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Sample CCM Comprehensive Care Plan

Pdf Summary

The Comprehensive Chronic Care Management (CCM) Care Plan is a detailed document designed to offer an organized approach to managing the care of patients with chronic conditions. It includes essential patient information such as name, address, contact details, and the primary caregiver. The plan identifies the designated care team members, specifying their names, specialties, contact information, and roles in the patient's care.<br /><br />A preventive care section suggests conducting assessments of caregivers using standardized tools like the Zarit Caregiver Burden Interview. The document also gathers essential information about the caregiver’s emergency contacts.<br /><br />The medication management section invites providers to review clinical indications and usage instructions with the patient or caregiver, noting any changes. It tracks vaccination history and catalogs current medications along with dosages.<br /><br />Community and social services engagement is recorded, listing any involved services such as home health or hospice care and noting the last interaction date with the provider.<br /><br />An environmental evaluation section reviews elements within the home to ensure a safe living environment, such as even walking surfaces, adequate lighting, and grab bars.<br /><br />The care plan includes a comprehensive problem list and details for each chronic condition the patient has. For each condition, it records the diagnosis, expected outcomes, prognosis, treatment goals, cognitive and functional assessment results, and planned interventions for symptom management. Conditions are itemized up to eight chronic issues, allowing for a very detailed and individual approach to the patient’s health management.<br /><br />This structured approach aims to provide holistic and continuous care tailored to the patient’s needs, ensuring all aspects of the patient’s health and living environment are considered and managed effectively.

Keywords

Chronic Care Management

CCM Care Plan

patient information

care team

preventive care

medication management

community services

environmental evaluation

problem list

holistic care