Care Plans

Overview

Once a client's basic demographics and authorization data have been entered, the next step is to build the care plan, which outlines care plan items for the client. Ankota uses the care plan to define the questions asked at the end of a caregiver's visit through telephony and the mobile app. Typically, care plans are assigned directly to the client, but generic/"universal" care plans can be assigned directly to the visit type if desired.

For information on retroactively reporting care plan items, see the article on Rework, Missed Visit, and On Hold Functionality.

This article includes the following sections:

Creating/Copying a Care Plan
Assigning Care Plan Items from Care Plan Categories
Creating & Assigning a Universal Care Plan (Legacy)
Editing a Care Plan
No Care Plan
Other

Creating/Copying a Care Plan

To create a Care Plan, select the Care Plan tab in the client's record, then click New.

The Client Detail page for Test Client displays contact information including primary phone 217-638-3032 and secondary phone not set, with the Care Plans tab selected showing options to create a new care plan, assign a plan, or print a care plan.

Accept the default care plan name, which is the same name as the client, if this is a unique care plan. (This will make it easier to manage care plans overall should care plan templates be used in the future.) If the care plan will be used by more than one client, give it a clear label, such as Tier 1 Care Plan.

If the care plan does not have an expiration date, click Create. To set an expiration date, uncheck the box next to "No Expiration Dates." Once the end date is set, click Create.

The Add Plan dialog box displays fields for creating a new plan named "Patient Test" with a checkbox for "No Expiration Dates" and an "Active From" date set to 11/30/2020, along with Cancel and Create buttons.

Once a care plan is created, it can be copied in the future as follows:

Enter the client's profile
Click the Care Plan tab
Click Assign Plan
Select the template to copy
Rename the plan
Adjust the dates if needed
Save

The Assign Plan dialog allows users to select a care plan from a dropdown (currently set to "Default Client Care Plan"), rename the plan (showing "John Doe's Care Plan"), and set an active date (01/18/2022) with a checkbox for "No Expiration Dates" enabled. The dialog includes Cancel and Save buttons.

Assigning Care Plan Items from Care Plan Categories

After the plan has been created, click the Plan Name to update it. In the example below, that would mean clicking on the name Paul Cezanne.

From here, care plan categories can be updated. Categories vary according to the organization and state requirements, but common categories include:

Personal Care
Homemaker
Advanced Personal Care
Respite
Advanced Respite
CDS
Private Pay

To assign care plan items to the categories, click Update next to the appropriate Care Plan Category. Select the appropriate items with the check box to the right and then click Assign Selected Item.

Screenshot.

Once the care plan items have been assigned, users can:

Add specific notes

Notes, when entered, are visible to all caregivers using the mobile app. These notes can be helpful in outlining the details of a care plan item. For example, a care plan item might be "assist with mobility," and the note may say "Stay on the client's weak right side."

The Care Plan Detail screen for Suzie Sunshine displays a Care Plan Items Category table showing Activities of Daily Living (ADLs) with columns for Item and Note; visible items include Complete/Partial Bath (noted "if not bath given, note MUST be provided"), Dressing/Undressing (noted "assistance only"), and Assist with Toileting (noted "supervise"), each with expand buttons.

Blank lines may be included for clarity/organization in long notes if needed. Exceptionally long notes will be minimized with an "Additional Information" button.

Report Items page displaying two problem categories: "Activity Problem: Little or no activity involvement" and "Alcohol Problem: Risk for injury related to alcohol withdrawal," each with an N/A checkbox and expandable additional information links, followed by empty text input fields for notes.

Add a Min and Max times per week

To limit how many times per week to ask about a care plan item, set limits in the Times/Week section. For example, Make Bed/Change Bed Linen could be limited to 1–2 times per week. In this case, after asking the question and receiving 2 confirmations that this care plan item was completed, the question will no longer be asked. To have the item reported on every visit, leave the min and max blank.

The Kansas Nursing Items table for Specialized Medical Care/Private Duty Nursing displays nursing care items with columns for Item, Note for Caregiver, Times/Week (Min - Max), and Block Down Days. The Times/Week column is highlighted with a red box, showing input fields for minimum and maximum values for each nursing item listed including Special Diet/Oral Feeding, NG-tube, and G-tube.

Uncheck All to define specific days of week

Limits can also be set by day. For a unique event that can only be asked about on certain days, such as a Friday Bingo social event, set the specific day to Friday. Only do this with items that truly cannot be performed on other days. If the visit is rescheduled to Thursday, the question will not be asked — which is perfect for a once-a-week social event like Bingo or a doctor's appointment, but would not work for laundry.

Creating & Assigning a Universal Care Plan (Legacy)

An existing care plan can be copied and re-named using the Assign Care Plan button at any time.

Alternately, use the legacy function to create care plans at the Care Plan (Settings) level, then assign the care plan on a client-by-client basis.

Click Settings, then Care Plan. (Care Plan may be under the subsection Services Settings in some environments.) Then click Add New Plan.

The Care Plan page displays a search and filter interface with fields for Plan Name (text input), Plan Type (dropdown set to "Caregiver"), and Plan Status (dropdown set to "Active"), along with "Search Plans" and "Add New Plan" buttons on the right side.

In this location, adding a new care plan will look different than at the Client level, but the concept is the same. Give the plan a name, leave the plan type and plan status defaulted, and then check the box next to each appropriate care plan item.

Scroll down and click Save Plan before exiting.

The bottom portion of a medical planning form showing two checked checkboxes for "Medication Injection" and "Other" with associated time input fields, along with "Save Plan" and "Close" buttons in the lower right corner.

Going forward, this plan will be available to Assign under each client's Care Plan tab.

The Client Detail page for "Test Client" showing the Care Plans tab with an "Assign Plan" dialog box open. The dialog allows selection of a care plan (Tier 1 PPCare Plan), setting an active from date (10/07/2021), and includes a "No Expiration Dates" checkbox option, with Save and Cancel buttons.

Editing a Care Plan

To edit a care plan, click on the care plan's name (typically the client's name) under the Care Plan tab. This opens the care plan, at which point any and all care plan items can be changed, added, or deleted.

No Care Plan

In some states, there is no care plan and no care plan items for specific visit types. This is common for Respite Care visits. As of 5/10/24, visits that have no care plan and no care plan items will no longer be flagged for violation in the visit approval dashboard. This is universal and is not a configurable option.

Other

For care plans where there are time-specific care plan items, see Multiple Care Plan Management.

For the next step in adding a client, see Calendar-Based Scheduling.

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