The Essential Elements of a Care Plan

Patient-centered care is a model of physical and emotional care that is provided to patients. This care plan is used by clinical staff to collect data on new patients and coordinate first-line patient care, clinical care, and ancillary support services. Programs such as CCM, RPM, and BHI are administered outside of normal visits to the doctor's office and the care plan helps coordinate external or specialized resources if needed. Physical care includes pain management and assistance with daily activities or needs.

This activity is part of the minimum of 20 minutes of patient participation required to bill Medicare for CCM, RPM, or BHI services. Care plans are a documented summary of a patient's chronic or behavioral health care needs or priorities and provide detailed information about medications, physical limitations, and dietary restrictions. According to British nurse Helen Ballantyne, care plans are a fundamental aspect of nursing and are intended to enable standardized, evidence-based holistic care. A comprehensive care plan should maintain a specific focus on the patient's priority needs and explain what to do if they get sick outside of the usual working hours of the general office.

Through basic notes included in the care plan, your staff can provide patients with any comments or input they may have. The four essential elements of a care plan are: patient participation, physical care, detailed information about medications, physical limitations, and dietary restrictions; coordination of external resources; and basic notes for comments or input from staff.