Interprofessional Care Plan

The Interprofessional Care Plan (ICP) is a Home Health (HH) tool within PARIS that supports the documentation and sharing of information related to a client’s needs, goals, and interventions. It enables efficient documentation and easy retrieval of relevant information, supporting effective care planning, improved coordination across health care teams, and clearer communication with and about the client.

The ICP is accessed through the Interprofessional Care Plan application, which for Home Health users is located near the upper left corner of the Home Screen, directly below the Shortcuts tile.

Other applications available within this tile include Casenotes, Assessments, Risk Screen, Clinical Care Plan, and Goals of Care.

Below is a list of all the various sections of the ICP and their contents.

The Relevant Information section of the ICP serves several important purposes.

First, it is used to view or assign a Most Responsible Clinician (MRC) to the client. If an MRC has already been allocated, this information will appear in the Most Responsible Clinician area. If no MRC has been assigned, clinicians can allocate one by using the button. Until an MRC is assigned, the remainder of the ICP will remain read-only and cannot be edited.

This section also displays key client information that is entered elsewhere in PARIS, including:

• GP/NP: Displays the same provider entered in the GP/NP field within Central Index – Personal Details
• Pharmacy(s): Displays the current pharmacy listed in the External Agencies / Other Professionals grid

In addition, this section contains the Review Date field, which is used to flag when the ICP requires an overall review by the MRC.

If the client has an active care plan in the Clinical Care Plan (CCP) application—such as when clients are shared across programs (e.g., Home Health and Mental Health & Substance Use)—a red message will appear at the top of this section stating:
“This client has active entries in the Clinical Care Plan application, please review.”
Clinicians can review this information by navigating to the CCP tile via the navigation bar.

The Form Tools section provides access to all ICP reports and includes a button that allows users to navigate directly to the Add & Review Needs, Goals & Interventions section of the ICP.

There are two report buttons available in this section:

Print Client’s Copy

Select this button to generate the Client Copy of the Care Plan. This report is designed for the client’s records and excludes potentially sensitive clinical information.

All Care Plan Reports

Select this button to choose between the ICP Staff Caseload Report or the ICP Report.

• ICP Staff Caseload Report
  This report provides a high level overview of client information and is useful for reviewing key details at a glance. Information included in this report may include:

Client PARIS ID

Client name and age

All teams involved in providing care

ICP review status (next review due, upcoming, or overdue)

Date the backup plan was last updated and by whom

Whether a Goals of Care conversation has been documented in PARIS, and the most recent update date 

All active Needs and Interventions (picklist headings only)

Intervention review dates, including upcoming and overdue reviews

Discipline responsible for each intervention

Staff member assigned as the Key Provider for each discipline referral

Any additional individuals or groups tasked with carrying out interventions on behalf of the responsible discipline 

• ICP Report
  This report reproduces a full copy of an individual client’s care plan. This version is different from the Client’s Copy report as that report has been designed to remove potentially sensitive client information.

The Involved Staff – Review Only section is a read only view that lists all staff members allocated to an active client referral across any program within PARIS. For each staff member, the section displays their allocation type, referral reason, and allocated team.
 

The Goals of Care – Key Topics – Review Only section is a read only area that displays the most recent Key Topics information recorded in the Goals of Care (GOC) tile in PARIS. This information is presented here to help inform and guide the client’s care planning.

In addition to the key topics content, the section also displays the following details:

• Status – Indicates the status of the most recent GOC entry. A GOC entry will have one of the following statuses: Active or Historic.
• Last Updated – Shows the date the GOC entry was last modified, along with the name of the staff member who made the change.

Available Actions

The following buttons are located in the upper right corner of this section:

• Full Screen – Opens the GOC entry within the ICP in full screen view.
• View Full GOC – Displays the entire GOC entry in a PARIS report format.

A Guidance Note button is also available. Selecting this button opens a window that provides additional information about the purpose of this section and its importance in supporting a client’s care plan.

If the Goals of Care – Key Topics – Review Only section is blank, this indicates that the client does not have any Goals of Care entries on file.

For more information on the Goals of Care tile, refer to the Goals of Care PARIS user help page.



The Medical and Psychosocial History section is a free text field where clinicians can document the client’s current and past medical and psychosocial history. As a client’s health status may change over time, this section can be updated at any point to reflect new or evolving information.

This section also includes a Guidance Notes button. When selected, it opens a window containing detailed instructions to support accurate and consistent documentation in the Medical and Psychosocial History field.

In addition, a read only Last Updated field displays the name of the most recent clinician to modify this section, along with the date the update was made.
 

The Client’s Desired Outcomes section is a free text field where clinicians document the client’s goals. Client goals should be expressed in the client’s own words and reflect what the client wants to achieve, as well as what is meaningful and important to them. The Client’s Desired Outcomes provide the core focus and direction for all care plan entries within the ICP.

This section also includes a Guidance Notes button. Selecting this button opens a window with detailed instructions to assist clinicians in completing the Client’s Desired Outcomes field effectively.

A read only Last Updated field is also displayed, showing the name of the most recent clinician to update this section and the date the change was made.
 

