Developing interprofessional care plans in chronic care: a scoping review

BMC Family Practice

Research Article

Marloes Amantia van Bokhoven¹  Trudy van der Weijden¹  Ramon Daniëls²  Wencke Wilhelmina Gerarda Petronella Emonts²  Anna Beurskens³  Jerôme Jean Jacques van Dongen³ 

[1] Department of Family Medicine, Maastricht University, CAPHRI School for Public health and Primary Care, Maastricht, The Netherlands;Research Centre for Autonomy and Participation for People with Chronic Illnesses, Zuyd University of Applied Sciences, Nieuw Eyckholt 300, 6419 DJ, Heerlen, The Netherlands;Research Centre for Autonomy and Participation for People with Chronic Illnesses, Zuyd University of Applied Sciences, Nieuw Eyckholt 300, 6419 DJ, Heerlen, The Netherlands;Department of Family Medicine, Maastricht University, CAPHRI School for Public health and Primary Care, Maastricht, The Netherlands;

关键词: Systematic review;    Interprofessional collaboration;    Shared care plan;    Goal setting;    Scoping review;    Chronic disease;    Patient-centred practice;   

DOI  :  10.1186/s12875-016-0535-7

 received in 2016-06-02, accepted in 2016-09-15,  发布年份 2016

来源: Springer

【 摘 要 】

BackgroundThe number of people suffering from one or more chronic conditions is rising, resulting in an increase in patients with complex health care demands. Interprofessional collaboration and the use of shared care plans support the management of complex health care demands of patients with chronic illnesses. This study aims to get an overview of the scientific literature on developing interprofessional shared care plans.MethodsWe conducted a scoping review of the scientific literature regarding the development of interprofessional shared care plans. A systematic database search resulted in 45 articles being included, 5 of which were empirical studies concentrating purely on the care plan. Findings were synthesised using directed content analysis.ResultsThis review revealed three themes. The first theme was the format of the shared care plan, with the following elements: patient’s current state; goals and concerns; actions and interventions; and evaluation. The second theme concerned the development of shared care plans, and can be categorised as interpersonal, organisational and patient-related factors. The third theme covered tools, whose main function is to support professionals in sharing patient information without personal contact. Such tools relate to documentation of and communication about patient information.ConclusionCare plan development is not a free-standing concept, but should be seen as the result of an underlying process of interprofessional collaboration between team members, including the patient. To integrate the patients’ perspectives into the care plans, their needs and values need careful consideration. This review indicates a need for new empirical studies examining the development and use of shared care plans and evaluating their effects.

【 授权许可】

CC BY   
© The Author(s). 2016