Comprehensive Care Plan

Comprehensive care is health care that is based on identified goals for the episode of care. These goals are aligned with the patient’s expressed preferences and healthcare needs, consider the impact of the patient’s health issues on their life and wellbeing and are clinically appropriate.

Comprehensive care means that the patient receives care that is planned and coordinated around their physical, mental and cognitive health needs. Patients should also continue to receive comprehensive and compassionate care at the end of their life.

Comprehensive Care Plans help patients work with their Care Team to plan, document and accomplish individualized care goals and healthier outcomes. Care Plans are also used and reviewed in Care Team Coordination Meetings and medical appointments to ensure patients are keeping up with their health goals.

Individuals who have or are at risk for multiple complex health conditions,

multiple detrimental social determinants of health or a combination of both that contribute to preventable service utilization and poorer overall healthcare management that negatively impacts the individual’s overall health status.

Yes, if you are enrolled in the CCM (Chronic Care Management) program.