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).”
4.B.1 Incorporates patient preferences and functional/lifestyle goals.
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4.B.2 Identifies treatment goals.
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4.B.3 Assesses and addresses potential barriers to meeting goals.
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4.B.4 Includes a self-management plan.
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4.B.5 Is provided in writing to the patient/family/caregiver.
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