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Care Plans: Objectives & Template for Chronic Care Management

Care plans keep patients connected and engaged between visits by offering personalized, patient-centered roadmaps for achieving better health. These plans integrate personalized and attainable health goals and lifestyle adjustments into a patient’s daily routines while addressing care gaps, encouraging medication adherence, and promoting self-management for chronic illnesses.

Care plans become more effective with consistent monthly reinforcement. In Chronic Care Management (CCM) programs, compassionate and knowledgeable care managers maintain regular communication with enrolled patients, updating care goals, providing ongoing education, and addressing Social Determinants of Health (SDOHs) that affect their care journey.

In this article, we will explore the objectives and components of care plans, provide templates for care plan goals, and show how CCM can help ensure the successful implementation of care plans.

What are care plans?

A care plan is a comprehensive document outlining a patient’s healthcare needs and the measures required to achieve optimal clinical outcomes. Care plans include:

Preventative care, like cancer screenings, vaccinations, and lab work
Exercise, nutrition, and social goals
The patient’s unique medical history, current illnesses, preferences, and concerns.

Progress is routinely monitored, and adjustments are made based on patient feedback, new or developing health conditions, and provider observations.

What are Chronic Care Management care plans?

Chronic Care Management (CCM) care plans are provider- and patient-directed roadmaps that help patients with multiple chronic conditions reduce their risk factors and reach their healthcare goals through realistic, relevant, and individualized action steps.

CCM programs encourage enrolled Medicare patients to actively engage in their healthcare journey and reduce their risk of hospitalization and emergency room visits. Every patient needs a customized, accessible care plan documenting their medical history and needs. This document is shared with the patient’s network of providers so they can be aware of any changes in their healthcare status. The care plan is stored in the provider’s electronic health record (EHR) and updated regularly.

CCM patients usually face challenging healthcare journeys involving separate care providers across networks, numerous medications, and frequent appointments. Patients faced with this level of complexity often find it challenging to manage their symptoms and adhere to provider recommendations.

To help these patients adhere to care plans, CCM calls provide opportunities for patients to discuss their care plan progress with trained, compassionate healthcare personnel between clinical visits. If a care manager notices that a patient is struggling to follow their prescriptions, care goals, and appointment schedules, they can offer the patient assistance in a timely manner. This assistance could include arranging transportation to and from screenings, making provider-approved goal adjustments, and aiding in medication refills and delivery.

Learn more: Chronic Care Management: Benefits, Requirements, & Reimbursements for Providers

What are nurse care plans?

Nurse care plans outline strategies for coordinated care in hospital settings, which assemble the patient’s diagnosis, planned interventions, and follow-up care in a centralized document. These plans compile the patient's diagnoses, nursing interventions, expected outcomes, and follow-up care into a centralized document that guides the nursing team's approach. Nurse care plans focus on short-term, immediate care in hospital settings, outlining nursing interventions for specific diagnoses during a patient’s stay.

In contrast, CCM care plans are long-term, designed to manage chronic conditions across multiple providers and focus on ongoing, coordinated care outside the hospital to prevent complications. Though nurse and CCM care plans are not the same, a CCM care coordinator can follow up when a patient has been discharged from the hospital to see whether any elements of the nurse care plan, like new diagnoses or medications, need to be incorporated into the CCM care plan.

What are the components of a care plan?

The components of a patient’s care plan outline the comprehensive profile of the patient’s health history and the overall management of their current conditions. This includes information on a patient’s conditions, medications, allergies, and providers. For programs like CCM, CMS has detailed and specific elements that must be covered by care plans to receive reimbursement.

