Milestone 3: Care Planning
Establish sustainable process for shared care planning, including self-care management support/goal setting/action planning
A care plan is a detailed approach to patient care that is customized to incorporate an individual patient’s needs, goals, and preferences. In order for care plans to be successful, the patient must be an engaged partner in the care planning process. Care plans are called for when patients can benefit from personalized physician instruction and feedback regarding management of their condition(s). The patient will be involved in goal setting for the issues he or she feels are most important. While there are critical assessments and elements that should be part of a care plan, the exact format will vary based on your charting process and electronic capabilities; there is not a single template for care plan development. Whatever format you use, the provider clinical liaison will provide tools and resources to develop the care plans and it should not require duplicative documentation. A care plan should enhance your patient’s treatment plan, and should provide a broader level of assessment than a standard patient history and physical to efficiently manage care. Explore our toolkit resources to find a sample care plan template and additional care plans.
Care Planning and Coordination Resources:
Our care plan playbook outlines the purpose of care plans and which patients can benefit most from them. It includes sample patient assessment metrics and a goal-setting framework, along with links to external resources that can help guide care planning.
BCBSGA worksheet introducing the concept of medication adherence and related strategies.
Completion of a comprehensive assessment during each patient visit helps ensure that all the patient’s needs are addressed, and can help the provider identify and address chronic conditions that may otherwise go undiagnosed and/or untreated. Early detection of conditions and changes in patients’ health status allows for early intervention and can prevent the need for significant medical interventions such as hospitalization. To better understand the health risks and other needs of patients and families, the provider should perform a comprehensive health assessment at least annually with regular updates thereafter.
BCBSGA worksheet introducing the concept of medication reconciliation and related implementation strategies.
This template care plan is meant to help guide primary care team members as they develop a care plan with a patient. Providers are not required to use the template, but are welcome to use it as a starting point to help guide discussion and planning.
This guide from the Patient-Centered Primary Care Collaborative (PCPCC) discusses the reasons medication management is so important to a functioning patient-centered medical home, and outlines how to adopt a formal process for medication management.
Self-management support is an important element of patient-centered care. This guide from Institute for Healthcare Improvement (IHI) provides a step-by-step process for beginning to offer self-management support to patients with chronic disease.
Self-management support for patients with chronic illness is a routine function of clinical care in many primary care organizations. This report from the California Healthcare Foundation (CHCF) describes models that have been successful in involving these patients in a well-planned and efficient way.
This CDC two-page guide for providers outlines the benefits of self-management programs for patients with chronic diseases.
This two-page guide for community organizations from the CDC outlines the benefits of self-management programs for people with chronic disease, and how to implement one.
Motivational Interviewing Resources:
This overview offers a brief explanation of the ways Motivational Interviewing can assist patients and help providers encourage self-management and engagement.
This self-quiz allows providers to gauge their own expertise and confidence level with individual aspects of Motivational Interviewing. Provided by HealthTeamworks.
This self-assessment scale can help providers gauge their own mastery of Motivational Interviewing skills. Provided by HealthTeamworks.
A Survivorship Care Plan is a coordinated post-treatment plan between the Survivor’s oncology team, a primary care physician and other health care professionals. The oncologist creates a summary of the Survivor’s treatment and includes direction for future care. This document introduces Survivorship Care Plans, what they are, why they matter and best practices for creating and maintaining them for patients. Link also included to the authoring “Journey Forward” program.
Lists potentially inappropriate medications for use in older adults.
This white paper defines Brief Action Planning, describes the eight clinical competencies to use it effectively, explains the rationale for its development, and discusses ways to use it in health care and medical education, health care systems, and Patient Centered Medical Homes.
An article from CMSA Today shares the lessons learned on the role of nurse care manager to enhance patient centered work in a Massachusetts Patient-Centered Medical Home Initiative.