The Problem
CMS requires that CCM and APCM patients have a comprehensive, patient-centered care plan that's created, revised, and maintained electronically — not a PDF stapled to a chart note. Keeping that plan current, and visible to everyone on the care team, is easy to fall behind on without a dedicated workflow.
Who This Is For
Any practice running CCM or APCM needs a care plan per enrolled patient — whether that's a single care manager serving a handful of patients, or a larger team split across several care coordinators.
The Feature
ChronicSync's care plan tooling lets a care manager document goals, interventions, and a review schedule for each enrolled patient, kept as a living record the whole care team can see and update — rather than a static document that goes stale between visits.
Workflow
A care plan is created when a patient is enrolled, referencing their qualifying conditions. As the patient's care progresses, the plan is revised to reflect new goals or interventions, and reviewed on a schedule the care team sets — see our full CCM workflow for how care planning fits alongside enrollment, time tracking, and billing preparation.
Related Program
Care plans are a documentation requirement for both CCM and APCM — see either guide for the specific documentation expectations CMS describes.