Care Plans

The Care Plans feature in LyfeAI Provider enables healthcare teams to create, manage, and track comprehensive care plans for patients with chronic conditions or complex care needs.

Overview

Care plans provide:

• Structured treatment goals
• Coordinated interventions
• Progress tracking
• Team collaboration
• Evidence-based templates
• Outcome measurement

Care Plan Types

Pre-built Templates

LyfeAI Provider includes templates for common conditions:

1. Diabetes Management

   • Blood glucose monitoring
   • Medication adherence
   • Lifestyle modifications
   • Complication screening

2. Hypertension Control

   • Blood pressure targets
   • Medication optimization
   • Diet and exercise
   • Risk factor reduction

3. Post-Surgical Recovery

   • Wound care
   • Activity progression
   • Pain management
   • Follow-up schedule

4. Chronic Pain Management

   • Pain assessment
   • Multimodal therapy
   • Functional goals
   • Quality of life measures

5. Custom Plans

   • Build from scratch
   • Combine templates
   • Personalize goals

Creating Care Plans

Using Templates

1. Navigate to patient's Care Plans tab
2. Click "Create Care Plan"
3. Select template or "Custom"
4. Customize for patient:

const carePlan = {
  patientId: "patient-123",
  name: "Type 2 Diabetes Management Plan",
  type: "diabetes",
  startDate: new Date(),
  endDate: addMonths(new Date(), 6),
  
  goals: [
    {
      description: "Achieve HbA1c < 7%",
      targetDate: addMonths(new Date(), 3),
      metrics: "HbA1c level",
      baseline: "8.2%",
      target: "< 7%"
    },
    {
      description: "Weight loss of 10 lbs",
      targetDate: addMonths(new Date(), 6),
      metrics: "Body weight",
      baseline: "220 lbs",
      target: "210 lbs"
    }
  ],
  
  interventions: [
    {
      type: "medication",
      description: "Metformin 500mg twice daily",
      frequency: "Daily",
      assignedTo: "Dr. Johnson"
    },
    {
      type: "lifestyle",
      description: "150 minutes moderate exercise/week",
      frequency: "Weekly",
      assignedTo: "Patient self-management"
    },
    {
      type: "monitoring",
      description: "Blood glucose monitoring",
      frequency: "Daily before meals",
      assignedTo: "Patient with nurse review"
    }
  ]
};

Custom Care Plans

Build personalized plans:

1. Define Goals

   • Specific and measurable
   • Time-bound targets
   • Relevant metrics
   • Realistic expectations

2. Add Interventions

   • Medical treatments
   • Lifestyle changes
   • Monitoring schedules
   • Education needs

3. Assign Responsibilities

   • Provider tasks
   • Nursing activities
   • Patient self-care
   • Family involvement

Managing Care Plans

Progress Tracking

Monitor goal achievement:

// Update goal progress
const updateGoalProgress = async (carePlanId, goalId, progress) => {
  await updateCarePlanGoal(carePlanId, goalId, {
    status: progress.status, // "Not Started", "In Progress", "Completed"
    currentValue: progress.value,
    lastUpdated: new Date(),
    notes: progress.notes
  });
};

Status Indicators

• 🟢 On Track: Meeting targets
• 🟡 Needs Attention: Behind schedule
• 🔴 At Risk: Significant delays
• ✅ Completed: Goal achieved

Team Collaboration

Care team features:

1. Task Assignment

   • Assign to team members
   • Set due dates
   • Track completion

2. Progress Notes

   • Document updates
   • Share observations
   • Coordinate care

3. Notifications

   • Overdue tasks
   • Goal milestones
   • Team messages

Care Plan Components

Goals

Well-defined objectives:

interface CareGoal {
  id: string;
  description: string;
  category: 'clinical' | 'functional' | 'psychosocial';
  
  // SMART criteria
  specific: string;
  measurable: {
    metric: string;
    baseline: string;
    target: string;
  };
  achievable: boolean;
  relevant: string;
  timeBound: {
    startDate: Date;
    targetDate: Date;
  };
  
  // Progress tracking
  status: 'not-started' | 'in-progress' | 'completed' | 'discontinued';
  progress: Array<{
    date: Date;
    value: string;
    notes?: string;
    recordedBy: string;
  }>;
}

Interventions

Specific actions to achieve goals:

interface Intervention {
  id: string;
  type: 'medication' | 'procedure' | 'education' | 'lifestyle' | 'monitoring';
  description: string;
  
  // Scheduling
  frequency: string;
  duration?: string;
  startDate: Date;
  endDate?: Date;
  
  // Assignment
  assignedTo: string | string[];
  role: 'primary' | 'support';
  
  // Instructions
  details: string;
  patientInstructions?: string;
  
  // Tracking
  completed: Array<{
    date: Date;
    completedBy: string;
    notes?: string;
  }>;
}

Barriers

Identify and address obstacles:

• Financial constraints
• Transportation issues
• Language barriers
• Cognitive limitations
• Social support
• Motivation levels

