CCP Army Chronic Pain, LBP, Pysch

Date: [date name="variable_1" default="today"]
Patient Care Plan was updated for the following condition(s): 
[comment memo="The patient has one of the following diagnosis; therefore, the patient requires a Chronic Care Plan documented in their encounter"]

[checklist name="diagnoses" value="Chronic Low Back Pain|Pain Management|Behavioral Health Condition|Chronic Substance Use"]

Patient Self-Management Assessment: [select name="variable_2" value="Independent |Requires Caregiver support| Requires Case Management"]

Self-Management Resources  [checklist name="variable_3" value="Communication Via Secure Messaging|Handouts|Referrals|Disease Manage classes"]

Duty/Activity Restrictions: [select name="job" value="NONE|See Below"]
[conditional field="job" condition="(job).is('See Below')"]Reason: [text name="Restrictions:"]Start date: [date name="variable_4" default="08/14/2020"] End date: [date name="variable_4" default="08/14/2020"] 
Restrictions: [textarea name="variable_5" default="sample text"][/conditional]

BARRIERS TO ACHIEVING GOALS: [checklist name="barriers" value="Behavioral Health Diagnosis|Social environment|Precontemplative Stage of change|Contemplative Stage of change|Relapse Stage of change|Patient not aligned with treatment plan|Physical limitation|Cognitive limitation|Communication barrier"]

[conditional field="diagnoses" condition="(diagnoses).is('Chronic Low Back Pain')"]
Low Back Pain Care Plan 
Date last updated: 

DIAGNOSIS:  [  ] Non-specific LBP   [  ] LBP assoc w/ Radicular Symptoms or Spinal Stenosis   [  ] LBP w/ other specific cause   [  ] Chronic Disabling LBP
FUNCTIONAL LIMITATIONS (Dx and Date): 
PRIOR EPISODES (Dx and Date): 

GOALS:  [  ] Achieve Individualized Functional Goal of: 

ACTIONABLE DATA:
     Date:               Current Functional Deficits: 
     Date:               Imaging Results: 
     Date:               Opioid Risk Score: 
     Date:               Pain Disability Index: 
     Y/N                  Pain Agreement in Place
     Name:             Sole Provider Designated

COMANAGING TEAM/CONSULTANTS:  [  ] Physical Therapy   [  ] Behavioral Health   [  ] Neurosurgery   [  ] Pain Management   [  ] Physiatry/PM&R   [  ] Other
 
Provider Section:
BARRIERS TO ACHIEVING GOALS:  [  ] Tobacco/Alcohol/Substance Use   [  ] Compensation Claim in dispute     [  ] Job Dissatisfaction   [  ] Co-Morbid Behavioral Health Diagnosis   [  ] Patient alignment with treatment plan

FOLLOW-UP PLAN: 
 
PATIENT INTERIM GOALS: 
[/conditional]

[conditional field="diagnoses" condition="(diagnoses).is('Pain Management')"]
DIAGNOSIS: Chronic pain secondary to: [textarea name="variable_1" default="sample text"]
 
DATE Initiated Opioid therapy: [date name="variable_1" default="08/14/2020"]
Name of Primary Opioid Provider: [text name="variable_1" default="sample text"]
 
Current Treatment Regimen: see med rec
 
Baseline DVPRS Supplemental Score: DATE: [date name="variable_456" default="today"] 
Activity: 
Mood: 
Sleep:
Stress: 

Current DVPRS Supplemental Score: DATE: [date name="variable_745" default="today"] 
Activity: 
Mood: 
Sleep:
Stress: 

Opioid Risk Score: [text name="variable_45" default="sample text"] DATE: [date name="variable_97" default="08/14/2020"] 
DIRE Score: [text name="variable_543" default="sample text"] DATE:[date name="variable_1" default="08/14/2020"]
[select name="variable_51" value="No|Yes"] Urinary Drug Testing consistent with therapy.  DATE of last UDT: [date name="variable_1" default="08/14/2020"]
[select name="variable_51" value="No|Yes"] Patient on Pill counts. # of Pills:
[text name="variable_1" default="sample text"]  DATE of last count:[date name="variable_1" default="08/14/2020"]
 
