Care Planning Toolkit
For Patient-Centered Primary Care Homes
August 2022
Editable versions of the templates included in this toolkit can be found at the
PCPCH Resources and Technical Assistance webpage.
Click here to see…
PCPCH Program Care Plan Guidance & Tools:
• Extra Guidance on PCPCH Measure 5.C.3
• Care Plan Template Guide
• General Care Plan Template & Example
• SMART Care Plan Template & Example
More Care Plan Examples:
• OHSU: Shared Care Plan for Children & Youth with Special Health Needs
• St Charles Health System: EHR Care Plan Template & Example
• Salem Clinic: Adult High-risk Patient Care Plan Template
Additional Guidance on Creating SMART Goals:
• CDC: Guidance on Writing SMART Objectives
• MDH: Tips on Writing Meaningful Goals and SMART Objectives
This document provides extra guidance around Measure 5.C.3 under the Patient-Centered Primary
Care Home Program’s 2020 Recognition Criteria. The full technical specifications for this measure are
available in the 2020 PCPCH TA Guide.
Intent of Standard 5.C
Care coordination is an essential feature of a primary care home. The intent of this standard is to
ensure that PCPCHs deliberately consider care coordination functions, explicitly assign these
functions to specific staff members, take extra steps to coordinate the care of diverse patients with
complex care needs, and communicate clearly to patients, families, and caregivers about who they
can contact at the practice to help coordinate their care. Measure 5.C.3 within standard 5.C also
promotes the development of individualized care plans for diverse patients with complex medical and
social needs to help coordinate and integrate their care. Identifying patients with higher health risks,
implementing a strategy to help those most in need, and effectively coordinating and managing care
for higher risk sub-populations can help prevent exacerbations of illness and other health
complications.
Building a Care Plan
Care planning is a detailed approach to customizing care to an individual patient’s needs. Care plans
are most impactful when a patient can benefit from personalized instruction and feedback to help
manage a health condition or multiple conditions.
Generally, care plans include, but are not limited to:
1
• Patient-identified goals for a patient’s health status
• Established timeframes for re-evaluation
• Resources that might benefit the patient, including a recommendation or referral to the
appropriate level of care or community resources
• Planning for continuity of care, including assistance making the transition from one care
setting to another
• Collaborative approaches to health, including family participation and other healthcare
providers when necessary
The care plans must include, at a minimum:
• Patient-specific short-term and long-term health goals
• The action plan for achieving these goals or managing the patient’s condition
• Three elements from across the two lists on pages 112-113 (primary and supportive services)
that the practice has determined to be most impactful to individual patients and their overall
treatment/ management plan. These can be from either the primary or supportive elements
list, depending on what is most important to the individual patient’s care.
5.C.3
PCPCH collaborates with diverse patients, families, or caregivers to develop
individualized written care plans for complex medical or social concerns.
15
points
PCPCH Measure 5.C.3 – Care Planning
Extra Guidance
Guiding Principles
• Care plans should be developed collaboratively with each patient or patient’s family and/or
caregivers.
• Care plans should be written in the patients’ preferred language, at an appropriate health
literacy level, accessible by individuals with disabilities, documented in the medical record,
and updated regularly.
• Care plans are not for every patient, but rather those with the most complex needs and
medical and/or social concerns as identified by the practice.
• The is no single “right” template for care plans that a practice should follow. However, the
care plan format should fit into the care team’s workflow and should be delivered to the
patient in their preferred format.
• When appropriate, care plans should be shared with specialists and community partners that
the patient is working with for optimal health.
Step-by-Step Approach to Building a Care Plan: Example
Below is an example of building a care plan for an adult patient seen in a primary care practice
2
• Problem statement with an action plan that is measurable, obtainable, and important to this
unique patient.
• What is the highest priority for the patient?
• What the patient wants to happen/do when they’ve met their goals
• Barrier(s): Any factor that can limit the patient from achieving the goals set forth in the care
plan (i.e. lack of transportation, financial issues, social issues, lack of knowledge).
• Intervention(s): The steps that need to be taken to assist the patient in reaching the goal(s):
- Intervention must be customized for each patient and designed to resolve the
issue/problem that will have the highest impact on patient’s health status. These can
be identified from the primary and supportive elements listed on pages 112-113 in the
TA guide.
- Continuous reprioritization of the care/interventions for the patient must occur based
on the most recent interactions and new information
• Evaluation: Ongoing review and revision of the care plan until goals are met. This may include
development of new goals.
1
Partnering in Self-management Support: A Toolkit For Clinicians: Ihi
http://www.ihi.org/knowledge/Pages/Tools/SelfManagementToolkitforClinicians.aspx
2
(2021). Retrieved 18 January 2021, from
https://www22.anthem.com/providertoolkit/SS3_UpdatedCarePlanPlaybook_EMPIR.pdf
PCPCH Care Plan Template Guide
PCPCH Measure 5.C.3
Introduction
This template guide is intended to help practices evaluate or develop a care plan template that meets the
specifications for PCPCH Measure 5.C.3 under the 2020 PCPCH Recognition Criteria. The full specifications
for the care planning process are described on pages 111-113 of the 2020 PCPCH Technical Assistance
Guide. Additional guidance, templates, and examples of care plans can be found on the PCPCH Resources
and Technical Assistance webpage, which also contains resources on how to improve the health literacy
and cultural competency of your care plans.
Care Plan Template Requirements
To meet PCPCH Measure 5.C.3, a typical patient care plan at your practice must include, at a minimum:
1. The patient’s short-term and long-term health goals.
2. The action plan for achieving these goals or managing their condition.
3. Three additional elements from the lists below that the practice has determined to be the most
impactful to the individual patient and their overall treatment/management plan.
Primary Elements
(Most commonly found in care plans)
• Patient-specific education regarding
conditions and treatment(s)
• Self-management of chronic conditions (a
contingency plan for exacerbations, such as
• asthma care plan, diabetes, CHF)
• Names and roles of community-based
support or services outside the practice
• Behavioral health or substance use disorder
treatment(s)
• Barriers to care and potential solutions
• Psychosocial concerns and coordination of
health-related social needs (HRSN) resources
• Coordination with sub-specialists
Supportive Services Elements
(Often applied in pediatric practices and used
to support patient self-identified goals and/or
Interventions)
• Equipment (e.g., tracheostomies,
gastronomy tubes, wheelchair, orthotics)
• Appliance/Assistive technology (e.g.,
nebulizers, wheelchairs, orthotics, walkers)
• Therapies (e.g., speech, physical therapy,
occupational therapy)
• Individualized Education Program (IEP)
• Individual Family Service Plan, 50448
• Home care/nursing services
• Developmentally Disabled (DD) Waiver
The following pages will clarify and provide examples for each of these categories.
