CCM Template 2023

CCM INITIAL/FOLLOW-UP CALL
CCM INITIAL CALL// care plan 02/03/23 Borja, Raul 02/16/1951

MONITORING START TIME: 13:20
CHART REVIEW:
LAST LAB WORK DONE : 05/05/2023
HgA1c: 6.57 % LDL 135 mg/dL
LAST OV 05/05/2023 Last OV BP: 110/68 mmHg
colonoscopy: NA
mammogram: NA
dexa: Pending
Chronic Care Management Call conducted via phone. Called performed welcome call and introduction to the Chronic Care Program. Pt is Alert and
oriented x3. Reviewed all current medications, compliance, potential interactions, and allergies. instructed patient on care plan including:
CARE PLAN DIAGNOSIS: Diabetes/ Hyperlipidemia
Any Recent hospital admissions or recent ER Visits? No

DATE ADMITTED: NA DATE DISCHARGED: NA REASON: NA
GOAL PROGRESS:
• Goal # 1 for normal BMI is < 25, last OV BMI 35.5

• Goal # 2 To keep a1C below 8, last lab work 6.57%
• Goal # 3 LDL below 100, last lab work 135 mg/dL
Any changes to your diet? Eating balanced, not eating fatty foods and decreasing carbs intake
Has your appetite increased or decreased: No, keeps as asual
Are you stressed ? No How do you handle stress: NA
Are you still taking all your your medications: Yes Medication compliance: 100%
Does not need refill for now.
ACTIVITY TOLORENCE: independent
HOW OFTEN DO YOU EXCERSICE: She walks outdoors every day for 10-15 minutes
DO YOU SMOKE: No
DO YOU DRINK: No
ANY SAFETY CONCERNS: No
Do you need assistance with booking an appointment: No
Other than your health care team, who could you turn to for help with your health related problems ( ex, family members, friends, a spiritual
leader?) Family
COMMENTS:
Patient verbalized understanding care plan .
Follow up appt scheduled: 07/11/2023
end call time : 16:10
cm nurse: mbarreto, MA
CCM INITIAL CALL// care plan 01/20/2023 Carrion, Martha 12/25/1949

CHART REVIEW:
LAST LAB WORK DONE: 07/11/2022, pending lab work
LAST OV 06/02/2023 GI visit Last OV BP: 138/83 mmHg
colonoscopy: 10/09/2015
mammogram: Pending
dexa: Pending
CARE PLAN DIAGNOSIS: Hypertension/ Hyperlipidemia

GOAL PROGRESS:

• Goal # 2 SBP less than 135 and DBP less than 90, last OV BP 138/83
• Goal # 3 LDL less than 70, last lab work since o7/2022.
We need to get new one done. Gonna call back to schedule an appt for AWV probably next week, for now there’re no space available.
Any changes to your diet? Eating balanced, not eating fatty foods and only low carbs
HOW OFTEN DO YOU EXCERSICE: She walks outdoors for 45 minutes 5 days a week
DO YOU SMOKE: No
DO YOU DRINK: No
Other than your health care team, who could you turn to for help with your health related problems ( ex, family members, friends, a spiritual leader?) Not
really, sometimes family helps
COMMENTS:
CCM FOLLOW-UP CALL 07/12/23// care plan 01/20/2023 Carrion, Martha 12/25/1949
CHART REVIEW:
Last encounter (telemed) Dr Escobar 07/07/2023 Last OV BP: 138/83 mmHg (06/02/23 Dr Glombicki)
Colonoscopy: No
Mammogram: Pending
Dexa: Pending
PSA screening: NA
New referrals during last OV: No

GOAL PROGRESS:

• Goal # 2 BP < 135/90 mmHg, last OV BP 138/83 mmHg
• Goal # 3 LDL less than 70, last lab work since 07/2022.
LIFESTYLE CHANGES
Any changes to your diet? Eating balanced, trying to reduce carbs and fatty foods intake
Has your appetite increased or decreased: No, keeps as usual
Are you stressed? No How do you handle stress: NA
MEDICATIONS
06/28/2023 Irbesartan 300mg Tablet

06/28/2023 24 HR metoprolol succinate 100 MG Extended Release Oral
06/28/2023 Levothyroxine Sodium 75mcg Tablet
06/28/2023 Atorvastatin Calcium 20mg Tablet
06/08/2023 Hydrocortisone 0.5% Topical Cream
06/02/2023 Anusol HC 25mg Rectal Suppository
Are you still taking all your medications: Yes Medication compliance: 100%
SYMPTOMS
- Swollen ankles or feet? No

- Chest pain or shortness of breath? No
- Dizziness? No
- Fatigue/ weak? No
- Problems sleeping? No
- Excesive sleeping? No
- Depressed? No
- Other problems:
HOW OFTEN DO YOU EXCERSICE: She is swimming everyday 30 minutes, does errands and walk at home because outside is too hot
DO YOU DRINK: No
Do you need assistance with booking an appointment: No, does it by herself
Other than your health care team, who could you turn to for help with your health related problems ( ex, family members, friends, a spiritual leader?) She
comes to appts by herself.
COMMENTS:
Patient feeling good at the moment of the call, following diet, meeting 1/3 goals. Blood work is due, need to schedule an appt for new labs, BP and BMI re-
evaluation. Also, mammogram and dexa. Patient said she’ll call to schedule appt because she’s busy right now.
Patient verbalized understanding care plan
End call time: 10:40
CM nurse: mbarreto, MA
CCM INITIAL CALL// care plan 03/20/2023 Gonzalez, Isabel 08/10/1947

CHART REVIEW:
LAST LAB WORK DONE: 04/10/2023
HgA1c: 5.43%
colonoscopy: NA
mammogram: 01/24/2023
dexa: 10/11/2022
CARE PLAN DIAGNOSIS: Hypertension/ DM2


GOAL PROGRESS:
• Goal # 1 for normal BMI is <25, last OV BMI 22
Any changes to your diet? Eating balanced, not eating fatty foods
HOW OFTEN DO YOU EXCERSICE: She walks outdoors for 1 hour everyday now that she’s visiting her family out of town. Normally she walks 30 min
5 days per week
DO YOU SMOKE: No
DO YOU DRINK: No
leader?) Family
COMMENTS:
CCM FOLLOW-UP CALL // care plan 03/20/2023 Gonzalez, Isabel 08/10/1947

CHART REVIEW:
LAST LAB WORK DONE: 04/10/2023, pending blood work.
HgA1c: 5.43%
LAST OV Dr Herrera 05/08/2023 Last OV BP: 120/73 mmHg
Colonoscopy: No
Mammogram: 01/24/2023, impression: BI-RADS category 1-negative
Dexa: 10/11/2022, impression: osteopenia of lumbar spine, osteoporosis of femoral necks
PSA screening: NA

GOAL PROGRESS:
• Goal # 1 for normal BMI is <25, last OV BMI 22
LIFESTYLE CHANGES
Any changes to your diet? Eating balanced

MEDICATIONS
05/08/2023 Pantoprazole Sodium 40mg Delayed-Release Tablet

05/08/2023 Hydroxyzine Hydrochloride 25mg Tablet 10
05/08/2023 Lisinopril 10mg Tablet
04/10/2023 Tizanidine Hydrochloride 4mg Tablet
04/10/2023 Alendronate Sodium 70mg Tablet
SYMPTOMS

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
HOW OFTEN DO YOU EXCERCISE: She takes walks for about 30 minutes 4-5 times a week and does household chores
DO YOU DRINK: No
COMMENTS:
Patient’s feeling good at time of the call, improving her diet, achieving 1/1 goals. Says her BP is under control and she has no pain. Blood work is due,
need to schedule an appt for new labs.
CCM INITIAL CALL// care plan 01/20/2023 Mendez, Elvira 01/25/1950

CHART REVIEW:
HgA1c: 6.01%
colonoscopy: NA
mammogram: 06/07/2022
dexa: 02/18/2022
CARE PLAN DIAGNOSIS: Hypertension/ DM2

GOAL PROGRESS:
• Goal # 1 for normal BMI is < 25, last OF BMI 27.9

• Goal # 2 A1c less than 7%, last work lab 6.01%
• Goal # 3 SBP less than 135 and DBP less than 90, last OV BP 142/81
Any changes to your diet? Eating balanced, patient states that she has never eaten so much.
HOW OFTEN DO YOU EXCERSICE: She doesn’t exercise, just regular errands. Educate about the importance of exercise at least 15 minutes 2-3 days
DO YOU SMOKE: No
DO YOU DRINK: No
Other than your health care team, who could you turn to for help with your health related problems ( ex, family members, friends, a spiritual leader?) Her
husband drives her to appts
COMMENTS:
Schedule appt with PCP for lab work for A1c 3 months follow-up and WW on 06/29/2023
She’s going to ask for a prescription to get blood pressure monitor because doesn’t have one at home
CCM FOLLOW-UP CALL 07/12/23// care plan 01/20/2023 Mendez, Elvira 01/25/1950
CHART REVIEW:
LAST LAB WORK DONE: 01/20/2023, pending blood work.
HgA1c: 6.01%
LAST OV Dr Escobar for retinal exam 07/11/2023 Last OV BP: 142/81 mmHg (02/14/23)
Colonoscopy: No
Mammogram: Pending, last 07/06/2022, impression: BI-RADS 2: Benign
Dexa: Pending, last 02/18/2022, impression: osteopenia of right femoral neck
PSA screening: NA
Last OV diabetic retinal exam: Type 2 diabetes w unsp diabetic rtnop w/o macular edema
CARE PLAN DIAGNOSIS: Hypertension/ Diabetes

GOAL PROGRESS:
• Goal # 1 for normal BMI is < 25, last OF BMI 27.9

• Goal # 2 A1c less than 7%, last work lab 6.01%
• Goal # 3 BP < 135/90, last OV BP 142/81 mmHg
LIFESTYLE CHANGES
Any changes to your diet? Trying to reduce carbs and fatty foods intake
MEDICATIONS
06/21/2023 Amlodipine 5 MG / Benazepril hydrochloride 10 MG Oral Capsule
05/04/2023 Metformin Hydrochloride 1000mg Tablet
01/20/2023 Simvastatin 40 MG Oral Tablet
SYMPTOMS

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
HOW OFTEN DO YOU EXCERSICE: She goes to the gym 3 times per week for 20 minutes
DO YOU DRINK: No
comes to appts with her husband.
COMMENTS:
Patient’s feeling good at the time of the call, improving her diet, meeting 1/3 goals. Blood work is due, need to schedule an appt for new labs and BMI re-
evaluation. She’s going on vacation and will call to office when gets back to schedule Annual Physical
CCM INITIAL CALL// care plan 01/19/2023 Knox, Reathey M 11/08/1951

CHART REVIEW:
HgA1c: 4.9%
clonoscopy: Pending, already have referral letter to Dr Glombicki for screening (01/19/23)
mammogram: Pending
dexa: Pending

GOAL PROGRESS:

• Goal # 2 BP below 140/80, today’s home BP 138/80 mmHg
• Goal # 3 LDL below 100, last blood work LDL 99 mg/dL
Any changes to your diet? Trying to avoid carbs and fatty foods but still eating them
Are you stressed ? A little bit, personal issues. Doesn’t want to share How do you handle stress: Talking to family

HOW OFTEN DO YOU EXCERSICE: She takes outdoor walks 15 minutes 3 times per week when goes to the market and other errands.
DO YOU SMOKE: No
DO YOU DRINK: No
assists to appts by herself
COMMENTS:
She’s going to call us to schedule an appt for Annual Physical and with Dr Glombicki for colonoscopy.
CCM FOLLOW-UP CALL 07/12/23// care plan 01/19/2023 Knox, Reathey M 11/08/1951
MONITORING START TIME:
CHART REVIEW:
HgA1c: 4.9%
LAST OV Dr Reyes 06/07/2023 Last OV BP: 124/75 mmHg
Colonoscopy: Pending, already have referral letter to Dr Glombicki for screening (01/19/23)
Mammogram: Pending
Dexa: Pending
PSA screening: NA

GOAL PROGRESS:

• Goal # 2 BP below 140/80, last OV 124/75 mmHg
• Goal # 3 LDL below 100, last blood work LDL 99 mg/dL
LIFESTYLE CHANGES
MEDICATIONS
06/07/2023 Hydrochlorothiazide 25mg Tablet

06/07/2023 Cyanocobalamin 1000mcg/mL Solution for Injection
06/07/2023 Bupropion Hydrochloride 150mg Extended-Release (XL) Tablet
06/07/2023 Aspirin 81mg Tablet
SYMPTOMS
- Swollen ankles or feet? Swollen legs

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
HOW OFTEN DO YOU EXCERSICE: She tries to go out for a short walk every day, but is not always possible because she has varicose veins on both
extremities with pain
DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call, improving her diet, meeting 2/3 goals. Schedules Annual Physical for mammogram and dexa scan.
Annual Physical appt:
Follow up appt scheduled:
End call time:
CCM INITIAL CALL// care plan 02/22/2023 Mcguire, Dorsey A 07/14/1954

