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How to Create and Update a Care Plan

January 4th, 2021 | 7 min. read

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Creating and updating a care plan is one of the most important parts of Medicare programs like Chronic Care Management (CCM), Principle Care Management (PCM), and Behavioral Health Integration (BHI).

The care plan should be a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources.

Essentially, the care plan should serve as a comprehensive plan of care for all health issues, with a particular focus on the chronic conditions being managed.


Working with hundreds of providers across the country, we have assisted many care managers in developing care plans for patients. Our software has a guided-interview care plan, walking care managers through the necessary steps required by the Centers for Medicare and Medicaid Services (CMS).


The biggest hurdle providers come up against however is the cultural shift that is required when switching to a patient-centered care model.


Under this model, all employees become engaged in the patient’s health, impacting the hiring, training, and overall culture of your practice. It requires providers to view patients and their family and friends not just as passive participants, but active members of the care team.


But how do you develop an extensive, patient-centered care plan? And what goes into the monthly updates required by CMS?


In this article, we’ll answer both of those questions at length and show you how care management software can make the process a breeze.

What Goes Into Creating a Care Plan?

A care plan involves comprehensive care management that should include:

  • Systematic assessment of the patient’s medical, functional, and psychosocial needs
  • System-based approaches to ensure timely receipt of all recommended preventive care services
  • Medication reconciliation with review of adherence and potential interactions
  • Oversight of patient self-management of medications
  • Coordinating care with home- and community-based clinical service providers

While creating care plans isn’t a difficult task, you want to be sure you are tailoring your care plan to the patient. Avoid using a cookie-cutter approach that includes the same visit frequencies, vague interventions, and unmeasurable goals.


So let’s get into the actual steps of creating a comprehensive, patient-centered care plan.

8 Steps To Create a Care Plan

Once you have identified the condition(s) the patient has, you can begin creating your care plan.

1) Defining the Patient’s Goals

The first step in creating a care plan should include defining the goals of the patient.

Goals are measurable and should be tracked over time and easily updated. These goals are more for the care team and provider to evaluate treatment options.

For example, if the patient’s condition is hypertension, you’ll want to focus on common goals that patients with hypertension aim for, such as:

  • Lower my blood pressure to my goal
  • Stay on my low salt eating plan
  • Exercise more regularly
  • Not have a heart attack
  • Not have a stroke
  • Protect my kidneys

Your goals should include metrics that emphasize clear values with set ranges, indicating the need for evaluation or continuation of interventions.

Definable goals also drive accountability and transparency between care manager and patient, as you’ll be able to track the progress of the patient and better help them achieve their goals.

2) Listing Barriers to a Patient’s Goals

Now that you’ve identified the patient’s goals, you’ll want to identify potential barriers for the patient reaching their goals.

Continuing with the hypertension condition we used above, some barriers the patient may face include:

  • Food doesn't taste good without salt
  • Can't understand food labels to check sodium in food
  • No energy to exercise regularly
  • No place to get regular exercise
  • Don't have a home BP monitor that works
  • Can't understand how to use my home BP monitor

3) Identify Symptoms the Patient Experiences

You’ll now want to list the symptoms the patient has been experiencing for the condition(s) you’ve identified.

For hypertension, the patient may be experiencing things like a pounding heartbeat, headache, flushing/feeling hot, or other hypertension-related symptoms.

4) List Interventions You’d Like to Make

Interventions are actions taken by the care manager to achieve patient goals and get desired outcomes. Common interventions include educating the patient, giving medications, checking vital signs regularly, or assessing the patient’s pain levels at certain intervals.

