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)