Care Plan (Case Management)

Plan Status: [Active / On Hold / Completed / Discontinued] (If On Hold or Discontinued, state reason: [Reason])

Plan Timeframe: Start date: [Start date]; Target end date: [Target end date / Not applicable]; Next scheduled review: [Review date]

Version: [Version identifier]; Last updated: [Last updated date]

Author: [Name], [Role]

Program/Context: [Care management program or context]

Encounter: Date: [Date]; Modality: [phone / video / in-person / asynchronous]; Participants: [Names and roles] (Include only if this update occurred during a specific encounter; otherwise omit this field)

Care Plan Overview

[Brief orientation summarizing why case management is involved, high-level priorities, patient's top stated goals in their own words when available, and key barriers or risks driving the plan] (2–4 sentences in patient-centered, plain language. If goals are not documented, state "Patient goals not yet elicited.")

Care Team and Communication

• Primary owner of care plan: [Name, role, preferred contact]
• Patient: [Name, preferred contact method, preferred language]
• Caregiver/Guardian: [Name, relationship, contact] (Omit if not applicable)
• Case Manager/Care Coordinator: [Name, role, contact]
• Primary Care Clinician: [Name, role, contact]
• Specialists: [Names, specialties, contacts] (Omit if not applicable)
• Community Agencies/Services: [Agency names, contacts, service scope] (Omit if not applicable)
• Other key participants: [Names, roles, contacts] (Omit if not applicable)

Patient communication preferences: Preferred language: [Language]; Interpreter: [Needed / Not needed]; Preferred contact method: [phone / text / portal / email / mail]; Preferred contact time: [Time window]; Accessibility accommodations: [Accommodations / None identified]

Consent for coordination with external parties: [Obtained / Declined / Deferred]; Limits requested: [Patient-specified limits / None]

Assessment Summary

(Include on initial plan creation or when significant changes occur. Omit during routine updates if unchanged.)

Date and source of assessment: [Date]; Source(s): [Patient interview / Caregiver / Chart review / Clinician / Claims / Other]

• Medical/clinical status and recent utilization: [Active conditions, stability, recent ED/inpatient/urgent care use]
• Medication considerations: [Adherence, reconciliation issues, polypharmacy, high-risk meds, cost barriers]
• Functional status and ADLs/IADLs: [Mobility, self-care, instrumental tasks, supports]
• Cognitive function and health literacy: [Cognition screen status, understanding of conditions and plan]
• Psychosocial factors and support system: [Mood, stressors, coping, family/community support]
• Social determinants: [Housing stability, transportation, food security, utilities, safety, financial/insurance barriers]
• Planned assessments: [Domains to be assessed and target dates] (Include only if assessments are pending)

Problems and Care Domains

(List problems in priority order. Combine issues that share the same interventions and measures. Use "Unknown" or "Not documented" for required fields where information is unavailable.)

[Problem/Domain name]: [Brief statement of what is happening and why it matters now]

Priority: [High / Medium / Low] — [Brief rationale]

Status: [Active / Improving / Worsening / Stable / Resolved]

Long-term Goal: [Desired patient-centered outcome in accessible language]

Measurable Objectives

• Objective: [Specific measurable statement]
  Baseline: [Value and date]; Target: [Target value]; Measure/Data source: [EHR metric / patient report / device / claims / assessment tool]; Target date: [Date]
  Current status: [Not Started / In Progress / Met / Partially Met / Not Met / Deferred / Discontinued]

(Repeat for each objective. Each objective should represent one measurable result.)

Interventions

• Intervention: [Brief description]
  Responsible party: [Patient / Caregiver / Case manager / Clinician / Agency / Name]; Start date: [Date]; Expected completion/frequency: [Completion date / Ongoing with frequency]
  Completion criteria: [Definition of done]; Dependencies: [Prerequisites / None]

(Repeat for each intervention. Every intervention must have an identified responsible party.)

Barriers and Mitigation (Prioritize patient-identified barriers)

• [Barrier] — Mitigation: [Specific step]
• Safety concerns and escalation: [Triggers, who to contact, escalation pathway] (Include only if applicable)

Follow-up Plan

• Next review: [Interval] via [phone / video / in-person / portal]
• Focus for next review: [What will be assessed]
• Early review triggers: [ED visit / hospitalization / missed appointments / symptom changes / other]

(Repeat the above problem structure for each active problem/domain in priority order. For resolved problems, retain brief record with status marked Resolved and resolution date.)

Review Summary

(Include when updating an existing plan; omit on initial creation.)

• Changes since last review: [Summary of updates to goals, objectives, or interventions]
• Objectives met or status changes: [List by objective/problem]
• Key events: [Hospitalizations, ED visits, new diagnoses, falls, major life changes]
• Clinical trajectory: [Areas improving and areas worsening]
• New or evolving barriers: [Details]

Change Log

(Maintain a running log to preserve longitudinal continuity. Do not delete prior entries.)

• [Date]: [Author]
  What changed: [Goal / Objective / Intervention affected]; Reason: [Clinical update / Patient preference / System barrier / Other]; Expected impact: [Brief statement]

(Repeat for each significant change.)

Case Closure Planning

(Include only when actively planning to close or transition the case.)

• Graduation criteria: [Goals met / Stability achieved / Patient preference / Other]
• Handoff plan: [Receiving provider/agency, contact, effective date, information transferred]
• Re-entry criteria: [Events or thresholds that should trigger re-referral to case management]
• Post-closure follow-up: [Timing and purpose / Not planned]

Patient Agreement

• Agreement status: [Agrees / Partially agrees / Declines / Deferred]
• If any part declined: What was offered: [Intervention/goal]; Patient-stated reason: [Reason]; Risks explained: [Summary]; Alternative plan: [Plan] (Include only if patient declined any part of the plan)
• Preference-sensitive decisions: [Discussion summary, options considered, trade-offs acknowledged] (Include only if applicable)
• Signature/attestation: [Patient / Guardian]; Date: [Date]; Interpreter used: [Yes, language / No] (Include only if required by program)