Executive Summary
According to CMS, a comprehensive care plan is a person-centered, electronic care plan that covers all health issues, with a particular focus on managing chronic conditions. At Cosán Group, we recognize the care plan as the foundation of effective chronic care management, central to enabling coordinated, personalized care that supports better outcomes, care team communication, and care continuity between visits and care settings. When optimized, the care plan functions as a dynamic, patient-centered roadmap that connects care delivery, reduces fragmentation, and enables timely clinical decision-making.
This white paper outlines how optimizing care plans improves outcomes for patients, enhances operational efficiency for providers, and supports alignment with the Centers for Medicare & Medicaid Services (CMS) care management guidelines.
Elements of a Comprehensive Care Plan
Care plans are essential components of Chronic Care Management (CCM) and Principal Care Management (PCM) services as defined by CMS. According to CMS, a comprehensive care plan should include several key elements:
- Problem list
- Expected outcome and prognosis
- Measurable treatment goals
- Cognitive & functional assessment
- Symptom management
- Planning interventions
- Medication management
- Environmental evaluation
- Caregiver assessment
- Interaction and coordination with outside resources, practitioners, and providers
- Requirements for periodic review
- When applicable, revision of the care plan
Example in Practice
A patient qualifies for CCM under Medicare, and their provider develops an electronic care plan that includes their chronic diagnoses (e.g., diabetes, hypertension), medication review, treatment targets, functional and cognitive assessments, planned interventions, and coordination with a home care service. The plan is provided to the patient and caregivers, stored in an EHR, and accessible to all involved providers. Over time, the plan is reviewed and updated monthly to reflect changes in health status, adherence, or goals, supporting billing for ongoing CCM services.
Benefits for Patients
Optimized care plans directly improve the patient’s experience by making care proactive, personalized, and accessible.
When care plans are current and visible to the care team, risks are flagged before they escalate. Patients are more likely to participate in their care when they see progress toward their own goals. Shared care plans foster patient activation, adherence, and trust. This reduces isolation and promotes continuity.
At Cosán, we capture patient-reported outcomes and document both condition-specific and patient-specific goals directly within the care plan. This ensures each plan reflects what truly matters to the individual, whether managing chronic illness, preventing complications, or supporting wellness. By integrating this information into our workflows, we personalize care in a way that empowers patients and guides clinical action across the care team.
Benefits for Providers
For providers, care plan optimization supports clinical prioritization, collaboration, and regulatory compliance. Providers can see which patients are high-risk, overdue follow-up, or falling behind on goals. Care plans create a shared source of truth across interdisciplinary teams. CMS billing and audit standards for CCM, PCM, and related services require accurate documentation of goals, activities, and time tracking. Optimized care plans support audit readiness and help close gaps in care.
Cosán actively incorporates provider feedback to refine both the visual layout and functional structure of the care plan document. By engaging clinicians across primary care and specialty practices, we ensure that care plans are intuitive, aligned with clinical workflows, and tailored to the unique needs of diverse patient populations. These improvements help providers access the right information at the right time, enhancing usability and driving more efficient, patient-centered care.
Conclusion
Optimized care plans are the cornerstone of effective care management. They help unify fragmented information, empower both patients and care teams, and improve outcomes across the continuum of care.
At Cosán Group, we are committed to advancing care plan standardization and optimization, not just to meet CMS requirements, but to elevate the quality of life for those we serve.
As the healthcare landscape continues to shift toward value-based, care plan optimization is not optional; it is essential.
References
Centers for Medicare & Medicaid Services. Chronic Care Management Services. MLN909188; May 2024. Baltimore, MD: CMS; 2024. Retrieved from: https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf.
About the Author
Dr. Jon Pomeroy is a dual-board certified physician in internal medicine and clinical informatics and also holds a PhD with a focus on AI application in healthcare. He has deep experience in healthcare artificial intelligence, clinical informatics,clinical pathways, clinical decision support, clinical and operational outcomes, and chronic disease management.
About Cosán
Cosán is a digital health organization committed to building a more cohesive, proactive, tech-enabled, and personalized care experience for patients and their families. We seek to improve health outcomes, enhance aging in place, and restore human dignity in healthcare for patients – all while reducing the administrative burden, cost, and time challenges for traditional healthcare providers
