2014 - PCMH4B: Difference between revisions

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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.
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).”


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

Revision as of 19:09, 1 December 2015

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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).”

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

Description Example/Screenshot/Documentation Source Date Added

4.B.2 Identifies treatment goals.

Description Example/Screenshot/Documentation Source Date Added

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

Description Example/Screenshot/Documentation Source Date Added

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

Description Example/Screenshot/Documentation Source Date Added

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

Description Example/Screenshot/Documentation Source Date Added