MCC eCare Plan Draft Implementation Guide - Local Development build (v0.1.0). See the Directory of published versions

Patient Story

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Following an appointment with her nephrologist, Dr. Jones, Patricia visits her primary care physician, Dr. Carlson, to discuss how to better manage her multiple chronic conditions (MCCs), which include CKD,** type 2 diabetes, **congestive heart failure, chronic pain, and clinical depression.

In the examination room, Dr. Carlson takes and documents Patricia’s vitals and discusses her health concerns. Patrica states her concerns:

• Worried and depressed regarding her progressive CKD and what to do if her kidneys fail.

• Concerned about addiction and interested in tapering off the opioids she is currently using to manage her lower back pain.

• Struggles to exercise due to pain.

• Struggles to manage her diet and find affordable healthy food choices under her financial strain.

To address Patricia’s concerns and food insecurity risk from financial strain, Dr. Carlson recommends they develop a comprehensive care plan that documents Patricia’s health concerns, identifies goals to address those concerns, and establishes the right interventions and treatments for both the health concerns and the social risk.

Dr. Carlson states the in-house care coordinator, Julie, will help update the care plan in the practice’s electronic health record system (EHR). The care plan will be made available electronically (based on Patricia’s consent) to allow Patricia and her care team (her daughter Rose, nurse educator, nephrologist, cardiologist, and pain specialist) to access, view, and update. Dr. Carlson invites Julie to the examination room. Julie begins by reviewing the care summary notes and other care plan data. She confirms with Patricia the following shared patient and provider goals:

1. Lower high BMI count by losing 10 lbs. in 1 year

2. Improve access to affordable food

3. Control pain with fewer narcotics

Julie confirms with Patricia the following interventions:

1. Increase exercise activities, starting with 10 minutes once or twice a week

2. Referral to registered dietitian for medical nutrition therapy

3. Referral to follow up with nurse educator at her nephrologist’s office for kidney disease education

4. Referral to a local food bank with healthy food options

5. Referral to pain specialist to discuss alternative pain treatment options

Julie documents the agreed upon health concerns, patient goals, and interventions/referrals in the EHR. She documents Patricia’s consent to share the care plan with her care team.

Julie confirms that Patricia wants a paper copy of her care plan and would also like an electronic copy sent to her care team. Julie also walks Patricia through how to view and update her care plan using the new mobile app the practice now offers. Julie shows Patricia how to download the app onto her phone and how to log in to view her health information and care plan.

Patricia’s care team receives an alert via the EHR that an updated version of her electronic care plan is available. The care team members view the updates and start the process to follow up on the respective interventions. After the visit, Patricia shows Rose how she can access the care plan on the mobile app. Rose also downloads the app on her phone to receive alerts when changes occur.

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