CHART REVIEW:
HgA1c: 6.51%
colonoscopy: NA
mammogram: NA
dexa: Pending

GOAL PROGRESS:
• Goal # 1 for normal BMI is < 25, last OV BMI 36

• Goal # 2 BP below 130/80, last OV BP 130/90 mmHg. Hasn’t taken BP at home today yet
• Goal # 3 A1C below 8, last blood work A1c 6.51%
Any changes to your diet? Eating balanced, still eating twice a week fatty foods and carbs but trying to reduce them
HOW OFTEN DO YOU EXCERSICE: He exercises 20 minutes 4 times a week

DO YOU SMOKE: No
DO YOU DRINK: No

leader?) Family helps sometimes; he comes to appts by himself
COMMENTS:
Patient feeling good at the moment of the call, trying to improve his diet, doing exercise and achieving 2/3 goals
CCM INITIAL CALL// care plan 06/05/2023 Escobar Reyes, Jose - 04/08/1951
CHART REVIEW:
HgA1c: 6.3%
LAST OV Dr Escobar 06/05/2023 Last OV BP: 113/70 mmHg
colonoscopy: No
mammogram: NA
dexa: No

GOAL PROGRESS:
• Goal # 1 for normal BMI is < 25, last OV BMI is 26.6

• Goal # 2 BP below 130/80, last OV BP 113/70 mmHg
• Goal # 3 LDL < 100, last blood work LDL 116 mg/dL
Are you stressed? Yes, because of work How do you handle stress: Talking to family
HOW OFTEN DO YOU EXCERSICE: He does not exercise but works as grower and has a lot of activity
DO YOU SMOKE: No
DO YOU DRINK: No
Other than your health care team, who could you turn to for help with your health related problems ( ex, family members, friends, a spiritual leader?) He
comes to appts by himself
COMMENTS:
Patient feeling good at the moment of the call, trying to improve his diet, achieving 1/3 goals
Follow up appt scheduled: //2023
CCM FOLLOW-UP CALL 07/12/23// care plan 06/05/2023 Escobar Reyes, Jose - 04/08/1951
CHART REVIEW:
HgA1c: 6.3%
Colonoscopy: No
Mammogram: NA
Dexa: Pending
PSA screening: last 04/07/22, PSA TOTAL 1.0 ng/mL.

GOAL PROGRESS:

• Goal # 2 BP below 130/80, last OV BP 113/70 mmHg
• Goal # 3 LDL < 100, last blood work LDL 116 mg/dL
LIFESTYLE CHANGES
Any changes to your diet? Trying to reduce carbs and fatty foods intake.
MEDICATIONS
06/05/2023 Meclizine 25mg Tablet

06/05/2023 Montelukast Sodium 10mg Tablet
06/05/2023 Meclizine 25mg Tablet
06/05/2023 Fenofibrate 160mg Tablet
SYMPTOMS

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
HOW OFTEN DO YOU EXCERCISE: He does not exercise but works as grower and has a lot of activity.
DO YOU DRINK: No
comes to appts by himself.
COMMENTS:
Patient’s feeling good at the time of the call, improving diet, achieving 1/3 goals.
CCM INITIAL CALL// care plan 06/05/2023 Escobar, Tomasa D 01/21/1952
CHART REVIEW:
HgA1c: 6.7%
colonoscopy: No
mammogram: Pending, last one 03/07/2022
dexa: Pt states that rheumatologist did it 4 months ago and apparently no signs of osteoporosis
CARE PLAN DIAGNOSIS: Diabetes/ Hypertension

GOAL PROGRESS:

• Goal # 2 BP < 130/80, last OV BP 140/74 mmHg today at rheumatologist’s office
• Goal # 3 A1c < 7, last blood work A1c 6.7%
Are you stressed? Yes, because her mom passed away one month ago How do you handle stress: Working
HOW OFTEN DO YOU EXCERSICE: She does not exercise but works as cleaning personnel and has a lot of activity
DO YOU SMOKE: No
DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call, trying to improve her diet, achieving 1/3 goals. She’s seeing Dr Mehrzad Zarghouni for abnormal CBC
(thrombocytopenia) and states that he told her everything’s okay so far.
CCM FOLLOW-UP CALL// care plan 06/05/2023 Escobar, Tomasa D 01/21/1952

CHART REVIEW:
HgA1c: 6.7%
Colonoscopy: No
Mammogram: Pending, last 03/07/2022, impression: BI-RADS 2: Benign
Dexa: 4 months ago, apparently no signs of osteoporosis. No record within InSync
PSA screening: NA

GOAL PROGRESS:

• Goal # 2 BP < 130/80, last BP 140/74 mmHg
LIFESTYLE CHANGES
Any changes to your diet? Trying to reduce carbs and fatty foods intake, eating balanced.
Are you stressed? Yes, because her mom passed away 2 months ago How do you handle stress: Working
MEDICATIONS
06/05/2023 Rosuvastatin Calcium 20mg Tablet

06/05/2023 Losartan Potassium/Hydrochlorothiazide 100mg-12.5mg Tablet
06/05/2023 Januvia 100mg Tablet
06/05/2023 Glipizide/Metformin Hydrochloride 2.5mg-500mg
06/05/2023 Calcitriol 0.25mcg Capsule
SYMPTOMS

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
HOW OFTEN DO YOU EXCERCISE: She does not exercise but works as cleaning personnel and has a lot of activity.
DO YOU DRINK: No
COMMENTS:
Patient’s feeling good at the time of the call, improving her diet, achieving 1/3 goals.
CCM INITIAL CALL// care plan 06/06/2023 Macias, Rodolfo E 09/13/1952

CHART REVIEW:
HgA1c: 5.45%
Colonoscopy: No
Mammogram: NA
Dexa: 05/18/23, impression: normal bone marrow density
PSA screening: 01/12/23 PSA TOTAL: 0.3 ng/mL, 33% free.

GOAL PROGRESS:

• Goal # 2 BP < 130/85, last OV 119/67 mmHg.
LIFESTYLE CHANGES
MEDICATIONS
ACTIVITY TOLORENCE: independent// SWOLLEN LEGS
HOW OFTEN DO YOU EXCERCISE: He takes light walks for about 10 minutes 3-4 times a week.
DO YOU SMOKE: No
DO YOU DRINK: No
Do you need assistance with booking an appointment: His wife makes appts for both of them
comes to appts with his wife.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals. Pt had US arterial and venous bilateral lower extremity Doppler and is waiting
for results.
CCM INITIAL CALL// care plan 06/05/2023 Flores, Haydee E 06/29/1945

CHART REVIEW:
HgA1c: 6.9%
colonoscopy: No
mammogram: Pending, last one 07/25/2022
dexa: 06/13/23, impression: normal bone marrow density

GOAL PROGRESS:

• Goal # 2 BP < 130/80, last OV BP 136/63 mmHg
DO YOU SMOKE: No
DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call, trying to improve her diet, achieving 1/3 goals. She’s seeing Dr Mehrzad Zarghouni for abnormal CBC
(thrombocytopenia) and states that he told her everything’s okay so far.
CCM INITIAL CALL// care plan 06/05/2023 Garcia, Sofia 04/30/1945

CHART REVIEW:
HgA1c: 8.7%
colonoscopy: No
mammogram: Pending
dexa: Pending, last one 03/28/22
Any Recent hospital admissions or recent ER Visits? Yes, admitted to MHHS Southwest Hospital
DATE ADMITTED: 05/30/2023 DATE DISCHARGED: 06/02/2023 REASON: Lobar pneumonia
GOAL PROGRESS:
• Goal # 1 for normal BMI is < 25, last OV 27.9

• Goal # 2 LDL < 75, last blood work 28 mg/dL
• Goal # 3 A1c < 7, last blood work 8.7%
DO YOU SMOKE: No
DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call, trying to improve her diet, achieving 1/3 goals.
End call time:
Alberto Villalobos
CCM INITIAL CALL// care plan 06/06/2023 Reyes, Rigoberto - 02/03/1950

CHART REVIEW:
HgA1c: Pending
colonoscopy: Pt refused screening at last visit

mammogram: NA
dexa: 06/09/2023. Impression: Osteopenia of lumbar spine
PSA screening: 06/07/2023

GOAL PROGRESS:

• Goal # 3 A1c < 7, pending
Any changes to your diet? Eating balanced having fruits and vegetables daily, denies fatty foods intake
Patient does not take any medication, he’s well controlled on diet and exercise
HOW OFTEN DO YOU EXCERSICE: He walks everyday around 10-15 minutes

DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call, following the treatment on diet and exercise, achieving 1/3 goals.
CCM FOLLOW-UP CALL// care plan 06/06/2023 Reyes, Rigoberto - 02/03/1950

CHART REVIEW:
LAST OV Dr Escobar 06/27/2023 Last OV BP: 144/77 mmHg.
Colonoscopy: Pt refused screening at last visit

Mammogram: NA
Dexa: 06/09/2023, impression: osteopenia of lumbar spine.
PSA screening: 06/07/2023, PSA TOTAL 0.7 ng/mL.
b

GOAL PROGRESS:

• Goal # 3 A1c < 7, pending, last HbA1c on 06/2022
LIFESTYLE CHANGES
Any changes to your diet? Eating balanced.

MEDICATIONS
Patient does not take any medication for now, he’s well controlled on diet and exercise.
SYMPTOMS

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
HOW OFTEN DO YOU EXCERCISE: He walks around 10-15 minutes every day.
DO YOU DRINK: No
COMMENTS:
Patient’s feeling good at the time of the call, following diet, achieving 1/3 goals.
CCM INITIAL CALL// care plan 06/06/2023 Valverde, Sylvia - 07/25/1956

CHART REVIEW:
HgA1c: 7.4%
Colonoscopy: No
Mammogram: last 09/30/2022, impression: no mammographic features of malignancy
Dexa: last 11/03/2022, impression: normal bone marrow density
PSA screening: NA

GOAL PROGRESS:

• Goal # 2 BP < 130/85, last OV 139/76 mmHg
Any changes to your diet? Trying to reduce carbs and fatty foods intake, drinking a lot of water
HOW OFTEN DO YOU EXCERSICE: She is not exercising right now because of the heat, but does a lot of errands and walks around the house
DO YOU SMOKE: No
DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call, trying to improve her diet, achieving 0/3 goals. She’s going to physiptherapy because had bilateral shoulder
pain, no findings within the CT and X-rays and says that the pain is improving.
CCM FOLLOW-UP CALL// care plan 06/06/2023 Valverde, Sylvia - 07/25/1956

CHART REVIEW:
HbA1c: 7.4%
Last OV Dr Escobar 06/20/2023 Last OV BP: 122/72 mmHg
Colonoscopy: No
Mammogram: 09/30/2022, impression: no mammographic features of malignancy
PSA screening: NA
New referrals during last OV: No. She keeps all the appts with different providers.