Care Plans
PCPCH Care Plan Template Guide
PCPCH Measure 5.C.3
1) Patient’s Health Goals
The care plan must include both the short-term and long-term health-related goals that the practice has
worked with the patient or caregiver/family to develop.
Short-Term Goals: Immediate or priority goals, such as learning how to monitor their condition or ensuring
transportation to the clinic for regular checkups.
Long-Term Goals: More long-term health goals or lifestyle changes, such as increasing exercise, improving
nutrition, or improving housing conditions. Ideally, these goals will be personalized, minimize medical
jargon, and take into account the patient’s unique conditions, lifestyle and values. What motivates this
particular patient to be healthy? For example, rather than “keep a systolic blood pressure of less than 120” a
more personalized long-term health goal would be “learn how to cook healthy and delicious meals”, “take a
yoga class” or “take grandchildren on hikes.”
2) Action Plan
The care plan must also include the steps that the patient can take to meet these goals or manage their
condition. It might include steps such as reading or discussing patient-specific education on their condition
with their care team, keeping self-management tools in a visible area and using them regularly, attending a
workshop, or any other actions that would help them meet their short-term and long-term goals. This list of
actions should be easily digestible to the patient, so feel free to get creative with checklists or visual cues!
3) Three Additional Components
Patient-Specific Education
Patient education materials will vary based on the patient but will typically include an overview of the
patient’s condition(s), causes, symptoms, progression, treatment, and other relevant information. Below is
and example of what patient-specific education might look like:
• Spina Bifida Association – Type 2 Diabetes
Self-Management Materials & Support
Self-management materials or support will vary based on the patient but typically include tools or resources
that help patients monitor their condition/symptoms, a contingency plan for exacerbations, and/or tools for
improving their health. Below is some additional guidance on delivering successful self-management
support, as well as some examples of what a self-management tool might look like:
• AHRQ: Self- Management Support and Health Literacy Action Plans
• AllCare Health Plan – Exacerbation Action Plan & Protocol
• American Lung Association – Asthma Action Plan
• The Physician Alliance - Diabetes Action Plan
PCPCH Care Plan Template Guide
PCPCH Measure 5.C.3
Community-Based Support & Services
The care plan may include the names, roles, contact information, and other relevant information for external
entities that can assist the patient in managing their condition or achieving their health goals. Below are
some examples:
• Living Well with Chronic Disease Self-Management Programs (CDSMPs)
• Yoga Classes or nutritional cooking class
Behavioral Health or Substance Use Treatment(s)
The care plan may include referrals, medication and treatment regimen(s), roles, contact information, or
other relevant information regarding the management of the patient’s behavioral health condition or
achievement of their health goals. Below are some examples:
• Referral to behavioral health provider (i.e. details that are relevant/useful to the patient)
• Medication Assisted Treatment (MAT) plan
• Identified roles of those involved in patient’s behavioral health care
• Contact information for a substance use sponsor
• Goal for attending substance use treatment meetings such as AA
Barriers and Solutions
The care plan may include a list of barriers to health that the patient and practice have identified and the
plan or steps towards addressing these barriers.
Psychosocial concerns and coordination of Health-related Social Needs (HRSN) resources
The care plan may include referrals, roles, contact information, or other relevant information regarding the
management of the patient’s psychosocial concerns or coordination of their health-related social needs.
Below are some examples:
• Identified psychosocial needs and/or health related social needs (i.e. a completed HRSN screening
tool that specifies HRSN needs)
• Referral to community-based organization or service provider (i.e. details that are useful to patient)
• Identified roles and contact information
• Goal for following up with specific services or organizations
Coordination with Subspecialists
The care plan may include a list of specialists within or outside the practice that the patient has been
referred to or is already seeing, along with their contact information.
Medical Equipment or Supplies
The care plan may include the equipment or supplies that the patient can or should use to manage their
condition, as well as the contact information of the entities that can supply or maintain them. Examples
include tracheostomies, gastronomy tubes, orthotics, etc.
PCPCH Care Plan Template Guide
PCPCH Measure 5.C.3
Appliance/Assistive Technology
The care plan may include the appliances or assistive technologies that the patient can or should use to
manage their condition, as well as the contact information of the entities that they can reach out to for
assistance with these appliances/technologies. Examples include nebulizers, wheelchairs, walkers, etc.
Therapies
The care plan may include the therapies that the patient has been prescribed and/or referred to and any
relevant providers, roles, and contact information. Examples include speech therapy, physical therapy,
occupational therapy, etc.
Individualized Education Program (IEP)
The care plan may include a patient’s IEP plan, which lays out the special education instruction, supports
and services the patient needs to thrive in school.
Individual Family Service Plan (IFSP)
The care plan may include a patient’s IFSP or the components that relate to the patient’s care, such as
information on the child’s functional ability across five developmental areas: Physical (including vision and
hearing), Cognitive, Communication, Social/Emotional, and Adaptive.
Home care/Nursing Services
The care plan may include information on the services provided to a patient for them to live and age safely
in their home. This could include (but is not limited to):
• Assistance with adhering to medication regimen
• Companionship/emotional support
• Self-hygiene assistance
• General provision of patient’s condition
Developmentally Disabled Waiver (DDW)
The care plan may include the details of a patient’s DDW that relate to services that enhance or support
their overall care. This could include (but is not limited to):
• Household assistance
• Social activities support and supervision
• Community inclusion
• Meals delivered
• Work force habituation
[Practice website or patient portal]
[Practice phone number]
My Care Plan
Insert Practice Logo Here
[ Patient Name]
Care Plan Updated & Approved: [Date]
My Health Goals
Immediate Health Goals
• [Short-term Goal]
• [ Short-term Goal]
• [ Short-term Goal]
Goals for a healthy future
• [Long-term Goal]
• [Long-term Goal]
• [Long-term Goal]
Action Plan
My care team’s plan:
[Action that will help patient meet health goals above]
[Action that will help patient meet health goals above]
[Action that will help patient meet health goals above]
My plan:
[Action that will help patient meet health goals above]
[Action that will help patient meet health goals above]
[Action that will help patient meet health goals above]
My Care Team
[Provider type] [Name of provider] [Contact Information]
[Provider type] [Name of provider] [Contact Information]
[Provider type] [Name of provider] [Contact Information]
[Provider type] [Name of provider] [Contact Information]
[Practice website or patient portal]
[Practice phone number]
My Care Plan
Insert Practice Logo Here
[Relevant Care Plan Element]
[Include a care plan element that is relevant to this patient. A list of care plan elements can be
found on pages 112-113 of the PCPCH Technical Assistance Guide and a description of each
element can be found in the PCPCH Care Plan Template Guide.]
