Using SETMA's Disease Management tools Diabetes, Hypertension and Lipids
to fulfill the NCQA requirements for a written Plan of Care and Treatment Plan
Providing our patients a written personal Treatment Plan and a written personal Plan of Care for diabetes, hypertension and lipid management are requirements for achieving Tier 3 recognition by NCQA as a Patient-Centered Medical Home. Since 2001, SETMA has been producing Follow-up Documents for each of the chronic diseases on which we are now reporting in pursuit of recognition as a Patient-Centered Medical Home.
We have made modifications in these tools so that the Follow-up Document fulfills all of the requirements for a Treatment Plan and a Plan of Care. This tutorial addresses only the Treatment Plan and Plan of Care. For a full review of the disease management see:
- Diabetes T
- Lipids T
- Hypertension T
- CHF T
The Plan of Care and Treatment Plan are given to the patient at each visit making it possible for them to assume responsibility for their own care and to begin participating actively in their care.
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