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? trying to reduce carbs and fatty foods intake
MEDICATIONS
06/06/2023 Tradjenta 5mg Tablet

06/06/2023 Lisinopril/Hydrochlorothiazide 20mg-25mg Tablet
06/06/2023 Fenofibrate 160mg Tablet
06/06/2023 Amlodipine Besylate 5mg Tablet
SYMPTOMS

- Dizziness? No
- Fatigue/ weak? No
- Excessive sleeping? No
- Depressed? No
- Other problems: Bilateral shoulder pain that has improved with physical therapy to 4/10.
ACTIVITY TOLORENCE: independent/ BILATERAL SHOULDER PAIN
HOW OFTEN DO YOU EXCERSICE: She goes to physical therapy 3 times a week and does household chores. Sometimes takes light walks.
DO YOU DRINK: No
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 0/3 goals. Patient says shoulder pain is improving with physical therapy and sometimes
takes naproxen.
CCM INITIAL CALL// care plan 06/06/2023 Henriquez, Alberto 10/09/1936

CHART REVIEW:
HgA1c: 5.6%
Colonoscopy: No
Mammogram: NA
Dexa: Pending
PSA screening: 05/05/2022, prostatectomy
CARE PLAN DIAGNOSIS: Hyperlipidemia/ Hypertension

GOAL PROGRESS:

Any changes to your diet? Eating balanced, prefers chicken and fish rather than meat. Eats fruits and vegetables everyday.
HOW OFTEN DO YOU EXCERSICE: He does not exercise but works as bus washer and has a lot of activity
DO YOU DRINK: No
Do you need assistance with booking an appointment: Her sister helps scheduling
COMMENTS:
Patient feeling good at the moment of the call, following the diet, achieving 2/3 goals. He was referred to Oncology for further evaluation due to abnormal
coagulation tests, thrombocytopenia and decreased blood cell count, he has the appointment on 07/14/2023.
CCM FOLLOW-UP CALL// care plan 06/06/2023 Henriquez, Alberto 10/09/1936

CHART REVIEW:
HbA1c: 5.6 %
Colonoscopy: No
Mammogram: NA
Dexa: Pending
PSA screening: 05/05/2022, prostatectomy

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? trying to reduce carbs and fatty foods intake, eating balanced.
MEDICATIONS
06/06/2023 Simvastatin 20mg Tablet

06/06/2023 Olmesartan Medoxomil 40mg Tablet
06/06/2023 Hydralazine Hydrochloride 100mg Tablet
06/06/2023 Finasteride 5mg Tablet
06/06/2023 Famotidine 20mg Tablet
06/06/2023 Eplerenone 25mg Tablet
06/06/2023 Doxazosin Mesylate 4mg Tablet
06/06/2023 Allopurinol 100mg Tablet
SYMPTOMS

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
HOW OFTEN DO YOU EXERCISE: He does not exercise but works as bus washer and has a lot of activity.
DO YOU DRINK: No
Do you need assistance with booking an appointment: His sister helps scheduling.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals. Pt had appt with oncologist on 07/14/23 and
End call time:
CCM INITIAL CALL// care plan 06/06/2023 Garcia, Ofir - 07/28/1949

CHART REVIEW:
HgA1c: 6.6%
Colonoscopy: No
Mammogram: Pending, last 05/31/2022 impression: BI-RADS 2: benign
Dexa: Pending, last 05/26/2022 impression: osteopenia of both femoral necks
PSA screening: NA

GOAL PROGRESS:


MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She doesn’t exercise but does household chores and errands
DO YOU DRINK: No
Do you need assistance with booking an appointment: She does it by herself
comes to appts with her daughter or son.
COMMENTS:
Patient’s feeling good at the time of the call, following the diet, achieving 2/3 goals. Scheduled Annual Physical for mammogram and dexa on 08/14/23
15:15 pm
CCM INITIAL CALL// care plan 06/05/2023 Cauder, Jose G 02/10/1950

CHART REVIEW:
HgA1c: 5.6%
Colonoscopy: No
Mammogram: NA
PSA screening: 06/22/2023, normal levels

GOAL PROGRESS:

Any changes to your diet? Eating balanced, prefers chicken and fish rather than meat. Eats fruits and vegetables everyday.
HOW OFTEN DO YOU EXCERSICE: He does not exercise but works as bus washer and has a lot of activity
DO YOU DRINK: No
Do you need assistance with booking an appointment: Her sister helps scheduling
COMMENTS:
Patient feeling good at the moment of the call, following the diet, achieving 3/3 goals.
CCM INITIAL CALL// care plan 06/07/2023 Forest, Andrella M 05/29/1964

CHART REVIEW:
HgA1c: 4.46%
Colonoscopy: No
Mammogram: Pending
Dexa: Pending
PSA screening: NA
CARE PLAN DIAGNOSIS: COPD/ Hypertension

GOAL PROGRESS:

• Goal # 2 BP < 130/85, last OV 150/88 mmHg, hasn’t taken BP at home yet
• Goal # 3 COPD medication compliance and control exacerbation, doesn’t have any symptoms right now
DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call, improving her diet, achieving 1/3 goals. She was referred to vein specialist because varicose painful veins
Annual Physical appt: I’ll call back on 07/17/2023 to schedule
CCM FOLLOW-UP CALL// care plan 06/07/2023 Forest, Andrella M 05/29/1964

CHART REVIEW:
LAST LAB WORK DONE: 02/27/2023 (blood work is due)
HgA1c: 4.46%
Colonoscopy: No
Mammogram: Pending
Dexa: Pending
PSA screening: NA
New referrals during last OV: Yes, to Cardiologist Dr. Ali.
CARE PLAN DIAGNOSIS: Hypertension/ COPD

GOAL PROGRESS:

• Goal # 3 COPD medication compliance and control exacerbation
Pt doesn’t have symptoms now and is 100% compliance with medications.
LIFESTYLE CHANGES
MEDICATIONS
06/07/2023 Irbesartan 75mg Tablet

06/07/2023 hydrochlorothiazide 12.5 MG Oral Tablet
SYMPTOMS
- Swollen ankles or feet? Bilateral lower extremity edema

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
HOW OFTEN DO YOU EXCERCISE: She takes light walks for about 10 minutes 4 times per week, only if her legs don’t hurt because of varicose veins.
DO YOU DRINK: No
COMMENTS:
Patient’s feeling good at the time of the call, improving her diet, achieving 1/3 goals. Referred to cardiologist Dr. Ali for further evaluation and treatment of
varicose veins. Mammogram, dexa and blood work are due, suggested to schedule Annual Physical but refused for now.
CCM INITIAL CALL// care plan 06/07/2023 Williams, Alice 01/05/1940

CHART REVIEW:
HgA1c: 5.47%
Colonoscopy: No
Mammogram: Pending
Dexa: Pending
PSA screening: NA

GOAL PROGRESS:

DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call, improving her diet, achieving 2/3 goals.
End call time:
CCM INITIAL CALL// care plan 06/07/2023 Holomon, Mary - 08/14/1945

CHART REVIEW:
HgA1c: 8.2%
Colonoscopy: No
Mammogram: 03/23/2023, impression: no mammographic evidence of malignancy
Dexa: 02/13/2023, impression: 1/5 regions is osteopenic
PSA screening: NA

GOAL PROGRESS:

DO YOU DRINK: No
COMMENTS:
End call time:
CCM FOLLOW-UP CALL// care plan 01/18/2023 Galvan, Hortencia 01/11/1952

CHART REVIEW:
HgA1c: 7.59%
Colonoscopy: No
Mammogram: Pending, last 08/29/2022
Dexa: Pending
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? Eating balanced, reducing carbs and fatty foods intake.
MEDICATIONS
05/16/2023 ferrous sulfate 324 MG Delayed Release Oral Tablet

05/05/2023 Voltaren 1% Topical Gel
05/05/2023 Losartan Potassium 50mg Tablet
05/05/2023 Levemir FlexPen 100units/mL Solution for Injection
05/05/2023 Jardiance 25mg Tablet
05/05/2023 Gabapentin 300mg Capsule
05/05/2023 Furosemide 20mg Tablet
05/05/2023 Clopidogrel 75mg Tablet
05/05/2023 Amlodipine Besylate 10mg Tablet
05/05/2023 Actos 30mg Tablet
SYMPTOMS

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
HOW OFTEN DO YOU EXCERSICE: She does household chores and tries to go out for a light walk every day, but is not always possible because she has
varicose veins on both legs with pain but is improving.
DO YOU DRINK: No
COMMENTS:
Patient’s feeling good at time of the call, improving her diet, achieving 1/3 goals. She had bilateral leg pain due to varicose veins, but she’s taking
medication and it’s getting better.
CCM FOLLOW-UP CALL// care plan 01/19/2023 White, Helen M - 07/06/1953

CHART REVIEW:
HgA1c: 5.71% blood work 10/03/2022
Colonoscopy: No
Mammogram: Pending
Dexa: Pending
PSA screening: NA
CARE PLAN DIAGNOSIS: Weight management/ Hypertension

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
SYMPTOMS
- Swollen ankles or feet? Swollen legs

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
DO YOU DRINK: No
COMMENTS:
End call time:
CCM INITIAL CALL// care plan 06/07/2023 Flores, Maria - 01/15/1949

CHART REVIEW:
HgA1c: 8.1%
Colonoscopy: Pt refused at visit

Mammogram: Pt refused at visit
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? Eating balanced, reduced carbs and fatty foods intake
Has your appetite increased or decreased: Decreased, because she has shoulders pain and affects too
Are you stressed? Yes, because of pain How do you handle stress: Working
MEDICATIONS
06/28/2023 Voltaren 1% Topical Gel So far no additional refill is processed / accepted 2
06/07/2023 Trulicity 1.5mg/0.5mL Solution for Injection
06/07/2023 Levothroid 75mcg Tablet
06/07/2023 Gabapentin 300mg Capsule
06/07/2023 empagliflozin 12.5 MG / metformin hydrochloride 1000 MG Oral Tablet
06/07/2023 Duloxetine 30mg Delayed-Release Capsule
06/07/2023 Clopidogrel 75mg Tablet
04/03/2023 Ibuprofen 800mg Tablet
HOW OFTEN DO YOU EXCERSICE: She’s not exercising right now because bilateral shoulder pain, but still doing errands and walking around home.
DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call but with a lot of shoulders pain that’s not responding to the meds, improving her diet, achieving 2/3 goals.
CCM INITIAL CALL// care plan 06/07/2023 Reyes, Dianne - 04/09/1953

CHART REVIEW:
HgA1c: 6.5%
Colonoscopy: No
Mammogram: Pending
Dexa: Pending
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? Trying to reduce carbs and fatty foods intake, pt says she doesn’t eat all meals because her appetite has always been reduced but
this is normal for her and not craving for food.
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She tries to go out for a short walk every day, but is not always possible because she has varicose veins right now
her left knee is hurting.
DO YOU DRINK: No
Do you need assistance with booking an appointment: No, does it by herself every 3 months
COMMENTS:
Patient feeling good at the moment of the call, just left knee is hurting, following diet, achieving 2/3 goals.
CCM INITIAL CALL// care plan 01/17/2023 Ponce, Eleazar - 08/24/1952

CHART REVIEW:
LAST LAB WORK DONE : 03/23/2023
HGA1c: 10.14%
colonoscopy: NA
mammogram: NA
dexa: Pending
Chronic Care Management Call conducted via phone. Called performed welcome call and introduction to the Chronic Care
Program. Pt is Alert and oriented x3. Reviewed all current medications, compliance, potential interactions, and
allergies. instructed patient on care plan including:
Called performed with patient’s wife cause he’s deaf.
Any Recent hospital admissions or recent ER Visits? Admitted to HCA Houston Healthcare Northwest after visiting Dr
Reyes because had his left second toe with gangrene and it was amputated.
DATE ADMITTED: 03/23/2023 DATE DISCHARGED: Patient’s wife didn’t remember
GOAL PROGRESS:
• Goal # 2 A1C below 8, last lab work done on 03/23/23 A1C 10.14%
• Goal # 3 LDL below 100, last lab work done on 03/23/23 LDL 44
Has your appetite increased or decreased: He’s appetite has increased
HOW OFTEN DO YOU EXCERSICE: He’s not exercising right now because he had surgery and still on recovery, but he’s
able to walk around his home
DO YOU SMOKE: No
DO YOU DRINK: No
Do you need assistance with booking an appointment: Yes, patient’s wife takes care of it
Other than your health care team, who could you turn to for help with your health related problems ( ex, family
members, friends, a spiritual leader?) His wife and daughter
COMMENTS:
Patient is recovering from amputation surgery, feeling better and walking
CCM FOLLOW-UP CALL// care plan 01/17/2023 Ponce, Eleazar - 08/24/1952

CHART REVIEW:
HgA1c: 10.14%
Colonoscopy: No
Mammogram: NA
Dexa: No
PSA screening: No
Called performed with patient’s wife cause he’s deaf.

DATE ADMITTED: NA DATE DISCHARGED: NA
GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
07/12/2023 Rosuvastatin calcium 20 MG Oral Tablet

07/12/2023 pioglitazone 30 MG Oral Tablet
07/12/2023 Metformin hydrochloride 1000 MG Oral Tablet
07/12/2023 Lisinopril/Hydrochlorothiazide 20mg-25mg Tablet
07/12/2023 Lantus SoloStar 100units/mL Pre-Filled Pen Solu
SYMPTOMS

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
Pt was in recovery from left toe amputation and is already healed.

HOW OFTEN DO YOU EXCERSICE: He doesn’t exercise but works at supermarket on the days he’s not in dialysis and does homework
DO YOU DRINK: No
Do you need assistance with booking an appointment: Yes, patient’s wife takes care of it
Other than your health care team, who could you turn to for help with your health related problems ( ex, family members, friends, a spiritual leader?) His
wife and daughter.
COMMENTS:
Patient’s feeling good at the moment of the call, he’s recovered from left toe amputation, walking and has returned to work, improving his diet, achieving
3/3 goals. His BP has improved and continues with dialysis.
CCM FOLLOW-UP CALL// care plan 01/12/2023 Taylor, Rosa - 03/30/1955

CHART REVIEW:
HgA1c: 5.76% last blood work 01/06
LAST OV Dr Bandi 05/15/2023 Last OV BP: 118/56 mmHg
Colonoscopy: No
Dexa: Pending, last 12/29/2021
PSA screening: No
New referrals during last OV: Dermatology, Dr Sewell 05/15/2023 due to Right upper arm nodular rash for years

GOAL PROGRESS:

• Goal # 3 Eat healthy and continue medications along with regular physical activity to improve cholesterol
LIFESTYLE CHANGES
MEDICATIONS
05/15/2023 Pravastatin Sodium 10mg Tablet

05/15/2023 Naprosyn 500mg Tablet
05/15/2023 Hydrochlorothiazide 25mg Tablet
05/15/2023 Cetirizine Hydrochloride 10mg Tablet
05/15/2023 Atenolol 50mg Tablet
SYMPTOMS
- Swollen ankles or feet?