[Relevant Care Plan Element]
[Include a care plan element that is relevant to this patient. A list of care plan elements can be
found on pages 112-113 of the PCPCH Technical Assistance Guide and a description of each
element can be found in the PCPCH Care Plan Template Guide.]
[Relevant Care Plan Element]
[Include a care plan element that is relevant to this patient. A list of care plan elements can be
found on pages 112-113 of the PCPCH Technical Assistance Guide and a description of each
element can be found in the PCPCH Care Plan Template Guide.]
www.ladybugclinic.com/portal
Phone #: 503-233-1111
My Care Plan
James Doe
Care Plan Updated & Approved: 3/1/2022
My Health Goals
Immediate Health Goals
Go on walks three days per week
Drink less soda
Get Photo ID to qualify for housing
Goals for a healthy future
Move into own home
Lower A1C
Lower blood pressure
Action Plan
My care team :
Contact housing agencies to get Jim on list for housing
Enroll Jim in diabetes education class
My plan:
Read this packet and put the Diabetes Zone on fridge for daily reminder
Start only buying one liter of soda per week
Get new walking shoes
Join Marsha (daughter) when she takes the dog for a walk
Work with Marsha to make sure DMV paperwork is completed
Do YouTube yoga with Marsha once per week to reduce stress
Attend bi-monthly diabetes education class
The
patient's
care
plan
can
be
updated at regular intervals
as
determined by the care team.
Patient's
short-term
and
long-
term health goals (required in
a care plan to meet PCPCH
Measure 5.C.3)
Action
plan
(required
in
a
care
plan to meet PCPCH
Measure
5.C.3)
Ideally,
the
care
plan
avoids
medical jargon and uses
plain language that is
familiar
to
the
patient
www.ladybugclinic.com/portal
Phone #: 503-233-1111
My Care Plan
My Care Team: Blue Team
Primary Care Provider Dr. Johnson 503-222-2222
Care Coordinator Nurse Maria 503-222-2222
Community Health Worker Mark 503-222-2222
My Specialists
Cardiologist Dr. Smith 503-999-8542
Dermatologist Dr. Paulson 503-744-2202
Endocrinologist Dr. Mounds 503-324-6547
About Type 2 Diabetes
What is Type 2 Diabetes?
sugar at
normal levels. About 90-95% of people with diabetes have type 2. It develops over many
years and is usually diagnosed in adults (but more and more in children, teens, and young
r blood sugar tested if
such as losing weight, eating healthy food, and being active.
What Causes Type 2 Diabetes?
Insulin is a hormone made by your pancreas that acts like a key to let blood sugar into the
to insulin; this is called insulin resistance. Your pancreas makes more insulin to try to get cells
to respond. Even
stage for prediabetes and type 2 diabetes. High blood sugar is damaging to the body and
can cause other serious health problems, such as heart disease, vision loss, and kidney
disease.
This
particular
care
plan
includes
"coordination
with
subspecialists"
as
one
of
its additional care plan elements (care plans must include at least three
additional care plan elements to meet PCPCH Measure 5.C.3)
This
care
plan
includes
“patient-specific
education”
as
one
of
its
additional
care plan elements. This sample of patient education was drawn from the
CDC website but practices may choose to include their own version of
patient education on various conditions. It's always best to use plain
language and to include visuals such as diagrams and charts. Practices
may include patient-specific education in the care plan itself as shown, or
provide it as a separate document or packet.
www.ladybugclinic.com/portal
Phone #: 503-233-1111
My Care Plan
Symptoms and Risk Factors
Type 2 diabetes symptoms often develop over several years and can go on for a long time
o know the risk factors and to see your doctor
to get your blood sugar tested if you have any of them.
Testing for Type 2 Diabetes
A simple blood test
results are accurate.
Managing Type 2 Diabetes
Unlike many health conditions, diabetes is managed mostly by you, with support from your
health care team (including your primary care doctor, foot doctor, dentist, eye doctor,
registered dietitian nutritionist, diabetes educator, and pharmacist), family, and other
important people in your life. Managing diabetes can be challenging, but everything you do
to improve your health is worth it!
You may be able to manage your diabetes with healthy eating and being active, or your
doctor may prescribe insulin, other injectable medications, or oral diabetes medicines to
pressure and cholesterol close to the targets your doctor sets for you and get necessary
screening tests.
it and what your target blood sugar levels should be. Keeping your blood sugar levels as
close to target as possible will help you prevent or delay diabetes-related complications.
Stress is a part of life, but it can make managing diabetes harder, including managing your
blood sugar levels and dealing with daily diabetes care. Regular physical activity, getting
enough sleep, and relaxation exercises can help. Talk to your doctor and diabetes educator
about these and other ways you can manage stress.
treatment plan and to get help with new ideas and strategies if needed.
This
care
plan
includes
“self-management
materials
and
support”
as
one of its additional care plan elements. This summary and the
chart
on the next page were drawn from the CDC website and AllCare
Health Plan but practices may choose to include their own self-
management information and materials. It's always best to use
plain
language and tools that make it easy for patients to monitor and
improve their condition. Practices may include information on self-
management in the care plan itself as shown, or provide self-
management tools/support as a separate document or packet.
www.ladybugclinic.com/portal
Phone #: 503-233-1111
My Care Plan
Whether you were just diagnosed with diabetes or have had it for some time, meeting with a
diabetes educator is a great way to get support and guidance, including how to:
Develop a healthy eating and activity plan
Test your blood sugar and keep a record of the results
Recognize the signs of high or low blood sugar and what to do about it
If needed, give yourself insulin by syringe, pen, or pump
Monitor your feet, skin, and eyes to catch problems early
Buy diabetes supplies and store them properly
Manage stress and deal with daily diabetes care
Ask your doctor about diabetes self-management education and support services and to
recommend a diabetes educator, or search the Association of Diabetes Care & Education
for a list of programs in your community.
