Figure 1.

My Dialysis Plan care planning approach, depicted in 3 phases: before, during, and after the care plan meeting. In the weeks before the care plan meeting, a designated care team member issues invitations and schedules meetings. Just before the meeting, the care team huddles to review individual assessments. During the meeting, the care team elicits patient needs and priorities and uses shared decision making to develop an individualized plan of care with specific action items for care team members and the patient. At meeting conclusion, the care team reviews the care plan with the patient to confirm understanding and agreement. After the meeting, care team members perform assigned actions, provide updates on progress, and follow up with the patient to identify changing priorities. Abbreviation: EHR, electronic health record.