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
DO YOU DRINK: No

COMMENTS:
End call time:
CCM INITIAL CALL// care plan 06/09/2023 Vazquez, Sabas - 04/18/1940

CHART REVIEW:
HgA1c: 9.9%
Colonoscopy: No
Mammogram: NA
Dexa: No

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS

DO YOU DRINK: No
COMMENTS:
End call time:
CCM INITIAL CALL// care plan 06/07/2023 Suarez, Miryam - 10/04/1951

MONITORING START TIME: 16: 38
CHART REVIEW:
HgA1c: 6.0%
LAST OV Dr Meshri 07/06/2023 Last OV BP: 138/77 mmHg
Colonoscopy: No
Mammogram: Pending, last 06/08/2022, impression: BI-RADS 1: Negative
Dexa: Pending, last 05/31/2022
PSA screening: NA
CARE PLAN DIAGNOSIS: Osteoarthritis/ Hyperlipidemia

GOAL PROGRESS:

• Goal # 2 LDL < 100, last blood work 01/24/23 174 mg/dL
• Goal # 3 Osteoarthritis pain control, she has hips and fingers pain every morning
LIFESTYLE CHANGES
Any changes to your diet? Trying to reduce carbs and fatty foods intake, eating balanced
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She tries to walk every day but not always possible because of hips pain, but does errands and walks at home
DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call, osteoarthritis pain at the mornings and improves during the day, following the diet, achieving 1/3 goals.
Pending blood work to re-evaluate lipids
CCM FOLLOW-UP CALL// care plan 02/22/2023 Mcguire, Dorsey A 07/14/1954

CHART REVIEW:
HgA1c: 6.51%
Colonoscopy: No
Mammogram: NA
Dexa: No
PSA screening: 02/22/2022, PSA TOTAL 8.83. Follows up with urologist.

GOAL PROGRESS:

• Goal # 2 BP < 130/80, last OV 130/90 mmHg. Pt doesn’t monitor BP at home.
LIFESTYLE CHANGES
MEDICATIONS
05/18/2023 Tamsulosin Hydrochloride 0.4mg Capsule

05/18/2023 Nifedipine 60mg Extended-Release Tablet
05/18/2023 Finasteride 5mg Tablet
05/18/2023 Carvedilol 25mg Tablet
SYMPTOMS

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
HOW OFTEN DO YOU EXCERSICE: He walks around 15-20 minutes every day.
DO YOU DRINK: No

COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 1/3 goals. Appt on 08/10/23 with PCP for f/u and meds refill.
CCM INITIAL CALL// care plan 06/12/2023 Carrasco, Maria Elena - 07/17/1954
CHART REVIEW:
HgA1c: 5.5%
LAST OV PA Measho 07/10/2023 Last OV BP: 152/73 mmHg
Colonoscopy: No
Mammogram: Pending
Dexa: 03/08/2022, impression: osteoporosis of lumbar spine
PSA screening: NA

GOAL PROGRESS:

• Goal # 2 BP < 130/85, last OV 152/ 73 mmHg
• Goal # 3 LDL < 100, triglycerides < 150, last blood work TG 288 mg/dL, LDL 73 mg/dL
LIFESTYLE CHANGES
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She walks daily around 10 minutes and does errands at home
DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call, improving her diet, meeting 1/3 goals. Her right knee was hurting but came to office on 07/10 and improved
with diclofenac
Mammogram and dexa are due, scheduled Annual Physical on 08/09/2023 11:00 am
CCM INITIAL CALL// care plan 06/07/2023 Gilkison, Carol Carter - 10/15/1947
CHART REVIEW:
LAST LAB WORK DONE: 12/27/2022, pending blood work
HgA1c: 5.8%
Last encounter (telemed) Dr Escobar 06/28/23 Last OV BP: 115/80 mmHg (06/07/23)
Colonoscopy: No
PSA screening: NA
CARE PLAN DIAGNOSIS: Hypertension/ Depression

GOAL PROGRESS:

• Goal # 3 DEPRESSION IMPROVE Selfesteem, MEDICATION COMPLIANCE
LIFESTYLE CHANGES
MEDICATIONS
DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call, improving her diet, meeting 1/3 goals. Blood work is due, suggest order at next visit.
End call time:
CCM INITIAL CALL// care plan 06/07/2023 Gilkison, James 03/24/1947

CHART REVIEW:
HgA1c: 9.1%
Colonoscopy: No
Mammogram: NA
Dexa: 07/07/2022, impression: osteopenia of right femoral neck
PSA screening: No

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call, improving her diet, meeting 1/3 goals. Pt had Healed remote fracture dislocation of the base of the
fifth phalanx, no longer painful.
End call time:
CCM INITIAL CALL// care plan 06/12/2023 Banda, Sanjuana - 11/09/1950

CHART REVIEW:
HgA1c: 5.92%
Colonoscopy: No
Mammogram: Pending, last 06/13/22, impression: BI-RADS 2: benign
Dexa: 06/14/2023, impression: osteopenia of lumbar spine, left and right femoral neck
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? Trying to reduce carbs and fatty food intake
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She walks daily around15 minutes, does errands and walks at home
DO YOU DRINK: No
COMMENTS:
Patient feeling good at the moment of the call, following diet, meeting 2/3 goals. She’s going to schedule Annual Physical for mammogram next office visit
End call time: 17: 46
CCM INITIAL CALL// care plan 06/08/2023 Banda, Ruben - 09/23/1945

CHART REVIEW:
HgA1c: 7.07%
Colonoscopy: No
Mammogram: NA
Dexa: No

GOAL PROGRESS:

• Goal # 2 BP < 130/85, today’s home BP 140/ 90 mmHg
LIFESTYLE CHANGES
Any changes to your diet? Trying to reduce carbs and fatty food intake
Are you stressed? No How do you handle stress: He prays and reads Bible daily
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: He does gardening at home and other errands, takes short walks 3 times/ week
DO YOU DRINK: No
Do you need assistance with booking an appointment: His wife makes appts for both of them, they come to office together
Other than your health care team, who could you turn to for help with your health related problems ( ex, family members, friends, a spiritual leader?) His
family, church community and friends
COMMENTS:
Patient’s feeling good at the time of the call, improving his diet, meeting 1/3 goals. He sees the cardiologist and says that next appt will be in a year
because is well controlled
End call time: 9:56
CCM INITIAL CALL// care plan 06/08/2023 Garza, Blanca E - 12/17/1952

CHART REVIEW:
HgA1c: 5.4%
Colonoscopy: No
Mammogram: Pending, last 07/29/2022 impression: BI-RADS 2: Benign
Dexa: 07/05/2023, impression: osteopenia of lumbar spine, left and right femoral neck.
PSA screening: NA
CARE PLAN DIAGNOSIS: Hypertension/ Osteoarthritis

GOAL PROGRESS:

• Goal # 2 BP < 130/85, last OV 144/73 mmHg.
• Goal # 3 Osteoarthritis medication compliance and pain controlled, 100% compliance but pain is not under control.
LIFESTYLE CHANGES

Has your appetite increased or decreased: decreased appetite, food is not tasty for her anymore
Are you stressed? Yes, because of neuro consult How do you handle stress: Family helps
MEDICATIONS
ACTIVITY TOLORENCE: independent, sometimes she uses her husband’s walker when goes outside because she gets tired
HOW OFTEN DO YOU EXCERSICE: She does not exercise because joints pain, just walks around the house but gets tired too fast
DO YOU DRINK: No
Do you need assistance with booking an appointment: No, does it by herself when comes to visit
comes to appts with her daughter or sometimes with friends from church.
COMMENTS:
Patient’s feeling good at time of the call, improving her diet, complains of bilateral leg pain due to osteoarthritis even though she’s compliant with
medication and denies dizziness and headaches. She’ll have an appt on Monday 07/31 because she’s having surgery. Patient’s daughter (Ms. Brenda)
requested PCP’s fax number to send Dr Diaz’s report and provided it.
CCM INITIAL CALL// care plan 06/08/2023 Benites, Ana 02/29/1944

CHART REVIEW:
Colonoscopy: No
Mammogram: Pending
Dexa: Pending
PSA screening: NA
CARE PLAN DIAGNOSIS: Hyperlipidemia/ Diabetes

GOAL PROGRESS:

• Goal # 2 A1c <7, last blood work is due (10/31/2022)
• Goal # 3 LDL < 70, last blood work is due (10/31/2022)
LIFESTYLE CHANGES
Any changes to your diet? Eating balanced, she doesn’t eat carbs
MEDICATIONS
DO YOU DRINK: No
Do you need assistance with booking an appointment: Her husband helps with that
COMMENTS:
Patient’s feeling good at time of call, improving diet, meeting 1/3 goals. Blood work is due for goals assessment, scheduled Annual Physical for it and also
mammogram and dexa on 08/15/23.
CCM INITIAL CALL// care plan 06/08/2023 Galvan, Amelia F - 07/30/1954

CHART REVIEW:
HbA1c 7.5%
Colonoscopy: 2022, impression: normal

Mammogram: 06/26/23, impression: BI-RADS 2: Benign
Dexa: 06/13/23, impression: osteopenia of right femoral neck
PSA screening: NA

GOAL PROGRESS:

• Goal # 2 A1c <7, last blood work 7.5%
• Goal # 3 BP <130/85, BP today at home 100/75 mmHg
LIFESTYLE CHANGES
Any changes to your diet? Eating balanced, reducing carbs intake and says doesn’t eat fatty foods
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She’s not doing any kind of exercise besides errands and walks at home. Says sometimes she feels a little tired,
according to last blood work she has anemia and was referred to hematology, waiting for appointment.
DO YOU DRINK: No
COMMENTS:
Patient feeling good at time of call, improving diet, meeting 1/3 goals. Pt was referred to hematology regarding abnormal blood work.
CCM INITIAL CALL// care plan 06/08/2023 Martinez, Irene - 04/05/1956

CHART REVIEW:
HbA1c 7.01%
Colonoscopy: No
Mammogram: Pending
Dexa: Pending
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She walks daily around 1 hour

DO YOU DRINK: No
COMMENTS:
Patient’s feeling good at time of call, improving diet, meeting 2/3 goals. Scheduled Annual Physical for mammogram and dexa on 08/21/23
CCM INITIAL CALL// care plan 06/09/2023 Soto, Silvia - 04/02/1956

CHART REVIEW:
HbA1c 5.5%
Colonoscopy: No
Mammogram: Pending
Dexa: 06/14/2023, impression: osteopenia of lumbar spine, right and left femoral necks
PSA screening: NA
CARE PLAN DIAGNOSIS: Hyperlipidemia/ Liver Cancer

GOAL PROGRESS:

• Goal # 2 LIVER CANCER PAIN MEDICATIONS, CHEMO STATUS , SPECIALIST FOLLOWUP, she’s seeing oncology and has chemo ses-
sion 07/20/23. Taking pain meds and does not need refill right now
LIFESTYLE CHANGES

Has your appetite increased or decreased: appetite varies, sometimes she's hungry and others not, but tries to eat something
Are you stressed? Yes, she’s concerned because is getting divorced How do you handle stress: Family helps
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She’s not in the mood for exercise, but does errands and walks at home
DO YOU DRINK: No

COMMENTS:
Patient feeling good at time of call, improving diet, meeting 2/3 goals. She’s getting chemo on 07/20/23 and not in pain right now.
CCM INITIAL CALL// care plan 06/14/2023 Perla, Juana - 06/24/1954

CHART REVIEW:
HbA1c 5.39%
Colonoscopy: No
Mammogram: Pending
Dexa: Pending, last 04/07/2022, impression: osteoporosis of L2 and osteopenia of remainder lumbar spine and left femoral neck
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES

MEDICATIONS
Pt asked if Dr Escobar could prescribe an alternative to Prolia because is not covered by insurance
HOW OFTEN DO YOU EXCERSICE: She goes to the gym 3 times per week 1-1.5 hr
DO YOU DRINK: No
COMMENTS:
Patient feeling good at time of call, following diet, meeting 2/3 goals. Scheduled Annual Physical for mammogram and dexa 08/08/23 9:30 am
CCM INITIAL CALL// care plan 06/12/2023 Ibanez, Myriam - 06/25/1943

CHART REVIEW:
HbA1c 5.8%
LAST encounter Dr Escobar (telemed) 06/27/2023 Last OV BP: 135/73 mmHg (06/12/23)
Colonoscopy: No
Mammogram: 03/16/23 at Houston Methodist, we don’t have results on chart, pt will bring it on next visit
Dexa: Pending, last 03/21/2022, impression: development of osteopenia of both femoral necks
PSA screening: NA
CARE PLAN DIAGNOSIS: Hyperlipidemia/ Osteoporosis

