title: Developing interprofessional care plans in chronic care: a scoping review.
abstract: BACKGROUND
  The number of people suffering from one or more chronic conditions is rising, resulting in an increase in patients with complex health care demands. Interprofessional collaboration and the use of shared care plans support the management of complex health care demands of patients with chronic illnesses. This study aims to get an overview of the scientific literature on developing interprofessional shared care plans.
  
  
  METHODS
  We conducted a scoping review of the scientific literature regarding the development of interprofessional shared care plans. A systematic database search resulted in 45 articles being included, 5 of which were empirical studies concentrating purely on the care plan. Findings were synthesised using directed content analysis.
  
  
  RESULTS
  This review revealed three themes. The first theme was the format of the shared care plan, with the following elements: patient's current state; goals and concerns; actions and interventions; and evaluation. The second theme concerned the development of shared care plans, and can be categorised as interpersonal, organisational and patient-related factors. The third theme covered tools, whose main function is to support professionals in sharing patient information without personal contact. Such tools relate to documentation of and communication about patient information.
  
  
  CONCLUSIONS
  Care plan development is not a free-standing concept, but should be seen as the result of an underlying process of interprofessional collaboration between team members, including the patient. To integrate the patients' perspectives into the care plans, their needs and values need careful consideration. This review indicates a need for new empirical studies examining the development and use of shared care plans and evaluating their effects.
authors.affiliation: Research Centre for Autonomy and Participation for People with Chronic Illnesses, Zuyd University of Applied Sciences, Nieuw Eyckholt 300, 6419 DJ, Heerlen, The Netherlands. jerome.vandongen@zuyd.nl.|Department of Family Medicine, Maastricht University, CAPHRI School for Public health and Primary Care, Maastricht, The Netherlands. jerome.vandongen@zuyd.nl.
authors.forename: Jerôme Jean Jacques
authors.initials: JJ
authors.lastname: van Dongen
authors.affiliation: Department of Family Medicine, Maastricht University, CAPHRI School for Public health and Primary Care, Maastricht, The Netherlands.
authors.forename: Marloes Amantia
authors.initials: MA
authors.lastname: van Bokhoven
authors.affiliation: Research Centre for Autonomy and Participation for People with Chronic Illnesses, Zuyd University of Applied Sciences, Nieuw Eyckholt 300, 6419 DJ, Heerlen, The Netherlands.
authors.forename: Ramon
authors.initials: R
authors.lastname: Daniëls
authors.affiliation: Department of Family Medicine, Maastricht University, CAPHRI School for Public health and Primary Care, Maastricht, The Netherlands.
authors.forename: Trudy
authors.initials: T
authors.lastname: van der Weijden
authors.affiliation: Research Centre for Autonomy and Participation for People with Chronic Illnesses, Zuyd University of Applied Sciences, Nieuw Eyckholt 300, 6419 DJ, Heerlen, The Netherlands.
authors.forename: Wencke Wilhelmina Gerarda Petronella
authors.initials: WW
authors.lastname: Emonts
authors.affiliation: Research Centre for Autonomy and Participation for People with Chronic Illnesses, Zuyd University of Applied Sciences, Nieuw Eyckholt 300, 6419 DJ, Heerlen, The Netherlands.|Department of Family Medicine, Maastricht University, CAPHRI School for Public health and Primary Care, Maastricht, The Netherlands.
authors.forename: Anna
authors.initials: A
authors.lastname: Beurskens
keywords: Chronic disease; Goal setting; Interprofessional collaboration; Patient-centred practice; Scoping review; Shared care plan; Systematic review