All Condition Chronic Care Plan
Chronic Condition Patient Goals / Interventions / Barriers / By / DatePt adheres to treatment plan / Assess for any cultural barriers
Assess and pursue support systems needs related to disease
Educate and support adherence to treatment plan
Communicate with provider on appropriate management of condition
Educate Pt on importance of medication adherence
Pt is able to recognize signs and symptoms of their condition early and uses a written action plan to manage them / Educate Pt on disease process & treatment plan
Educate on self-monitoring
Educate on managing symptoms with written action plan
Educate on prevention of long-term complications
Uses healthcare services appropriately / Evaluate and support Pt choice of appropriate transportation options
Educate Pt on options in resources
Educate on value of utilizing Primary Care Provider as alternative to Emergency Room
Support continuity of care with Pt
Follow up with providers for continuity of care
Coordinate services for special needs/disability barriers
Support coordination of care
Reinforce Pt understanding of disease process prevention of complications
Explore recurrence of inappropriate ER visits with Pt
Follow up on management of co-morbidities
Assure continuity of care / Support coordination of care
Follow up on continuity of care with provider
Follow up on continuity of care with Pt
Assess for equipment needs
Evaluate on resource options
Evaluation need/availability of caregiver support
Assure adequate coping skills / Collaborate with provider regarding self-care practices
Reinforce on treatment plan
Educate on early recognition of worsening symptoms
Evaluate need/ availability of caregiver support
Educate on resource options
Identify and coordinate services related to fear, anxiety, & hopelessness
Manage condition effectively / Collaborate with provider regarding treatment guidelines and management of condition
Follow up on appropriate management of condition
Educate on management of co-morbidities
Educate on symptom management
Educate on guidelines and appropriate management of condition
Follow up regarding management of co-morbidities
Coordinate care / Coordinate appropriate healthcare services
Support coordination of care
Refer to community resources
Post-discharge phone call
Post-discharge medication reconciliation
Discharge plan initiated pre-discharge
Verify authorization and set up of requested services
Verify appointmentsare made for post-acute care
Medication administration and monitoring plan is present and effective / Follow up and review safe administration of medications
Reviewhow to recognize signs of medication side effects
Teach importance of medication adherence
Follow up on medication side effects
Coordinate provider on problems with medications
Follow up with Pt on medication adherence
Coordinate referrals for medication assistance
Demonstrates understanding of disease process / Educate on purpose of disease management program
Educate Pt on disease process, prevention of long-term complications
Verify understanding of disease process, prevention of complications by Pt and/or Caregiver
Assess and address support systems in place related to condition
Symptoms are managed appropriately / Educate member/caregiver on disease process
Educate member/family on effect of smoking on disease process
Educate on appropriate management of condition
Educate on coping strategies
Educate on correlation between behavioral health & disease process
Educate on disease process and prevention of long-term complications
Follow up on appropriate management of condition
Maintain physical conditioning / Educate on exercise and maintenance of physical conditioning
Support adherence to treatment plan
Follow up on exercise and maintenance of physical conditioning
Coordinate referral to physical or occupational therapy (with provider and Pt approval)
Reinforce understanding & adherence to treatment plan
Pt/caregiver aware of basic nutrition needs / Pt/caregiver aware of basic nutrition needs
Request referral to Dietitian from PCP if needed
Avoid missed school or work days / Educate Pt/Caregiver on disease process
Educate Pt on coping strategies
Follow up with Pt/Caregiver on self-care practices
Pt pursues optimal self-care practices / Collaborate with provider on Pt’s self-care practices
Support optimal health care practices and adherence with plan
Support independence and optimal functional status
Follow up with Pton self-care practices
Psychosocial issues will be managed effectively / Assess availability of caregiver support
Support optimal health care practices and adherence with plan
Follow up on adequate support for caregiver
Follow up on effective management of psychosocial issues
Assess and address support systems in place related to condition
Educate Pt/family on community support/resources
Provide list of community resources for support
Educate signs and symptoms of depression
Identify and coordinate services related to depression
Return to optimal & realistic medical and functional status / Support adherence to treatment plan
Educate on importance of medication adherence
Educate on Pt & Caregiver on treatment plan
Support optimal health care practices and adherence with plan
Educate on managing symptoms with written action plan
Follow up on action plan
Follow up with Pt on medication understanding & adherence
Follow up regarding adherence to treatment plan
Support independence and optimal functional status
Request referral forPt, family Pt or Caregiver to appropriate treatment provider
Identify and manage risk factors / Educate Pt on disease process
Educate on appropriate management of condition
Educate on exercise and maintenance of physical conditioning
