Care Plans document a Client's care and progress over a given period of time. They are designed to provide a holistic view of a Client's health needs and facilitate care planning, scheduling, and clinical reporting within the web and mobile applications.
Care Plans are configured at the system level. Individual Care Plans can then be created for Clients.
Certain elements within the Care Plan will flow through into the Visits for the use of the Care Provider.
The Care Plan 2.0 and Forms 2.0 Feature Flags must be enabled together. It is not possible to turn on one feature without the other.
Configure Care Plans at the System Level
Care Plans are configured at the system level.
It is also possible to create Care Plan Libraries. Care Plan Libraries allow you to define standard templates to use in the creation of individual Client Care Plans.
- What are the different Care Plan Settings in AlayaCare?
- How do I add/publish a Care Plan Library?
- How do I archive/re-publish a Care Plan Library?
- How do I copy a Care Plan Library?
- How do I add Care Plan Items (Diagnoses, Goals, and Interventions) to a Care Plan Library?
Care Plans at the Client Level
While only a single Care Plan can be active for a Client at a given time, you can create several Care Plans and consult them at any time, allowing you to review any past or future planned care. You can use Care Plan Libraries to speed up or standardize the creation process of new Care Plans. You have the option to print a Client's Care Plan for reference.
A Care Plan contain up to three types of items: Diagnoses, Goals, and Interventions.
- How do I add/publish/edit a Care Plan for a Client?
- How do I copy a Care Plan?
- How do I complete a Care Plan?
- What are the different Care Plan Statuses?
- How do I add Items from a Care Plan Library to a Client Care Plan?
- How do I print a Client's Care Plan?
- How do I bulk edit Care Plan items?
Diagnoses are the health problems that a Client's Care Plan is designed to address — in other words, the reasons the Client is in care. Care Plans are created to manage the Diagnoses by implementing Interventions and setting Goals. The Diagnoses of a Care Plan are those relevant for the care that is being provided and not necessarily the medical diagnosis (ICD-10 diagnosis) for the Client.
You can add Tags, Departments, and Services to your Diagnoses for filtering and reporting purposes only.
Goals represent what the outcomes of the Care Plan should be. They generally serve as the link between the Client's Diagnoses and Interventions. For example, a Client with the Diagnosis "Risk for Falls" may have the related Goal "Client should be able to walk 1000m without support." Interventions like "Walk for 5 minutes without support" and "Balance exercises" might then be implemented to help the Client resolve the Diagnosis and achieve the Goal set on the Care Plan.
You can add Tags, Departments, and Services to your Goals for filtering and reporting purposes.
Interventions are the actions performed by Care Workers during Visits to help Clients resolve the Diagnoses and reach the Goals on their Care Plan.
You can add Tags, Departments, and Services to your Interventions for filtering and reporting purposes.
Interventions can be linked to another Module in Alayacare: Forms, Vitals, Medication, or Infusion.
- How do I add/edit an Intervention?
- What are the different Intervention Frequency Types?
- How do I change the Interventions for a scheduled Visit?
- How do I view/edit Interventions when scheduling a Visit for a Client?
- How do I view the Completion History for a Care Plan Intervention?
Following the Care Plan During a Visit
A Care Worker completing a Visit for a Client with an Active Care Plan will be able to complete Interventions and update Goals from the Care Plan that are assigned as Service Tasks to an individual Visit. The specific Interventions and Goals assigned to a specific Visit will depend on the items' Start and End Dates, whether they are linked to the Service, and the Intervention Frequency Types set for the Interventions. All Interventions, Goals, and Forms that should be completed during a particular Visit will be found in the Service Tasks tab for the Visit.
- How do I complete my Service Tasks (Forms, Interventions, and Goals) on mobile?
- How do I archive a Care Plan item (Diagnosis, Goal, or Intervention) on mobile?
- How do I complete/resolve a Care Plan item (Diagnosis, Goal, or Intervention) on mobile?
- How do I review my Client's Care Plan on mobile?
- How do I edit the Service Tasks for a Closed Work Session (a Visit in the past)?
- How do I update/complete a Goal during a Visit on web?
- How do I add/complete Interventions during a Visit on web?
- How do I review Service Tasks for a Visit on web?
- How do I view the Revision History of a Care Plan item (Diagnosis, Goal, or Intervention)?
- How do I resolve/complete a Care Plan item (Diagnosis, Goal, or Intervention) on web?