2014 - PCMH4B - Revision history

Tim at 19:15, 1 December 2015

2015-12-01T19:15:23Z

@@ Line 15: / Line 15: @@
 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.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.  =
-{| border = "1"
+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.

Tim at 19:09, 1 December 2015

2015-12-01T19:09:42Z

← Older revision		Revision as of 19:09, 1 December 2015
Line 14:		Line 14:
	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. =

Tim at 19:08, 1 December 2015

2015-12-01T19:08:42Z

← Older revision		Revision as of 19:08, 1 December 2015
Line 6:		Line 6:

	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:		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.


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

Tim at 01:41, 9 July 2014

2014-07-09T01:41:01Z

← Older revision		Revision as of 01:41, 9 July 2014
Line 1:		Line 1:
	[http://pcmh.pcc.com/index.php/ Back to PCMH Resources Page]		[http://pcmh.pcc.com/index.php/2014_Main Back to PCMH Resources Page]

	[http://pcmh.pcc.com/index.php/2014_-~~_PCMH3E~~ << Move to previous PCMH element - 3E]		[http://pcmh.pcc.com/index.php/2014_-_PCMH4A << Move to previous PCMH element - 4A]

	[http://pcmh.pcc.com/index.php/2014_-~~_PCMH4B~~ >> Move to next PCMH element - 4B]		[http://pcmh.pcc.com/index.php/2014_-_PCMH4C >> Move to next PCMH element - 4C]

	The ~~practice establishes a systematic process~~ and ~~criteria for identifying patients who may benefit from~~ care ~~management. The process~~ includes ~~consideration~~ of the ~~following~~:		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:

	=4.A.1 ~~Behavioral health conditions~~. =		=4.B.1 Incorporates patient preferences and functional/lifestyle goals. =

	{\| border = "1"		{\| border = "1"
Line 17:		Line 17:
	\|}		\|}

	=4.A.2 ~~High cost/high utilization~~.=		=4.B.2 Identifies treatment goals. =

	{\| border = "1"		{\| border = "1"
Line 27:		Line 27:
	\|}		\|}

	=4.A.3 ~~Poorly controlled or complex conditions~~. =		=4.B.3 Assesses and addresses potential barriers to meeting goals. =

	{\| border = "1"		{\| border = "1"
Line 37:		Line 37:
	\|}		\|}

	=4.A.4 ~~Social determinants of health~~. =		=4.B.4 Includes a self-management plan. =

	{\| border = "1"		{\| border = "1"
Line 47:		Line 47:
	\|}		\|}

	=4.A.5 ~~Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff or~~ patient/family/caregiver. =		=4.B.5 Is provided in writing to the patient/family/caregiver. =

	~~{\| border = "1"~~
	~~! style="background:#8facd9; width:40%;" \|'''Description'''~~
	~~! style="background:#8facd9; width:20%;" \|'''Example/Screenshot/Documentation'''~~
	~~! style="background:#8facd9; width:20%;" \|'''Source'''~~
	~~! style="background:#8facd9; width:20%;" \|'''Date Added'''~~
	\|-
	\|}

	~~=4.A.6. The practice monitors the percentage of the total patient population identified through its process and criteria. CRITICAL FACTOR)~~ =

	{\| border = "1"		{\| border = "1"

Tim: Created page with "[http://pcmh.pcc.com/index.php/ Back to PCMH Resources Page] [http://pcmh.pcc.com/index.php/2014_-_PCMH3E << Move to previous PCMH element - 3E] [http://pcmh.pcc.com/index.p..."

2014-07-09T01:36:48Z

Created page with "[http://pcmh.pcc.com/index.php/ Back to PCMH Resources Page] [http://pcmh.pcc.com/index.php/2014_-_PCMH3E << Move to previous PCMH element - 3E] [http://pcmh.pcc.com/index.p..."

New page

[http://pcmh.pcc.com/index.php/ Back to PCMH Resources Page]

[http://pcmh.pcc.com/index.php/2014_-_PCMH3E << Move to previous PCMH element - 3E]

[http://pcmh.pcc.com/index.php/2014_-_PCMH4B >> Move to next PCMH element - 4B]

The practice establishes a systematic process and criteria for identifying patients who may benefit from care management. The process includes consideration of the following:

=4.A.1 Behavioral health conditions. =

{| border = "1"
! style="background:#8facd9; width:40%;" |'''Description'''
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''
! style="background:#8facd9; width:20%;" |'''Source'''
! style="background:#8facd9; width:20%;" |'''Date Added'''
|-
|}

=4.A.2 High cost/high utilization.=

{| border = "1"
! style="background:#8facd9; width:40%;" |'''Description'''
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''
! style="background:#8facd9; width:20%;" |'''Source'''
! style="background:#8facd9; width:20%;" |'''Date Added'''
|-
|}

=4.A.3 Poorly controlled or complex conditions. =

{| border = "1"
! style="background:#8facd9; width:40%;" |'''Description'''
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''
! style="background:#8facd9; width:20%;" |'''Source'''
! style="background:#8facd9; width:20%;" |'''Date Added'''
|-
|}

=4.A.4 Social determinants of health. =

{| border = "1"
! style="background:#8facd9; width:40%;" |'''Description'''
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''
! style="background:#8facd9; width:20%;" |'''Source'''
! style="background:#8facd9; width:20%;" |'''Date Added'''
|-
|}

=4.A.5 Referrals by outside organizations (e.g., insurers, health system, ACO), practice staff or patient/family/caregiver. =

{| border = "1"
! style="background:#8facd9; width:40%;" |'''Description'''
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''
! style="background:#8facd9; width:20%;" |'''Source'''
! style="background:#8facd9; width:20%;" |'''Date Added'''
|-
|}

=4.A.6. The practice monitors the percentage of the total patient population identified through its process and criteria. CRITICAL FACTOR) =

{| border = "1"
! style="background:#8facd9; width:40%;" |'''Description'''
! style="background:#8facd9; width:20%;" |'''Example/Screenshot/Documentation'''
! style="background:#8facd9; width:20%;" |'''Source'''
! style="background:#8facd9; width:20%;" |'''Date Added'''
|-
|}