GOALS:  
Achieve Individualized Functional and Overall Goals of: 
[textarea name="variable_1" default="sample text"]
[select name="variable_1" value="AT GOAL|NOT AT GOAL"] DATE: [date name="variable_1" default="08/14/2020"]

PATIENT RESPONSIBILITIES/INTERVENTIONS: 
 
BARRIERS TO ACHIEVING GOALS:
[select name="variable_645" value="Yes|No"] Current or past Behavioral Health History or Substance Use Disorder (See SUD or BH TSWF CCP) 
 
COMANAGING TEAM/CONSULTANTS: [text name="variable_1" default="sample text"]
 
FOLLOW-UP PLAN: 
[/conditional]

[conditional field="diagnoses" condition="(diagnoses).is('Behavioral Health Condition')"]
Behavioral Health Care Plan  
Date last updated: 

DIAGNOSIS:
   [  ] Major Depressive Disorder
   [  ] Bipolar Disorder
   [  ] Adjustment Disorder
   [  ] PTSD
   [  ] OCD
   [  ] Generalized Anxiety Disorder
   [  ] Panic Disorder
   [  ] Other: 
 
GOALS:
   [  ] Depression:  PHQ<5
   [  ] PTSD:  PCL < 13
   [  ] Anxiety: GAD-7 < 6
   [  ] Other: 
   [  ] Achieve Individualized Functional Goal of: 
 
ACTIONABLE DATA:
 Baseline score/date           
Most recent score/date
     PHQ-9: 
     PCL-5:
     GAD-7: 
     MMSE: 
 
COMANAGING TEAM/CONSULTANTS:
   [  ] Social Work
   [  ] BHC
   [  ] Psychology
   [  ] Psychiatry
   [  ] Family Advocacy
   [  ] Chaplain
 
>>> Provider Section <<<
BARRIERS TO ACHIEVING GOALS:
   [  ] Co-morbid Substance Use
   [  ] Co-morbid Medical Conditions
   [  ] Social Environment
   [  ] Patient Alignment with Treatment Plan
 
INTERVENTION
   [  ] Prescribed Medication
   [  ] Supportive Counseling
 
REFERRED TO:
   [  ] BHC
   [  ] Behavioral Health Clinic
   [  ] Network Provider
   [  ] Other
 
FOLLOW-UP PLAN: 
 
PATIENT INTERIM GOALS: 


[/conditional]

[conditional field="diagnoses" condition="(diagnoses).is('Chronic Substance Use')"]
Substance Use Care Plan 
Date last updated: 

DIAGNOSIS:
[  ] Tobacco use
[  ] Alcohol abuse/dependence
[  ] Other drug abuse/dependence
 
GOALS:  Abstinence
 
ACTIONABLE DATA:
Stage of Change:
[  ] Precontemplation
[  ] Contemplation
[  ] Preparation
[  ] Action
[  ] Maintenance
[  ] Relapse/Recycle
 
Drug Abuse/Dependence Only: 
Date:               Drug screen result:        	 
Date:               GGT result:
 
COMANAGING TEAM/CONSULTANTS:
[  ] Tobacco Cessation Program
[  ] Substance Abuse Program
 
Provider Section:
BARRIERS TO ACHIEVING GOALS:
[  ] Stage of change
[  ] Social environment
[  ] Pain
[  ] Chronic Pain Syndrome
[  ] Co-morbid behavioral health diagnosis
[  ] Patient alignment with treatment plan
 
FOLLOW-UP PLAN: 
 [  ]Y  [  ]N  The patient/family requires additional care management support
 
PATIENT INTERIM GOALS: 
.....
[/conditional]