In Holistic Care Coordination (HCC), it's critical to identify needs and establish a plan for meeting those needs in partnership with the individual or family. One way to do this is through a tool called the Shared Plan of Care (SPoC), or Action Plan. This plan is a living document to assure the care provided meets needs and ensures accountability from all parties.
Be comprehensive. The SPoC should include all important components of the individual’s life, such as health summary; clinical, functional, developmental and social goals; any upcoming transitions, such as medical or social transitions; an emergency plan; and a disaster plan (see Standard 2.3 for more information).
Electronic communication. Communicating and the ability to share plans electronically with others (e.g., patients, families, providers, individual-serving systems) will support successful implementation of these plans. (see Standards 2.8, 2.10, and 2.11 for more information).
Plans for communicating. The SPoC should include a communication plan for individuals and/or families to contact members of the care team via phone, email or text (see Standard 2.7 for more information).
Review, revise and reframe regularly. The SPoC should be reviewed, monitored and updated regularly. This depends on the intensity of care coordination, life events (e.g. response to a triggering event) and family need (see Standard 2.9 for more information).