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ecareplan.ahrq.gov/collaborate/pages/viewpage.action?navigatingVersions=true&pageId=9469968
August 19, 2022 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … clinical information models (CIM) using existing CKD data elements & standards Develop e-care plan application … application in diverse clinical settings in patients with MCC, including CKD Establish an e-care plan … page 2 Clinical Care Model In progress MCC Clinical Information Model (CIM) Analysis and Development … Connect With Us
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ecareplan.ahrq.gov/collaborate/pages/viewpage.action?navigatingVersions=true&pageId=9830402
August 19, 2022 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … clinical information models (CIM) using existing CKD data elements & standards Develop e-care plan application … application in diverse clinical settings in patients with MCC, including CKD Establish an e-care plan … page 2 Clinical Care Model In progress MCC Clinical Information Model (CIM) Analysis and Development … Connect With Us
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ecareplan.ahrq.gov/collaborate/pages/viewpage.action?navigatingVersions=true&pageId=10518529
August 19, 2022 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … Create clinical information models (CIM) using existing CKD data elements & standards Develop e-care … the e-care plan application in diverse clinical settings in patients with MCC, including CKD Establish … an e-care plan repository and development collaborative Expand the draft e-care plan application & IG … page 2 Clinical Care Model In progress MCC Clinical Information Model (CIM) Analysis and Development
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ecareplan.ahrq.gov/collaborate/pages/viewpage.action?navigatingVersions=true&pageId=10158081
August 19, 2022 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … clinical information models (CIM) using existing CKD data elements & standards Develop e-care plan application … application in diverse clinical settings in patients with MCC, including CKD Establish an e-care plan … page 2 Clinical Care Model In progress MCC Clinical Information Model (CIM) Analysis and Development … Connect With Us
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ecareplan.ahrq.gov/collaborate/pages/viewpage.action?navigatingVersions=true&pageId=9469964
August 19, 2022 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … clinical information models (CIM) using existing CKD data elements & standards Develop e-care plan application … application in diverse clinical settings in patients with MCC, including CKD Establish an e-care plan … page 2 Clinical Care Model MCC Clinical Information Model (CIM) Analysis and Development 3 SMART on … Connect With Us
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ecareplan.ahrq.gov/collaborate/pages/viewpage.action?navigatingVersions=true&pageId=9469965
August 19, 2022 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … clinical information models (CIM) using existing CKD data elements & standards Develop e-care plan application … application in diverse clinical settings in patients with MCC, including CKD Establish an e-care plan … page 2 Clinical Care Model In progress MCC Clinical Information Model (CIM) Analysis and Development … Connect With Us
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ecareplan.ahrq.gov/collaborate/pages/viewpage.action?navigatingVersions=true&pageId=9109510
August 19, 2022 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … for persons with chronic kidney disease and multiple chronic condition
Quick Links FAQs HL7 … clinical information models (CIM) using existing CKD data elements & standards Develop e-care plan application … application in diverse clinical settings in patients with MCC, including CKD Establish an e-care plan … page 2 Clinical Care Model 3 SMART on FHIR App
Upcoming Testing Opportunities The MCC eCare
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ecareplan.ahrq.gov/collaborate/pages/viewpage.action?pageId=9109510
August 19, 2022 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … for persons with chronic kidney disease and multiple chronic condition
Quick Links FAQs HL7 … clinical information models (CIM) using existing CKD data elements & standards Develop e-care plan application … application in diverse clinical settings in patients with MCC, including CKD Establish an e-care plan … page 2 Clinical Care Model 3 SMART on FHIR App
Upcoming Testing Opportunities The MCC eCare
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ecareplan.ahrq.gov/collaborate/pages/viewpage.action?pageId=9109507
August 19, 2022 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … for persons with chronic kidney disease and multiple chronic condition
Quick Links FAQs HL7 … clinical information models (CIM) using existing CKD data elements & standards Develop e-care plan application … and implementation guide (IG) for point of care data review/entry Implement & evaluate the e-care plan … application in diverse clinical settings in patients with MCC, including CKD Establish an e-care plan
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ecareplan.ahrq.gov/collaborate/pages/viewpage.action?navigatingVersions=true&pageId=9109507
August 19, 2022 - Project Purpose The Development of an FHIR (electronic) e-Care Plan, application, and clinical models … for persons with chronic kidney disease and multiple chronic condition
Quick Links FAQs HL7 … clinical information models (CIM) using existing CKD data elements & standards Develop e-care plan application … and implementation guide (IG) for point of care data review/entry Implement & evaluate the e-care plan … application in diverse clinical settings in patients with MCC, including CKD Establish an e-care plan
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www.ahrq.gov/sites/default/files/2025-02/silver-report.pdf
January 01, 2025 - at risk due to post-acute care or post-surgical clinical needs, diminished capacity for self-care, … , or task-focused home care services. … LTA
Care plan training LTA –
incomplete (uninformed)
Care plan training LTA –
inaccurate (org … “Rescue”
care
Care plan
implementation
LTA
1. … professional can determine patient's status” or “management
and evaluation of patient care plan.”