GOAL PROGRESS:

• Goal # 2 Osteoporosis Medication compliance and side effects, she has no side effects and 100% compliance
LIFESTYLE CHANGES
Are you stressed? Yes, because she will have a catheterization on august How do you handle stress: Talking to family
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She walks daily around 20 minutes and does household chores
DO YOU DRINK: No
comes to appts by herself and sometimes with her daughter.
COMMENTS:
Patient’s feeling good at time of call, improving diet, meeting 2/3 goals. She has a cardiology appointment on 08/20 to talk about catheterization, is
concerned about it.
CCM INITIAL CALL// care plan 06/15/2023 Moya, Gladys - 06/01/1944

CHART REVIEW:
HbA1c 5.53%
Colonoscopy: No
Mammogram: Pending
Dexa: 05/18/2023, impression: osteopenia of left and right femoral necks.
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES

Are you stressed? She is concerned about her husband's memory loss. How do you handle stress: Family helps
MEDICATIONS
ACTIVITY TOLORENCE: independent// HEADACHE
HOW OFTEN DO YOU EXCERSICE: She does household chores and sometimes takes light walks.
DO YOU DRINK: No
COMMENTS:
Patient feeling good at time of call, improving diet, meeting 1/3 goals. She complained of a headache that had been coming and going for a week.
Improved with Tylenol but keeps coming back. Explain that this could be related to hypertension and says that PCP adjusted the antihypertensive dosage.
Provided alert symptoms for ER. She’s waiting for results of US carotid Doppler and bilateral lower extremities arterial Doppler. Still pending PET brain
metabolic evaluation, only her husband had it.
CCM INITIAL CALL// care plan 06/15/2023 Moya, Luis - 07/08/1946

CHART REVIEW:
HbA1c 5.56%
Colonoscopy: No
Mammogram: NA
Dexa: Pending
PSA screening: No

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: He takes light walks daily but for the past week he has had severe headaches that are disabling
DO YOU DRINK: No
Do you need assistance with booking an appointment: He does it by herself or his wife
COMMENTS:
Patient’s feeling good at time of call but has had severe headaches that come and go for the past week and are disabling, let him know he needs to go to the
emergency room. He’s improving diet, meeting 2/3 goals.
CCM FOLLOW-UP CALL// care plan 01/18/2023 Munoz Santana, Malucas - 10/18/1952
CHART REVIEW:
HbA1c 6.79%
Last encounter Dr Escobar (telemed) 06/29/2023 Last OV BP: 130/65 mmHg (04/21/23)
Colonoscopy: No
Mammogram: last 03/07/23, impression: BI-RADS 2: Benign
Dexa: last 02/22/22, impression: osteopenia of right femoral neck
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? Trying to reduce carbs and fatty foods intake, eating balanced, avoiding meat
Has your appetite increased or decreased: Yes, it has increased.
MEDICATIONS
04/21/2023 Bydureon BCise 2mg/0.85mL Extended-Release Suspension for Injection

04/21/2023 Xigduo XR 5mg-1000mg Extended-Release Tablet
04/21/2023 Pioglitazone Hydrochloride 30mg Tablet
04/21/2023 Rosuvastatin Calcium 5mg Tablet
SYMPTOMS
- Swollen ankles or feet? Feet tingling

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
HOW OFTEN DO YOU EXCERSICE: She does chores at home and started to take light walks 3 times per week
DO YOU DRINK: No
Do you need assistance with booking an appointment: Her daughter helps with that
comes to appts with her daughter.
COMMENTS:
Patient’s feeling good at time of call, improving diet, she has more appetite and sleeps better, meeting 2/3 goals. She just had diabetic retinal exam and is
waiting for results. Scheduled appt for Annual Physical on 07/25/23
CCM INITIAL CALL// care plan 06/15/2023// Zurita, Gladys 08/14/1951

CHART REVIEW:
HbA1c 5.3%
Colonoscopy: No
Mammogram: last 04/08/22, impression: BI-RADS 2: Benign
Dexa: Pending
PSA screening: NA
CARE PLAN DIAGNOSIS: Parkinson/ Osteoporosis

GOAL PROGRESS:

• Goal # 2 Parkinson medication compliance, side effects and medication effectiveness
• Goal # 3 Osteoporosis medication compliance and side effects
Pt is compliant with medication, but Parkinson’s meds are causing drowsiness and apathy.
LIFESTYLE CHANGES
Any changes to your diet? Eating balanced but not too much because is not hungry
Has your appetite increased or decreased: Yes, it has decreased because of Parkinson’s meds.
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She’s not in the mood for exercise, does chores at home
DO YOU DRINK: No
Do you need assistance with booking an appointment: Yes, her family helps
comes to appts with family.
COMMENTS:
Patient feeling good at time of call but sleepy and doesn’t want to socialize, following diet but appetite has decreased, meeting 2/3 goals.
CCM INITIAL CALL// care plan 06/15/2023 Escobar, Jesus Alba 03/22/1954
CHART REVIEW:
HbA1c 10.55%
Colonoscopy: No
Mammogram: Pending
Dexa: Pending
PSA screening: NA

GOAL PROGRESS:

• Goal # 3 LDL 75, last blood work 89 mg/dL
LIFESTYLE CHANGES

MEDICATIONS
DO YOU DRINK: No
COMMENTS:
Patient’s feeling good at time of call, following diet. She feels tired and fatigued, already has an appt on 07/28/23 with PCP to evaluate this condition and
perform blood work if necessary. Educate about this possibility and fast just in case.
CCM INITIAL CALL// care plan 06/15/2023 Rios, Maria 05/10/1957

CHART REVIEW:
HbA1c 7.39%
Colonoscopy: No
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She walks daily around 10 minutes and does errands at home
DO YOU DRINK: No
COMMENTS:
Patient feeling good at time of call, improving diet, meeting 2/3 goals.
CCM INITIAL CALL// care plan 06/16/2023 Garcia, Maria D 08/02/1965

CHART REVIEW:
HbA1c 5.26%
Colonoscopy: 11/2021: impression: normal

Mammogram: Pending, last 06/24/22, impression: BI-RADS 1: negative
Dexa: 06/15/22, impression: mild osteopenia of both hips
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
Are you stressed? Yes, she’s going have endoscopy tomorrow How do you handle stress: Family helps
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She does household chores at home and errands. She was walking for about 15 minutes every day but right knee
started to hurt and couldn't continue. She just had x-ray and will have MRI to see what’s wrong.
DO YOU DRINK: No
COMMENTS:
Patient’s feeling good at time of call, she has pain in her right knee just had x-ray and will have MRI but is on medication and is improving, following diet,
meeting 1/3 goals. Blood work is due, need new one for re-evaluation of goals.
CCM INITIAL CALL// care plan 06/16/2023 Carrillo, Adan - 09/05/1955

CHART REVIEW:
HbA1c 8.1%
Colonoscopy: No
Mammogram: NA
Dexa: last 06/13/22, impression: mild osteopenia in right femoral neck
PSA screening: 12/16/22, PSA total 25.5 ng/mL. Follow up with Urology, diagnosed with prostate cancer.

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: He does not exercise but works as car washer and has a lot of activity.
Do you need assistance with booking an appointment: No, does it by himself
COMMENTS:
Patient’s feeling good at time of call, improving diet, meeting 0/3 goals.
CCM INITIAL CALL// care plan 06/15/2023 Martinez, Osvaldo - 09/04/1951

CHART REVIEW:
HbA1c 6.3%
Colonoscopy: No
Mammogram: NA
Dexa: Pending
PSA screening: 08/05/22, PSA total 0.648 ng/mL


GOAL PROGRESS:

LIFESTYLE CHANGES
FATTY LIVER
MEDICATIONS
HOW OFTEN DO YOU EXCERCISE: He takes light walks 10 minutes 2 times a week and does housework.
comes to appts by himself and sometimes with family member.
COMMENTS:
Patient’s feeling good at time of call, improving diet, meeting 1/3 goals. Pt had abdominal US (liver) and is waiting for results, scheduled an appt for it.
CCM INITIAL CALL// care plan 06/15/2023// Argueta, Milagros M - 09/18/1956

CHART REVIEW:
HbA1c 6.3%
Colonoscopy: No
Dexa: 06/16/23, impression: osteopenia of lumbar spine
PSA screening: NA
CARE PLAN DIAGNOSIS: Hypothyroidism/ Hyperlipidemia

GOAL PROGRESS:

• Goal # 2 TSH <4, medication compliance, last blood work 1.21 uIU/mL
LIFESTYLE CHANGES
MEDICATIONS
ACTIVITY TOLORENCE: independent // BOTH KNEES AND RIGHT SHOULDER PAIN
HOW OFTEN DO YOU EXCERSICE: She walks every day around 10 minutes and does household chores and errands.
COMMENTS:
Patient’s feeling good at time of call, she has pain in both knees and right shoulder, is waiting for orthopedics referral for further evaluation and treatment,
following diet, meeting 1/3 goals. She also asked to change omega 3 prescription because it’s not covered by insurance. Sent message to Dr Escobar’s
POD.
CCM INITIAL CALL// care plan 06/15/2023// Guzman De Diaz, Maria G - 12/12/1958
CHART REVIEW:
HbA1c 5.5%
Colonoscopy: No
Mammogram: 12/19/22, impression: BI-RADS 1: negative
Dexa: Pending
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? She’s not following diet because says her appetite increased. Educate about the importance of reducing carbs and fatty foods
intake, agreed.
Has your appetite increased or decreased: pt says it has increased
MEDICATIONS
ACTIVITY TOLORENCE: independent // RIGHT KNEE PAIN
HOW OFTEN DO YOU EXCERSICE: She walks around 10 minutes 3 times per week but right now is not walking because of right knee pain. She does
household chores and errands.
COMMENTS:
Patient’s feeling good at time of call, trying to improve diet, achieving 1/3 goals. Today she had Family Encounter with Dr Escobar for right knee pain and
it’s improving after dexamethasone/triamcinolone injection.
CCM INITIAL CALL// care plan 06/15/2023 Escobar Flores, Mauricio - 03/26/1947
CHART REVIEW:
HbA1c 11.77%
Colonoscopy: No
Mammogram: NA
Dexa: Pending
PSA screening: 07/01/22, PSA TOTAL 1.27 ng/mL

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? Pt says he eats fatty foods 2 times a week but is trying to reduce intake and eat a balanced diet.
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: He does household chores such as gardening and errands. Sometimes takes light walks for 10 minutes.
Do you need assistance with booking an appointment: He does it by himself or his wife
comes to appts with his wife
COMMENTS:
Patient’s feeling good at time of call, improving diet,
End call time: 9:56
CCM INITIAL CALL// care plan 06/18/2023 Velez Rivera, Ada O - 12/09/1948
CHART REVIEW:
HbA1c 7.8%
Colonoscopy: No
Mammogram: Pending
Dexa: 07/21/23, impression: osteopenia of lumbar spine and left femoral neck
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES

Has your appetite increased or decreased: Decreased appetite due to pneumonia
Are you stressed? Yes, because of pneumonia How do you handle stress: Praying and family helps.
MEDICATIONS
ACTIVITY TOLORENCE: independent // MULTIPLE JOINT PAIN
HOW OFTEN DO YOU EXCERSICE: She does not exercise but does household chores. She’s not doing anything right now because has pneumonia and
feels tired and short of breath.
comes to appts by herself or with family members.
COMMENTS:
Patient’s following diet, achieving 1/3 goals. She had x-ray 07/21 and has pneumonia, PCP started antibiotics. She has SOB and fatigue, fever is gone. ER
visit suggested but she hasn’t gone yet because says she feels better than yesterday.
CCM INITIAL CALL// care plan 06/13/2023 Cordova, Carlos - 01/12/1954

CHART REVIEW:
HbA1c 7.8%
Colonoscopy: No
Mammogram: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
He needs omeprazole and atorvastatin, tomorrow he has family encounter for f/u and attestation and will ask for them.
HOW OFTEN DO YOU EXCERSICE: He does household chores and some homework such as carpentry and some errands.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 1/3 goals. Sometimes he has knee pain but not limiting.
CCM INITIAL CALL// care plan 06/15/2023 Castro, Rodolfo - 04/30/1948

CHART REVIEW:
HbA1c 6.1%
Colonoscopy: No
Mammogram: NA
Dexa: Pending

GOAL PROGRESS:

LIFESTYLE CHANGES

MEDICATIONS
ACTIVITY TOLORENCE: independent // OSTEOARTHRITIS
HOW OFTEN DO YOU EXCERSICE: He does housework and sometimes takes light walks.
COMMENTS:
Patient’s feeling good at time of call, following diet, achieving 3/3 goals. Joint pain is under control but sometimes hurts 2/10.
End call time: 9:37
CCM INITIAL CALL// care plan 06/19/2023 Garcia, Rogelio M - 08/24/1950