Please
visit
the
PCPCH
"Resources
&
Technical
Assistance"
webpage
for
additional
guidance,
templates, and examples of care plans under Measure 5.C.3, as well as additional examples
of patient-specific education and self-management tools.
https://www.oregon.gov/oha/HPA/dsi-pcpch/Pages/Resources-Technical-Assistance.aspx
Shared Care Plan
[Name of Practice]
[Patient Portal or Website]
[Practice Phone Number]
My Care Plan
Shared Care Plan
Updated & Approved: [Date]
About the Patient
Name: Preferred Name:
Gender identity: Pronouns:
Preferred Language: Date of Birth:
Name of relevant family or caregiver(s): Phone Number:
Other notes (conditions, allergies, special considerations, etc.):
Care Team
Role
Name
Phone
Other notes (care team name, etc):
Put practice logo here
Shared Care Plan
[Name of Practice]
[Patient Portal or Website]
[Practice Phone Number]
My Care Plan
Health Goals & Action Plan
Immediate Health Goals
Short-Term Goal
Person
Action
By When Done
For a Healthy Future
Long-Term Goal Person Action
By When Done
Shared Care Plan
[Name of Practice]
[Patient Portal or Website]
[Practice Phone Number]
My Care Plan
[Relevant Care Plan Element]
[Include a care plan element that is relevant to this patient. A list of care plan elements can be found on pages
112-113 of the PCPCH Technical Assistance Guide and a description of each element can be found in the
PCPCH Care Plan Template Guide.]
[Relevant Care Plan Element]
[Include a care plan element that is relevant to this patient. A list of care plan elements can be found on pages
112-113 of the PCPCH Technical Assistance Guide and a description of each element can be found in the
PCPCH Care Plan Template Guide.]
[Relevant Care Plan Element]
[Include a care plan element that is relevant to this patient. A list of care plan elements can be found on pages
112-113 of the PCPCH Technical Assistance Guide and a description of each element can be found in the
PCPCH Care Plan Template Guide.]
Patient Portal: www.ladybugclinic.com/portal
Clinic phone #: 503-233-1111
My
Care Plan
Shared Care Plan
Updated & Approved: 3/1/2022
About the Patient
Name: James Doe Preferred Name: Jim Doe
Gender identity: Male Pronouns: He/Him
Preferred Language: English Date of Birth: 1/25/1965
Name of relevant family or caregiver:
Marsha (daughter)
Phone Number: 503-555-5555
Other notes (conditions, allergies, special considerations, etc.):
Type 2 Diabetes
Allergic to Apidra
Temporarily living with Marsha
Care Team & Specialists
Role Name Phone
Primary Care Provider Dr. Johnson 503-222-2222
Care Coordinator Nurse Maria 503-222-2222
Community Health Worker Mark 503-222-2222
Cardiologist Dr. Smith
503-999-8542
Dermatologist Dr. Paulson
503-744-2202
Endocrinologist Dr. Mounds 503-324-6547
Other notes (care team name, etc): Your care team is the BLUE TEAM
The
patient's
care
plan
can
be
updated at regular intervals
as
determined by the care team.
In
addition
to
the
patient's
short-term
and
long-term
health
goals
and action plan seen on the next page, to meet PCPCH Measure
5.C.3 care plans must also include at least 3 additional care plan
elements listed in the PCPCH Technical Assistance Guide. This
particular care plan example includes 4 such elements. Here you
can
see one of them: “coordination with subspecialists.”
Patient Portal: www.ladybugclinic.com/portal
Clinic phone #: 503-233-1111
My
Care Plan
Health Goals & Action Plan
Immediate Health Goals
Short-Term Goal Person Action
By When Done
Drink less soda Jim
Read Type 2 Diabetes packet and put
Diabetes Zone Tool on fridge for daily
reminder
Only buy one liter of soda per week
4/1/22
Go on walks three
days per week
Jim
Get new walking shoes
Join Marsha when she takes the dog for
a walk
4/1/22
Get Photo ID to
qualify for housing
Jim
Work with Marsha to make sure DMV
paperwork is completed
5/15/22
For a Healthy Future
Long-Term Goal Person Action
By When Done
Move into own home Mark
Contact housing agencies to get Jim on
list for housing
6/1/22
Lower A1C Mark & Jim
Mark: enroll Jim in diabetes education
class
Jim: attend bi-monthly class
9/1/22
Lower blood pressure
Jim
Do YouTube yoga with Marsha once per
week to reduce stress
9/1/22
Patient's
short-term
and
long-
term health goals and action
plan (required in a care plan
to
meet PCPCH Measure 5.C.3)
Ideally,
the
care
plan
avoids
medical
jargon and uses plain language that
is
familiar to the patient
Patient Portal: www.ladybugclinic.com/portal
Clinic phone #: 503-233-1111
My
Care Plan
Medical Supplies
Nebulizer Parts:
Providence Home Health
503-541-9855
CPAP Parts:
Norco Medical
503-874-5874
Patient Education
Your Type 2 Diabetes packet will tell you what you need to know about diabetes and what you can do to stay
Self-Management
Your Diabetes Zone Tool and Diabetes Education Class will tell you what you need to know about managing
diabetes and what to do if symptoms are getting worse.
This
care
plan
includes
“medical
equipment or supplies” as one of
its
additional care plan elements.
This
care
plan
includes
“patient-specific
education”
as
one
of
its
additional
care
plan
elements. Practices may include patient-specific education in the care plan itself or
provide
it as a separate document or packet. The following pages include an example of a patient
education packet.
This
care
plan
includes
“self-management
materials
and
support”
as
one
of
its
additional
care plan elements. Practices may include information on self-management in the care
plan
itself or provide self-management tools/support as a separate document or packet. The
last
page of this care plan sample includes an example of such a tool.
This
example
of
patient-specific
education
was
drawn
from
the
Spina
Bifida Association but practices may choose to include their own
version of patient-specific education on various conditions. It's
always best to use plain language and to include visuals such as
diagrams and charts.
