Patient is also assessed for Longer term management needs including Needs for other professional care services Rheumatologist Physiotherapist Occupational therapist Dietitian Pharmacist Clinical psychologist Social worker, etc Plan of care for The PCP/GP develops a plan of care for managementof management of the patient’s complex complex health health concerns/problems arising from the problems rheumatoid arthritis Referral to other health care providers LCC Perspective: The patient agrees with the longer term plan Plan of Care is of care and referrals to other health care created when 2 professional as recommended by PCP/GP or more treatment plans need to be reconciled) + referrals The patient makes appointment with and is nil seen by the following health care professionals / specialist for assessment and care: Rheumatologist Physiotherapist Occupational therapist Dietitian Pharmacist Clinical psychologist Discipline specific Social worker, etc treatment plans Each health care professional/specialist LCC Perspective: identifies one or more health or Plans of Care concern/problem from his/her perspective, (depending on # discusses discipline specific treatment plan of health LCC with the patient concerns per Perspective: The treatment plans are accepted by the specialist) Care Plan is patient (some with modifications) Each health care professional/specialist Progress notes Discipline produces a progress report that includes (with treatment specific plan of relevant components of treatment plan to plan components) care be sent to patient’s PCP/GP to PCP/GP Progress notes with treatment and plan of care
Patient is also assessed for Longer term management needs including Needs for other professional care services Rheumatologist Physiotherapist Occupational therapist Dietitian Pharmacist Clinical psychologist Social worker, etc The PCP/GP develops a plan of care for management of the patient’s complex health concerns/problems arising from the rheumatoid arthritis Referral to other health care providers The patient agrees with the longer term plan of care and referrals to other health care professional as recommended by PCP/GP Plan of care for managementof complex health problems LCC Perspective: Plan of Care is created when 2 or more treatment plans need to be reconciled) + referrals The patient makes appointment with and is seen by the following health care professionals / specialist for assessment and care: Rheumatologist Physiotherapist Occupational therapist Dietitian Pharmacist Clinical psychologist Social worker, etc Each health care professional/specialist identifies one or more health concern/problem from his/her perspective, discusses discipline specific treatment plan with the patient The treatment plans are accepted by the patient (some with modifications) Each health care professional/specialist produces a progress report that includes relevant components of treatment plan to be sent to patient’s PCP/GP Discipline specific treatment plans LCC Perspective: or Plans of Care (depending on # of health concerns per specialist) Progress notes (with treatment plan components) to PCP/GP Discipline specific plan of care Progress notes with treatment and plan of care nil LCC Perspective: Care Plan is
PatientJourney-PCP_care-and-Types_of_CarePlan_v-2013-11-27_SChu_LCCv2.docx