Abstract
Care plans for home-based patients often do not provide specific goals for maintaining and managing patients, such as clinical test results and vital signs, only aiming to “comply with the prescribed medication”. This makes maintenance and management goals unclear, and leads to the implementation of care plans with no sharing of clear treatment goals among healthcare professionals. Therefore, it is important to set specific maintenance and management goals in care plans in order to provide appropriate treatment for patients through multi-professional cooperation. This study investigated whether physicians provide specific goals of maintenance and management when care managers develop a care plan, and the frequency of specifying goals in care plans.
As the results of a survey, 43 and 55% of care managers responded that they do and do not set specific goals in care plans based on physicians’ orders or patients’ health status, respectively. In approximately 40-60% of care plans for patients with cardiovascular disease, diabetes, reduced renal function, and pain, physicians did not instruct care managers to describe specific goals for maintaining and managing patients. “Being too busy” was one of the reasons why physicians do not respond to inquiries from care managers about maintenance and management goals. However, this inquiry leads to many questions that can be resolved if pharmacists ask physicians, indicating the need for the active involvement of pharmacists in the preparation of care plans.