CHART REVIEW:
HbA1c 5.48%
Colonoscopy: No
Mammogram: NA
Dexa: Pending

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: He does housework and takes light walks 3-4 times a week.
COMMENTS:
Patient’s feeling good at time of call, following diet, achieving 2/3 goals. Blood work is due, need to schedule appt for new labs.
CCM INITIAL CALL// care plan 06/19/2023 Aguilar, Margarita J - 07/20/1947

CHART REVIEW:
HbA1c 6.7%
Colonoscopy: No
Dexa: Pending, last 02/16/22 impression: osteopenia of lumbar spine
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
Has your appetite increased or decreased: Her appetite had increased because she was stressed, but now is back to normal.
Are you stressed? Yes, because his husband is in chemo How do you handle stress: Family helps
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She does household chores and used to take light walks every day but with husband’s chemos it wasn’t possible.
But tomorrow is his last session and she’ll start walking again.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 1/3 goals. Mammogram and dexa are due, on Friday 08/04 she has an appointment for
blood work to re-evaluate A1c and Annual Wellness.
CCM INITIAL CALL// care plan 06/19/2023 Aguilar, Jose - 06/10/1947

CHART REVIEW:
HbA1c 5.9%
Colonoscopy: Normal (3 years ago)

Mammogram: NA
Dexa: Pending
PSA screening: 01/10/23, PSA TOTAL 5.2 ng/mL. Follow-up with Urology, diagnosed with prostate cancer.
Called with Mr. Aguilar’s wife, Mrs. Margarita Aguilar.
CARE PLAN DIAGNOSIS: Hyperlipidemia/ Prostate cancer
Any Recent hospital admissions or recent ER Visits? He’s in chemo

DATE ADMITTED: NA DATE DISCHARGED: NA REASON: Prostate cancer
GOAL PROGRESS:

• Goal # 2 Prostate cancer: chemo and radiation status. Results of PET scan an update on treatment
• Goal # 3 LDL <75, last blood work 104 mg/dL
Patient is in chemo and according to his wife, today is the last session.
LIFESTYLE CHANGES

Has your appetite increased or decreased: Decreased appetite because of chemos.
Are you stressed? Yes, because of cancer How do you handle stress: Family helps
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: He’s not exercising right now but walks at home
Do you need assistance with booking an appointment: His wife makes appts for both of them
comes to appts with his wife
COMMENTS:
Patient’s feeling good at time of call, following diet, achieving 1/3 goals. He’s in chemo right now and his wife said today is the last session. Blood work is
due, need to schedule appt for new labs. On Friday 08/04 he has appt for Annual Wellness.
CCM INITIAL CALL// care plan 06/20/2023 Cortez, Miriam - 05/20/1952
CHART REVIEW:
LAST LAB WORK DONE: 05/12/2022 (pending new labs)
HbA1c 7.26% (05/12/22)
Colonoscopy: No
Dexa: Pending
PSA screening: NA
Any Recent hospital admissions or recent ER Visits? Yes, 3 months ago

DATE ADMITTED: NA DATE DISCHARGED: NA REASON: Pleura edema
GOAL PROGRESS:

• Goal # 2 BP < 130/85, today’s home BP 108/70 mmHg
• Goal # 3 A1c <7, last blood work is due (05/12/22), can’t evaluate goal
Today’s home capillary glucose: 99
LIFESTYLE CHANGES

MEDICATIONS
ACTIVITY TOLORENCE: She uses walker, left leg prosthesis
HOW OFTEN DO YOU EXCERSICE: She doesn’t exercise but does household chores and walks around home.
comes to appts with one of her daughters.
COMMENTS:
Patient’s feeling good at time of call, following diet, achieving 1/3 goals, blood sugar appears to be well controlled and so is BP. Mammogram and dexa are
due, scheduled Annual Physical on 08/08/23. Recent visit to ophthalmologist for exam and inject, pt says it’s helping a lot.
CCM INITIAL CALL// care plan 06/20/2023 Godoy, Prospero - 10/09/1952

CHART REVIEW:
HbA1c 6.1%
Colonoscopy: No
Mammogram: NA
Dexa: Pending
PSA screening: 05/24/23, PSA TOTAL 12.5 ng/mL. Referred to urology.
Called with patient’s daughter Ms. Ingrid Galindo

GOAL PROGRESS:

• Goal # 3 LDL <75, last blood work 141 mg/dL
LIFESTYLE CHANGES

MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: He takes light walks for 10 minutes 3 times a week.
Do you need assistance with booking an appointment: His wife makes the appointments.
comes to appts with his wife and sometimes with the daughter.
COMMENTS:
Patient’s feeling good at time of call, following diet, achieving 1/3 goals. Pt was referred to urology because of elevated PSA total. Two days ago (07/25)
he had a biopsy and is waiting for results.
CCM INITIAL CALL// care plan 06/20/2023 Godoy, Aura - 06/14/1954

CHART REVIEW:
HbA1c 9.63% (lab work 05/22/23)
Colonoscopy: No
Mammogram: Pending
Dexa: Pending
PSA screening: NA
Called with patient’s daughter Ms. Ingrid Galindo

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? Trying to reduce bread and tortillas intake.
MEDICATIONS
At last telemed encounter, PCP discontinued Kerendia 10 mg for hyperkalemia and referred to urology.
ACTIVITY TOLORENCE: Independent
HOW OFTEN DO YOU EXCERCISE: She takes light walks with his husband and dog for 10 minutes 3 times a week and does some household chores.
comes to appts with his husband and sometimes with her daughter.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 1/3 goals. Pt was referred to nephrology for further evaluation and treatment because of
abnormal metabolic panel.
CCM INITIAL CALL// care plan 06/23/2023 Rojo, Maria - 01/05/1957

CHART REVIEW:
HbA1c 6.9%
Last OV Dr Reyes 07/20/2023 Last OV BP: 110/70 mmHg
Colonoscopy: No
Mammogram: 07/18/23, impression: BI-RADS 0: incomplete, additional imaging evaluation needed
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? Not following a diet but trying to reduce carbs and fatty foods intake
MEDICATIONS
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals. Pt has a pending right breast ultrasound because of an unspecified lump in the
mammogram, the appointment is tomorrow (07/28/23).
CCM INITIAL CALL// care plan 06/23/2023 Alfaro, Jose F - 04/10/1944

CHART REVIEW:
HbA1c 5.84%
Colonoscopy: No
Mammogram: NA
Dexa: last, 04/14/22 impression: persistent osteopenia
PSA screening: 04/11/22, PSA TOTAL 1.07 ng/mL.
Called with patient’s daughter Miss Maritza Alfaro
Any Recent hospital admissions or recent ER Visits? Daughter said he was recently admitted, but didn’t want to give more details, she was busy.
GOAL PROGRESS:

• Goal # 3 LDL <75/ triglycerides < 150, last blood work LDL 75 mg/dL TG 228 mg/dL
LIFESTYLE CHANGES
MEDICATIONS
Are you still taking all your medications: No Medication compliance: NA

Patient’s daughter said Dr Escobar knows her father’s situation and he won’t continue with hypertension meds
HOW OFTEN DO YOU EXCERSICE: He does not exercise because of his current condition, just walks around home
Do you need assistance with booking an appointment: Yes, his daughter takes care of it.
comes to appts with his daughter.
COMMENTS:
Ms. Alfaro didn’t share too much information, almost every question I asked her response was that the PCP was aware of it, but apparently patient is not
doing so well because of recent imaging findings. However, he’s meeting 2/3 goals. Pt was referred to nephrology for CKD 3a; to oncology for abnormal
histopathology of parotid core biopsy and to neurology for Alzheimer’s dementia for further evaluation and treatment.
CCM INITIAL CALL// care plan 06/22/2023 Morrison, Brenda - 11/01/1953

CHART REVIEW:
HbA1c 5.36%
Last OV Dr Bandi 06/22/2023 Last OV BP: 143/86 mmHg
Colonoscopy: No
Mammogram: 10/19/22, impression: BI-RADS 2: benign
PSA screening: NA

GOAL PROGRESS:

• Goal # 3 LDL < 100 and compliance with medication, last blood work 117 mg/dL
LIFESTYLE CHANGES

MEDICATIONS // hyperlipidemia meds?? Atorvastatin
COMMENTS:
Patient’s feeling good at time of call, following diet, achieving 0/3 goals.
End call time:
CCM INITIAL CALL// care plan 06/19/2023 Bowman, Lynda - 01/08/1940

CHART REVIEW:
HbA1c 4.65%
Last OV Dr Herrera 06/22/2023 Last OV BP: 118/75 mmHg
Colonoscopy: No
Dexa: Pending
PSA screening: NA
CARE PLAN DIAGNOSIS: Hypertension/ Depression/ Hypothyroidism

GOAL PROGRESS:

• Goal # 2 take medications daily as prescribed, do not skip a dosage
• Goal # 3 follow TSH level, labs due
LIFESTYLE CHANGES

MEDICATIONS
COMMENTS:
End call time:
CCM INITIAL CALL// care plan 06/19/2023 Pacheco, Estebana - 01/20/1953

CHART REVIEW:
HbA1c 5.32%
Colonoscopy: No
Mammogram: Pending, last 04/27/22, impression: BI-RADS 3: probably benign. Small mas in left breast, benign cyst cluster and intramammary lymph
node.
Dexa: Pending
PSA screening: NA
CARE PLAN DIAGNOSIS: Hypertension/ Osteoporosis/ Lupus

GOAL PROGRESS:

• Goal # 2 take medical daily, do not skip
• Goal # 3 do bone scans
LIFESTYLE CHANGES

MEDICATIONS
ACTIVITY TOLORENCE: independent// BILATERAL SHOULDER PAIN  injection
COMMENTS:
Patient’s feeling good at time of call, following diet, achieving 1/3 goals. According to encounter note dated 06/19/23 pt had dexa scan but couldn’t find
results within facesheet.
End call time:
CCM INITIAL CALL// care plan 06/23/2023 Castro Molina, Manuel - 10/19/1953
CHART REVIEW:
HbA1c 5.7%
Colonoscopy: referred to Dr Glombicki for screening on 06/26/23.

Mammogram: NA
Dexa: Pending
Talked with Mr. Castro’s wife

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
Does not need meds refill now.
HOW OFTEN DO YOU EXCERSICE: He does housework and takes light walks every morning and evening.
comes to appts by himself and sometimes with his wife
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 1/3 goals. Appointment with GI on 08/03/23 for colonoscopy.
CCM INITIAL CALL// care plan 06/27/2023 Turrent Fernandez, Eugenio - 04/05/1936
CHART REVIEW:
HbA1c 5.54%
Colonoscopy: No.
Mammogram: NA
Dexa: Pending
CARE PLAN DIAGNOSIS: Dementia/ Blindness

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
He needs omeprazole and atorvastatin, tomorrow he has family encounter for f/u and attestation and will ask for them.
HOW OFTEN DO YOU EXCERSICE: He does household chores and some homework such as carpentry and some errands.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 1/3 goals. Blood work is due, suggest to schedule an appt for new labs to asses goals.
End call time:
CCM INITIAL CALL// care plan 06/27/2023 Nunez De Turrent, Maria GUADALUPE - 12/02/1944
CHART REVIEW:
HbA1c 5.06%
Colonoscopy: No
Mammogram: Pending
Dexa: Pending
PSA screening: NA
CARE PLAN DIAGNOSIS: Hypertension/ Rheumatoid arthritis

GOAL PROGRESS:

• Goal # 2 pain control,
• Goal # 3 BP control, last OV 102/73 mmHg
LIFESTYLE CHANGES

MEDICATIONS
ACTIVITY TOLORENCE: independent// Knee and shoulder pain
COMMENTS:
Patient’s feeling good at time of call, following diet, achieving 2/3 goals. Blood work is due, suggest to schedule an appt for new labs to asses goals.
End call time:
CCM INITIAL CALL// care plan 06/29/2023 Calderon De Jesus, Sandra - 01/08/1956
CHART REVIEW:
HbA1c 5.67%
Colonoscopy: No
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES

MEDICATIONS
ACTIVITY TOLORENCE: independent// RIGHT KNEE PAIN (last encounter)
HOW OFTEN DO YOU EXCERSICE: She walks on treadmill for 20 minutes every day.
COMMENTS:
Patient’s feeling good at time of call, following diet, achieving 2/3 goals. Pt was referred to orthopedic due to right knee pain and abnormal MRI. She says
the orthopedist suggested surgery, but she refused and wants a second opinion. He gave an injection and prescribed meloxicam, now pain is well
controlled.
CCM INITIAL CALL// care plan 06/29/2023 Ramirez, Benjamin - 03/31/1950

