Welcome To PCPCI | Patient Centered Primary Care Institute



Chronic Condition Patient GoalsInterventionsBarriersByDatePt adheres to treatment plan Assess for any cultural barriers Assess and pursue support systems needs related to disease Educate and support adherence to treatment plan Communicate with provider on appropriate management of condition Educate Pt on importance of medication adherence Pt is able to recognize signs and symptoms of their condition early and uses a written action plan to manage themEducate Pt on disease process & treatment plan Educate on self-monitoring Educate on managing symptoms with written action plan Educate on prevention of long-term complications Uses healthcare services appropriately Evaluate and support Pt choice of appropriate transportation options Educate Pt on options in resources Educate on value of utilizing Primary Care Provider as alternative to Emergency Room Support continuity of care with Pt Follow up with providers for continuity of careCoordinate services for special needs/disability barriers Support coordination of care Reinforce Pt understanding of disease process & prevention of complications Explore recurrence of inappropriate ER visits with Pt Follow up on management of co-morbidities Assure continuity of care Support coordination of care Follow up on continuity of care with provider Follow up on continuity of care with Pt Assess for equipment needs Evaluate on resource options Evaluation need/availability of caregiver support Assure adequate coping skills Collaborate with provider regarding self-care practices Reinforce on treatment plan Educate on early recognition of worsening symptoms Evaluate need/ availability of caregiver support Educate on resource options Identify and coordinate services related to fear, anxiety, & hopelessness Manage condition effectivelyCollaborate with provider regarding treatment guidelines and management of condition Follow up on appropriate management of condition Educate on management of co-morbidities Educate on symptom management Educate on guidelines and appropriate management of condition Follow up regarding management of co-morbidities Coordinate careCoordinate appropriate healthcare services Support coordination of care Refer to community resources Post-discharge phone callPost-discharge medication reconciliation Discharge plan initiated pre-dischargeVerify authorization and set up of requested services Verify appointments are made for post-acute care Medication administration and monitoring plan is present and effective Follow up and review safe administration of medications Review how to recognize signs of medication side effects Teach importance of medication adherence Follow up on medication side effects Coordinate provider on problems with medications Follow up with Pt on medication adherence Coordinate referrals for medication assistance Demonstrates understanding of disease process Educate on purpose of disease management program Educate Pt on disease process, prevention of long-term complications Verify understanding of disease process, prevention of complications by Pt and/or Caregiver Assess and address support systems in place related to condition Symptoms are managed appropriately Educate member/caregiver on disease process Educate member/family on effect of smoking on disease process Educate on appropriate management of condition Educate on coping strategies Educate on correlation between behavioral health & disease process Educate on disease process and prevention of long-term complications Follow up on appropriate management of condition Maintain physical conditioning Educate on exercise and maintenance of physical conditioning Support adherence to treatment plan Follow up on exercise and maintenance of physical conditioning Coordinate referral to physical or occupational therapy (with provider and Pt approval) Reinforce understanding & adherence to treatment plan Pt/caregiver aware of basic nutrition needs Pt/caregiver aware of basic nutrition needs Request referral to Dietitian from PCP if neededAvoid missed school or work daysEducate Pt/Caregiver on disease process Educate Pt on coping strategies Follow up with Pt/Caregiver on self-care practices Pt pursues optimal self-care practicesCollaborate with provider on Pt’s self-care practices Support optimal health care practices and adherence with plan Support independence and optimal functional status Follow up with Pt on self-care practices Psychosocial issues will be managed effectively Assess availability of caregiver support Support optimal health care practices and adherence with plan Follow up on adequate support for caregiver Follow up on effective management of psychosocial issues Assess and address support systems in place related to condition Educate Pt/family on community support/resources Provide list of community resources for support Educate signs and symptoms of depression Identify and coordinate services related to depression Return to optimal & realistic medical and functional status Support adherence to treatment plan Educate on importance of medication adherence Educate on Pt & Caregiver on treatment plan Support optimal health care practices and adherence with plan Educate on managing symptoms with written action plan Follow up on action plan Follow up with Pt on medication understanding & adherence Follow up regarding adherence to treatment plan Support independence and optimal functional status Request referral for Pt, family Pt or Caregiver to appropriate treatment provider Identify and manage risk factorsEducate Pt on disease process Educate on