This
self-managment
tool
was
drawn
from
Alliant
Heath
Solutions
but practices may choose to include their own self-management
information and materials. It's always best to use plain language
and tools that make it easy for patients to monitor and improve
their
condition. Tools such as this can be modified or tailored to specific
thresholds
or
patient
needs
(see
blanks
below).
Please
visit
the
PCPCH
"Resources
&
Technical
Assistance"
webpage
for
additional
guidance,
templates, and examples of care plans under Measure 5.C.3, as well as additional examples of
patient-specific education and self-management tools.
https://www.oregon.gov/oha/HPA/dsi-pcpch/Pages/Resources-Technical-Assistance.aspx
Last Updated: XX-XX-XXXX
1
Shared Care Plan
for Children and Youth with Special Health Needs
Child/youth name:
Necessary releases obtained:
☐
Yes
☐
No
Child/youth likes to be called:
Team meeting date:
Date of birth:
Meeting location:
Parent(s):
Referred by:
Parent phone #:
Other:
Primary care provider: Interpreter (if applicable):
Gender identity:
☐
M
☐
F
☐
Other, please specify:
Pronouns:
☐
She/Her
☐
He/Him
☐
Other, please specify:
Child/Family Strengths and Assets
Child/Family Language and Culture
Child/Family Concerns and Goals
For today:
For the longer term:
Last Updated: XX-XX-XXXX
2
Brief Medical Summary
Diagnosis:
Medications:
Current Interventions:
Tried Interventions:
Health Care Providers:
Other Important Medical Information (Allergies/Alerts):
Preferred Hospital:
Preferred Pharmacy:
Brief Summary of Involvement with Education/Community-Based Services
Team Members Contact List
Note: Initial next to name to note attendance at meeting. Add rows as needed.
Name
Role/Responsibility
Best way to contact
Family member
Primary care provider
Education
Mental/behavioral health
Public health
Health plan/insurance
Interpreter
Last Updated: XX-XX-XXXX
3
Action Plan
Note: Add rows as needed.
The first goal of the team should be one that is identified by the family as a priority.
If the child/youth is aged 12 or older, include a minimum of one goal focused on the transition to adult healthcare.
Shared goal:
Who?
Is doing what?
By when?
This person
Will take this action
By this date
Date completed:
This person
Will take this action
By this date
Date completed:
This person
Will take this action
By this date
Date completed:
This person
Will take this action
By this date
Date completed:
Date identified:
Notes:
Date resolved:
Last Updated: XX-XX-XXXX
4
Action Plan
Note: Add rows as needed.
The first goal of the team should be one that is identified by the family as a priority.
If the child/youth is aged 12 or older, include a minimum of one goal focused on the transition to adult healthcare.
Shared goal:
Who?
Is doing what?
By when?
This person
Will take this action
By this date
Date completed:
This person
Will take this action
By this date
Date completed:
This person
Will take this action
By this date
Date completed:
This person
Will take this action
By this date
Date completed:
Date identified:
Notes:
Date resolved:
Last Updated: XX-XX-XXXX
5
Action Plan
Note: Add rows as needed.
The first goal of the team should be one that is identified by the family as a priority.
If the child/youth is aged 12 or older, include a minimum of one goal focused on the transition to adult healthcare.
Shared goal:
Who?
Is doing what?
By when?
This person
Will take this action
By this date
Date completed:
This person
Will take this action
By this date
Date completed:
This person
Will take this action
By this date
Date completed:
This person
Will take this action
By this date
Date completed:
Date identified:
Notes:
Date resolved:
© 2020, rev. 2021 Oregon Health & Science University
This project is funded by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under
Oregon's Title V Maternal and Child Health Block Grant (#B04MC28122, in the amount of $1,859,482) and the “Enhancing the System of Services for
Oregon’s CYSHCN” grant (#D70MC27548, in the amount of $300,000). The project receives no nongovernmental funding. This information or content
and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by
HRSA, HHS, or the U.S. Government. To request permission to use this template please contact [email protected]
St. Charles Health System: EHR Care Plan Template
Patient-Centered Primary Care Home Program Key:
Text in black font = Examples of care plan elements that are required or can be used to meet PCPCH Measure 5.C.3
under the 2020 PCPCH Recognition Criteria
Text in blue font = Additional care plan elements that St. Charles Health System has decided to include but are not
required or relevant to PCPCH Measure 5.C.3
Smartphrase Template
Care plans look slightly different based off of disease process, which is driven by the OP Care Plan tasks and education
provided in the AVS Discharge summary. Each section below has separate drop-down boxes pertaining to the disease
process.
Patient name:
Patient address:
[Name] provided verbal consent to care planning on [date]
Care Plan Status:
[Name]'s Priorities (short-term and long-term goals):
You said that what is important to you is:
You said that what worries you about your health is:
You said something that you think would help improve your health/well-being is:
Primary Care Provider's Stated Health Goal:
[Patient Name]’s Clinical Goals:
The following symptom management action plans reviewed with and provided for [Name]:
Education Provided to: [Name]
PLEASE REFER TO PATIENT EDUCATION FOR DETAILS
Referral Made to:
Plan For Followup:
Patient Care Team:
Barriers to Health & Resources:
This is an active and comprehensive care plan for [Name], developed as part of the RN Care Management Program at St
Charles Family Care. A copy of this care plan was given to [Name]. The care team can be reached by calling your
primary care clinic or through MyChart.
Patient Care Plan Example
This is the format if a letter is mailed to the patient or sent via MyChart. If the patient is in clinic or has a telehealth visit with
the RNCC, the patient’s information is copied into the AVS discharge summary which can be viewed in EPIC. The AVS
discharge summary for outpatient looks exactly like the inpatient AVS discharge summary.
ST CHARLES FAMILY CARE MADRAS
480 NE A ST
MADRAS OR 97741-1844
541-475-4800
John Doe
123 Example Lane
Madras, OR 97741
Please review the attached care plan.
John provided verbal consent to care planning on January 1
st
, 2022.
