Camden Coalition of Healthcare Providers

Camden Coalition of Healthcare Providers

Care Plan

Patient Name: ______Birth date: ______

Patient Overarching Goal: ______

Clinical Goal / Action Steps / Date Due / Date Complete / Days since Enrollment
Address Driving Diagnosis:
xxxxx / ·  _____
·  _____
·  _____ / ______
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Address Secondary Diagnosis:
xxxxxxx
xxxxxxx / ·  ______
·  ______
·  ______
·  ______/ ______
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Please see attached sheet for Driving Diagnosis Action Steps

Medication Reconciliation / ·  Facilitate Prescription Filling as necessary
·  Assess knowledge of medication regimen
·  Pack Pill Box
·  High Risk Medication Teaching as necessary
·  Medication Teaching (All Meds)
·  Med Rec following PCP visit
·  Medication Coordination among providers
·  Reinforce of Medication Regimen / ______
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Will be added to the care plan based on intake tool

Nutrition Needs Met / ·  If Food Stamps Eligible, Applied
·  If Manna Eligible, Applied
·  If Meals on Wheels Eligible, Applied
·  Nutrition Counseling / ______
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Durable Medical Equipment Needs Met / ·  Durable Medical Needs Assessment Complete
·  ______/ ______
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Coordination of Ongoing Care / ·  Home Health Coordination / Assessment Complete
·  Coordination with / Referral to Adult Day Program as necessary
·  ______/ ______
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Behavioral Health Goal / Action Steps / Date Due / Date Complete / Days since Enrollment
Depression / Anxiety Addressed
(If PHQ-4 score of ____) / ·  PHQ-9 Complete
·  Referral to Counseling
·  Referral / Coordination of Psychiatry Care
·  Referral to other resources as necessary / ______
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Substance Abuse Addressed / ·  NIDA Substance Abuse Screen complete and reviewed with Mark
·  Resources for cessation provided if patient desires
·  ______/ ______
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Pain Addressed / ·  Patient provided tool to track symptoms and pain medication intake
·  Pain Specialty Appointment Coordination as necessary
·  ______/ ______
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Social Health Goal / Action Steps / Date Due / Date Complete / Days since Enrollment

Will be added to the care plan based on intake tool

Reliable Housing / ·  ______
·  ______/ ______
______/ ______
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Reliable Monthly Income / ·  Determine eligibility for entitlements
·  Accompany patient to Board of Social Services to complete applications
·  Coach patient on discussing paperwork with physician if necessary
·  Coach patient on seeking work placement if appropriate / ______
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Patient has Budgeting Skills / ·  Ask patient their comfort in creating a monthly budget
·  Assess income / monthly bills, costs
·  coach patient to create in the context of his/her priorities
·  coach patient on how to communicate with physician about affordability of medications / ______
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Reliable Transportation to Provider Appointments / ·  Assess insurance to determine transportation options
·  Complete applications / phone calls for transportation service
·  Coach patient on how to use transportation service
·  Skill complete when patient uses service successfully / ______
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Patient displays effective communication with his/her provider / ·  Assess how comfortable patients are with discussing care with physicians
·  Coach patient to come up with an agenda of their top three issues for each visit
·  Coach patients on how to ask questions and listen to answers
·  Coach patients on bringing medications with them to their appointments / ______
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State IDs / Legal Paperwork Completed as necessary / ·  ______
·  ______
·  ______/ ______
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