CHRONIC CARE PLAN

Patient: [Name, date of birth]
Plan date: [Date]
Plan status: [New plan, or update of the plan dated]
Lead clinician: [Name, credentials]
Care coordinator: [Name, role, and direct phone]
Present at planning: [Patient, and caregiver, family, or interpreter]
Communication needs: [Preferred language, interpreter, hearing, vision, or reading support]

WHAT MATTERS TO THE PATIENT
In their words: [What matters most to the patient right now]
Patient's goals: [Two or three goals the patient chose, such as an activity to keep doing]
Barriers: [Cost, transport, memory, mood, living alone, or caregiving duties]
Advance care planning: [Wishes discussed, the person who decides if the patient can't, and documents on file]

PROBLEM LIST
Condition 1: [Diagnosis, year diagnosed, and status: at target, improving, not at target, or worsening]
Condition 2: [Diagnosis, year diagnosed, and status]
Condition 3: [Diagnosis, year diagnosed, and status, or none]
Other issues: [Pain, falls, mood, memory, frailty, or social needs]
Allergies: [Drug and reaction, or none known]
Medications: [Reconciled list attached, with the date and the source checked]

TARGETS
Target 1: [Measure, today's value, the target, and the date to reach it]
Target 2: [Measure, today's value, the target, and the date]
Target 3: [Measure, today's value, the target, and the date]
Patient's own measure: [Something the patient can track, such as steps, stairs, or a symptom score]

PLAN BY CONDITION
Condition 1: [Medications started, changed, or stopped; tests and how often; referrals]
Condition 2: [Medications, tests, and referrals]
Condition 3: [Medications, tests, and referrals]
Medication safety: [Drugs to avoid, sick-day rules, and pill organizer or blister packs]

SELF-MANAGEMENT AND RESOURCES
Patient's actions: [What the patient agreed to do, and how often]
Home monitoring: [Device, how often, and where readings are recorded]
Education given: [Topics covered, checked by teach-back, and materials given]
Programs and community services: [Self-management classes, rehabilitation, home care, meals, transport, or caregiver support, with contacts]

CARE TEAM
Clinician: [Name and responsibilities]
Nurse: [Name and responsibilities]
Pharmacist: [Name and responsibilities]
Care coordinator: [Name and responsibilities]
Specialists and others: [Name, service, and what they manage]
Patient: [Responsibilities]
Caregiver: [Name, relationship, phone, and responsibilities, or none]

ACTION PLAN
Green, doing well: [Usual symptoms and readings, and what to keep doing]
Yellow, getting worse: [Warning signs and readings, what to do, and who to call the same day]
Red, emergency: [Danger signs, and to call 911 or go to the nearest emergency department]
After hours: [Number to call when the clinic is closed]

CHECK-INS AND REVIEW
Between visits: [Who contacts whom, how often, and by phone, video, or portal]
Readings to send: [Which readings, and how]
Tests due: [Each test and its date]
After an emergency visit or hospital stay: [Who to tell, and follow-up within how many days]
Next review: [Date, and sooner if a target is missed or something changes]

AGREEMENT
Patient agreement: [Plan discussed and agreed, and consent to share it with the care team]
Copies given to: [Patient, caregiver, home care, pharmacy, or specialists, and how]
Patient or decision-maker: [Signature and date]
Clinician: [Name, credentials, signature, and date]