Shared Care Management Plan

A single source of information about anticipated care in specific circumstances by each team participant (including patient) for a specific patient.
  • Care plan template standardized within the accountable organization
  • Care plan accessibility by all designated providers and specified health plan case managers involved in care
  • Care plan accessibility by the patient and designated caregivers
  • Customize to patient need: health maintenance, chronic care management, minimal excess morbidity in complicated patients, advanced directives
  • Include patient directed goals, patient preferences and directions, planned provider interventions, planned patient interventions, information on barriers to care, and Medical Orders for Life Sustaining Treatment (MOLST) if available
  • Be modified (with audit trail) by any care team member (including patient)