person-centered care plan within precision medicine, which can be used as a guide for current and future care planning products, services and health policy.

The principles of person-centered care planning

CARE PRINCIPLES

  1. Care is person-centered
  2. The care recipient is a full partner in their own care and its leader to the best of their wishes and ability. Care planning leads with person-centered participation followed by provider-centered education.

  3. Education is a part of care
  4. Care recipients must understand and accept the reasoning and rationale for medical treatment to the best of their wishes and abilities, increasing motivation and responsibility for their own health.

  5. Know the health agenda
  6. Care planning by members of one’s care team begins with an assessment of health concerns, goals, values, preferences, and capacity.

  7. Use the social determinants of health
  8. Care planning merges management of environmental concerns (environmental, behavioral, social, biological, medical) with the management of medical problems (treatments and therapeutics) leading to identification of goals and action planning.

  9. Keep accountability
  10. Important steps in the person-centered care plan include who’s accountable, when goals and actions will be completed, and where to go as questions arise.

  11. Communication is open
  12. Streams of communication should be open and accessible to all care team members as their roles and permissions allow.


DESIGN PRINCIPLES

  1. The intervention engine drives care
  2. The care planning service should provide actionable steps at the right time, based on new health information that is continuously being collected.

  3. Provide the right data at the right time
  4. Health is complex. Prevent information overload by analyzing, interpreting and providing the right health information at the right time for the right person.

  5. Population data drives precision medicine
  6. Care planning feeds the discovery of what works for individuals and populations. Population level data specific to the care recipients demographic and health situation can be used to drive health recommendations.

  7. Health data is continuous
  8. The care plan should be fluid in its understanding of the care recipient. It should continuously learn more about the care recipients values, preferences, and contraindications based on new information.


POLICY PRINCIPLES

  1. Data must be owned
  2. Access to your health data is a human right. The patient co-owns or fully owns every personal health data point about themselves.

  3. Data should be shared
  4. Clinicians will collaborate with patients to responsibly use health data for betterment of public and patient health.

  5. Data must be responsibly used
  6. Criminalize the pejorative use of personal health care data.

  7. Health data is a public resource
  8. Provide access to scientific research, develop tools and materials to engage the imagination of the public and accelerate scientific discovery.

  9. Data usage must be transparent
  10. Visibility into who, what, when, how people and services use your health data.


By Danny Van Leeuwen, Edwin Choi, Juhan Sonin

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