I’m trying to standardize CCM visits for diabetes and hypertension, and I’m looking for patient-facing goal sheets or smart phrases that help us co-create goals and capture med changes in under 10 minutes. If you have shareable templates (Epic SmartPhrase, Word, or PDF) that work in a 20‑minute follow-up, I’d love to see what you’re using.
One thing that’s helped: I send a T‑48 email with the exact IATA Timatic snippet and ask clients to reply “PASSPORT OK” so I can paste their response in the PNR; that reply headed off a counter challenge ex‑JFK last week. Caveat: some agents won’t read remarks, so I also attach the snippet as a PDF on the e‑ticket to make it hard to miss.
I use an Epic SmartPhrase (.CCMDMHTN) that drops a one-liner template: “Goal (next 2 weeks): ___; Confidence 1–10: ___; Med change start/stop/titrate: ___; Home BP avg: /; FBG/A1c note: ___; Barriers: ___; Next step: ___,” and it keeps me out of note-bloat… Building on @akearney33’s pre-visit ping idea, a 24‑hr text for home BP + one goal makes the 20‑min follow-up doable, but it depends on MAs teeing up vitals.
I use a half‑sheet ‘One step + barrier + Plan B’ mirrored via Epic.CCM3M to AVS; PDF, <10m…
Quick example: for 20‑min CCM I use a “traffic light goals” card mirrored to AVS, plus a SmartText that auto-pulls last A1c/BP and forces three fields — Goal (2 wks), Barrier, and Med tweak with start/stop/titrate checkboxes — so I’m done in <10 minutes. If you want a patient-facing starter, this AHRQ Action Plan is what I adapted: https://www.ahrq.gov/health-literacy/improve/precautions/tool10.html; small caveat, add a teach-back line or it falls flat. Shout to @akearney33 — love the confidence ruler, but I only add it when we’re ahead because, , clicks.
What sped this up for me was adding a one‑line goal bar to the AVS that we fill in together: “This week I’ll ____ because ____; readiness 0–10: ___.” I tied it to a SmartText that drops a single line in the note — “Med change: ____; rationale: ____” — and mirrors the same wording to the AVS so the patient leaves with it. Caveat: it only stays quick if rooming preloads vitals and the med list; otherwise I keep a Word snippet to paste.