Chronic Care Management Template with Examples

Dr. Maxwell Beresford

March 13, 2025•12 min read

Fact checked by Dr. Ben Condon

Chronic Care Management Template

This Chronic Care Management Care Plan Template is AI-powered to help family medicine specialists comprehensively document follow-up visits for patients with chronic conditions. With Heidi, the AI medical scribe for healthcare providers, you can instantly generate chronic care management plans that:

Capture patient-reported symptoms, physical exam findings, and care management plans for multiple conditions.
Identify potential risks, complications, and other barriers to care plan adherence.
Evaluate the effectiveness of current treatment plans and recommend necessary adjustments. ‍

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See Sample PDF

What is a Chronic Care Management Template?

A Chronic Care Management (CCM) Template is a structured document or digital tool used by healthcare providers to organize, document, and manage the ongoing care of patients with chronic conditions.

A CCM template enhances care coordination and communication between healthcare providers, improving treatment consistency. Additionally, by tracking medications, symptoms, and interventions in a centralized document, healthcare providers can proactively manage chronic conditions to prevent potential complications, and promote improved adherence to established treatment plans.

In this article, we’ll discuss the key components of an effective chronic care management plan template, share a step-by-step guide on how you can write and use a CCM template to improve patient outcomes, and most importantly, provide you with customizable, AI-enabled CCM templates you can use for your medical practice.

Key Components of an Effective Chronic Care Management Template

An effective chronic care management documentation template must comprehensively capture the following key elements:

Patient Information

This first section contains basic details including their name, age, and medical history, along with the specific reason for their visit.

Diagnosis and Chronic Conditions

The second part covers a detailed overview which lists each one of the patient’s chronic conditions along with their reported symptoms and severity.

Medications and Allergies

An outline of the patient’s allergies and medications, including dosages and adherence. Note if the medications are effectively controlling the symptoms.

Care Goals and Treatment Plan

SMART (Specific, Measurable, Achievable, Relevant, Time-Bound) targets that align with the patient’s condition. Changes in medication, diet, or activity should also be documented.

Interventions and Action Steps

The specific steps the healthcare provider will take to address the patient’s condition. This includes the patient’s self-management responsibilities such as prescribed lifestyle e.g., diet, and exercise. Emergency actions, in case symptoms worsen, are also outlined here.

Follow-Up Schedule and Coordination Notes

A record of the patient’s future visits, as well as any referrals necessary for continuity of care. This section also contains information that must be shared with the rest of the care team e.g., recent lab results, and instructions for the patient’s self-care.

Dr. Neil Aitken, owner of Kinetic Physio, now saves 1 to 2 hours per day on notes and admin work with the help of Heidi. Neil states, “When the last patient closes the door, my notes for the day are done. It’s saving me a good chunk of time at the end of every day.”

How to Write and Use a CCM Template to Improve Patient Outcomes (Step-by-Step Guide)

This guide will walk you through the process of writing and using a CCM template effectively, so you get a better understanding of how the key components discussed previously are put into practice:‍

1. Start with a Clear Patient Overview‍

Summarize the patient’s current status, including medical history relevant to their current condition, and the chronic conditions themselves in a concise format. You should also document the primary reason for their visit here to provide further context, and ensure focused care.

Sample Notes: Jack Marston, a 67-year old male with a history of hypertension, type 2 diabetes, and chronic kidney disease presents for a follow up-visit.‍

2. Document Patient-Reported Symptoms and Concerns‍

Write down patient-reported symptoms clearly and accurately, and note whether their symptoms are improving, worsening, or stable.

Sample Notes: Patient reports experiencing mild headaches a couple of times a week, without associated dizziness or visual disturbances. The intensity of headaches has been consistent, but occur more frequently when stressed.

3. Set Individualized Care Goals

Tailor goals to the patient’s condition and capabilities. Set SMART targets that the patient can realistically achieve, so you can continue to motivate them throughout the entire care plan. Include both short term and long-term goals to boost motivation and improve health outcomes respectively.

Sample Notes: Lower HbA1c to under 7% within three months through medication adjustments and improved diet. Reduce blood pressure spikes within two weeks, and maintain stable levels over six months.‍

4. Create an Actionable Treatment and Follow-Up Plan‍

Outline specific care and self-management tasks for healthcare providers and the patient respectively. You should also define milestones to make progress assessment easier, and identify if there’s any need to adjust the care plan. Finally, ensure that the patient understands and supports the care plan fully.

