A system for determining a treatment plan for a patient comprises a database of patient data elements indicative of a medical condition associated with a patient. A predictive model is applied to patient assessment data and used to prepare a treatment plan. A rules engine applies a patient rule consistent with the treatment plan to selected data elements stored in the database to produce an output indicative of a change in the medical condition of the patient. The output from the rules engine is used to determine if intervention is warranted. The predictive model is applied continuously to determine whether to update the treatment plan and, if necessary, the patient rule.