As a nurse or clinician, creating and updating a care plan is crucial to effectively coordinating patient services and interventions, and overseeing medication management.
Care planning is also a core activity for reimbursable Medicare services, such as Chronic Care Management (CCM), Principal Care Management (PCM), and Behavioral Health Integration (BHI).
A patient-centered care plan is most effective when it’s based on a physical, behavioral, cognitive, psychosocial, functional, and environmental assessments or reassessment.
A comprehensive plan identifies and prioritizes health issues, paying particular attention to any comorbidities and chronic conditions.
As the foundation of care coordination, how can clinicians and nurses ensure they create effective patient-centered care plans? And, what does CMS require for care plans used in care management programs? What monthly updates must be made?
A care plan created as part of comprehensive care management should include the following five elements:
ThoroughCare is a comprehensive platform that helps providers streamline care coordination and management.
Once a patient is enrolled in a care management program and medical or behavioral conditions have been identified and prioritized, it’s time to lay the foundation for improved health through collaboration, coaching, and healthy actions.
The first step in creating a care plan includes identifying and solidifying the patient’s goals.
Because goals are measurable and can be tracked and updated over time, they give patients, care teams, and providers focus.
For example, if the patient’s condition is hypertension and their goal is to participate in more physical activities with their grandchildren, the nurse can focus on common activities that support their success, including:
When patient goals are data-driven, the goals focus on metrics that have clear ranges. Within these boundaries, care teams can regularly reevaluate and intervene.
Clearly defined goals drive accountability and transparency between nurses or care managers and their patients, giving both a way to track progress and change tasks or tactics if progress stalls.
Identifying potential roadblocks to patients reaching their goals is critical to anticipating obstacles and determining if-then actions.
Continuing with the hypertension condition used above, the patient may face common barriers, including:
Discuss and uncover the symptoms the patient has been experiencing for the conditions you’ve identified.
For hypertension, the patient may be experiencing symptoms like a pounding heartbeat, headache, flushing or feeling hot, and other hypertension-related symptoms.
Interventions are actions the nurse or care manager takes toward achieving patient goals and realizing desired outcomes. Common interventions include:
Related to hypertension, some common interventions could include:
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 are key to a successful patient-centered care plan.
Make a list of everyone involved in the patient’s health, including contact information.
Ensure that any prescribed new treatment won’t trigger allergies or be contraindicated with their medications. If the patient’s clinical picture is complex, engage a pharmacist for review.
First, determine which patient vitals are primary, which may include weight, BMI, and blood pressure.
Next, identify needed lab work. For a patient with hypertension, consider tracking lab results like HgbA1C, LDL cholesterol, HDL cholesterol, total cholesterol levels, INR (if on Warfarin), and Triglyceride levels.
Expected outcomes are similar to goals but take a broader view of what the patient looks forward to seeing more or less in a future state.
For a patient with hypertension, expected outcomes could include:
These steps ensure that a nurse or care manager has created a holistic, patient-centered care plan. Armed with this foundational tool, the care team can spend more time on patient engagement and education with a focus on goal-oriented action.
Once established, the care plan should be updated monthly.
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, accounting for specific patient health problems.
For example, each month, the care manager should review the medication list and any associated problems and, if necessary, inform the physician of new issues or needs.
Using the initial care plan as a baseline, the care manager can discuss and document any relevant issues or concerns in regard to the patient’s health.
The update should include any actions the patient is taking to address those issues to ensure progress is being made toward their goals.
Additionally, the care manager should review any preventive services or upcoming screenings that are due and address any care gaps. Once discussed, the care manager can order needed services.
While CMS doesn’t provide details on what they look for in care plan updates, these steps ensure the care plan is current.
Our platform provides evidence-based assessments, education, and workflows to enable a patient-centered care planning approach. We give nurses and care managers the tools to take all necessary steps required by CMS for care management delivery.
Featuring clinical content based on recommendations from the American Academy of Family Physicians, our guided interview walks care managers and nurses through a patient-centered care plan, providing the most common questions and answers to effectively identify, manage, and treat every patient’s chronic conditions.
Additionally, ThoroughCare can help clinicians: