Coordinated Care Plans (CCPs) are a key feature in SHIIP used to support Health Links. The CCP allows patients, families, caregivers, and providers to take a collaborative approach to the patient’s goals and care. In SHIIP, each section of the CCP is split into the following pages:
- CCP Information: records administrative information about the CCP.
- My Identifiers: records the patients identifying information, as well as their concerns and what is most important to them.
- My Care Team: records information about the patient’s care team
- My Care Consent & Advanced Care Planning: records a list of substitute decision makers for the patient.
- My Health: records the patient’s conditions, issues, and / or diagnosis.
- More About Me: records the patient’s social determinants of health and other factors that may affect the coordination of care.
- My Goals & Action Plan: records the patient’s goals and plan for those goals.
- My Medication Coordination: records the support components for organizing the patient’s medications.
- My Allergies: records the patient’s allergies / intolerance and associated symptoms.
- (Appendix #1) My Medications: records the patients list of medications and information relating to those medications.
- (Appendix #2) My Health Assessments: records the patient’s assessments that could help inform the care team.
- (Appendix #3) My Last Hospital Visit: records information for the patient’s most recent hospital visit.
- (Appendix #4) My Palliative Approach to Care: records information regarding the patient’s palliative wishes and support plan.
Each patient’s CCP can be saved in PDF format for print. This PDF document aligns with the design and structure of the latest CCP document version.
Full Revision History
When viewing a patient’s CCP, users can see exactly what has been updated on a specific page. This includes who updated the page, when it was updated, and any old / new values.
SHIIP leverages a check-out / check-in system to prevent users from overwriting the work of others. While a CCP is checked out, drafts of the document are saved to ensure that work is not lost in the event of connectivity issues.