A care plan typically includes, but is not limited to:

A list of the patient’s current medical conditions, including the patient’s prognosis, expected clinical outcomes, and any mental or behavioral illness.
Records of symptoms the patient is experiencing
Details about the patient’s medications, including adherence, management, and potential side effects and interactions
Relevant information from other practices and specialists
Quantifiable and actionable care goals, including improved exercise, nutrition, and social connection
Planned, specific interventions to help patients achieve and maintain their care goals
Notes on any community service needs and barriers to care access that may impede a patient from following through on their care plans
Documentation of all CCM engagements
Health insurance information
Healthcare providers’ contact information

Care plans should incorporate feedback from a patient’s primary care provider, which is frequently added during Annual Wellness Visits (AWVs). AWVs are preventative care-focused appointments that take a holistic approach to assessing the patient’s health and future.

After the patient completes a Health Risk Assessment (HRA), the attending provider will build on this information to create an individualized care plan for the patient to follow throughout the year.

If a patient is participating in a CCM program and in an AWV, their care coordinator will incorporate the information gained from the AWV into the patient’s care plan and also seek the patient’s feedback.

ChartSpan offers a proprietary software program, called RapidAWV™, that allows patients to quickly and seamlessly complete HRAs from the comfort of your office’s waiting room before appointments. RapidAWV™ HRAs are customizable, comprehensive, and an excellent launching pad for creating care plans.

Learn more: The Ultimate Guide to Annual Wellness Visits

What are the objectives of care plans?

Care plans are designed to facilitate optimal patient outcomes by creating patient-centered strategies and care goals. Care goals are aligned with a patient’s chronic conditions and customized to their needs.

Control the progression of chronic illness: Through medications, lifestyle adjustments, and self-management, care plans help mitigate and slow the progression of chronic conditions.
Eliminate gaps in care: Care plans help patients prioritize preventative services, like screenings, vaccinations, and testing, and help providers obtain potentially life-saving biometric data. When patients are proactive about their health, they face better clinical outcomes.
Implement exercise and proper nutrition: Care plans set realistic, measurable, and sustainable goals for patients to improve their diets and exercise habits.
Encourage medication adherence: Care plans help patients comply with their prescriptions, reducing hospitalization rates and preventing avoidable deaths due to non-adherence.
Incorporate the individual perspective and values of the patient into their overall care: Care plans incorporate the patient’s unique perspective, values, and conditions to ensure the plan is centered on their needs.
Help providers account for Social Determinants of Health (SDOHs): Care plans consider SDOHs like economic stability, social and community context, and access to healthcare. Care plans reflect whether patients have access to housing, food, and transportation, and care coordinators can address these gaps when necessary.
Facilitate clearer care coordination: Patients with chronic illnesses statistically face poorer care coordination, but care plans offer a streamlined path for patients, providers, and care coordinators to follow.
Centralize patient information: Care plans provide a single, accessible document for patients and providers to share information across different healthcare settings.

Why are patient-centered care plans important?

Patient-centered care plans are important because they empower patients to confidently navigate the healthcare system by involving them in decision-making. This collaboration gives patients a sense of agency while ensuring their medical needs are met appropriately.

Personalized care plans are more effective because they align with a patient’s unique beliefs and preferences, increasing the likelihood of adherence. Generic diet and exercise plans are abandoned because patients become disillusioned and defeated by their lack of progress or because they don’t match with patients’ cultural background and preferences. By addressing individual concerns with a CCM care coordinator and making tailored adjustments, healthcare providers and care managers can help patients stay engaged and motivated.

How do you individualize a patient’s care plan?

To individualize a patient’s care plan, consider their diagnoses, medical history, risk factors, and social and cultural background. This information, combined with clinical insights from lab results and preventative screenings, helps create a personalized care plan that engages the patient in their healthcare journey.

Common ways to effectively individualize a care plan include:

Implementing care goals that align with a patient’s lifestyle, cultural preferences, and personal beliefs
Listening and incorporating patient feedback rather than imposing impractical or generic care plans on them
Paying attention to what the patient desires for their own health and future
Understanding how a patient’s unique set of chronic conditions impacts their daily life
Keeping the patients, providers, and specialists all unified and engaged with the patient’s broader healthcare goals
Evaluating the patient’s broader health history and family medical background to inform the individual needs and risks of a patient

Care plans are dynamic and should be updated as healthcare providers and care coordinators gather new patient information.