appropriate management of condition Educate on exercise and maintenance of physical conditioning Educate on coping strategies Evaluate need/availability of caregiver support Follow up on adequate support for caregiver Educate on medication actions and potential side effects Educate Pt/family on effect of smoking on disease process Educate on correlation between behavioral health issues & disease process Educate on risk factors Educate on early recognition of worsening symptoms Support safe transitions of careSupport coordination of care Provide list of community resources for support Coordinate referral to home healthcare (with provider and Pt approval) PCP informed of Pt's participation in care management program and consulted on care plan Collaborate with provider on appropriate management of condition Collaborate with provider on adherence to treatment planContact provider on requested services Collaborate with provider regarding medication adherence problems Collaborate with provider on appropriate program closure Follow up on continuity of care with provider Review treatment plan with provider to assure compliance with patient’s wishes on advance directives Care will not be compromised by financial need Coordinate services for special needs/disability barriers Address for stress issues and/or barriers to care Coordinate community resources/services Educate on options regarding financial barriers Follow up on options regarding financial barriers Reinforce education on types, prescribed dosage and administration of prescribed medications Follow up with Pt on medication adherence Communicate with provider regarding medication adherence problems Asthma Patient GoalsInterventionsBarriersByDateAsthma Action Plan is in place Educate on treatment plan Educate on early recognition of worsening symptoms Follow up on appropriate management of condition Follow up with Pt regarding self-care practices Pt is encouraged to maintain symptom recordEducate on appropriate management of disease Educate on coping strategies Support independence and optimal functional status Pt/caregiver aware of Asthma triggers Educate Pt on disease process Follow up on understanding of disease process & prevention of complications Uses peak flow meter appropriately and effectively Educate on/support use of peak flow meter for monitoring condition Educate on importance of optimal peak flow 80% of personal best Uses nebulizer, inhaler, spacer appropriately and effectively Collaborate with provider regarding use of nebulizer, inhaler, spacer Educate Pt/Caregiver on proper use of nebulizer Educate Pt/Caregiver on proper use of inhalerFollow up regarding nebulizer, inhaler, spacer use Pt can describe at least 2 signs or symptoms of their condition that indicates the need for quick reporting to medical provider Teach and Pt to recognize signs of medication side effects Educate Pt on importance of monitoring peak flowEducate Pt on disease process & complicationsEducate on management of common co-morbidities Teach Pt asthma self-care practices Teach Pt to recognize early signs of worsening symptoms Pt will have a plan to stop using tobacco/smoking Assess Pt's readiness to change Refer Pt to smoking cessation classes Reinforce smoking cessation counseling Educate Pt/family on effect of smoking on disease process Follow up on smoking cessation Educate on value of a written action plan Support Pt goal setting for action plan Encourage adherence to action planMonitor effects of any tobacco cessation medications Keep influenza vaccination up to dateEducate on influenza vaccination Follow up on influenza vaccination Keep pneumonia vaccination up to date Teach importance of pneumococcal vaccine Reinforce understanding and performance of self-care practices Report problems regarding self-care practices to provider CHF Patient GoalsInterventionsBarriersByDateBlood pressure at target range < 130/80 Teach Pt importance of regular blood pressure monitoring Review use of Pt BP Record with PtFollow up on blood pressure levelPt can describe at least 2 signs or symptoms of their condition that indicates the need for quick reporting to medical provider Teach and Pt to recognize signs of medication side effects Educate on ACE inhibitor / ARB Educate member on importance of monitoring BP Educate member on disease process & complicationsEducate on management of common co-morbidities Teach Pt heart failure self-care practices Teach Pt to recognize early signs of worsening symptoms Ace Inhibitor / ARB or contraindication is noted Educate Pt on disease process and treatment planMember will have a plan to stop using tobacco/smoking Assess member's readiness to change Refer Pt to smoking cessation classes Reinforce smoking cessation counseling Educate member/family on effect of smoking on disease process Follow up on smoking cessation Educate on value of a written action plan Support Pt goal setting for action plan Encourage adherence to action planMonitor effects of any tobacco cessation medications Keep influenza vaccination up to dateEducate on heart failure self-care practices Educate on influenza vaccination Follow up on influenza vaccination Keep pneumonia vaccination up to date Teach importance of pneumococcal vaccine Reinforce understanding and performance of self-care practices Report problems regarding self-care practices to provider Pt has accurate, readable scale Educate on daily weights Teach purpose of weight management Monitor daily weights Follow up on weight management Follow up on resource needs Pt recognizes signs of fluid retention Educate Pt/caregiver to note rapid weight