2017 - Competency CM-B

Table of Contents

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Competency B: For patients identified for care management, the practice consistently uses patient information and collaborates with patients/families/ caregivers to develop a care plan that addresses barriers and incorporates patient preferences and lifestyle goals documented in the patient’s chart.

CM 04 (Core): Establishes a person-centered care plan for patients identified for care management

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.

Use NCQA's Record Review Workbook to choose a sample of relevant patients identified (and flagged) from CM 01 and check for the relevant items.

Use PCC's Care Plan tracking functionality for patients identified for care management. Some practices may prefer to create a special protocol to add to visits for patients identified as needing care management. The benefit of using PCC's integrated care plan functionality is that the plan is tracked discretely within the patient's medical summary and is easily accessible at any visit.

Use the "Care Plans by Date" report in PCC's EHR Report Library to identify patients with a Care Plan

CM 05 (Core): Provides a written care plan to the patient/family/caregiver for patients identified for care management

The practice provides the patient’s written care plan to the patient/family/caregiver. The practice may tailor the written care plan to accommodate the patient’s health literacy and language preference. (i.e., the patient version may use different words of formats from the version used by the practice team)

Report or Record Review Workbook and patient examples are required.

Use the EHR Component Builder to create a new Handout Order called "Written care plan provided". Add this order to your visit protocols and check it off when a written care plan is provided to patients during a visit. This will allow you to track whether the written care plan was provided.

CM 06 (1 Credit): Documents patient preference and functional/lifestyle goals in individual care plans

The practice works with patients/families/caregivers to incorporate patient preferences and functional lifestyle goals in the care plan.

Report or Record Review Workbook and patient examples are required.

CM 07 (1 Credit): Identifies and discusses potential barriers to meeting goals in individual care plans

Addressing barriers supports successful completion of the goals stated in the care plan. Barriers may include physical, emotional or social barriers

Report or Record Review Workbook and patient examples are required.

CM 08 (1 Credit): Includes a self-management plan in individual care plans

The practice works with patients/families/ caregivers to develop self-management instructions to manage day-to-day challenges of a complex condition. The plan may include best practices or supports for managing issues related to a complex condition identified in the care plan.

Report or Record Review Workbook and patient examples are required.

CM 09 (1 Credit): Care plan is integrated and accessible across settings of care

Sharing the care plan supports its implementation across all settings that address the patient’s care needs. The practice makes the care plan accessible across external care settings. It may be integrated into a shared electronic medical record, information exchange or other cross-organization sharing tool or arrangement.

The patient Care Plan is accessible to patients within the Patient Portal. Consider using that as an example of providing accessibility of the Care Plan to patients in any clinical setting

Documented process and evidence of implementation is required.