The Add & Review Needs, Goals & Interventions section is a read only grid that displays all active care plan entries and is used to navigate through them. Users can select a care plan entry within the grid to view its details. Once selected, the corresponding information is displayed in the Needs, Goals & Interventions section below.

This section is also used to create new care plan entries through the following buttons:

• Add Need
  Select this button to create a new care plan entry in the Needs, Goals & Interventions section below. Each new care plan entry must include:

One Need
One SMART Goal
At least one Intervention

• Add SMART Goal
  Select this button to add a new SMART Goal and at least one associated Intervention under an existing Need. Before selecting this button, the user must first choose the relevant Need from the Add & Review Needs, Goals & Interventions grid so PARIS knows where to place the new entry. The newly added information will appear in the Needs, Goals & Interventions section below.

The Needs, Goals & Interventions section is used to enter and view detailed care plan information. Within this section, users can view and/or record the following details:

Need and Smart Goal Information

• Need – A mandatory pick list field used to select or view the identified need for the care plan entry.
• Need Date Created – An auto populated date field that records when the need was created.
• Smart Goal Created – An auto populated date field indicating when the smart goal was created.
• Status – An auto populated field displaying the current status of the smart goal.
• Smart Goal – A mandatory free text field used to enter or view the smart goal associated with the need.

Intervention Information

• Intervention – A mandatory pick list field used to select or view the intervention for the care plan entry.
• Status – A mandatory, auto populated field displaying the current status of the intervention.
• Discipline – A mandatory, auto populated field identifying the discipline responsible for the intervention. PARIS automatically derives this from the profession linked to the user’s account.
• Review Date – A date field used to enter or view when the intervention should be reviewed.
• Frequency – A pick list field used to enter or view how often the intervention is expected to occur.
• Carried Out By – A pick list field used to specify who will carry out or assist with the intervention when an individual or group other than the identified discipline is involved.
• Date Created – An auto populated date field recording when the intervention was created.
• Ongoing – A checkbox used to indicate interventions that are expected to be lifelong (e.g. related to non curable illnesses, chronic diseases, or chronic wounds).
• Details – A mandatory free text field used to enter or view detailed information about the intervention.

A button is available within this section that opens the Interprofessional Care Plan – OneVCH page, where users can access regionally approved ICP care plan templates.

For detailed guidance on entering an ICP entry, refer to the [VCH] Interprofessional Care Plan Guide, specifically the How to Create a New Interprofessional Care Plan section.

Note: Care plan intervention details cannot be modified, closed, or marked as entered in error within this section. All updates, closures, or error corrections must be completed from within the casenote tile.

The Focused Plans section is used to enter and view plans that are triggered by specific situations rather than by an identified client need or goal. Available entries are the Ambulatory Clinic Screener, Back Up Plan, and Seasonal Readiness Plan. Because these plans are not tied to a client need or goal, they are not captured within the Needs, Goals & Interventions section.

This section also includes a Guidance Note button. When selected, it opens a window containing additional information about the purpose and appropriate use of Focused Plans.

Note: Only one active Ambulatory Clinic Screener, Back Up Plan, and Seasonal Readiness Plan may exist at any given time. If a user attempts to add a second plan of the same type (e.g., a second back Up Plan), PARIS will prevent the duplicate entry from being saved.

The MRC Notifications section of the ICP is where the Most Responsible Clinician (MRC) can view system generated notifications. These notifications are triggered when significant changes occur in a client’s care plan that require MRC awareness or review.

In addition to appearing in this section, the MRC will also receive a generic inbox notification indicating that one or more items are available for review in the MRC Notifications section of the ICP.

Events That Trigger Notifications

System generated notifications are created when any of the following significant changes occur:

• Creation or closure of a Need
• A new discipline is added to the ICP for the first time
• A discipline exits the ICP
• Changes are made to the Back Up Plan
• One or more interventions are left without an assigned overseeing discipline

Note: PARIS performs its checks for these changes overnight. As a result, notifications will not appear in the MRC Notifications section until the following day.

Available Actions

This section includes the following buttons:

• Include historic (6 months) – Displays MRC notifications from the past six months in addition to outstanding notifications.
• Show Outstanding Only – Appears only after selecting Include historic (6 months) and returns the view to outstanding notifications only.
• Clear Notifications – Clears all outstanding notifications from the grid and moves them to the historic list. This action should only be taken once the MRC has reviewed all outstanding items.

A Guidance Note button is also available. Selecting it opens a window containing additional information about the purpose and use of the MRC Notifications section.

 

This grid displays the most recently entered casenotes, showing up to 50 records. The Linked Intervention(s) column indicates which intervention(s), if any, each casenote is associated with. If this column is blank, the casenote is not linked to a care plan component.

Users can double click a casenote entry to view its full documentation directly from this grid, without needing to navigate to the Casenotes tile.

Additional Resources:
Most Responsible Clinician Support Document
[VCH] Interprofessional Care Plan Guide
OneVCH Interprofessional Care Plan Page

Videos:
Interprofessional Care Plan PARIS Demo Video 1
Interprofessional Care Plan PARIS Demo Video 2