Before the patient visit, the student team should review the medical records and work with the patient’s care team and/or preceptors to determine the team’s goals of the patient encounter.
The care team, including preceptor(s), will determine what type of patient and/or family/caregiver encounter is appropriate. This decision will take into account existing visit options, team size and composition, and patient/family/caregiver characteristics. The patient visit may be a home visit, which can be conducted with a social worker or nurse, with overall supervision by the practice preceptor. The visit may also take place in the office setting, long term care facility, hospital, correctional institution, homeless shelter, and/or other appropriate setting.
Criteria CM4–CM8 from Care Management and Support (CM) Competency B are addressed in the patient and/or family/caregiver visit. For instance, the visit should include the student team working collaboratively with the patient and/or family/caregiver to develop and/or update an individualized care plan that includes:
- Patient preferences and functional/lifestyle goals
- Treatment goals using evidence-based guidelines
- Assessments of potential barriers to meeting treatment and functional/lifestyle goals, which may involve working with other providers and community resources, in addition to the patient and/or family/caregiver
- Strategies for addressing potential barriers to meeting goals
- A self-management plan that includes goals and self-care management strategies, as well as instructions and resources to address barriers. If treatment goals are being met, instructions for maintaining the current self-care plan will be documented
- Documentation of the care team members, including the primary care provider of record, health care team members, and community-based providers/services
- Services offered by and responsibilities of the primary care practice as well as those of external health care providers and community-based programs
- Appropriate and non-redundant aspects of care plans created for the patient by non-primary care practices
- Current problem list (may include historical problems, at the practice’s discretion)
- Current medications
- Medication allergies
CMS defines a care plan as, “The structure used to define the management actions for the various conditions, problems, or issues. A care plan must include at a minimum the following components: problem (the focus of the care plan), goal (the target outcome) and any instructions that the provider has given to the patient. A goal is a defined target or measure to be achieved in the process of patient care (an expected outcome).”
Although much of the process of active care planning can be carried out at this student visit, finalizing the plan may not take place until the students meet with the practice team to review and/or revise the preliminary plan presented by the students.
As far as is appropriate to their profession and the visit setting, the assessment will involve interviewing and conducting a physical exam with the patient as well as interviewing family members/caregivers.
- Self-Management Support AHRQ (with links to additional resources)
- Video on Coaching Patients on Self-Management (California Health Care Foundation)
- Video on Motivational Interviewing IHI
- PPT Overview of Motivational Interviewing SAMHSA-HRSA Center for Integrated Health Solutions
- Motivational Interviewing Reminder Card (11 reminders for providers about MI)