2017 - Competency CM-B
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