Care Redesign
Relentless Reinvention

Making the Comprehensive Shared Care Plan a Reality

Article · May 18, 2016

A central component of reforming the health care delivery system is improving the quality of care coordination, but clinicians and patients often lack the necessary tools. Care planning has always been a core part of nursing in acute care and institutional settings, and for patients with complex needs (e.g., dementia, end-stage renal disease, intellectual and developmental disabilities, HIV/AIDS). But many clinicians, including most physicians, are not familiar with using a care plan. Furthermore, although interventions that involve care plans have shown benefits, wide variation makes design and implementation challenging.

The care plan traditionally used in nursing has inspired interest in a new tool that is designed to support person-centered care by a multidisciplinary team: the comprehensive shared care plan (CSCP). As described by the National Partnership for Women and Families, the CSCP is not setting-specific; it uses information technology to enable the clinical team to collaborate seamlessly as they help address the full spectrum of the patient’s needs across all care settings and over time. Although barriers to widespread adoption still exist, we believe that robust collaboration between the health care and technology communities can help to advance this promising approach.

The Vision for Shared Care Plans

In April 2015, the U.S. Department of Health and Human Services (HHS) convened a diverse group of stakeholders (physicians, nurses, policymakers, and patient advocates) for a one-day listening session aimed at articulating a vision for CSCPs. Overall, this group conceived of a CSCP as a vehicle for secure, virtual exchange of information among clinicians who all care for a single patient, regardless of the clinicians’ (and the patient’s) locations.

The stakeholders concurred that today’s care plans function more as “disaster recovery” efforts, initiated only after something has gone wrong. Instead, people need a plan that anticipates changes in health status, links them to services early in their care trajectories, and helps them manage key transition periods in their lives. Ultimately, the group concluded that a plan that focuses merely on clinical care is inadequate for meeting all of a person’s needs — clinicians should instead strive to create a “total plan for health.”

The group identified these key goals for a CSCP:

  • It should allow a clinician to electronically view information that is directly relevant to his or her role in the care of the person; to easily identify which clinician is doing what; and to update other members of an interdisciplinary team on new developments.
  • It should put the person’s goals (captured in his or her own words) at the center of decision-making and give that individual direct access to his or her information in the CSCP.
  • It should be holistic and describe both clinical and nonclinical (including home- and community-based) needs and services.
  • It should follow the person through high-need episodes (e.g., acute illness), as well as periods of health improvement and maintenance.

Putting a CSCP into Practice  

Some innovative communities and organizations have begun to implement tools that reflect this vision. Maimonides Medical Center’s Brooklyn Health Home Consortium has developed an interactive online tool for patients with multiple chronic conditions and serious mental illness, which enables multidisciplinary care teams across organizations to develop and maintain a dynamic plan of care in real time for enrollees. Different members of a care team across organizations can view the status of the care plan on a dashboard and make changes to the plan over time.

Through another New York City–based pilot initiative, under the Medicaid Delivery System Reform Incentive Program, physician practices are seeking to share and receive electronic care plans that are housed by qualified health-information exchange (HIE) entities in New York State. Clinicians who document a care plan for the patient can send it to their HIE, either as a structured clinical document or as a simple PDF. When a clinician requests a care plan, the qualified HIE will return any care plan it has on file and will query other qualified HIEs for care-plan documents for that patient. After completing interventions within the care plan or making other updates, the clinician can communicate these changes to a care manager, who will reconcile these for the next clinician’s use. The end result: asynchronous collaboration among all members of the clinical care team.

The Path to Widespread Adoption

Interest in more widespread use of CSCPs is growing. To broaden the adoption of these tools, motivated organizations must confront three main barriers:

Operational. Implementing a CSCP in clinical settings is not easy. First, an organization must decide which individuals it serves are most likely to benefit from a CSCP. Care team members must agree on roles and responsibilities for accessing, exchanging, updating, and reconciling information in the plan.

They must also decide whether to designate an owner (curator) who manages access to the CSCP and reconciles changes. For example, some Medicaid health homes view the care manager as the driver of the care plan; others limit him or her to coordinating and implementing the decisions of the multidisciplinary care team. Organizations must also decide how patients can access and modify their CSCPs in a way that permits that access without overburdening clinicians.

To even begin to address these nuts-and-bolts issues, clinicians must become more familiar with CSCPs, learn what works for them and their patients, and then lead the way in defining CSCP design and function. Team-based care in medical education and training can help lay a foundation of knowledge and experience. Health services and implementation-science researchers also can help advance the field by rigorously evaluating care plans to identify their most effective form and function.

Technological. Ensuring easy access to CSCPs, by patients and clinicians alike, and efficient integration into clinical workflows requires well-designed technology with user-friendly interfaces that foster patient, caregiver, and clinician engagement. Clinicians must also be able to seamlessly share CSCPs across settings that use different IT systems. In the past several years, public and private stakeholders have taken a first step toward developing a technical standard for exchanging CSCP documents, which is now included in the HHS Office of the National Coordinator Health IT Certification Program. Technology companies must be willing to innovatively build on this standard, driven in part by demand from the health care community and from patients, families, and caregivers.

Financial. Creating the right set of care-coordination tools will not happen without appropriate investments from both clinicians and technology developers. Alternative payment models that reward quality and value — including accountable care organizations (ACOs), advanced primary care medical homes, and bundled payments — are likely to play a major role in creating the demand for CSCPs and other care-coordination tools in coming years. To succeed in these models, clinicians must make measurable improvements in outcomes, service utilization, and costs. Better care coordination, enabled by tools such as CSCPs, will help them reach those goals.

Government’s Role

Stakeholders have emphasized the importance of aligning CSCP requirements at the local, state, and federal levels — from Medicare requirements for home-health agencies, to state requirements for Medicaid health homes, to home- and community-based services (HCBS) performance measurement, to requirements for physicians who provide enhanced monthly care management to Medicare patients with chronic conditions through Medicare’s Chronic Care Management code. Federal and state funding, such as federal Medicaid matching funds that states can access under the HITECH Act, might also be available to support CSCP adoption.

Through efforts such as the Comprehensive Primary Care Initiative, the Transforming Clinical Practice Initiative, and the Testing Experience and Functional Tools grants, the federal government can accelerate learning about CSCPs and other care-coordination tools. These efforts feature robust learning systems that offer technical assistance to participating providers and disseminate best practices from high-achievers. In addition, the Agency for Healthcare Research and Quality recently announced a funding opportunity for the development, implementation, and evaluation of care plans and related tools and strategies to promote care coordination in patients with multiple chronic conditions. Finally, HHS’s Office of the National Coordinator for Health Information Technology and the Centers for Medicare and Medicaid Services are partnering with stakeholders to create a new framework for an electronic Long-term Services and Supports (eLTSS) plan. Six states are now testing eLTSS plans in Medicaid to improve the coordination of health and social services that support individuals’ mental and physical health.


To realize the benefits of comprehensive shared care plans, government, private industry, consumers, academic communities, and an array of clinicians and other providers must work together, not unlike the way in which CSCPs enable clinicians to collaborate on a smaller scale. Only through such coordination can we achieve a more connected, person-centered health care delivery system.


The views expressed in this article are those of the authors and do not necessarily represent the views or policy of the Centers for Medicare & Medicaid Services or the Office of the National Coordinator for Health Information Technology.

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