Using hypertension, some common interventions could include:

  • Teaching the patient what is occurring in the heart during systole and diastole
  • Reviewing goal blood pressure levels set for the patient by their provider
  • Teaching the patient the possible health outcomes if blood pressure remains high: stroke, heart attack, kidney disease, vision loss, etc.
  • Educate the patient in the goal sodium level set by the provider
  • Educating the patient in the role a high sodium level plays to increase blood pressure
  • Teaching the patient how to read a food label to check the sodium levels of the foods they eat
  • Educating the patient in the lifestyle changes that help to decrease blood pressure, such as a daily exercise routine
  • Teaching the patient the important role medications play in controlling blood pressure

5) Documenting All Support the Patient is Receiving

It's extremely important to have an accurate list of all providers involved in the patient’s health care. Active collaboration and shared decision making between patients, families, and providers is key to a successful patient-centered care plan.

Make a list of everyone involved in the patient’s health, including their contact information.

6) Identify Patient Allergies and Medications

You want to ensure that any new treatment that is prescribed to the patient is not going to conflict with allergies the patient may have or other medications they may be using.

7) Decide Which Metrics to Track

First list if there are any patient vitals you want to track. These can include weight, BMI, blood pressure, etc.

Next, you’ll do the same for lab work. For a patient with hypertension, you may want to track lab results like HgbA1C, LDL cholesterol, HDL cholesterol, total cholesterol levels, INR (if on Warfarin), and Triglyceride levels.

8) Notate Expected Outcomes from Treatment

Expected outcomes are similar to goals, but not the same. As we stated in our first step, goals are measurable and tracked over time.

Expected outcomes are something for the patient to look forward to - more of what the patients themselves want to happen as a result of the treatment they’re receiving.

For a patient with hypertension, expected outcomes could include the following:

  • Less worry that my blood pressure is high
  • Less worry about having a stroke
  • Less worry about having a heart attack
  • Less worry about not being able to see as well
  • Less worry about my kidneys being affected
  • Can take my blood pressure at home, less often
  • Won't need to add more medicines
  • Feel more relaxed

That completes all the steps in developing a holistic care plan for a patient. Now you can begin managing the patient’s health in a variety of Medicare programs, using the care plan as your guide.

Your next step will be updating the care plan monthly.

What Goes Into Monthly Updating of Care Plans?

CMS requires providers to update the patient care plan monthly with any relevant information.

Care plans should be written to enable systematic assessment on a month-to-month basis, noting changes, improvements, or interventions needed and taken on specific patient health problems.

For example, each month the care manager should review medications the patient is using, any associated problems noted should be reviewed and if needed, make the provider aware of problems or needs.

We designed our guided-interview care plan to enable this easy follow-up. Using the initial care plan as your baseline, the care manager will talk with the patient and follow up on any relevant issues or concerns in regards to the patient’s health.

You should include in your update any actions the patient is taking to address those issues to ensure progress is being made towards the goals you’ve set. If necessary, you should report any needs to the physician to address the patient’s health issues.

The care manager should also be able to track whether the patient is due for preventive service and encourage the patient to receive the preventive service the provider has ordered.

If the service has not been ordered, the care manager could call the office and ask if the service is needed.

While CMS doesn’t provide detail on what they look for in care plan updates, by doing your due diligence as outlined above, you’ll cover everything you need to stay compliant with CMS and provide the best care for your patient.

How ThoroughCare’s Software Makes Care Plan Creation A Breeze

Technology will immensely help your ability to implement a patient-centered care model.

That is why our software at ThoroughCare revolves around a patient-centered care plan, with content designed by our clinical staff and workflows designed to keep patients engaged and healthy.

With clinical content based on recommendations from the American Academy of Family Physicians, our guided interview walks care managers through a patient-centered care plan, providing the most common questions and answers to effectively identify, manage, and treat every patient’s chronic conditions.

Many physicians we work with loved how easy it is to build, create, and update patient care plans, keeping their staff efficient and effective.

Organizations can use ThoroughCare to improve the health and quality of their patients, or tie care plans to reimbursement programs like CCM, Remote Patient Monitoring, Annual Wellness Visits, and BHI.

A patient-centered care plan will put the patient’s needs, desires, and interests at the core of what you do, and our software allows for seamless delivery.

Let us show you how ThoroughCare can help you deliver the highest quality patient care by requesting a software demo or contacting us to learn more.