All patients enrolled in CCM require a care plan. Phamily's care plan builder allows you to quickly create a customized, relevant care plan to share with patients. Any staff member at your practice can create a care plan, regardless of their clinical experience. We'll work with your team during implementation to ensure you have processes in place to build a great care plan.
Gather Care Plan Information
For patients enrolled during an office visit
Have the provider complete a Phamily Prescription Sheet during the visit to document the patient's two (or more) chronic conditions and health goals. The care manager can use the sheet to populate the patient's care plan in just a few minutes.
Need a copy of the Phamily Prescription Sheet? Send us a note at support@phamily.com.
For patients enrolled via outreach
Use your EMR and the provider's notes from their most recent office visit to guide your work. The patient's chronic conditions will be highlighted in the patient's chart along with condition-specific recommendations. You can use the recommendations to create goals for the patient (for example, a provider's recommendation to a hypertensive patient to eat less salt).
Either way, when the care plan is shared, Phamily asks the patient if there are any goals they'd like to focus on during their participation in your CCM program. You can always edit the care plan to align with the patient's goals later on.
Create a Care Plan
Locate the patient's profile in Phamily.
In the Care Plan section of the patient's profile, click the CREATE button.
3. Populate the patient's Care Plan Summary by clicking ADD.
This is where you'll add the three goals identified during the patient's visit or from the patient's recent visit notes.
4. Use Quick Plan templates to populate the body of the care plan.
Once you've selected the two Quick Plans that correspond with the patient's chronic conditions, review each section of the care plan to make updates as needed. This step is important as it allows you to fully customize the care plan - see below for more information.
To delete a section of the Quick Plan, click the X icon to the right
To add additional sections to the Quick Plan, click selections from the list of templates on the left side of the page
To edit an existing section of the Quick Plan, select the text you'd like to change and make any edits you need
5. Once the Care Plan is finalized, click the SAVE button at the bottom of the page.
Share the Care Plan
Scroll to the light blue bar at the top of the care plan builder and locate the two icons on the right side. The CLOUD icon allows you to download a PDF copy of the care plan to print or email. The PHONE icon allows you to send the care plan to the patient via text.
Pictured below: What the Patient sees once they click a shared Care Plan link. Patients must enter their Last Name and DOB to view their care plan. Last Name and DOB must match the information on their Phamily profile. DOB must be entered in the YYYY-MM-DD format to access the Care Plan.
Things to Note
Once shared, Patients have 48 hours to view their Care Plan on their mobile device.
For Patients with a Suffix in the Suffix field of their profile, only the Last name should be entered on the verification form.
Edit an existing Care Plan
As a general rule of thumb we recommend reviewing and updating existing care plans once every 1-2 months to ensure that they are still relevant. You may occasionally need to update the patients' goals in the care plan, too.
Make sure to share the Care Plan with the patient every time you update it.
1. Locate the patient's profile and click on Last Updated.
2. The care plan editor will open. Click the PENCIL icon to make any changes you need.
Be sure to save your work!
Once you have created a patient's care plan, you can engage the patient by sending them check-ins related to their conditions.
Need help?
Contact our Support Team at support@phamily.com, or click the question mark in Phamily, for assistance.