2014 - PCMH4B

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The care team and patient/family/caregiver collaborate (at relevant visits) to develop and update an individual care plan that includes the following features for at least 75 percent of the patients identified in Element A:

  • Incorporates patient preferences and functional/lifestyle goals
  • Identifies treatment goals
  • Assesses and addresses potential barriers to meeting goals
  • Includes a self-management plan
  • Is provided in writing to the patient/family/caregiver

According to NCQA, the care team and patient/family/caregiver collaborate on developing and updating an individualized care plan that addresses whole-person care. The care plan specifies the services offered by and responsibilities of the primary care practice and, if appropriate, integrates with a care plan created for the patient by a non-primary care specialty practice, to avoid potential overlap or gap in services and care.

CMS defines a care plan as, “The structure used to define the management actions for the various conditions, problems, or issues. A care plan must include at a minimum the following components: problem (the focus of the care plan), goal (the target outcome) and any instructions that the provider has given to the patient. A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome).”

Refer to PCC's Care Plan tracking functionality when working to meet these factors.

PCC recommends using NCQA's Record Review Workbook to choose a sample of relevant patients identified from element 4A and check for the relevant items.

4.B.1 Incorporates patient preferences and functional/lifestyle goals.

4.B.2 Identifies treatment goals.

4.B.3 Assesses and addresses potential barriers to meeting goals.

4.B.4 Includes a self-management plan.

4.B.5 Is provided in writing to the patient/family/caregiver.

In the Care Plan component in PCC EHR, press the <Print> button to print a Care Plan document to be given to the patient/family/caregiver.