A family practice preparing for its PCMH annual reporting sent us twelve care plans to look at. Every one had a problem list, a medication list and the phrase "continue current management." None had a goal the patient had said out loud, none named a barrier, and none showed that the patient had been given a copy. The care manager had done real work with these patients, weekly calls for some of them, and the documentation showed almost none of it. On paper, the practice had no care plans.
This happens because "care plan" means different things to different people. To a physician it is the assessment and plan at the bottom of a note. To an EHR vendor it is a module with checkboxes. To NCQA, in the Patient-Centered Medical Home program, it is a specific document built with the patient, containing specific elements, provided to the patient in writing and reviewed over time. A PCMH care plan that meets the care management criteria is not hard to produce, but it has to be built on purpose.
Key takeaways
- NCQA's Care Management and Support competency requires a person-centered care plan for patients identified for care management (CM 04) and a written copy provided to the patient, family or caregiver (CM 05); both are core criteria.
- Elective criteria CM 06 through CM 09 add patient preferences and functional or lifestyle goals, barriers to meeting goals, a self-management plan, and a care plan accessible across settings of care.
- Evidence is the record itself: NCQA reviews a sample of care-managed patients' charts, so the elements must be visible in the chart, not in a policy.
- A care plan reviewed and updated at a set cadence, which we recommend at least twice a year and after any hospitalization, is what keeps annual reporting from becoming a scramble.
- The same care plan can satisfy Medicare chronic care management documentation requirements if a few extra elements are included, so build one template that does both.
What the PCMH care plan criteria actually ask for
Care management, in NCQA's vocabulary, is the structured support a practice gives a subset of patients identified by criteria the practice sets under CM 01: behavioral health conditions, high cost or high utilization, poorly controlled or complex conditions, social determinants of health, and referrals from outside the practice. The care plan criteria apply to those patients, not to the whole panel. That distinction matters because practices sometimes try to write care plans for everyone and end up with none that meet the standard.
| Criterion | Type | What the chart must show |
|---|---|---|
| CM 04 | Core | A person-centered care plan for each patient identified for care management |
| CM 05 | Core | A written care plan provided to the patient, family or caregiver |
| CM 06 | Elective | Patient preferences and functional or lifestyle goals documented in the care plan |
| CM 07 | Elective | Potential barriers to meeting goals identified and discussed |
| CM 08 | Elective | A self-management plan included in the care plan |
| CM 09 | Elective | The care plan is integrated and accessible across settings of care |
"Person-centered" is doing a lot of work in CM 04. NCQA expects the plan to reflect the patient's own goals and to be developed with the patient, not delivered to them. In practice that means the chart shows the patient's words, an agreement, and a plan the patient can carry out. A care plan the patient has never seen fails CM 05 no matter how good it is, and the evidence for CM 05 is a note that a copy was given, mailed or posted to the portal, with the date.
The elements, and where each one lives in the chart
We build care plans with eight elements, in this order, because the order is roughly the order of the conversation with the patient.
- The problems being managed: the two to four conditions that put the patient in care management, stated plainly, not the whole problem list.
- The patient's own goals, in the patient's words: "I want to be able to walk to my daughter's house," "I want to stop waking up at night to use the bathroom." This is CM 06.
- Clinical goals, measurable and dated: an A1c under 8.0 by September, blood pressure under 140/90 at the next three visits, no emergency visits for heart failure in six months.
- Barriers, named and discussed: cost of insulin, no car on weekdays, lives alone, low literacy, depression. This is CM 07, and the chart must show the barrier was discussed, not just listed.
- The self-management plan: what the patient will do, specifically. Check glucose before breakfast and dinner, weigh every morning and call if up 3 pounds, walk 10 minutes after lunch. This is CM 08.
- What the practice will do: medication changes, referrals, the care manager's call schedule, community resources arranged.
- Who is responsible for each item, including the patient, a caregiver, the care manager and the physician.
- The review date and how the patient received the plan (printed, mailed, portal), with the date. This is CM 05.
Where these live depends on the EHR. Most systems have a care plan module that maps to some of these fields; the rest often end up in a structured care management note. The rule we follow is that all eight must be findable by a reviewer who has never used your EHR in under two minutes. If the patient's goal is in a phone note from February and the barriers are in a visit note from April, you have the content but not the care plan. Pull it into one place.
Patient involvement: how to show it in the record
Reviewers look for evidence that the patient participated. The simplest evidence is direct quotation and agreement language: "Patient states her main goal is to keep working part time." "Patient agreed to check her weight daily and felt this was realistic." "Patient declined a referral to the diabetes education class because of the evening schedule; will revisit in June." Declines are evidence of involvement too. A plan where the patient agreed to everything on the first pass reads like a plan the patient was not asked about.