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www.ahrq.gov/sites/default/files/publications2/files/diaginfo.pdf
July 01, 2005 - And it can be
even harder to make decisions about treating or managing your disease or
condition. … You probably have many questions about your disease or condition. … about your disease or condition. … • Contact your health plan or your local hospital, medical society, or medical
school. … This plan will
include everything that will be done to treat or manage your disease or
condition—including
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cmext.ahrq.gov/confluence/plugins/viewsource/viewpagesrc.action?pageId=114991555
and inserted into the integrated care plan. 14 Care Plan This is the least developed of the technologies … · How will the care plan fit into existing clinical workflows? … Guidelines) 13 Condition Management Policy/ Procedure/ Protocol AHRQ EPC Program (228) (229) 14 Care … and inserted into the integrated care plan. 14 Care Plan This is the least developed of the technologies … · How will the care plan fit into existing clinical workflows?
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digital.ahrq.gov/program-overview/research-stories/designing-digital-healthcare-technology-support-cognitive-team
January 01, 2023 - on the severity of the patient’s condition. … Each needs to know what has happened: the initial incident, the current clinical condition including … It is imperative that each role coordinates and communicates their patient assessment and plan across … what happened to the child, what the current clinical condition is, and what the plan is. … “The trauma surgeon may want to see some clinical data point or representation that is different from
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www.uspreventiveservicestaskforce.org/uspstf/document/draft-research-plan/screening-depression-suicide-risk-children-adolescents
April 30, 2020 - in progress
Draft Research Plan
Depression and Suicide Risk in Children and Adolescents: Screening … primary care or comparable settings in children and adolescents? … Does treatment (psychotherapy, pharmacotherapy, or collaborative care) of depression, anxiety, or increased … plan for suicide), history of suicide attempts (nonfatal, self-directed, and potentially injurious behavior … /no screening
KQ 2 (depression and anxiety): Clinical diagnosis based on structured clinical interview
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www.ahrq.gov/sites/default/files/wysiwyg/professionals/systems/long-term-care/resources/ontime/pruprev/saworksheet.docx
January 28, 2015 - Clinical areas to be covered
b. Timing or frequency of assessments
c. … to learn what is included in your pressure ulcer prevention care plan.
1. … Does your plan include interventions for skin care?
Yes No
3. … Care plan review
b. Report or brief with CNAs
c. … QAPI* or performance improvement plan meeting
f. Skin or wound meeting
g.
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www.ahrq.gov/patient-safety/settings/long-term-care/resource/ontime/prevhosp/impmaterials.html
June 01, 2017 - that the team can use to identify gaps in their clinical practice. … Do you develop a care plan for residents at risk for hospital transfers? … Does your plan include ongoing discussions about advance care planning with resident and/or family? … QAPI or Performance Improvement Plan meeting
f. … Care plan meeting
g. MD/APRN rounds
h.
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www.uspreventiveservicestaskforce.org/uspstf/document/draft-research-plan/screening-depression-anxiety-suicide-risk-children-adolescents
April 30, 2020 - in progress
Draft Research Plan
Screening for Depression, Anxiety, and Suicide Risk in Children … primary care or comparable settings in children and adolescents? … Does treatment (psychotherapy, pharmacotherapy, or collaborative care) of depression, anxiety, or increased … plan for suicide), history of suicide attempts (nonfatal, self-directed, and potentially injurious behavior … /no screening
KQ 2 (depression and anxiety): Clinical diagnosis based on structured clinical interview
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www.uspreventiveservicestaskforce.org/uspstf/document/final-research-plan/autism-spectrum-disorder-young-children-1
June 10, 2021 - disorder or condition, sleep disorder, feeding problem, or medical or genetic condition
Setting … settings KQs 4, 5: Clinical, educational, early intervention, or home settings
Screening … usual care KQ 2: Diagnosis of ASD through clinical assessment or medical record review KQs 4, 5: … No intervention/waitlist, usual care, standard treatment, or minimal intervention
KQs 4, 5: Active … genetic condition would be excluded.
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cmext.ahrq.gov/confluence/display/EC/Technical+Expert+Panels
November 08, 2022 - Plan Project Collaborative Site
MCC e-Care Plan Collaborative Site Pages Blog Page tree … Each TEP is focused on data elements relevant to specific condition(s) included in the initial proof-of-concept … for people with congestive heart failure, ischemic heart disease, hypertension, pain, opioid use, and/or … , the Pharmacy e-Care Plan, and PACIO. … plan (PDF, 2.1 MB) Patient personas and stories providing an example of what is what needed in a care