Care Plan Basics
What is the main purpose of an ECM Care Plan?
To identify the member’s needs, priorities, goals, barriers, strengths, and planned interventions in a member-centered way.
What does SMART stand for?
Specific, Measurable, Achievable, Relevant, and Time-bound.
Who determines what is most important to the member: the member or the CM?
The member.
What does POF stand for in ECM?
Population of Focus.
What is wrong with this goal: “Member will do better”?
It is vague and not measurable, specific, or time-bound.
Who should be involved in developing the Care Plan?
The member and the Care Manager, with input from appropriate providers, family, caregivers, or other supports when applicable and permitted.
Is “Member will improve their health” a SMART goal? & Why?
No. It is too vague and does not explain what will happen, how success will be measured, or by when.
Who is responsible for using professional judgment to identify barriers, care coordination needs, and appropriate interventions?
The Care Manager.
Why is the member’s POF important when completing the Care Plan?
It helps explain why the member qualifies for ECM and helps guide the needs, risks, care coordination priorities, goals, and interventions being addressed.
What is wrong with this intervention: “Housing”?
It does not explain what anyone will actually do. An intervention must identify an action.
Should a Care Manager complete a Care Plan by simply reading every question word-for-word to the member?
No. The CM should know which questions require the member’s input, which are completed using the CM’s assessment and available information, and which require both.
Turn this into a SMART goal: “Member wants a PCP.”
“Member will establish care with a primary care provider and complete an initial PCP appointment by XX-XX-XXXX.”
If a member says, “I want help finding housing,” who determines the exact CM activities that will be used to assist with that goal?
The CM develops appropriate interventions with the member.
Should every goal on the Care Plan be completely related to the member’s ECM needs or POF?
No. Goals should be meaningful to the member and relevant 1 linking to the POF.
What is wrong with a Care Plan where every intervention says only, “CM will follow up”?
The interventions are too vague. They should describe the actual assistance, coordination, referral, education, advocacy, follow-up, or other action the CM will perform.
Why is the member’s voice important in a Care Plan?
The Care Plan should reflect what the member actually wants to work on, their priorities, their barriers, and what matters to them—not just what the CM thinks should happen.
What is the difference between a goal and an intervention?
The goal describes what the member is working toward. The intervention describes what the CM and/or member will actually do to help achieve that goal.
A Care Plan asks about a member’s current needs and barriers. Is this always just a member question?
No. The member provides their experience and priorities, while the CM also uses assessment findings, records, observations, and professional judgment.
A member is experiencing homelessness and repeatedly missing medical appointments. Name two possible areas the Care Plan may address.
Housing stability and access to/coordination of medical care.
What is wrong with creating a goal the member never agreed to?
It is not member-centered and does not accurately reflect the member’s priorities or participation in the Care Plan.
What should happen when a member identifies several different needs during the Care Plan?
The CM should prioritize the needs with the member, identify appropriate POF-related or care-management issues, establish realistic goals, and develop interventions for the priorities being addressed.
A member’s goal is: “Member will establish behavioral health care by XX-XX-XXXX.” Give one CM intervention and one member intervention.
CM: Identify appropriate behavioral health providers and provide list to member.
Member: Participate in selecting a provider and notifying CM of choice.
What should the CM do if the member says they have no health concerns, but the CM identifies major care coordination needs?
Respect the member’s perspective while exploring the issue further, explaining the concern, and documenting appropriate needs and interventions without falsely stating that the member personally identified something they did not.
A member has several needs, but one of them is outside the scope of what the ECM team can directly provide. What should the CM do?
Identify the need, connect or refer the member to the appropriate resource/provider, coordinate as appropriate, and document the ECM intervention rather than promising a service ECM cannot provide.
Identify everything wrong with this example:
“Goal: Get housing. Intervention: CM will help. Timeframe: ASAP.”
The goal is not specific enough, there is no measurable outcome, the intervention does not state what the CM will actually do, “ASAP” is not a clear timeframe, and member responsibilities or agreed-upon steps may also be missing.