Multidisciplinary Care Planning

Lack of follow up on crucial items post-visit, or, “Care falling through the cracks” is one of the biggest deficiencies in the healthcare system to date. Key examples of this are:

• A lab test is ordered at an outside facility, but the results never make it back to the subspecialist.
• A consult is recommended but never gets scheduled
• An educational resource that gets suggested in appointment but never is followed through

In order to support improvements in care planning, the Integrated Care Program developed the “Action Grid” which is a structured, standardized tool designed to communicate action items defined at a patient encounter along with ownership and timeline. This tool has been trialed by multi-disciplinary care teams at Boston Children’s who care for highly complex patients. It is shared with the families and is now a standard part of their care operations. The Integrated Care team is currently working to embed this tool into Boston Children’s electronic health record to make it accessible to all BCH providers and ensure that it is shared with our patients’ primary care providers.

For an example of the tool template, please click here. If interested in using this, please contact Casey Fee.

For further information, please contact integratedcare@childrens.harvard.edu.