Educate on coping strategies
Evaluate need/availability of caregiver support
Follow up on adequate support for caregiver
Educate on medication actions and potential side effects
Educate Pt/family on effect of smoking on disease process
Educate on correlation between behavioral health issues & disease process
Educate on risk factors
Educate on early recognition of worsening symptoms
Support safe transitions of care / Support coordination of care
Provide list of community resources for support
Coordinate referral to home healthcare (with provider and Pt approval)
PCP informed of Pt's participation in care management program and consulted on care plan / Collaborate with provider on appropriate management of condition
Collaborate with provider on adherence to treatment plan
Contact provider on requested services
Collaborate with provider regarding medication adherence problems
Collaborate with provider on appropriate program closure
Follow up on continuity of care with provider
Review treatment plan with provider to assure compliance with patient’s wishes on advance directives
Care will not be compromised by financial need / Coordinate services for special needs/disability barriers
Address for stress issues and/or barriers to care
Coordinate community resources/services
Educate on options regarding financial barriers
Follow up on options regarding financial barriers
Reinforce education on types, prescribed dosage and administration of prescribed medications
Follow up with Pt on medication adherence
Communicate with provider regarding medication adherence problems
CareSync Consulting® 1
Asthma Care Plan
Asthma Patient Goals / Interventions / Barriers / By / DateAsthma Action Plan is in place / Educate on treatment plan
Educate on early recognition of worsening symptoms
Follow up on appropriate management of condition
Follow up with Pt regarding self-care practices
Pt is encouraged to maintain symptom record / Educate on appropriate management of disease
Educate on coping strategies
Support independence and optimal functional status
Pt/caregiver aware of Asthma triggers / Educate Pt on disease process
Follow up on understanding of disease process & prevention of complications
Uses peak flow meter appropriately and effectively / Educate on/support use of peak flow meter for monitoring condition
Educate on importance of optimal peak flow 80% of personal best
Uses nebulizer, inhaler, spacer appropriately and effectively / Collaborate with provider regarding use of nebulizer, inhaler, spacer
Educate Pt/Caregiver on proper use of nebulizer
Educate Pt/Caregiver on proper use of inhaler
Follow up regarding nebulizer, inhaler, spacer use
Pt can describe at least 2 signs or symptoms of their condition that indicates the need for quick reporting to medical provider / Teach and Pt to recognize signs of medication side effects
Educate Pt on importance of monitoring peak flow
Educate Pt on disease process & complications
Educate on management of common co-morbidities
Teach Pt asthma self-care practices
Teach Pt to recognize early signs of worsening symptoms
Pt will have a plan to stop using tobacco/smoking / Assess Pt's readiness to change
Refer Pt to smoking cessation classes
Reinforce smoking cessation counseling
Educate Pt/family on effect of smoking on disease process
Follow up on smoking cessation
Educate on value of a written action plan
Support Pt goal setting for action plan
Encourage adherence to action plan
Monitor effects of any tobacco cessation medications
Keep influenza vaccination up to date / Educate on influenza vaccination
Follow up on influenza vaccination
Keep pneumonia vaccination up to date / Teach importance of pneumococcal vaccine
Reinforce understanding and performance of self-care practices
Report problems regarding self-care practices to provider
CareSync Consulting® 1
Congestive Heart Failure Care Plan
CHF Patient Goals / Interventions / Barriers / By / DateBlood pressure at target range < 130/80 / Teach Pt importance of regular blood pressure monitoring
Review use of Pt BP Record with Pt
Follow up on blood pressure level
Pt can describe at least 2 signs or symptoms of their condition that indicates the need for quick reporting to medical provider / Teach and Pt to recognize signs of medication side effects
Educate on ACE inhibitor / ARB
Educate member on importance of monitoring BP
Educate member on disease process & complications
Educate on management of common co-morbidities
Teach Pt heart failure self-care practices
Teach Pt to recognize early signs of worsening symptoms
Ace Inhibitor / ARB or contraindication is noted / Educate Pt on disease process and treatment plan
Member will have a plan to stop using tobacco/smoking / Assess member's readiness to change
Refer Pt to smoking cessation classes
Reinforce smoking cessation counseling
Educate member/family on effect of smoking on disease process
Follow up on smoking cessation
Educate on value of a written action plan
Support Pt goal setting for action plan
Encourage adherence to action plan
Monitor effects of any tobacco cessation medications
Keep influenza vaccination up to date / Educate on heart failure self-care practices Educate on influenza vaccination
Follow up on influenza vaccination
Keep pneumonia vaccination up to date / Teach importance of pneumococcal vaccine
Reinforce understanding and performance of self-care practices
Report problems regarding self-care practices to provider
Pt has accurate, readable scale / Educate on daily weights
Teach purpose of weight management
Monitor daily weights
Follow up on weight management
Follow up on resource needs
Pt recognizes signs of fluid retention / Educate Pt/caregiver to note rapid weight changes
