DaVita® Medical Insights

5 Key Components for Individualized Care Plan Success

Within the field of nephrology and across the entire health care spectrum, patient-centered care has become a fundamental approach to creating higher levels of patient satisfaction, increased patient engagement, improved care coordination, better health outcomes and reduced care costs. Individualized care plans are a critical component of successful patient-centered care. Such plans empower care teams to address patient-specific issues, preferences and goals and enable the seamless delivery of care—ultimately driving better clinical results, reduced hospitalizations and better quality of life. The following five components may help develop and employ a successful individualized care plan.

  1. Patient risk stratification. The implementation of a care plan system aiming to improve health and reduce hospitalizations overall requires a prioritization of a team’s resources and attention to address first the needs of patients who are at the highest risk for health issues. Population health management software can provide a wealth of analytic information, including risk stratification of patient cohorts and individual care gaps, empowering care teams to intervene.
  2. Health data interoperability and connectivity. An ideal individualized care plan is developed using patient history and health data available via interoperability technologies. Through health connectivity—which allows for data exchange and, ideally, data normalization between electronic health record (EHR) systems—care teams can share and access patient data to gain a holistic view of each patient and apply to individualized care plans accordingly.
  3. Patient education and engagement. Patients who understand their conditions and engage in their own care may realize better health outcomes. Therefore, individualized care plans should include patient education (attuned to patient learning preferences and competencies) and patient-centric opportunities for increased engagement (e.g., patient web portals, mobile apps, kiosks) that allow for direct physician and care team messaging, telemedicine, appointment scheduling, appointment reminder notifications and other convenient communication.
  4. Care plan performance measurement. An effective individualized care plan should include performance checkpoints to evaluate whether the plan is on track, identify gaps and barriers to care (e.g., psychosocial factors and social determinants of health [SDOH]), and assess patient satisfaction. Care plans should include potential amendments, such as post-discharge follow-up actions, should a patient be hospitalized. Each care plan should be regarded as a living document to be adjusted as patient status and care requirements change.
  5. Global research findings. Information and insights gained from a population-level view of patients with chronic kidney disease and end stage renal disease can also be applied to individualized care plans. Research exploring the reasons behind adverse health events and hospitalizations provides the opportunity for evidence- and data-driven preemptive intervention.

Today’s health care ecosystem allows for the implementation (and success) of individualized care not previously possible. Ever-advancing technologies, a consumer-driven market and progressive research together present the opportunity for truly patient-centered care. By leveraging the aforementioned components for care plan development and application, we can help drive better health, reduce hospitalizations and improve the quality of life for our patients.

Allen R. Nissenson, MD, FACP, FASN, FNKF

Allen R. Nissenson, MD, FACP, FASN, FNKF

Prolific author and renowned authority on kidney disease, Allen R. Nissenson, MD, is chief medical officer at DaVita Kidney Care and emeritus professor of medicine at the David Geffen School of Medicine at UCLA, where he has served as director of the dialysis program and associate dean. Dr. Nissenson is also co-chair of the Kidney Care Partners Quality Initiative. Dr. Nissenson served as a Robert Wood Johnson Health Policy Fellow of the Institute of Medicine from 1994–1995 and worked in the office of the late Senator Paul Wellstone. He is a former president of the Renal Physicians Association (RPA), served on the RPA Board of Directors as a special advisor to the president and is a former president of the Southern California End-Stage Renal Disease Network. He is the author of more than 700 scientific papers and the editor of two dialysis textbooks, one in its fourth edition and the other just released in its 5th edition. Dr. Nissenson earned his medical degree from Northwestern University Medical School and is the recipient of various awards, including the AAKP Medal of Excellence award, the Lifetime Achievement Award in Hemodialysis and the National Kidney Foundation “Man of the Year” award. Twitter: @DrNissenson