CHART REVIEW:
HbA1c 5.5%
Colonoscopy: No
Mammogram: NA
Dexa: Pending
PSA screening: 06/30/23, PSA TOTAL 0.7 ng/mL// 17% free PSA (04/06/23)
CARE PLAN DIAGNOSIS: Hypertension/ BPH

GOAL PROGRESS:

• Goal # 3 BPH medication compliance and medication side effects
Patient is100% compliant with medication and reports no side effects.
LIFESTYLE CHANGES
Has your appetite increased or decreased: Appetite increased, but just sometimes. He drinks water, or eats a snack.
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: He does housework as gardening and takes care of his son and household chores, walks around at home.
Other than your health care team, who could you turn to for help with your health related problems (ex, family members, friends, a spiritual leader?) He
comes to appts by himself and sometimes with his daughter.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals. He’s waiting for last blood work results, has appt on 08/03.
End call time: 9:03
CCM INITIAL CALL// care plan 06/20/2023 Ramos, Dolores - 01/08/1957

CHART REVIEW:
HbA1c 6.0 %
Last OV Dr Meshri 07/19/2023 Last OV BP: 120/66 mmHg
Colonoscopy: No
Mammogram: Pending
Dexa: 03/21/22, impression: osteoporosis of lumbar spine, osteopenia of both femoral necks.
PSA screening: NA

GOAL PROGRESS:

• Goal # 2 < 130/85, 120/66 mmHg
LIFESTYLE CHANGES
Are you stressed? Yes, she feels anxious and sad almost every day How do you handle stress: Takes pills
According to PHQ-9 tool, she was positive for depression screening
MEDICATIONS
ACTIVITY TOLORENCE: independent// CHEST PAIN related to exercise
HOW OFTEN DO YOU EXCERSICE: She’s not exercising right now for PCP’s order due to chest pain related to exercise.
Other than your health care team, who could you turn to for help with your health-related problems (ex, family members, friends, a spiritual leader?) She
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 1/3 goals. Pt complained of head tremor at last OV with PCP, he ordered brain MRI and
she’s waiting for results. Says only has mild headaches sometimes and her mood is still not getting better, educated about how antidepressants work and
agreed.
CCM INITIAL CALL// care plan 06/21/2023 Mendez, Antonio - 10/15/1945

CHART REVIEW:
HbA1c 7.6 %
Colonoscopy: No
Mammogram: NA
Dexa: 07/07/22, impression: osteopenia of right femoral neck.

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
ACTIVITY TOLORENCE: independent// DIABETIC NEUROPATHY
HOW OFTEN DO YOU EXCERSICE: He’s not exercising nor doing any housework, educate about the importance of physical activity, agreed.
Do you need assistance with booking an appointment: Schedules appts when comes to OV.
COMMENTS:
Patient’s feeling good at time of call, improving diet, not meeting goals for now. Educate about the importance of diet and exercise, agreed. He has no
symptoms of diabetic neuropathy. Says he is compliant with HTN medications, but BP is not well controlled
CCM INITIAL CALL// care plan 06/14/2023 Moya, Hilda P - 11/26/1952

CHART REVIEW:
HbA1c 5.47 %
Colonoscopy: No
Dexa: 07/27/22, impression: osteopenia with moderate lifetime risk for hip fracture.
PSA screening: NA

GOAL PROGRESS:

• Goal # 2 < 130/85, 129/60 mmHg
LIFESTYLE CHANGES
MEDICATIONS Losartan
HOW OFTEN DO YOU EXCERSICE: She’s not exercising right now for PCP’s order due to chest pain related to exercise.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 1/3 goals
End call time:
CCM INITIAL CALL// care plan 06/28/2023 Galeas Salmeron, Elizabeth - 02/01/1954
CHART REVIEW:
HbA1c 6.9 %
Colonoscopy: August 2022, impression: 3 polyps nonneoplastic

Mammogram: Pending, last 04/13/22, impression: BI-RADS 0: need additional imaging
Dexa: Pending, last 05/03/22, impression: normal bone mass density.

GOAL PROGRESS:

• Goal # 2 < 130/85, today’s home BP 127/76 mmHg
LIFESTYLE CHANGES
MEDICATIONS
ACTIVITY TOLORENCE: independent// OSTEOARTHRITIS
HOW OFTEN DO YOU EXCERSICE: She walks about 1 hr 4 times a week.

Pt complains of joints pain and says she's not taking any medication for it, because sometimes it becomes disabling for daily activities.

COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals. She would like to discuss with PCP about pain management due to osteoarthritis
because is not under control. Pt has an appt at Solis tomorrow for mammogram and will have blood work a week before next OV. Educate about the
importance of dexa scan, agreed and will come for it.
CCM FOLLOW-UP CALL// care plan 01/17/2023 Ortega, Ramona 01/10/1955

CHART REVIEW:
HbA1c: 7.4%
Colonoscopy: No
Mammogram: last 04/05/22 impression: BI-RADS 1: negative
Dexa: Pending, last 03/28/22 impression: osteopenia of both femoral necks.
PSA screening: NA

GOAL PROGRESS:

• Goal # 3 LDL less than 70, last blood work 72 mg/dL
LIFESTYLE CHANGES
Any changes to your diet? trying to reduce carbs and fatty foods intake
Are you stressed? Yes, she’s taking care of a family member in Mexico How do you handle stress: Family helps
MEDICATIONS
06/20/2023 Clonazepam 0.5mg Tablet

06/20/2023 Losartan Potassium 25 MG Oral Tablet
SYMPTOMS
- Swollen ankles or feet? Swollen feet and paresthesia

- Dizziness? No
- Fatigue/ weak? No
- Depressed? No
- Other problems:
HOW OFTEN DO YOU EXCERSICE: She is out of town at family ranch in Mexico and she’s walking and doing household chores every day.
DO YOU DRINK: No
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 0/3 goals. She’ll call us when back in town to schedule Annual Physical appt because dexa
and mammogram are due.
CCM INITIAL CALL// care plan 06/28/2023 Garcia, Daniel - 07/04/1953

CHART REVIEW:
HbA1c 6.0 %
Colonoscopy: Patient declined on 06/28/23

Mammogram: NA
Dexa: Pending

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? eating balanced.

MEDICATIONS
Patient says he is 100% compliant with medication, however BP still not under control.
HOW OFTEN DO YOU EXCERSICE: He walks for about 40 minutes 4 times a week.
Do you need assistance with booking an appointment: No, does it by himself.
COMMENTS:
Patient’s feeling good at time of call, following diet, achieving 1/3 goals. His blood pressure is not under control, even though he says he is 100%
compliant with medications.
CCM INITIAL CALL// care plan 06/14/2023 Montalvo, Luis - 08/09/1951

CHART REVIEW:
HbA1c 5.21 %
Colonoscopy: No
Mammogram: NA
Dexa: Pending

GOAL PROGRESS:

LIFESTYLE CHANGES
Has your appetite increased or decreased: Appetite increased, but just sometimes. He drinks water, or eats a snack.
MEDICATIONS losartan/hydrochlorothiazide??
HOW OFTEN DO YOU EXCERSICE: He does housework as gardening and takes care of his son and household chores, walks around at home.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals.
End call time:
CCM INITIAL CALL// care plan 06/23/2023 Lopez, Isidro - 05/12/1965

CHART REVIEW:
LAST LAB WORK DONE: No recent labs within InSync
Last OV PA Measho 07/06/2023 Last OV BP: 112/69 mmHg
Colonoscopy: No
Mammogram: NA
Dexa: Pending
Any Recent hospital admissions or recent ER Visits? Yes, at UTMB Health in Galveston
DATE ADMITTED: 06/09/23 DATE DISCHARGED: 06/13/23 REASON: Urosepsis
GOAL PROGRESS:

• Goal # 3 A1c < 7, Pt states that last HbA1c was 7.4%
LIFESTYLE CHANGES/ Renal transplant
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: He does and walks around at home.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 1/3 goals. Hospital discharge in June for urosepsis, finished antibiotics and goes to UTMB
Health in Galveston every month for follow-up. He has an appt next Tuesday (08/08) for new labs. Requested to send results to PCP to have internal
control.
CCM INITIAL CALL// care plan 06/29/2023 Mares, Juana - 08/09/1955

CHART REVIEW:
Colonoscopy: No
Mammogram: 07/28/23, impression: no mammographic evidence of malignancy.
Dexa: 07/05/23, impression: osteopenia of lumbar spine and both femoral necks.
PSA screening: NA

GOAL PROGRESS:

• Goal # 2 < 130/85, last OV 147/80 mmHg
• Goal # 3 LDL < 75, blood work is due. Cannot evaluate goal.
LIFESTYLE CHANGES
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She does not exercise, does household chores and errands.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 0/3 goals. Blood work is due, cannot evaluate goals.
CCM INITIAL CALL// care plan 06/29/2023 Rodela, Armandina - 07/24/1946

CHART REVIEW:
HbA1c 6.79 %
Colonoscopy: No
Mammogram: last 01/10/23, impression: BI-RADS 1: benign
Dexa: Pending
PSA screening: NA

GOAL PROGRESS:

• Goal # 2 < 130/85, today’s home BP 138/76 mmHg
LIFESTYLE CHANGES
Are you stressed? Yes, because his son died 2 years ago How do you handle stress: Family helps.
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She doesn’t exercise but does household chores and errands.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals. Patient would like to discuss with PCP about sleeping pills.
CCM INITIAL CALL// care plan 06/29/2023 Rodriguez, Mario - 11/06/1957

CHART REVIEW:
HbA1c: 6.9%
Colonoscopy: Referred to GI on 06/29/23

Mammogram: NA
Dexa: Pending

GOAL PROGRESS:

• Goal # 2 HDL < 100, last blood work 33 mg/dL
LIFESTYLE CHANGES
MEDICATIONS

HOW OFTEN DO YOU EXCERSICE: He does and walks around at home.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals. Referred to GI for colonoscopy, appt on 08/24/23.
End call time:
CCM INITIAL CALL// care plan 06/29/2023 Macias, Mariano - 11/13/1938

CHART REVIEW:
HbA1c: 7.08 %
Colonoscopy: No
Mammogram: NA
Dexa: Pending
PSA screening: Pending

GOAL PROGRESS:

• Goal # 3 A1c < 7, last blood work 7.08 %
LIFESTYLE CHANGES
Are you stressed? Yes, he feels worried about bilateral leg pain How do you handle stress: NA
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: He takes light walks for about 10 minutes 2 times a week and does housework.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals. He has had bilateral leg pain for months but has never told PCP about it and
would like to be evaluated and treated. Referred to GI for colonoscopy, appt on 08/24/23.
CCM INITIAL CALL// care plan 06/29/2023 Aguilar, Gabriel - 08/25/1949

CHART REVIEW:
HbA1c: 6.5 %
Colonoscopy: Patient declined colonoscopy at last OV

Mammogram: NA
Dexa: Pending
PSA screening: 06/30/23, PSA total: 2.7 ng/mL

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? Not following diet, educate about the importance of reducing carbs and fatty foods intake.
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: He doesn’t exercise but does housework such as gardening.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals. Referred to ophthalmologist for diabetic eye exam, hasn’t made appt yet.
CCM INITIAL CALL// care plan 07/03/2023 Ramirez Junior, Juan - 06/05/1958
CHART REVIEW:
HbA1c: 6.0 %
Colonoscopy: No
Mammogram: NA
Dexa: Pending
CARE PLAN DIAGNOSIS: Hypertension/ Depression/ Anxiety


GOAL PROGRESS:

• Goal # 2 walk for 30 minutes 2-3 times per week
• Goal # 3 take medications as prescribed
LIFESTYLE CHANGES
MEDICATIONS
No medication prescribed for now.
HOW OFTEN DO YOU EXCERSICE: He doesn’t exercise but does housework and walks around at home.
Do you need assistance with booking an appointment: No, does it by himself or when comes to appts
COMMENTS:
Patient’s feeling good at time of call, improving diet. Regarding his mood, he feels normal, denies being depressed or anxious at the moment. Pt asked for
lab results and educated about prediabetes and the importance of exercise and a balanced diet, agreed. Referred to GI with Dr. Glombicki but hasn't made
the appt yet.
CCM INITIAL CALL// care plan 06/28/2023 Ramirez, Sanjuanita - 07/11/1950

CHART REVIEW:
HbA1c 5.55 %
Colonoscopy: No
Mammogram: Pending
Dexa: Pending, last 06/09/22 impression: osteopenia of lumbar spine and both femoral necks.
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES

MEDICATIONS
COMMENTS:
CCM INITIAL CALL// care plan 06/29/2023 Delgado, Elvia 10/08/1954

CHART REVIEW:
HbA1c 6.17 %
Colonoscopy: No
Mammogram: Pending, last 03/22/22 impression: BI-RADS 1: negative.
Dexa: Pending, last 03/07/22 impression: osteopenia of right femoral neck.
PSA screening: NA

GOAL PROGRESS:

• Goal # 2 A1c < 7, blood work is due, cannot evaluate goal
• Goal # 3 LDL < 75, blood work is due, cannot evaluate goal
LIFESTYLE CHANGES
MEDICATIONS

COMMENTS:
Patient’s feeling good at time of call, improving diet. Blood work is due since November 2022, cannot evaluate goals.
Scheduled Annual Physical for annual blood work, mammogram and dexa bone scan on 08/30/23.
CCM INITIAL CALL// care plan 06/29/2023 Delgado Diaz, Heraclio - 05/20/1952
CHART REVIEW:
HbA1c: 5.66 %
Colonoscopy: No
Mammogram: NA
Dexa: Pending
PSA screening: Pending, last 11/17/22 impression: PSA total 1.3 ng/mL, 15% free.
Called with Mr. Delgado’s wife Mrs. Elvia Delgado.

