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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
CM 05 (Core): Provides a written care plan to the patient/family/caregiver for patients identified for care management
CM 06 (1 Credit): Documents patient preference and functional/lifestyle goals in individual care plans
CM 07 (1 Credit): Identifies and discusses potential barriers to meeting goals in individual care plans
CM 08 (1 Credit): Includes a self-management plan in individual care plans
CM 09 (1 Credit): Care plan is integrated and accessible across settings of care