Value Based Care

Making It All About the Work: Aligning Assessments with Successful Care Planning

Keeping In Mind the Objectives of Assessments

There were as many definitions of assessments as there are types of assessments used in within human-services. So, here is my general definition which can be a starting off point. Assessments are a ‘systematic’ way in which information is gathered, where there is enough information to gain ‘working knowledge’ about something or someone. Now with that said, assessments can be informal almost like a chat, or very formal as in an intelligence testing. However, when they are being used within behavioral/mental health assessments are used to support treatment and track progress and/or outcomes of inventions.

Take a moment to let the last sentence you read really sink in for a moment. We are assessing those we serve to support both treatment and track progress towards successful outcomes. Now think of an individual within your workload which was recently assessed. The question now becomes, “How was that assessment directly used to guide treatment?” The answer is, that assessments are often just completed because of a mandate and placed with a person’s electronic health record (EHR).

Assessments are completed by a variety of entities, including school, primary health, mental health and while each may accurately capture what they evaluate, there are often kept in separate EHRs. For many systems struggling with ‘integration’ it is not integrated versus not integrated. Instead, it must be seen more as a continuum to fully achieve health equity for all.  The World Health Organization (WHO) notes that integrated person-centered care has been discussed for decades.

Integration is better seen as the organization of various tasks which need to be performed to provide a population with good quality health services. The WHO has developed a ‘working definition of integrated service delivery.’

The management and delivery of health services so that clients receive a continuum of preventive and curative services, according to their needs over time and across different levels of the health system.

What Leads Treatment Better Than Assessments

It would make sense that information or data we obtain through assessments would take the form of treatment or care planning. The reason someone is in care revolves around the need for change, feeling better and leading a happy healthy life. So, lets take the first step and important phase in the process of treatment. Discovering the ‘what’ connecting to individual’s challenges. It is the foundational question to answer in creation of solutions to find out ‘what’ is going on in the life of those being served.

As professional ‘helpers’ asking questions to gain important information about that person, as well as the supporting systems (families, schools, communities, friends). Utilizing communimetric perspective, specifically Transformational Collaborative Outcomes Management (TCOM) Tools, is very effective both gathering information and building rapport within the therapeutic relationship. If you want to gain some great insights about TCOM and the work being done by the worldwide collaborative subscribe to the TCOM Channel. This is also a great opportunity for you to share as well and let the world know your successes.

The data obtained through assessments builds the care plan signaling each person within a ‘care-circle’ where to focus their attention or interventions. However, without ‘real-time’ sharing of the data members within a care-circle often have difficulties tracking progress in-between ‘check-ins’ or team meeting (child/family team, joint-care reviews) connected with treatment.

Ultimately, data sharing is for the purpose of developing cohesive care planning, which is both effective and efficient, including a shared-vision of the work of the entire care-circle or team. This is not to be confused with a shared electronic health record or EHR. One of the largest benefits of this collaboration is to prevent an individual from having to retell their ‘story’ repeatedly, which may increase the chances for triggering around a trauma.

Why It Is Essential Connecting Pieces Together

Once the question of ‘what’ is going on begins to become clearer, then the next piece to effective care planning is the ‘why’ connected to the challenges. We as professional helpers often feel we must have the all the answers, especially since we have accumulated knowledge and letters of achievements after our name. However, who really knows the answers to many of the questions in treatment? Those we serve and others who are connected to them, friends and family.

This is where assessments and building a trust (rapport) assists as a conduit for increasing understanding, including breakthroughs leading to insights and moving those closer to healing, growth and change. However, the ‘big-picture’ or whole-person picture is needed to ultimately be successful at achieving sustainable health & saving lives. These pieces can be put together with interoperability or sharing of essential health information.

The sharing of data is essential to effective outcomes, keeping everyone (primary care, mental health, community supports) on the same page. Among the results of sharing information, it can eliminate redundancy (preventing someone from having to tell their story over again & again), streamlining treatment protocols, encouraging best practices, as well as improving research.

How The Work Gets Done Collaboratively Is Value-Based

Putting the person is the center of care and focusing on outcomes is the foundation of value-based care. To fully transform healthcare there must be a significant shift from service-delivery towards personalized healthcare, specific to the needs and strengths of the individual person in care. The time for innovative healthcare leaders to set forth goals, initiatives for heath-equity and to put improved patient experiences and outcomes first.

Opeeka is one of the leaders in Value-Based Care movement, where the emphasize is on prevention & well-being, and care-planning, in addition to treatment. The larger systemic focus is on improving outcomes for person and populations and to assist those in care to navigate their health care. Our Person-Centered Intelligence Solutions|P-CIS can systemically integrate and coordinate care, while also assisting agencies and organizations invest in outcomes driven practice transformation.

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