CVD Risk Reduction Group Case Management Documentation of Care Plans May 2005

Case Management Care Plans Draft Case Management Core Elements Individual Case Management Assessment of patient needs Development of a care plan Implementation/coordination of care Integration of team members in care plan/referrals Follow-up Use of flowsheets to monitor care Visits – monthly, then quarterly when controlled Multiple visits with team members Problem solving – transportation, barriers to care Outreach/Follow-up Correspondence/letters

Case Management Care Plans Documentation For patient care For CGP Project? Paper versions: PCC Form, Flowsheets? Electronic versions: DMS/Case Management Package/RPMS? Other? Today: Gathering information stage Waiting for examples, more information Grant program staff experience!

Case Management Care Plans Ideas, suggestions on how we should document individual case management care plans for participants in the CVD Risk Reduction Demonstration Project Items to make sure we all document? Templates, examples from current practice? Other ideas!