Instructions for Use of the Interdisciplinary Care Plan (ICP)

Purpose of the ICP:

To organize the interdisciplinary team based approach toward patients with complex medical issues in the outpatient setting.

Target Disease States:

We have chosen hypertension (HTN), Type II diabetes mellitus (AODM), and congestive heart failure (CHF) as our target disease states. These diseases were targeted because they offer complexity in terms of control of the disease state, medical management, and patient education; they are common; and they have potential for significant adverse outcomes if not well controlled. Due to these characteristics, these disease states contribute to a significant portion of resource utilization in health care. In addition, these diseases lend themselves to having “control” defined by a specific parameter – blood pressure for HTN, HgbA1C for AODM, and difference from dry weight for CHF.

Initiation of the ICP:

1. Any provider may initiate an ICP on any patient.

2. Specific triggers that might suggest that an ICP would be useful include, but are not limited to:

    a. HgbA1C > 8 on two or more checks

    b. Blood pressure >140/90 despite treatment, on three visits

    c. Multiple co morbidities

    d. Recent hospitalization for any of the target disease states

    e. New diagnosis of any of the target disease states

    f. Issues of patient adherence

    g. High utilization in terms of number of office visits, number of ER visits, and/or number of     hospitalizations

    h. Complex (>5 medications) medication regimen

Completion of the ICP:

1. Background information. The information at the top of the form must be completed on all patients.

2. Specified Goals and Objectives.

    a. Each column must be headed by the date of visit.

    b. Provider(Y/N):

        i. The Provider listed is the provider who completed the goal

        ii. The Provider will be identified by provider number (from PCN for residents and faculty,         assigned to FNP students and Pharmacy students as they enter the program)

        iii. If an FNP student or pharmacy student performs a function under direct supervision, they         should list the provider as “-S” (i.e. a resident or faculty observes a student performing an H&P         or doing patient education, the provider listed would be “NP1-S”)

        iv. If consultation is obtained for any area from another discipline (i.e. asking a pharmacist         which medication to use) that provider should be listed as the provider

        v. “Y/N/NA” refer to Yes, No, or NA in terms of whether the goal was completed on that visit.

    c. History and Physical. Obviously, this will be completed at most visits, but the responsible     provider should still be listed.

    d. Functional Assessment. An SF-36 should be completed at intake, and an SF-12 each     subsequent three months. The score should be entered on the ICP.

    e. Initiation of ICP/Goals Set. Enter whether the ICP is maintained at that visit (and who completed     it)

    f. Review/Modify medications.

    g. Health Maintenance Up to Date. Documentation of patient refusal is considered up to date.

    h. Lifestyle education. (diet, exercise, smoking, alcohol, stress)

    i. Disease Management education (specific to the disease state, like checking blood sugars,         using insulin)

    j. Use of Practice Guideline. Each target disease state has a practice guideline available in the     precepting room. List NA if you are not following a practice guideline for reasons documented in     the patient chart.

    k. Assessment/Plan. Again, it will happen each time, it’s just a matter of who does it.

    l. HgbA1C, BP, weight. Enter the actual number. Keep in mind that difference from goal (dry)     weight involves actually deciding what that weight is.

3. “Other” goals and objectives.

    a. Provider (Y/N) documented as above

    b. At least one goal should be patient initiated (i.e. decreased cost, decreased complexity of     medical regimen, functional outcome)

    c. Goals and interventions will be patient specific (i.e. smoking cessation, decreased utilization     (be specific about number of meds or visits), cardiac rehab, Lifetime Wellness, specific     medication changes)

4. Explanation of “No’s”. For any goal to which you answered “No” to whether it was completed, give a short explanation (i.e. patient refused; not done, but reminder put in EMR; patient non-adherence)

Assigned Roles:

1. On teams that include an FNP student, the FNP student will be responsible for initiating/completing the ICP. The FNP student will also be responsible for orienting the patient to the interdisciplinary team and ICP.

2. If there is no FNP student involved, the ICP will be done by whatever provider sees the patient for that visit.

3. On teams that include an FNP student, the FNP student will complete the functional assessments.