changes Teach Pt/caregiver to check for changes in breathing patterns Educate Pt/caregiver to check for swelling of feet, or changes in waist/abdomen COPD Patient GoalsInterventionsBarriersByDateCOPD Action Plan is in place Educate on treatment plan Educate on early recognition of worsening symptoms Follow up on appropriate management of condition Follow up with Pt regarding self-care practices Educate Pt/caregiver to observe for changes in breathing patterns Pt is encouraged to maintain symptom recordEducate on appropriate management of disease Educate on coping strategies Support independence and optimal functional status COPD is diagnosed by spirometry Communicate with provider regarding COPD diagnosis via spirometry Educate Pt/caregiver on spirometry testing Follow up regarding diagnosis of COPD via spirometry Uses peak flow meter appropriately and effectively Educate on/support use of peak flow meter for monitoring condition Educate on importance of optimal peak flow 80% of personal best Uses nebulizer, inhaler, spacer appropriately and effectively Collaborate with provider regarding use of nebulizer, inhaler, spacer Educate Pt/Caregiver on proper use of nebulizer Educate Pt/Caregiver on proper use of inhalerFollow up regarding nebulizer, inhaler, spacer use Pt can describe at least 2 signs or symptoms of their condition that indicates the need for quick reporting to medical provider Teach and Pt to recognize signs of medication side effects Educate Pt on importance of monitoring peak flowEducate Pt on disease process & complicationsEducate on management of common co-morbidities Teach Pt copd self-care practices Teach Pt to recognize early signs of worsening symptoms Pt will have a plan to stop using tobacco/smoking Assess Pt's readiness to change Refer Pt to smoking cessation classes Reinforce smoking cessation counseling Educate Pt/family on effect of smoking on disease process Follow up on smoking cessation Educate on value of a written action plan Support Pt goal setting for action plan Encourage adherence to action planMonitor effects of any tobacco cessation medications Keep influenza vaccination up to dateEducate on influenza vaccination Follow up on influenza vaccination Keep pneumonia vaccination up to date Teach importance of pneumococcal vaccine Reinforce understanding and performance of self-care practices Report problems regarding self-care practices to provider Maintains balanced nutrition with adequate hydration Educate on balanced nutrition with adequate hydration Refer to Dietician if needed Educate on weight management Follow up on weight management Follow up on balanced nutrition with adequate hydration Understands energy conservation techniques Educate on treatment plan Educate on managing symptoms with written action plan Educate on safe use of assistive devices Educate on early recognition of worsening symptoms Educate on exercise and maintenance of physical conditioning Educate on disease process, prevention of long-term complications Educate on coping strategies Assess availability of caregiver support Follow up on adequate support for caregiver Coordinate referral to physical or occupational therapy (with provider and Pt approval )Goals for Diabetes PatientsInterventionsBarriersByDateBlood pressure at target range < 130/80 Teach Pt importance of regular blood pressure monitoring Review use of Pt BP Record with PtFollow up on blood pressure levelPt can describe at least 2 signs or symptoms of their condition that indicates the need for quick reporting to medical provider Teach and Pt to recognize signs of medication side effects Educate on ACE inhibitor / ARB Educate member on importance of monitoring BP Educate member on disease process & complicationsEducate on management of common co-morbidities Teach Pt heart failure self-care practices Teach Pt to recognize early signs of worsening symptoms Ace Inhibitor / ARB or contraindication is noted Educate Pt on disease process and treatment planmedication administration and monitoring plan is present and effective Teach how to safely administer medications Teach and Pt to recognize signs of medication side effects Teach importance of medication adherence Follow up on medication side effects Coordinate provider on problems with medications Follow up with member on medication adherence Coordinate referrals for medication assistance Member will have a plan to stop using tobacco/smoking Assess member's readiness to change Refer Pt to smoking cessation classes Reinforce smoking cessation counseling Educate member/family on effect of smoking on disease process Follow up on smoking cessation Educate on value of a written action plan Support Pt goal setting for action plan Encourage adherence to action planMonitor effects of any tobacco cessation medications Keep influenza vaccination up to dateEducate on heart failure self-care practices Educate on influenza vaccination Follow up on influenza vaccination Keep pneumonia vaccination up to date Teach importance of pneumococcal vaccine Reinforce understanding and performance of self-care practices Report problems regarding self-care practices to provider Pt has accurate, readable scale Educate on daily weights Teach purpose of weight management Monitor daily weights Follow up on weight management Follow up on resource needs Pt recognizes signs of fluid retention Educate Pt/caregiver to note rapid weight changes Teach Pt/caregiver to check for changes in breathing patterns Educate Pt/caregiver to check for swelling of feet, or changes in waist/abdomen ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download