Care Planning for Digital Patient Engagement

Our wide range of Care Plans and eforms integrate into the Shared Care Record which enables care professionals to access a single version of a Care Plan which they can also contribute to (subject to permissions). Input from patients can also be supported with the ‘About Me’ eform via the Graphnet PHR App. Our Care Plans and eforms are invaluable and help achieve improved multi-agency management for people with long-term conditions, complex needs and those approaching end of life.

Our care planning suite transforms the delivery of care and improves the quality of life for patients with, or at risk of long-term, complex or life-limiting conditions. At the same time, our Care Planning platform delivers efficiencies and provides cost-saving opportunities for care providers.

Graphnet Care Planning Functionality

All Care Plans share similar functionality and mean that users can:

• Create new Care Plans and edit existing Care Plans using built in guidance and version control, enabling care professionals to view previous plans
• Print PDF and paper copies
• Complete the Plan/eform using built in logic, including mandatory fields, picklists, date fields and other logic based on responses to previous questions
• Make use of data collected in the Care Plan within our Population Health platform, which can be used for subsequent reporting and analysis
• Upload supporting documentation
• Manage permissions using comprehensive RBAC controls to determine which groups of users can view, create, edit, publish and review the forms.

Graphnet's Range of Care Plans and eforms

Our Care Plans and eforms currently include:

• Integrated Care and Support Plans comprising About Me, Lifestyle & Environment, Goal Tracking, Contingency Planning, Key Contacts, MDT (meetings etc)
• Frailty module, comprising forms/assessments for Care Planning, Cognition, Skin, Falls Risk, Nutrition, Wellbeing, Vitals/Quick Observations, Plans & Actions
• ReSPECT Plan, accredited by the Resus Council
• EPaCCS End of Life Plan
• Moving and Handling Risk Assessment
• Heart Failure
• Dementia
• Mental Capacity Assessment
• High risk pregnancy monitoring

Creating a Digital Patient Engagement Platform

Using details held within the Graphnet Shared Care Record, clinicians are able to identify and target cohorts of patients who will benefit most from proactive care. Depending on the situation, patients provide relevant information (for example: blood pressure, oximetry readings, mood details, etc.) via Personal Health Record (PHR) questionnaires and/or wearable devices in real-time to their care teams.

This information is then available to professionals to view via interactive dashboards which highlight changes using, for example, RAG ratings, so levels of care can be escalated as needed. From here, users can also drill down directly into the shared care record for a detailed, holistic view of the person. Individuals also benefit from receiving rules-based prompts, and further advice and support from their care teams.