Scenario #1A – Care Plan Structure: Beginner Level

Create a Care Plan Document that has 1 Health Concern. The Care Plan has 1 Goal and that Goal addresses the 1 Health Concern.  The Care Plan includes two planned Interventions. Both Interventions are associated with attaining the 1 Goal. The relationships between the Health Concerns, Goals, and Interventions are explicitly indicated in the Care Plan Document.

Scenario #1B- Care Plan Structure: Intermediate Level

Create a Care Plan Document that has 1 Health Concern. The Care Plan has 2 associated Goals.  The Care Plan includes five planned Interventions. Three Interventions are associated with attaining the first Goal and two are associated with attaining the second Goal. One of the Goals for addressing the second Health Concern also addresses the first Health Concern. The relationships between the Health Concerns, Goals, and Interventions are explicitly indicated in the Care Plan Document.

 

Scenario #2A – Care Plan Content: Experienced Level (t0)

The patient from Scenario #1 also has other comorbidities (other Problems) that are not the primary focus of the Care Plan but are considered relevant to the patient’s care. Also, an initial clinical assessment was done before the patient’s care plan was created.

Scenario #2B – Care Plan Content: Experienced Level (t1)

Start with the Care Plan from Scenario #2A. Produce a view of the plan later in time. At least one of the planned Interventions has been completed.

Scenario #2C – Care Plan Content: Experienced Level (t2)

Start with the Care Plan from Scenario #2B. Produce a view of the plan later in time.  An assessment has been performed to assess the progress the patient is making toward the goals of the Care Plan.

Scenario #2D – Care Plan Content: Experienced Level (t3)

Start with the Care Plan from Scenario #2C. Produce a view of the plan later in time. The patient’s care has been transferred to a new team. The patient has been discharged from the practice that managed the plan in Scenario #2C.  The care plan from Scenario #2C is no longer an active plan.  Create a Plan that reflects what the Care Plan looks like at the point of discharge when the plan was “completed” and the patient was transferred to the new team or transferred to self-care.

Scenario #3A-Care Team-Beginner Level

Start with the Care Plan from Scenario #1A. Add a Care Team Section and populate it narrative information about the Patient’s care team. Include one care team with more than one care team member.

Scenario #3B-Care Team-Intermediate Level

Start with the Care Plan from Scenario #1A. Add a Care Team Section and populate it narrative information about the Patient’s care team. Include at least one care team with more than one care team member. Include machine processable representation of the care team member information in the section.

Scenario #4A-Social Determinants of Health/ Long-Term Services & Supports-Beginner Level

Start with the Care Plan from Scenario #2A. Assume an LTSS assessment has been completed and serves as input to the Care Plan. Use the Problem Concern Act template within the Health Concern section to enter an Assessed Need (a community-based necessity or desire as identified through an assessment that should be addressed as a service).  For example, an assessed need for physical activity to address an obesity health concern. 

Add a Health Status Evaluation and Outcomes section.  In that section, add textual information about the date and type of Assessment performed and add a description of 1 Strength (a favorable attribute the individual has identified about themselves). Social Determinants of Health are defined by the CDC ( https://www.cdc.gov/nchhstp/socialdeterminants/definitions.html ) as, “The complex, integrated, and overlapping social structures and economic systems that are responsible for most health inequities. These social structures and economic systems include the social environment, physical environment, health services, and structural and societal factors. Social determinants of health are shaped by the distribution of money, power, and resources throughout local communities, nations, and the world”.

Also add 1 piece of information collected in that same assessment which is an observation about a relevant social determinant of health for this individual.