Care Planning

Our “Provider Toolkit” is offered to you as just one of the many resources that accompany our patient-centered care program to support your achievement of success as you journey through the changes asked for by this program. 
Care 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 each practice’s charting process and electronic capabilities; there is not a single template for care plan development. A care plan should enhance the 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.  
Self-Management Resources:  
Providing care and encouragement to people with chronic conditions helps them to understand their central role in managing their illness, make informed decisions about their care and engage in healthy behaviors.  
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