Care Plan Components
What list is required?
A problem list.
Comprehensive Care Plan includes all health issues with a focus on managing chronic conditions
Where can goals come from during first/initial engagement and subsequent engagements?
The patient or EMR
Where is the cognitive screening found?
SDOH
What two times does the full care plan need to be sent to the provider?
The initial encounter and annually.
What part of the care plan monitors the patient's medication regimen to help assess any potential medication interactions, adherence, and appropriate self-management?
Medication Management
What type of outcomes need to be included?
Expected outcomes and prognosis.
These are commonly found in the "plan" section of the last office visit. If there are no plans, you can use the hints in the condition module.
What is one activity the CC can do to help patients achieve goals?
Identify barriers
Document interventions to help patients overcome barriers.
Where is the functional assessment/screening found?
Care Assistance
What is covered in the first engagement regarding the care plan component for medication management?
Entering medications from the EMR to pathways
Checking for accuracy by reviewing all meds w/the pt/caregiver
Ensuring patient is taking medications as prescribed
Identifying the patients known allergies & reaction
Good idea is to make sure the pt can afford the medications
What purpose do tasks/interventions serve in the care planning process?
Task/Interventions are specific strategies that the patient can use to achieve their goals.
What should the treatment goals be?
Measurable
They should represent a realistic, achievable outcome for the patient within a specified timeframe.
In subsequent engagements with the patient, they should do what regarding goals?
The patient should communicate their continued agreement with the goal.
Where is the environmental evaluation found?
Environmental Safety
What is covered in subsequent engagements related to the medication management part of the care plan?
Are pts taking meds as prescribed; any barriers to taking meds?
Identifying and documenting any changes in meds (dosage, freq, new meds or discontinued meds, etc)
Does the pt have medications on hand?
Are they tolerating the medications well? Any new or worsening side effects?
Who creates a care plan?
Patients, providers and CCs work collaboratively to create care goals and a detailed, step-by-step plan to achieve goals.
When should the care plan be initiated?
During the first contact with the patient.
What can inhibit the patient's goal progression?
Barriers
CC should document barriers and interventions to address.
Where are questions related to caregiving found?
Environmental Safety
How often should care plans be updated?
Care plans should be updated monthly to ensure the patients are moving in a positive direction toward their health goals.
What is developed using a person-centered plan based on the patient's health issues, management and treatment of chronic conditions?
What part of a care plan addresses new or worsening symptoms?
First engagement: identify if the patient is experiencing any new or worsening symptoms, and document all relevant information to report to POR
Subsequent engagement: identify if there are new or worsening sx's; follow up on past reported sx's; document all relevant sx information and report to POR
What documentation regarding goals is important to provide?
Documenting barriers, goal progress, patient agreement, and any changes related to goal achievement provides a clear picture for both the patient and provider, helping to identify when adjustments are needed
What does SDOH stand for?
Social Determinants of Health
What are some of the components of SDOH which are important to address in the care planning process?
Social and community context, access to healthcare, economic stability.
It is essential to know any details related to issues surrounding access to things like transportation, healthy foods, and safe housing.
What can a comprehensive care plan do for a patient and provider?
Comprehensive care plans can help patients and providers gain quick access to information on patients problems, conditions, and health goals.