John’s Priorities:
You said that what is important to you is: Being healthy enough to take grandkids on day trips
You said that what worries you about your health is: Medications
You said something that you think would help improve your health/well-being is: Work on getting in with the nutritionist for
further diabetic diet management
Primary Care Provider's Stated Health Goal
Improve A1C goal to normal range A1C <9%
John’s Clinical Goals
implement dietary/lifestyle changes to improve your health, reduce or prevent unnecessary emergency department
utilization, reduce or prevent unnecessary hospital admissions, reduce barriers to getting your basic needs met, improve or
maintain regular engagement with your Primary Care team, improve or maintain regular engagement with your Behavioral
Health team/counseling and improve your health numbers (e.g. your vital signs, results of lab studies, etc.)
The following symptom management action plans reviewed with and provided for John
DIABETES ACTION PLAN: recognition of signs and symptoms of high or low blood sugar, and of a diabetic emergency
(ketoacidosis or a very low blood sugar). Reviewed what actions to take (e.g. when to call clinic versus go to the emergency
department). PLEASE REFER TO DIABETES ACTION PLAN FOR DETAILS.
Education Provided to John
DIABETES EDUCATION: Carb counting/meal planning, blood sugar emergencies, hypoglycemia, medications, foot care,
and exercise. PLEASE REFER TO PATIENT EDUCATION FOR DETAILS.
Referral Made to: CHE, Nutrition, Behavioral Health and Clinic RN
Plan For Followup: every two weeks
Patient Care Team: Blue Team
This is an active and comprehensive care plan for John Doe, developed as part of the RN Care Management Program at St
Charles Family Care. A copy of this care plan was given to John. The care team can be reached by calling your primary
care clinic or through MyChart.
FOLLOW UP INSTRUCTIONS
Return in about 1 week (around 11/4/2021) for care coordination.
Patients are given the RNCC’s direct line to contact in the event care coordination is needed prior to agreed upon date of
next call along with clinic information for contact.
BARRIERS TO HEALTH & RESOURCES
LACK OF TRANSPORTATION
Currently receiving rides through CET ride transportation. Also has a scooter.
UNABLE TO PREPARE MEALS
• John referred to social work and meal assistance programs
• Jane Doe, RN discussed meal prep with patient
• Note: Continued plan to work on this: John will see DM educator and nutritionist
RELIABLE FOOD SOURCE
• John referred to food insecurity resources
• Jane Doe, RN will reach out with support programs for affordable food
FINANCIAL HARDSHIP
• Joseph Miller, RN working with CHE to establish OHP and free phone through OHP services.
• Contacted insurance company to determine options
• Mellissa Doe, RM will continue follow up with Best Care Peer Support
• Jane Doe to refer John to community resources for help with financial hardship with meds
MED ADHERENCE
Goal: Record your blood sugar as directed
Long-Range Goal: Consistently take medications as prescribed
• Jane Doe, RN discussed barriers to medication adherence with John
• John educated on frequency and refill details of meds
• John assisted on frequency and refill details of meds
ACTION PLAN FOR DIABETES BLOOD SUGAR EMERGENCIES
How can you prevent a blood sugar emergency?
An important part of living with diabetes is keeping your blood sugar in your target range. You'll need to know what to do if
it's too high or too low. Managing your blood sugar levels helps you avoid emergencies. This care sheet will teach you about
the signs of high and low blood sugar. It will help you make an action plan with your doctor for when these signs occur.
Low blood sugar is more likely to happen if you take certain medicines for diabetes. It can also happen if you skip a meal,
drink alcohol, or exercise more than usual.
• You may get high blood sugar if you eat differently than you normally do. One example is eating more
carbohydrate than usual. Having a cold, the flu, or other sudden illness can also cause high blood sugar levels.
Levels can also rise if you miss a dose of medicine.
• Any change in how you take your medicine may affect your blood sugar level. So it's important to work with your
doctor before you make any changes.
CHECK YOUR BLOOD SUGAR:
Work with your doctor to fill in the blank spaces below that apply to you.
Track your levels, know your target range, and write down ways you can get your blood sugar back in your target
range. A log book can help you track your levels. Take the book to all of your medical appointments.
• Check your blood sugar ___4_ times a day, at these times:Before meals and at bedtime. (For example:
Before meals, at bedtime, before exercise, during exercise, other.)
• Your blood sugar target range before a meal is per nutrition/diabetic educator. Your blood sugar target
range after a meal is per diabetic educator/nutrition.
• Do this—take your insulin as instructed by MD_—to get your blood sugar back within your safe range if your
blood sugar results are elevated. (For example: Less than 70 or above 250 mg/dL.)
Call your doctor when your blood sugar results are less than 70 or greater than 250. (For example: Less than 70
or above 250 mg/dL.)
What are the symptoms of low and high blood sugar?
• Common symptoms of low blood sugar are sweating and feeling shaky, weak, hungry, or confused.
Symptoms can start quickly.
• Common symptoms of high blood sugar are feeling very thirsty or very hungry. You may also pass urine
more often than usual. You may have blurry vision and may lose weight without trying.
• But some people may have high or low blood sugar without having any symptoms. That's a good reason to
check your blood sugar on a regular schedule.
WHAT SHOULD YOU DO IF YOU HAVE SYMPTOMS?
Work with your doctor to fill in the blank spaces below that apply to you.
Low blood sugar
• If you have symptoms of low blood sugar, check your blood sugar. If it's below __70_ ( for example, below
70), eat or drink a quick-sugar food that has about 15 grams of carbohydrate. Your goal is to get your level
back to your safe range. Check your blood sugar again 15 minutes later. If it's still not in your target range,
take another 15 grams of carbohydrate and check your blood sugar again in 15 minutes. Repeat this until
you reach your target. Then go back to your regular testing schedule.
• Children usually need less than 15 grams of carbohydrate. Check with your doctor or diabetes educator for
the amount that is right for your child.
• When you have low blood sugar, it's best to stop or reduce any physical activity until your blood sugar is
back in your target range and is stable. If you must stay active, eat or drink 30 grams of carbohydrate. Then
check your blood sugar again in 15 minutes. If it's not in your target range, take another 30 grams of
carbohydrates. Check your blood sugar again in 15 minutes. Keep doing this until you reach your target.
You can then go back to your regular testing schedule.
If your symptoms or blood sugar levels are getting worse or have not improved after 15 minutes, seek
medical care right away.
