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How to Create and Update a Care Plan

Creating a Care Plan: A Detailed Guide


A care plan involves a thorough approach to care management that encompasses:

  1. Comprehensive Assessment: Evaluating the patient’s medical, functional, and psychosocial needs systematically.

  2. Preventive Care Services: Ensuring timely access to all recommended preventive care services through system-based approaches.

  3. Medication Reconciliation: Reviewing medication adherence and potential interactions while overseeing patient self-management of medications.

  4. Coordination with Clinical Service Providers: Collaborating with home- and community-based clinical service providers to ensure coordinated care.


While creating care plans isn’t overly complex, it’s essential to tailor them to each patient's needs rather than adopting a one-size-fits-all approach.


Let’s delve into the step-by-step process of creating a comprehensive, patient-centered care plan.


8 Steps to Create a Care Plan

  1. Define Patient Goals: Start by defining clear, measurable goals that align with the patient’s condition. These goals should be regularly tracked and updated to gauge progress.

  2. Identify Barriers: Recognize potential obstacles hindering the patient from achieving their goals, such as dietary preferences, lifestyle constraints, or lack of resources.

  3. Document Symptoms: List all symptoms experienced by the patient related to their condition to inform the care plan effectively.

  4. List Interventions: Outline actionable interventions aimed at helping the patient attain their goals. These may include educational sessions, medication management strategies, or lifestyle modifications.

  5. Document Support Networks: Compile a comprehensive list of all healthcare providers involved in the patient’s care, fostering collaborative decision-making and shared accountability.

  6. Identify Allergies and Medications: Ensure that any prescribed treatments align with the patient’s allergies and current medication regimen to prevent adverse reactions.

  7. Select Metrics for Tracking: Determine vital signs and laboratory parameters to monitor regularly, enabling timely adjustments to the care plan based on patient progress.

  8. Define Expected Outcomes: Establish anticipated outcomes of the treatment to motivate and reassure the patient, fostering engagement and adherence.


Monthly Updating of Care Plans


CMS mandates monthly updates to patient care plans, necessitating systematic assessments and documentation of any changes or interventions implemented. Here’s a breakdown of the monthly updating process:

  1. Review Medications: Evaluate the patient’s current medication regimen for any adjustments or issues and communicate these to the provider if necessary.

  2. Follow-Up on Patient Concerns: Address any ongoing concerns or issues raised by the patient regarding their health status or treatment plan.

  3. Monitor Preventive Services: Ensure adherence to scheduled preventive services and facilitate appointments as needed to promote proactive healthcare.


By diligently adhering to these guidelines, care managers can maintain compliance with CMS regulations while delivering optimal care tailored to each patient's needs.


Offer Chronic Care Management To Your Patients With ChronicCare


ChronicCare partners with Physicians, Hospitals, Payors, and Employers to offer Chronic Care Management Services to their patients. We are dedicated to helping people improve their health and quality of life by maximizing their healthcare outcomes. We bridge the gap between healthcare visits, in order to ensure patients are continually cared for each month. 


Click here to connect with our team, we'd love to discuss potential benefits to your patients, staff, and practice.

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