Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient’s goals and priorities, as well as desired outcomes of care.
ObjectiveDevelop, maintain, and share personalized care plans with at-risk patients to promote patient-centered care and improve patient experience.
Evidence of processes for developing and updating individual care plans for at-risk patients and sharing them with beneficiary and/or caregiver. Areas of focus and consideration might include social determinants of health, language and communication preferences, physical or cognitive limitations, as well as desired outcomes of care. Include both of the following elements:
1) Individual care plans for at-risk patients – Documentation of process for developing individual care plans for clinician-defined at-risk patients (e.g., template care plan, standardized type of note in the health record); AND
2) Use of care plan with beneficiary – Patient medical records demonstrating the documentation of the care plan using a standardized approach.
An eligible internal medicine clinician has a population within the practice of frail elderly patients who periodically miss appointments and have not refilled prescriptions. Many are at risk of falls. A plan is developed to identify all of these patients and create a template portion of the electronic health record that asks specific questions regarding caregiver support, ability to travel to appointments and the pharmacy, and the ability to get help whenever needed. The eligible clinician and staff work to help the patient identify solutions to problems.