Here are some examples of quick-sugar foods with 15 grams of carbohydrate:
• 3 or 4 glucose tablets
• 1 tablespoon (3 teaspoons) table sugar
• ½ cup to ¾ cup (4 to 6 ounces) of fruit juice or regular (not diet) soda
• Hard candy (such as 6 Life Savers)
High blood sugar
If you have symptoms of high blood sugar, check your blood sugar. Your goal is to get your level back to your target
range. If it's above 250 ( for example, above 250), follow these steps:
• If you missed a dose of your diabetes medicine, take it now. Take only the amount of medicine that you
have been prescribed. Do not take more or less medicine.
• Give yourself insulin if your doctor has prescribed it for high blood sugar.
• Test for ketones, if the doctor told you to do so. If the results of the ketone test show a moderate-to-large
amount of ketones, call the doctor for advice.
• Wait 30 minutes after you take the extra insulin or the missed medicine. Check your blood sugar again.
If your symptoms or blood sugar levels are getting worse or have not improved after taking these steps,
seek medical care right away.
Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your
doctor if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take.
Where can you learn more?
Go to https://www.healthwise.net/patientEd
Enter G983 in the search box to learn more about "Diabetes Blood Sugar Emergencies”
Your Action Plan.
Current as of: December 20, 2019 (Content Version: 12.6)
© 2006-2020 Healthwise, Incorporated.
Care instructions adapted under license by St. Charles Health System, Inc. If you have questions about a medical condition
or this instruction, always ask your healthcare professional. Healthwise, Incorporated disclaims any warranty or liability for
your use of this information.
PATIENT EDUCATION
PCPCH Note: Some practices may choose to include this in a separate packet or document from the care plan.
LEARNING ABOUT MEAL PLANNING FOR DIABETES
Why plan your meals?
Meal planning can be a key part of managing diabetes. Planning meals and snacks with the right balance of carbohydrate,
protein, and fat can help you keep your blood sugar at the target level you set with your doctor.
You don't have to eat special foods. You can eat what your family eats, including sweets once in a while. But you do have to
pay attention to how often you eat and how much you eat of certain foods.
You may want to work with a dietitian or a certified diabetes educator. He or she can give you tips and meal ideas and can
answer your questions about meal planning. This health professional can also help you reach a healthy weight if that is one
of your goals.
What plan is right for you?
Your dietitian or diabetes educator may suggest that you start with the plate format or carbohydrate counting.
The plate format
The plate format is a simple way to help you manage how you eat. You plan meals by learning how much space each food
should take on a plate. Using the plate format helps you spread carbohydrate throughout the day. It can make it easier to
keep your blood sugar level within your target range. It also helps you see if you're eating healthy portion sizes.
To use the plate format, you put non-starchy vegetables on half your plate. Add meat or meat substitutes on one-quarter of
the plate. Put a grain or starchy vegetable (such as brown rice or a potato) on the final quarter of the plate. You can add a
small piece of fruit and some low-fat or fat-free milk or yogurt, depending on your carbohydrate goal for each meal.
Here are some tips for using the plate format:
• Make sure that you are not using an oversized plate. A 9-inch plate is best. Many restaurants use larger plates.
• Get used to using the plate format at home. Then you can use it when you eat out.
• Write down your questions about using the plate format. Talk to your doctor, a dietitian, or a diabetes educator
about your concerns.
Carbohydrate counting
With carbohydrate counting, you plan meals based on the amount of carbohydrate in each food. Carbohydrate raises blood
sugar higher and more quickly than any other nutrient. It is found in desserts, breads and cereals, and fruit. It's also found in
starchy vegetables such as potatoes and corn, grains such as rice and pasta, and milk and yogurt. Spreading carbohydrate
throughout the day helps keep your blood sugar levels within your target range.
Your daily amount depends on several things, including your weight, how active you are, which diabetes medicines you
take, and what your goals are for your blood sugar levels. A registered dietitian or diabetes educator can help you plan how
much carbohydrate to include in each meal and snack.
A guideline for your daily amount of carbohydrate is:
• 45 to 60 grams at each meal. That's about the same as 3 to 4 carbohydrate servings.
• 15 to 20 grams at each snack. That's about the same as 1 carbohydrate serving.
The Nutrition Facts label on packaged foods tells you how much carbohydrate is in a serving of the food. First, look at the
serving size on the food label. Is that the amount you eat in a serving? All of the nutrition information on a food label is
based on that serving size. So if you eat more or less than that, you'll need to adjust the other numbers. Total carbohydrate
is the next thing you need to look for on the label. If you count carbohydrate servings, one serving of carbohydrate is 15
grams.
For foods that don't come with labels, such as fresh fruits and vegetables, you'll need a guide that lists carbohydrate in
these foods. Ask your doctor, dietitian, or diabetes educator about books or other nutrition guides you can use.
If you take insulin, you need to know how many grams of carbohydrate are in a meal. This lets you know how much rapid-
acting insulin to take before you eat. If you use an insulin pump, you get a constant rate of insulin during the day. So the
pump must be programmed at meals to give you extra insulin to cover the rise in blood sugar after meals.
When you know how much carbohydrate you will eat, you can take the right amount of insulin. Or, if you always use the
same amount of insulin, you need to make sure that you eat the same amount of carbohydrate at meals. If you need more
help to understand carbohydrate counting and food labels, ask your doctor, dietitian, or diabetes educator.
How can you plan healthy meals?
Here are some tips to get started:
• Plan your meals a week at a time. Don't forget to include snacks too.
• Use cookbooks or online recipes to plan several main meals. Plan some quick meals for busy nights. You also can
double some recipes that freeze well. Then you can save half for other busy nights when you don't have time to
cook.
• Make sure you have the ingredients you need for your recipes. If you're running low on basic items, put these items
on your shopping list too.
• List foods that you use to make breakfasts, lunches, and snacks. List plenty of fruits and vegetables.
• Post this list on the refrigerator. Add to it as you think of more things you need.
• Take the list to the store to do your weekly shopping.
Follow-up care is a key part of your treatment and safety. Be sure to make and go to all appointments, and call your
doctor if you are having problems. It's also a good idea to know your test results and keep a list of the medicines you take.
Where can you learn more?
Go to https://www.healthwise.net/patientEd
Enter X936 in the search box to learn more about "Learning About Meal Planning for Diabetes."
Current as of: December 17, 2020 (Content Version: 13.0)
© 2006-2021 Healthwise, Incorporated.
