Descriptions
The practice has a process to consistently develop patient care plans for the patients identified for care management. To ensure that a care plan is meaningful, realistic and actionable, the practice involves the patient in the plan's development, which includes discussions about goals (e.g., patient function/life style, goal feasibility and barriers) and considers patient preferences.
The care plan incorporates a problem list, expected outcome/prognosis, treatment goals, medication management and a schedule to review and revise the plan as needed. The care plan may also address community and/or social services.
The practice updates the care plan at relevant visits. A relevant visit addresses an aspect of care that could affect progress toward meeting existing goals or require modification of an existing goal.