Shared Plan of Care

Getting to know the patient and family

Part one of the SPOC explores the person. Health care is about people. It is personal and relational. Building an understanding of the patient and family is important to shaping the care that best fits the individual person and their surrounding family and supports.

In addition, where people are born, live, learn, work, play, worship and age has a significant impact on health and quality-of-life outcomes. These social determinants of health are important to the coordination of care.

Each person has their own unique strengths as well. A strengths-based approach takes into account what is functioning well, what the person does best and what resources the person has available to them.

A whole person approach acknowledges both empowerments and barriers to achieving best health and quality of life.

The portable medical summary

Part two of the SPOC is the informational snapshot of the patient’s health history and current state.  Collecting and synthesizing accurate information from the past history and the current whole care neighborhood allows for a clearer demonstration of the patient’s complex health needs. This makes it easier for everyone engaged in care delivery to have an aligned approach to that care. The SPOC summarizes chronic conditions, medications, treatments, equipment, subspecialists, procedures, and service providers.

Goals and actions

Part three of the SPOC summarizes “what’s next”. Patients and families who deal with medical complexity often describe themselves as in survival mode.  Families report that this creates a type of crisis thinking that can make it hard to imagine the future.  Care coordination works to alleviate existing initial crisis issues to afford the space to think proactively. To build strong relationships at the start, it starts with a question like “What is your priority or what you need most right now to help you?”  It works to create a view of the whole person to help families move towards developing a long-range vision for health and wellness, in addition to helping with the days that feel chaotic.

A structured and comprehensive intake interview can help families identify needs that they did not even realize they had. Care coordination shifts families and their healthcare team from a mindset of “putting out fires” to a frame that anticipates needs and helps patients flourish in their best lives.

Sharing SPOCs

If aligned care is the goal, it is critical to share SPOCs across the patient’s care neighborhood. SPOCs should be shared across different health systems where a patient may receive care. They should be shared with specialists, home care agencies, school nurses, other case managers and additional service providers who would better serve the person with this summarized information.

• In IC4, SPOCs are regularly updated—at least every six months and when new health events occur that change the plan.
• Patients and families are encouraged to keep a copy of the SPOC available to share any time they need to tell their story, for example at an emergency room visit.
• SPOCs are used at primary care visits to help the team provide effective and satisfying chronic care management for each patient and family based on their shared needs and priorities.