Templates Library

Clinical Templates

Chronic Disease Management

• Diabetes (Type 1 & 2)
• Heart failure
• COPD
• Asthma
• Chronic kidney disease

Preventive Care

• Annual wellness
• Cancer screening
• Immunization schedules
• Risk reduction

Specialty Care

• Post-cardiac event
• Stroke recovery
• Mental health
• Substance use

Creating Templates

Build reusable templates:

const createTemplate = async (template) => {
  return await saveCarePlanTemplate({
    name: template.name,
    category: template.category,
    description: template.description,
    
    // Template structure
    goals: template.goals.map(g => ({
      ...g,
      isTemplate: true
    })),
    
    interventions: template.interventions.map(i => ({
      ...i,
      isTemplate: true
    })),
    
    // Customization options
    requiredFields: template.required,
    optionalFields: template.optional,
    
    // Evidence base
    guidelines: template.guidelines,
    references: template.references
  });
};

Monitoring & Reporting

Dashboard View

Care plan overview:

• Active plans count
• Goal completion rate
• Overdue interventions
• Team performance

Progress Reports

Generate reports showing:

const generateProgressReport = async (carePlanId) => {
  const carePlan = await getCarePlan(carePlanId);
  
  return {
    summary: {
      totalGoals: carePlan.goals.length,
      completedGoals: carePlan.goals.filter(g => g.status === 'completed').length,
      progressRate: calculateProgressRate(carePlan),
      daysActive: daysSince(carePlan.startDate)
    },
    
    goalDetails: carePlan.goals.map(goal => ({
      description: goal.description,
      progress: calculateGoalProgress(goal),
      timeline: goal.progress,
      status: goal.status
    })),
    
    interventionCompliance: calculateInterventionCompliance(carePlan),
    
    recommendations: generateAIRecommendations(carePlan)
  };
};

Outcome Tracking

Measure care plan effectiveness:

• Clinical outcomes
• Functional improvements
• Quality of life measures
• Patient satisfaction
• Cost effectiveness

AI-Powered Features

Smart Recommendations

AI suggests:

• Goal modifications based on progress
• Additional interventions
• Barrier solutions
• Timeline adjustments

Predictive Analytics

Forecast outcomes:

const predictions = await aiService.predictCarePlanOutcomes({
  carePlan,
  patientHistory,
  populationData
});

// Returns:
{
  successProbability: 0.75,
  estimatedCompletionDate: "2024-06-15",
  riskFactors: ["Poor medication adherence", "Limited family support"],
  recommendations: ["Consider weekly check-ins", "Refer to social services"]
}

Evidence Integration

Access latest guidelines:

• Clinical practice guidelines
• Quality measures
• Best practices
• Research updates

Team Coordination

Role-Based Views

Different views for team members:

Physicians

• Medical interventions
• Clinical goals
• Medication adjustments

Nurses

• Daily tasks
• Patient education
• Monitoring activities

Care Coordinators

• Overall progress
• Resource allocation
• Barrier management

Patients

• Their goals
• Self-care tasks
• Progress tracking

Communication

Integrated messaging:

• Team discussions
• Patient updates
• Task handoffs
• Progress alerts

Integration

EHR Sync

Automatic updates:

• Import care plans from EHR
• Export to external systems
• Bi-directional sync
• Real-time updates

Quality Measures

Track metrics:

• HEDIS measures
• CMS quality indicators
• ACO metrics
• Custom measures

Billing

Support for:

• Care management CPT codes
• Time tracking
• Documentation requirements
• Billing compliance

Best Practices

Goal Setting

1. Use SMART Criteria

   • Specific objectives
   • Measurable outcomes
   • Achievable targets
   • Relevant to patient
   • Time-limited

2. Patient-Centered

   • Include patient preferences
   • Address patient priorities
   • Cultural sensitivity
   • Health literacy

3. Evidence-Based

   • Follow guidelines
   • Use proven interventions
   • Monitor outcomes
   • Adjust as needed

Documentation

1. Complete Records

   • All team activities
   • Patient interactions
   • Progress updates
   • Barrier notes

2. Regular Updates

   • Weekly progress
   • Goal reassessment
   • Intervention effectiveness
   • Patient feedback

Team Management

1. Clear Assignments

   • Specific responsibilities
   • Defined timelines
   • Accountability measures
   • Backup plans

2. Regular Reviews

   • Team meetings
   • Progress discussions
   • Barrier resolution
   • Plan adjustments

Troubleshooting

Common Issues

Goals Not Progressing

• Review goal realism
• Assess barriers
• Modify interventions
• Increase support

Poor Team Coordination

• Clarify roles
• Improve communication
• Use task assignments
• Regular check-ins

Patient Non-Engagement

• Assess readiness
• Address barriers
• Simplify plan
• Motivational interviewing

Technical Issues

Sync Problems

• Check connections
• Verify permissions
• Review error logs
• Contact support

Missing Data

• Audit entries
• Check integrations
• Verify saves
• Restore from backup