Involve the caregiver when the patient wants it, and document that the patient consented to the caregiver's involvement. For patients with cognitive impairment or limited English proficiency, note the accommodation used: interpreter, large print, a teach-back conversation. NCQA's criteria do not require any particular form for the written copy, but the copy must be one the patient can use, so a three-page printout of the EHR module in nine-point type is not the goal. We use a one-page patient version with the goals, the self-management steps and the phone number to call, and keep the fuller clinical version in the chart.
Review cadence and the annual reporting cycle
NCQA's criteria describe the plan and its elements; they leave the review frequency to the practice's policy. Our recommendation, and what the practices we support that report smoothly actually do, is a full review at least every six months, a targeted update after any hospitalization, emergency visit or major medication change, and a check-in on the self-management plan at every care management contact. Each review is documented as a dated entry that states what changed, or that nothing changed and why. A plan with no dated review in a year looks abandoned, and a reviewer will treat it that way.
Annual reporting under the current PCMH program asks the practice to show, each year, that the care management work continues. Practices that keep a care management registry, a list of identified patients with the date of the last care plan review and the date the written copy was last provided, can produce their evidence in an afternoon. Practices that do not spend weeks reconstructing it. The registry can be a spreadsheet; the EHR's care management module often has a report that does the same job. Our PCMH annual review work is mostly about setting up that registry once and then keeping it current.
One care plan for PCMH and Medicare chronic care management
Many care-managed patients are Medicare beneficiaries with two or more chronic conditions, which makes them eligible for chronic care management (CCM) under 99490 and related codes. CCM requires a comprehensive electronic care plan, and Medicare's description of that plan includes elements that overlap heavily with NCQA's: a problem list, expected outcome and prognosis, measurable treatment goals, symptom management, planned interventions, medication management, community and social services ordered, the responsible parties, and a schedule for periodic review. Medicare also wants a cognitive and functional assessment and a copy of the plan given to the patient.
Add prognosis, a cognitive and functional assessment and medication management to the eight PCMH elements and one template serves both programs. The practice then has a care plan that meets recognition requirements and supports a monthly care management code, which is how care management pays for itself. We think practices that keep two separate care plan documents for the same patient are creating work and inviting inconsistency.
A worked example
A 68-year-old patient with type 2 diabetes (A1c 9.4), heart failure and depression was identified for care management after two emergency visits in four months. She lives alone and does not drive. The care manager's plan, written with her by phone and mailed the same day, reads in part: patient goal, "get back to Sunday church without stopping to rest"; clinical goals, A1c under 8.0 by September 2026 and no emergency visits for six months; barriers, transportation on weekdays and forgetting evening medications; self-management plan, daily morning weight with a call if up 3 pounds, evening pill organizer set up by her son each Sunday, 10-minute walk after lunch; practice actions, cardiology follow-up scheduled by the care manager, PHQ-9 repeated at the next call, rides arranged through the county senior program; responsible parties named for each; review date September 2026; copy mailed March 20, 2026.
That plan is about 250 words. It satisfies CM 04 through CM 08 and, with a prognosis line, a functional assessment and the medication list attached, supports CCM. It took the care manager 25 minutes, including the call.
Questions we hear
Does every patient in the practice need a care plan?
No. The care plan criteria apply to patients identified for care management under the practice's CM 01 criteria. Most practices identify somewhere between 3 and 10 percent of their panel. Writing care plans for everyone dilutes the effort and produces plans that fail the person-centered test.
Can the physician's assessment and plan count as the care plan?
Rarely on its own. The assessment and plan documents the clinician's decisions; the care plan documents the patient's goals, barriers and self-management commitments alongside the clinical plan, and it is given to the patient. If a practice wants to use the visit note, it needs a section within it that contains all the elements and a documented handoff of a copy to the patient.
Who should write the care plan?
In most practices we work with, a nurse care manager or care coordinator drafts it with the patient and the physician reviews and signs off. Medical assistants can gather goals and barriers with training. What matters to a reviewer is that the content is there and the patient was involved, not the credential of the author. Our PCMH transformation team trains care managers on exactly this conversation.
What to do this week
- Pull five care plans for patients currently in care management and check each against the eight elements. Count how many show a patient goal in the patient's words and a dated written copy.
- Build a one-page patient version of the care plan and a clinical version template that includes the CCM elements.
- Start a care management registry with three columns you do not already track: last full review date, last written copy date, next review due.
- Write a one-paragraph policy setting the review cadence and the triggers for an unscheduled update, and date it.
- Schedule 20 minutes with the care manager to practice the goals and barriers conversation, using the worked example above as the script.
