Planning Care

To open the Planning Care page, navigate to a client’s profile or record, and click on the Planning Care tab from the navigation bar (Figure x).

The Planning Care page is divided into three sections, which should help guide the conservation with the client to record information about their values:

Values - Who or what is important to the client?

The Values section revolves around who or what is important to the client. This is an opportunity to better understand who the client relies on for emotional support, and who relies on the client for various reasons. It also gives providers and/or care coordinators a glimpse into the client’s level of social engagement, or isolation.

To add a value for the client:

1. Click on the Add button (Figure x).

2. Enter details about who or what is important to the client in the text-box (Figure x).

3. If this value is currently relevant to the client, make sure the Active checkbox is marked (Figure x). This checkbox may be unchecked if this value no longer plays a major role in the client’s life.

4. Expand the Tag drop-down list to add an additional description for this value (Figure x). For example, select Family if the client’s value is related to a family-member or their family life.

5. Once all necessary information has been entered, click on the Insert button to add the value to the client’s record (Figure x). Click on Cancel to cancel adding a new value for the client.

To edit or delete a value for the client:

• To edit a value for the client, click on the Edit button (Figure x). Update any necessary information, and click on the Update button (Figure x).

• To delete a value for the client, click on the Delete button for the desired value (Figure x). A confirmation message will pop up (Figure x). to proceed with deleting the value, click on OK. If not, click on Cancel.

Aspirations - What would the client like to be doing?

The Aspirations section notes what the client would like to be doing, if they were healthy, or if they were able. If these aspirations involve the people/things that are important to the client (documented in the Values section above), the aspiration can be linked to a value. An aspiration that has a value linked to it will be noted at the top of each box (Figure x).

To add an aspiration for the client:

1. Click on the Add button (Figure x).

2. Enter details about the client’s aspiration in the text-box (Figure x).

3. To link the aspiration to an existing value for the client, expand the Map/Unmap Value drop-down selection, and choose the related value (Figure x).

4. Click on the Insert button to finish adding this aspiration to the client’s profile or record (Figure x). Click on Cancel to cancel adding this aspiration to the client’s profile or record (Figure x).

To edit or delete an aspiration for the client:

• To edit an aspiration for the client, click on the Edit button (Figure x). Update any necessary information, and click on the Update button (Figure x).

• To delete an aspiration for the client, click on the Delete button for the desired aspiration (Figure x). A confirmation message will pop up (Figure x). to proceed with deleting the aspiration , click on OK. If not, click on Cancel.

Barriers - What gets in the client’s way?

The Barriers section allows for the provider or care coordination, along with the client, to explore what barriers are preventing the client from achieving the values and aspirations that were examined in the previous sections. By documenting a client’s barriers, providers or care coordinators and clients can lay the ground work for developing goals for the client’s Care Plan.

To add a barrier for the client:

1. Click on the Add button (Figure x).

2. Enter a description of the client’s barrier in the text-box (Figure x).

3. To link the barrier to an existing aspiration for the client, expand the Map/Unmap Value drop-down selection, and choose the related aspiration (Figure x).

4. Choose whether this barrier is a System-Level Barrier or a Personal Barrier (Figure x). A system-level barrier would be something that is outside of the client’s control, but is worth recording to generate evidence around common system-level barriers. A personal barrier is something that the client can change themselves; for example, a barrier that requires a behavioral change.

5. On a scale of 1 to 10, enter the number that signifies the client’s Readiness to Change, with 1 indicating that the client is not inclined to change, and 10 indicating that the client is highly motivated to change. All barriers that are marked as a 6 with regards to readiness to change can be translated into goals (Figure x).

6. Mark the Active checkbox if this barrier currently negatively affects the patient, or mark the Has been overcome? checkbox if the barrier is no longer an issue for the client.

7. Click on the Insert button to finish adding this aspiration to the client’s profile or record (Figure x). Click on Cancel to cancel adding this aspiration to the client’s profile or record (Figure x).

To edit or delete a barrier for the client:

• To edit an barrier for the client, click on the Edit button (Figure x). Update any necessary information, and click on the Update button (Figure x).

• To delete an barrier for the client, click on the Delete button for the desired barrier (Figure x). A confirmation message will pop up (Figure x). to proceed with deleting the barrier, click on OK. If not, click on Cancel.