Care instructions adapted under license by St. Charles Health System, Inc. If you have questions about a medical condition
or this instruction, always ask your healthcare professional. Healthwise, Incorporated disclaims any warranty or liability for
your use of this information.
Salem Clinic: Adult High-Risk Patient Care Plan Template
Patient-Centered Primary Care Home Program Key:
Text in black font = Examples of care plan elements that are required or can be used to meet PCPCH Measure 5.C.3
under the 2020 PCPCH Recognition Criteria
Text in blue font = Additional care plan elements that Salem Clinic has decided to include but are not required or
relevant to PCPCH Measure 5.C.3
Risk Score:
Primary Insurance:
Secondary Insurance:
Relationship:
Pain Contract:
Reason:
Medication(s):
Prescriber:
Problem list reflects pain contract management agreement.
Last Office Visit:
Last Hospitalization/ED Visit:
Number of Hospital Visits in the past 12 months:
Significant Past Medical and/or Mental Health History:
Labs:
Pertinent Lab Results & Date:
Follow-up labs needed:
Imaging:
Pertinent Imaging Results:
Follow-up Imaging needed:
Anticoagulation Care:
Anticoagulation followed by:
Next Appointment:
Hemodialysis:
Yes/No
Hemodialysis followed by:
Days patient receives hemodialysis:
Preventive Health Needs:
Barriers to Care & Possible Solutions:
Specialty Follow-up Appointment:
Medications Review:
Is patient able to afford medication co-pays?
Contact Documentation:
COVID-19 Screening:
Has the patient been tested for COVID-19?
If yes, assess for the following: Date of testing, result of test, was the patient's PCP notified?
If yes, did they follow proper quarantine protocol?
Chronic Illness Plan of Care and Action Plan for Exacerbation:
Action Plan Reviewed:
Action Plan:
Reviewed with ***, will mail *** a copy with a letter explaining the purpose of the Action plan.
Reviewed with ***, *** already has a copy at home. *** was encouraged to place the Action Plan in a
location that is easily visible.
*** declined to review at this time, will mail *** a copy with a letter explaining the purpose of the Action
plan.
What zone is the patient currently in? (ZONE COLOR)
Nursing Education Appointment:
Offered a nursing education appointment, *** accepted, messaged routed for scheduling.
Offered a nursing education appointment, *** declined at this time.
Nursing education appointment not needed, *** is literate on their chronic disease and has not had any
recent complications.
Activities of Daily Living:
Patient Short-Term and Long-Term Self-Management Goal(s):
Patient Care Team:
Resource Needs/Educational Materials:
November 21, 2018C296013-C
Evaluation Briefs
Writing SMART Objectives
No. 3b | updated August 2018
This brief is about writing SMART objectives. This brief includes an overview of objectives, how to write SMART
objectives, a SMART objectives checklist, and examples of SMART objectives.
Overview of Objectives
For DASH funded programs, program
planning includes developing ve-year
program goals (a broad statement
of program purpose that describes
the expected long-term effects of a
program), strategies (the means or
broad approach by which a program
will achieve its goals), and annual
workplan objectives (statements
that describe program results to
be achieved and how they will be
achieved).
Objectives are more immediate than
goals; objectives represent annual
mileposts that your program needs
to achieve in order to accomplish
its goals by the end of the ve-year
funding period.
Each year, your workplan objectives
should be based on the strategies you
have selected to reach your program
goals. Because strategies are
implemented through objectives and
program activities, multiple objectives
are generally needed to address a
single strategy. Objectives are the
basis for monitoring implementation
of your strategies and progress
toward achieving your program goals.
Objectives also help set targets for
accountability and are a source for
program evaluation questions.
Writing SMART Objectives
To use an objective to monitor your progress, you need to write it as a SMART
objective. A SMART objective is:
1. Specific:
• Objectives should provide the “who” and “what” of program activities.
• Use only one action verb since objectives with more than one verb
imply that more than one activity or behavior is being measured.
• Avoid verbs that may have vague meanings to describe intended
outcomes (e.g., “understand” or “know”) since it may prove difcult to
measure them. Instead, use verbs that document action (e.g., “At the
end of the session, the students will list three concerns...”)
• Remember, the greater the specicity, the greater the measurability.
2. Measurable:
• The focus is on “how much” change is expected. Objectives should
quantify the amount of change expected. It is impossible to determine
whether objectives have been met unless they can be measured.
• The objective provides a reference point from which a change in the
target population can clearly be measured.
3. Achievable:
• Objectives should be attainable within a given time frame and with
available program resources.
4. Realistic:
• Objectives are most useful when they accurately address the scope of
the problem and programmatic steps that can be implemented within a
specic time frame.
• Objectives that do not directly relate to the program goal will not help
toward achieving the goal.
5. Time-phased:
• Objectives should provide a time frame indicating when the objective
will be measured or a time by which the objective will be met.
• Including a time frame in the objectives helps in planning and
evaluating the program.
Objectives Checklist
Criteria to assess objectives YES NO
1. Is the objective SMART?
• Specific: Who? (target population and persons doing the activity) and What? (action/activity)
• Measurable: How much change is expected
• Achievable: Can be realistically accomplished given current resources and constraints
• Realistic: Addresses the scope of the health program and proposes reasonable programmatic
steps
• Time-phased: Provides a timeline indicating when the objective will be met
2. Does it relate to a single result?
3. Is it clearly written?
SMART Objectives Examples
Non-SMART objective 1: Teachers will be trained on the
selected scientically based health education curriculum.
This objective is not SMART because it is not specic,
measurable, or time-phased. It can be made SMART by
specically indicating who is responsible for training the
teachers, how many will be trained, who they are, and by
when the trainings will be conducted.
SMART objective 1: By year two of the project, LEA staff
will have trained 75% of health education teachers in the
school district on the selected scientically based health
education curriculum.
Non-SMART objective 2: 90% of youth participants will
participate in lessons on assertive communication skills.
This objective is not SMART because it is not specic
or time-phased. It can be made SMART by specically
indicating who will do the activity, by when, and who will
participate in lessons on assertive communication skills.
SMART objective 2: By the end of the school year, district
health educators will have delivered lessons on assertive
communication skills to 90% of youth participants in the
middle school HIV- prevention curriculum.
For further information or assistance, contact the
Evaluation Research Team at [email protected]. You can
also contact us via our website: http://www.cdc.gov/
healthyyouth/evaluation/index.htm