Sample Notes: Attending physician to adjust the dosage of Lisinopril based on blood pressure. Instructed patient to monitor their blood pressure at home twice daily and record the results in the provided tracking log. Blood pressure logs will be reviewed at the next follow-up. Explained the importance of consistent medication use and diligent blood pressure tracking to the patient. Provided written instructions for medication frequency and timings. ‍

5. Coordinate Care Among Healthcare Providers‍

Share copies of the established care plans with specialists and other care team members to align treatment strategies. It’s best to use a centralized documentation tool like an electronic health record (EHR) to keep all care team members updated in real-time.

Sample Notes: Informed the endocrinologist about changes to the patient’s diabetes medication. Updated the electronic health record (EHR) with latest lab results and medication changes.‍

6. Educate and Empower Your Patient‍

Provide patients with clear instructions for self-care practices and medication use, and involve them in tracking progress for both short and long-term goals. Identify potential barriers to their care plan adherence and provide assistance where possible.

Sample Notes: Advise the patient to reduce sodium intake and monitor blood pressure at home. Also advised to record blood sugar levels daily and report any unusual spikes. If medication costs become a challenge, explore patient assistance programs or alternative options.‍

7. Monitor Care Progress and Adjust as Needed‍

Review the care plan’s effectiveness during each follow-up visit, and document specific changes and reasons for adjustment. Finally, track long-term progress to identify trends and improve overall care quality.

Sample Notes: If blood pressure remains high despite medication adjustments, consider additional testing. Increased medication dosage due to persistent hypertension after dietary changes were implemented. HbA1c levels remain under control at 6.8% over three visits.

‍Chronic Care Management Template Example

Here’s a free sample chronic care management plan template in PDF and Google Doc form:

Creating, managing, and implementing chronic care plans is a delicate and time-consuming task which adds to the already demanding workload of the average healthcare provider. Fortunately, AI-powered healthcare solutions can now help streamline CCM plan documentation.

Easily Complete Chronic Care Management Templates with Heidi

Meet Heidi; our state-of-the-art AI medical scribe specially designed to help healthcare providers complete CCM documentation in real-time! With your patient’s permission, simply hit record and let Heidi work as you go!

Here’s how Heidi helps you document your chronic care management plans:

Transcribe – Open Heidi on your computer or mobile device and press Start so Heidi can capture your conversation in the background. Speak with the patient as you normally would and start gathering information for the care plan, then talk them through the prescribed care plan to be implemented. For specific information that you don’t want to verbalize, you can add them later under the context tab.
Customize – After the session, simply select your preferred CCM template and watch as Heidi perfectly transcribes the details of your conversation and context notes in the appropriate format!
Transform – After generating your CCM plans, you can ask Heidi to give additional documentation including medication instructions and follow-up care reminders if needed.

Heidi complies with jurisdiction-specific regulations, ensuring data localization for customers in Australia, Canada, the United States, the United Kingdom, and beyond. Read more about our compliance here.

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Free Customizable Chronic Care Management Templates

This CCM notes template helps nurses and healthcare professionals document patient information in detail, including their symptoms, chronic conditions, and other care plan needs to support effective care coordination.

View Template‍

Workflow Chronic Care Management Template

This CDM plan notes template is designed based on the guidance provided by Services Australia. This is an essential tool which helps healthcare providers manage the care plans of patients with chronic or terminal conditions to ensure Medicare compliance.

View Template

FAQs About Chronic Care Management Templates

How can chronic care management templates help improve patient outcomes?

By clearly outlining medication instructions, self-care tasks, and follow-up schedules aligned with long and short-term health goals, CCM templates empower patients to follow their care plans more consistently, and with greater confidence.

Can AI-generated CCM templates be customized for specific patient needs?

Yes! Heidi’s AI-enabled CCM templates can be easily tailored to fit specific patient conditions. We’ve designed Heidi to be highly-intuitive so you can adopt the system and improve your existing process right away. Quickly review our guide for note customization and document management to get started.

How does Heidi ensure that sensitive patient information in chronic care plans remains secure?

Heidi complies with relevant data security and industry standards such as HIPAA in the US, GDPR in Europe, and APP in Australia, among others. All data within Heidi is encrypted and securely stored to ensure confidentiality and compliance with local regulations.

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