If a barrier had a Readiness to Change value of 6 or more, a goal can be created for the client. To do this, click on Create Goal (Figure x). The Client Goal window will pop-up, where the drop-down selection for This goal is to overcome the barrier is pre-populated with the current barrier (Figure x). From here, a template goal can be created, or a new goal can be created (Figure x).

To create a template goal:

1. Select the Goal Category from the drop-down selection on the left (Figure x).

2. Select the Goal from the drop-down selection on the right (Figure x).

3. Edit any necessary information about this template goal:

   1. Goal Name – the goal name can be changed from the text-box.

   2. Social Determinant – select the social determinant that this goal applies to can be selected from the drop-down selection.

   3. Expected Start/End Dates – the expected start and/or expected end dates of the goal can be changed by entering the new date in m/d/yyyy format, or picking the date by clicking on the calendar icon button.

   4. Status – the status of the goal can be changed by selecting the status from the drop-down selection.

   5. Actual Start/Completion Dates – the actual start date and/or the actual completion date can be changed by entering the new date in m/d/yyyy format, or picking the date by clicking on the calendar icon button.

   6. Completed By – select which provider or care coordinator completed by this goal by selecting their name from the drop-down selection.

   7. Goal Description – enter a description of the goal in the text-box.

   8. Notes – Enter any other notes about the goal in the text-box.

4. If the goal has any action steps associated with it, they will be listed in the Action Steps grid (Figure x). The following fields are editable for the goal’s action steps:

   1. Responsible Person – When clicking this cell, a text-box will appear where the person who is responsible for this action step can be entered (Figure x). The person can also be selected by expanding the drop-down selection and choose the care coordinator or provider’s name, or choose Client.

   2. Description – When clicking this cell, a text-box will appear where a description of the action step can be entered or edited (Figure x).

   3. Priority – The priority of the action step can be changed by clicking on the cell, and picking a new priority from the drop-down selection (Figure x).

   4. Due Date – The due date of the action step can be entered or edited by clicking on the cell and typing the new date and time in m/d/yyyy m:hh AM/PM format. The new date and time can also be picked by clicking on the calendar icon button, or the clock icon button respectively (Figure x).

   5. Status – The status of the action step can be updated by clicking on the cell, and selecting a new status from the drop-down selection (Figure x).

5. Once all necessary information has been entered, be sure to click on the Add button to the goal to the client’s record.

To create a new goal:

1. Select Create New (Figure x).

2. The following fields can be entered about the new goal:

   1. Goal Name – the goal name can be changed from the text-box.

   2. Social Determinant – select the social determinant that this goal applies to can be selected from the drop-down selection.

   3. Expected Start/End Dates – the expected start and/or expected end dates of the goal can be changed by entering the new date in m/d/yyyy format, or picking the date by clicking on the calendar icon button.

   4. Status – the status of the goal can be changed by selecting the status from the drop-down selection.

   5. Actual Start/Completion Dates – the actual start date and/or the actual completion date can be changed by entering the new date in m/d/yyyy format, or picking the date by clicking on the calendar icon button.

   6. Completed By – select which provider or care coordinator completed by this goal by selecting their name from the drop-down selection.

   7. Goal Description – enter a description of the goal in the text-box.

   8. Notes – Enter any other notes about the goal in the text-box.

3. Any action steps relating to the new goal can also be entered in the Action Steps grid (Figure x). Add a new action step by clicking on the + Add New Action Step button (Figure x). The following fields can be entered for the goal’s action steps:

   1. Responsible Person – When clicking this cell, a text-box will appear where the person who is responsible for this action step can be entered (Figure x). The person can also be selected by expanding the drop-down selection and choose the care coordinator or provider’s name, or choose Client.

   2. Description – When clicking this cell, a text-box will appear where a description of the action step can be entered (Figure x).

   3. Priority – The priority of the action step can be changed by clicking on the cell, and picking the priority from the drop-down selection (Figure x).

   4. Due Date – The due date of the action step can be entered by clicking on the cell and typing the date and time in m/d/yyyy m:hh AM/PM format. The date and time can also be picked by clicking on the calendar icon button, or the clock icon button respectively (Figure x).

   5. Status – The status of the action step can be added by clicking on the cell, and selecting the status from the drop-down selection (Figure x).

4. Repeat the previous step if there are multiple action steps that need to be associated with this goal.

5. Once all necessary information has been entered, be sure to click on the Add button to the goal to the client’s record (Figure x).