ChartSpan’s CCM care plans: SMART goals for healthier patients

ChartSpan is an industry leader in delivering high-quality, full-service CCM. We use the “SMART” (Specific, Measurable, Actionable, Relevant, and Time-based) framework to create customized, person-centered care goals in collaboration with enrolled patients and their healthcare providers. The SMART model helps care coordinators and patients design effective and easy-to-follow lifestyle adjustments. These goals empower chronically ill patients to make meaningful changes to their diet, exercise, and habits.

Example care plan for CCM

Managing hypertensive patients with ChartSpan’s exercise care goals

ChartSpan takes a five-step approach to creating care goals to supplement provider-created care plans.

Step One: Initial Assessment

We start with a thorough assessment to understand the patient’s health and lifestyle. This involves:

Evaluating the patient’s medical history and any coexisting conditions.
Understanding the patient’s current activity level and preferences.
Identifying any physical limitations or concerns affecting their ability to exercise.

Example Assessment Questions:

How much exercise are you able to do each day or each week?
What type of exercise do you enjoy doing?
What exercise routine has your doctor or physical therapist recommended?
Are there any exercises or activities you’ve been told to avoid?

2. Setting Realistic and Achievable Goals

We collaborate with the patient to set exercise goals using the SMART framework.

Example SMART Goals:

Start with walking 20 minutes a day, five days a week.
Be active for at least 10 minutes each day.
Join a local gym or group exercise class within the next month.
Find an exercise partner within the next three weeks.
Record daily workouts in an exercise journal.
Stand up and stretch or walk every hour.
Use a pedometer to set and achieve daily step goals.

3. Providing Education and Resources

We offer comprehensive educational materials and resources to help patients understand the benefits of exercise in managing hypertension.

Key Educational Points:

The impact of regular exercise on lowering blood pressure and improving heart health.
Safe exercise practices and how to incorporate physical activity into daily routines.
Tips for overcoming mental and emotional barriers to exercise.

4. Monitoring and Support

We ensure monitoring and support to help patients stay on track with their exercise goals.

Monitoring and Support Activities:

Monthly check-ins to track progress and address challenges.
Adjusting the exercise plan based on patient feedback and progress.
Providing motivation and encouragement to maintain commitment.

5. Collaborating with Healthcare Providers

We work closely with the patient’s healthcare providers to ensure a coordinated approach to their care.

Collaboration Activities:

Sharing progress reports with the patient’s primary care physician.
Collaborating on necessary adjustments to the patient’s overall care plan.

Elevate patient-centered care plans through ChartSpan

CCM services are a transformative way to ensure the efficacy of care plans between clinical visits. Care managers actively monitor patient progress and offer relevant and individualized feedback. Crucially, they can intervene before medications are discontinued, goals are abandoned, and gaps in care emerge. Any changes in the patient’s health are stored in the patient’s care plan and are easily accessible for your practice and any other specialists treating the patient.

Continual support between office visits

Each month, our care managers spend at least 20 minutes on patient care, reviewing symptoms, medications, and care plans, checking in on progress, or setting new goals if needed. If patients can’t be reached, care coordinators request updated records from other providers to load into the care plan or gather health information and resources to send to the patient.

Addressing Social Determinants of Health

ChartSpan care managers assess SDOH factors like access to housing, food, and transportation, connecting patients to local resources when needed. We can also link patients to services like food delivery and exercise groups, ensuring they receive comprehensive support.

Seamless integration with your practice

ChartSpan streamlines care coordination, ensuring patient information is always up-to-date and readily available to your team. By integrating our CCM services with your practice, you can deliver more comprehensive, personalized care that addresses each patient's medical and social needs.