Year:  2017 2018 2019 2020 2021 2022 2023 2024 2025 

QPP Measure #NNEPTN3

Transforming Clinical Practice Initiative Common Measure Name: TCP01: Documentation of a Comprehensive Health and Life Plan Developed Collaboratively by the Patient and the Health Professional Team

Documentation of a comprehensive health and life plan developed collaboratively and holistically with bi-directional communications by the patient and the health team. The plan needs to be documented in the health record and easily accessible to the patient. The health and life plan encompasses all of the following elements: 1. Patient health concerns, life and health goals, behavioral/mental health , coping mechanisms, and self-management plans determined by: a. Patient communication b. Health professional assessments; 2. Identify gaps in the achievement of health and life plan; 3. Health status evaluations, interventions, and outcomes; 4. Action plans: a. An action plan is completed by a health professional in collaboration with the patient and includes specific directions for the management of all health and life goals. 5. Medication Management; 6. Identify community/social services and family support; 7. Advanced directives

Submission Methods: Registry

There are no codes for this QPP measure.

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