Teach Pt/caregiver to check for changes in breathing patterns
Educate Pt/caregiver to check for swelling of feet, or changes in waist/abdomen
CareSync Consulting® 1
COPD Care Plan
COPD Patient Goals / Interventions / Barriers / By / DateCOPD Action Plan is in place / Educate on treatment plan
Educate on early recognition of worsening symptoms
Follow up on appropriate management of condition
Follow up with Pt regarding self-care practices
Educate Pt/caregiver to observe for changes in breathing patterns
Pt is encouraged to maintain symptom record / Educate on appropriate management of disease
Educate on coping strategies
Support independence and optimal functional status
COPD is diagnosed by spirometry / Communicate with provider regarding COPD diagnosis via spirometry
Educate Pt/caregiver on spirometry testing
Follow up regarding diagnosis of COPD via spirometry
Uses peak flow meter appropriately and effectively / Educate on/support use of peak flow meter for monitoring condition
Educate on importance of optimal peak flow 80% of personal best
Uses nebulizer, inhaler, spacer appropriately and effectively / Collaborate with provider regarding use of nebulizer, inhaler, spacer
Educate Pt/Caregiver on proper use of nebulizer
Educate Pt/Caregiver on proper use of inhaler
Follow up regarding nebulizer, inhaler, spacer use
Pt can describe at least 2 signs or symptoms of their condition that indicates the need for quick reporting to medical provider / Teach and Pt to recognize signs of medication side effects
Educate Pt on importance of monitoring peak flow
Educate Pt on disease process & complications
Educate on management of common co-morbidities
Teach Pt copd self-care practices
Teach Pt to recognize early signs of worsening symptoms
Pt will have a plan to stop using tobacco/smoking / Assess Pt's readiness to change
Refer Pt to smoking cessation classes
Reinforce smoking cessation counseling
Educate Pt/family on effect of smoking on disease process
Follow up on smoking cessation
Educate on value of a written action plan
Support Pt goal setting for action plan
Encourage adherence to action plan
Monitor effects of any tobacco cessation medications
Keep influenza vaccination up to date / Educate on influenza vaccination
Follow up on influenza vaccination
Keep pneumonia vaccination up to date / Teach importance of pneumococcal vaccine
Reinforce understanding and performance of self-care practices
Report problems regarding self-care practices to provider
Maintains balanced nutrition with adequate hydration / Educate on balanced nutrition with adequate hydration
Refer to Dietician if needed
Educate on weight management
Follow up on weight management
Follow up on balanced nutrition with adequate hydration
Understands energy conservation techniques / Educate on treatment plan
Educate on managing symptoms with written action plan
Educate on safe use of assistive devices
Educate on early recognition of worsening symptoms
Educate on exercise and maintenance of physical conditioning
Educate on disease process, prevention of long-term complications
Educate on coping strategies
Assess availability of caregiver support
Follow up on adequate support for caregiver
Coordinate referral to physical or occupational therapy (with provider and Pt approval )
CareSync Consulting® 1
Adult Diabetes Care Plan
Goals for Diabetes Patients / Interventions / Barriers / By / DateBlood pressure at target range < 130/80 / Teach Pt importance of regular blood pressure monitoring
Review use of Pt BP Record with Pt
Follow up on blood pressure level
Pt can describe at least 2 signs or symptoms of their condition that indicates the need for quick reporting to medical provider / Teach and Pt to recognize signs of medication side effects
Educate on ACE inhibitor / ARB
Educate member on importance of monitoring BP
Educate member on disease process & complications
Educate on management of common co-morbidities
Teach Pt heart failure self-care practices
Teach Pt to recognize early signs of worsening symptoms
Ace Inhibitor / ARB or contraindication is noted / Educate Pt on disease process and treatment plan
medication administration and monitoring plan is present and effective / Teach how to safely administer medications
Teach and Pt to recognize signs of medication side effects
Teach importance of medication adherence
Follow up on medication side effects
Coordinate provider on problems with medications
Follow up with member on medication adherence
Coordinate referrals for medication assistance
Member will have a plan to stop using tobacco/smoking / Assess member's readiness to change
Refer Pt to smoking cessation classes
Reinforce smoking cessation counseling
Educate member/family on effect of smoking on disease process
Follow up on smoking cessation
Educate on value of a written action plan
Support Pt goal setting for action plan
Encourage adherence to action plan
Monitor effects of any tobacco cessation medications
Keep influenza vaccination up to date / Educate on heart failure self-care practices Educate on influenza vaccination
Follow up on influenza vaccination
Keep pneumonia vaccination up to date / Teach importance of pneumococcal vaccine
Reinforce understanding and performance of self-care practices
Report problems regarding self-care practices to provider
Pt has accurate, readable scale / Educate on daily weights
Teach purpose of weight management
Monitor daily weights
Follow up on weight management
Follow up on resource needs
Pt recognizes signs of fluid retention / Educate Pt/caregiver to note rapid weight changes
Teach Pt/caregiver to check for changes in breathing patterns
Educate Pt/caregiver to check for swelling of feet, or changes in waist/abdomen
CareSync Consulting® 1