Planning Together:  Use of the care plan the support the health goals of adults with serious mental illness

 Miriam Tepper

Individuals with serious mental illnesses (SMI) such as schizophrenia face a 20-30 year mortality gap compared with the general population, an inequity thought to be due in large part to adverse health behaviors. Behavior change is hard for all of us, and even more challenging for those with SMI.  Yet behavior change in this population is possible, and represents a key step in bending the curve of the mortality gap.  In this project, I will examine the use of the care plan, which is a tool in the health record which includes patients’ and providers’ stated health goals as well as patients’ identified challenges and supports in meeting these goals.  Because any provider can view the care plan and talk with patients about health goals, the care plan is an ideal tool for facilitating the kind of repeated attention to health promotion needed for adults with SMI.  Every clinical encounter therefore represents an opportunity to support patients in their health goals.  Our clinical team has seen repeatedly that our patients want to be healthier; they are often not so interested in talking about illness, but are very interested in working on wellness.  And while there is so much in healthcare that is provider-driven, framing a clinical encounter with an open question to patients about their health goals shifts the focus of the encounter toward co-production.  This project aligns with CHA’s strategic emphasis on cross-disciplinary coordination and integration of care.  On a broader scale, addressing the institutional goal of healthier patients and communities will require the accruing of many, many individual-level behavior changes.  Using an improvement science approach, I aim to determine whether care plans have the potential to serve as a vehicle for promoting this behavior change.