GOAL PROGRESS:

• Goal # 3 LDL < 75, triglycerides < 150, blood work is due cannot evaluate goal
LIFESTYLE CHANGES

MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: He takes light walks for about 10 minutes 3 times a week.
Do you need assistance with booking an appointment: His wife makes appts for both of them.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 1/3 goals. Scheduled Annual Physical on 08/30/23 in order to re-evaluate goals.
CCM INITIAL CALL// care plan 06/30/2023 Castellanos, Jose V - 03/14/1949

CHART REVIEW:
HbA1c: 5.64 %
Colonoscopy: No
Mammogram: NA
Dexa: Pending
PSA screening: Pending, last 05/17/22 impression: PSA total 0.991 ng/mL

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? Not following diet nor eating balanced. Educate about the importance of reducing carbs and fatty foods intake.
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: He doesn’t exercise, does housework and walks around at home.
Do you need assistance with booking an appointment: No, he does it by himself.

COMMENTS:
CCM INITIAL CALL// care plan 06/28/2023 Ramirez, Maria - 05/21/1956

CHART REVIEW:
HbA1c 6.2 %
Colonoscopy: Referred to GI on 06/29/23

Dexa: Pending
PSA screening: NA
CARE PLAN DIAGNOSIS: Hypertension/ Hypothyroidism

GOAL PROGRESS:

• Goal # 3 TSH < 4.0, last blood work 1.68 uIU/mL
LIFESTYLE CHANGES
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She doesn’t exercise but does household chores and works part-time as a cleaner in a clinic, so she has a lot of
activity.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals. Referred to GI for colonoscopy, appt on 08/17/23 11:30 am.
CCM INITIAL CALL// care plan 06/26/2023 Flores, Maria 10/13/1946

CHART REVIEW:
HbA1c 5.42 %
Colonoscopy: on 05/20/16, impression: normal, next screening in 10 years.

Mammogram: NA, bilateral mastectomy due to breast cancer.
Dexa: 03/27/23, impression: osteopenia of lumbar spine and bilateral femoral necks.
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She takes light walks for about 10 minutes 3 times a week. She works as ironer and does household chores too.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 1/3 goals. She had bilateral knee xray and is waiting for results, says she’s doing better and
pain is not disabling. She keeps all the appts with different providers; last oncology visit on 06/26/23 continues with surveillance and letrozole + ribociclib
treatment.
CCM INITIAL CALL// care plan 06/30/2023 Lopez, Daniel - 09/02/1971

CHART REVIEW:
HbA1c: 6.6 %
Colonoscopy: Referred to GI for screening, appt on 08/03/23 11 a.m.

Mammogram: NA
Dexa: Pending

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? Not following diet nor eating balanced. Educate about the importance of reducing carbs and fatty foods intake.
MEDICATIONS
Do you need assistance with booking an appointment: No, he does it by himself.

COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 1/3 goals. Pt has colonoscopy yesterday 08/03/23,
End call time:
CCM INITIAL CALL// care plan 07/06/2023 Sierra, Bilma - 08/15/1948

CHART REVIEW:
HbA1c 6.8 %
Colonoscopy: Around 4 years ago.

Dexa: Pending
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
HOW OFTEN DO YOU EXCERSICE: She takes light walks for about 10 minutes 3 times a week.
COMMENTS:
End call time:
CCM INITIAL CALL// care plan 07/06/2023 Moses, Sandra W - 08/21/1944

CHART REVIEW:
HbA1c 6.2 %
Colonoscopy: No
Mammogram: Pending ???????
Dexa: Pending
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
ACTIVITY TOLORENCE: Ambulating with walker
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 0/3 goals. Pt was referred to neurology for low memory.
End call time:
CCM INITIAL CALL// care plan 06/30/2023 Stapleton, Shirley 07/14/1941

CHART REVIEW:
HbA1c 5.9 %
Colonoscopy: About 5 years ago, normal

Mammogram: Pending
Dexa: Pending
PSA screening: NA
CARE PLAN DIAGNOSIS: Hypertension/ Asthma

GOAL PROGRESS:

• Goal # 3 asthma compliance with medication
LIFESTYLE CHANGES
MEDICATIONS
ACTIVITY TOLORENCE: Ambulating with walker
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 0/3 goals. Pt says is 100% compliance with medication but blood pressure is not under
control.
End call time:
CCM FOLLOW-UP CALL// care plan 01/19/2023 DORETHEA JOHNSON, MCCORMICK - 08/17/1954
CHART REVIEW:
HbA1c 8.9 %
Colonoscopy: Referred to GI for screening

Mammogram: Pending, total mastectomy of right breast
PSA screening: NA
CARE PLAN DIAGNOSIS: Diabetes/ Maintain or improve weight

Hx pancreatic cancer
GOAL PROGRESS:
• Goal # 1 Diabetes to avoid low and high blood sugars

• Goal # 2 maintain and improve weight, last OV BMI 20.8
LIFESTYLE CHANGES
MEDICATIONS
ACTIVITY TOLORENCE:
HOW OFTEN DO YOU EXCERSICE: She doesn’t exercise because is having chemotherapy, but does household chores and walks around at home.

comes to appts with his husband or daughter.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 0/3 goals. Pt says is 100% compliance with medication but blood pressure is not under
control.
End call time:
CCM INITIAL CALL// care plan 06/30/2023 Taylor, Michael R - 12/01/1956

CHART REVIEW:
HbA1c: 5.7 %
Colonoscopy: Referred to GI for screening. Appt on 08/03 canceled by provider, pt will call to reschedule.
Mammogram: NA
Dexa: Pending

GOAL PROGRESS:

LIFESTYLE CHANGES

MEDICATIONS
ACTIVITY TOLORENCE: independent/ lower back pain
Do you need assistance with booking an appointment: No, he does it by himself or when comes to visits.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 3/3 goals. Pt was referred to GI for colonoscopy but office canceled and he’ll call to
reschedule. Follows-up with pulmonary physician.
CCM INITIAL CALL// care plan 07/06/2023 Miller, Cynthia - 04/22/1958

CHART REVIEW:
HbA1c 5.66 %
Colonoscopy: No
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
Has your appetite increased or decreased: Decreased, because of abdominal pain.
Are you stressed? She feels sad almost every day How do you handle stress: Pt is on antidepressants treatment.
Pt smokes half a pack a day, educate about the importance of quitting smoking and how it affects health.
MEDICATIONS
ACTIVITY TOLORENCE: Knee and back pain
HOW OFTEN DO YOU EXCERCISE: She does not exercise because of chronic pain, does household chores and walks around at home.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 0/3 goals. Referred to GI for intractable GERD and pain management for chronic knee and
back pain.
CCM INITIAL CALL// care plan 07/06/2023 Bell, Janice - 03/08/1953

CHART REVIEW:
Colonoscopy: No
Mammogram: Pending, last 06/17/22, impression: BI-RADS 2: benign
Dexa: 04/28/22, impression: osteopenia of both femoral necks.
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
Has your appetite increased or decreased: No, keeps as usual.
Are you stressed? No How do you handle stress: NA.
MEDICATIONS
HOW OFTEN DO YOU EXCERCISE: She does not exercise, does household chores and walks around at home.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals. Pt will have cataract surgery, according to clearance she has moderate risk. She
follows up with different providers.
CCM INITIAL CALL// care plan 06/28/2023 Young, Lezley - 12/29/1954
CHART REVIEW:
HbA1c 6.2 %
Colonoscopy: Pending, had prep slip by Dr. Glombicki but has no appt yet.
Mammogram: Pending
Dexa: Pending
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES

MEDICATIONS
HOW OFTEN DO YOU EXCERCISE: She takes light walks 3 times a week and does household chores.

COMMENTS:
CCM INITIAL CALL// care plan 06/13/2023 Carter, Barbara - 11/05/1950

CHART REVIEW:
HbA1c 6.6 %
Colonoscopy: Pending
Mammogram: 07/27/23, impression: BI-RADS 1: incomplete, needs additional imaging evaluation
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? Discussed about the importance of reducing fatty foods and excessive carbs intake.
MEDICATIONS
HOW OFTEN DO YOU EXCERCISE: She does not exercise but does household chores and walks around at home.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 0/3 goals. Abnormal mammogram, requested ultrasound with possible additional views. Pt
says she’s 100% compliance with medication, but blood pressure is not under control.
CCM INITIAL CALL// care plan 07/10/2023 Kendrick Guidry, Maggie L - 08/19/1956
CHART REVIEW:
HbA1c 6.5%
Colonoscopy: 2022, normal

Mammogram: Pending
Dexa: Pending
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
Any changes to your diet? Trying to reduce fatty foods and excessive carbs intake.
MEDICATIONS
ACTIVITY TOLORENCE: independent/ OSTEOARTHRITIS
HOW OFTEN DO YOU EXCERCISE: She takes light walks and does household chores. Joint pain is under control with medication.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 0/3 goals. Pt follows up with different providers. Mammogram and dexa are due, orders
given.
CCM INITIAL CALL// care plan 06/20/2023 AGUIRRE, RAY - 08/19/1957

CHART REVIEW:
HbA1c: 6.9 %
Colonoscopy: No.
Mammogram: NA
Dexa: Pending

GOAL PROGRESS:

• Goal # 2 healthy, low carb diet.
• Goal # 3 check BP 3 times per week, take meds daily.
Pt says his BP is being normal, around 120-130/70-80 mmHg
LIFESTYLE CHANGES
MEDICATIONS
ACTIVITY TOLORENCE: independent/ left hand pain and numbness
HOW OFTEN DO YOU EXCERSICE: He takes light walks for around 15 minutes 4 times a week.
Do you need assistance with booking an appointment: No, he does it by himself or when comes to visits.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals. Left hand pain has improved with ibuprofen intake but still present. Follows-up
with cardiologist.
CCM INITIAL CALL// care plan 06/23/2023 Dunn, Gem L - 02/05/1948

CHART REVIEW:
HbA1c 7.02 %
Colonoscopy: Ordered
Mammogram: Pending, last 05/09/22 impression: BI-RADS 3: probably benign (US). History of right breast cancer.
Dexa: Pending
PSA screening: NA

GOAL PROGRESS:

LIFESTYLE CHANGES
MEDICATIONS
ACTIVITY TOLORENCE: independent/ both feet pain

HOW OFTEN DO YOU EXCERCISE: She takes light walks and does household chores.
COMMENTS:
Patient’s feeling good at time of call, improving diet, achieving 2/3 goals. Pt had bilateral lower extremity arterial Doppler US and the results were not
favorable. CT angiography ordered.
CCM INITIAL CALL// care plan 06/26/2023 Moore, Minnie M - 04/24/1930

CHART REVIEW:
HbA1c 6.3 %
Colonoscopy: No
Mammogram: Pending.
Dexa: 06/27/23, impression: osteoporosis of lumbar spine and both femoral necks.
PSA screening: NA
CARE PLAN DIAGNOSIS: Hypertension/ Dementia

GOAL PROGRESS:

• Goal # 3 Dementia, compliance with medication.
LIFESTYLE CHANGES

Are you stressed? She feels sad and concerned. How do you handle stress: NA.
MEDICATIONS
ACTIVITY TOLORENCE: Uses walker/ knee pain
HOW OFTEN DO YOU EXCERCISE: She does not exercise because of back and knee pain but does household chores and walks around at home.
comes to appts by herself or with family.
COMMENTS:
Patient’s feeling good at time of call, following diet, achieving 2/3 goals. She follows up with different providers. Continues with knee pain but improved
with prolia injection.

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CCM INITIAL/FOLLOW-UP CALL

CCM INITIAL CALL// care plan 02/03/23 Borja, Raul 02/16/1951

CARE PLAN DIAGNOSIS: Diabetes/ Hyperlipidemia

Any Recent hospital admissions or recent ER Visits? No

• Goal # 1 for normal BMI is < 25, last OV BMI 35.5

ACTIVITY TOLORENCE: independent

Do you need assistance with booking an appointment: No

CCM INITIAL CALL// care plan 01/20/2023 Carrion, Martha 12/25/1949

CARE PLAN DIAGNOSIS: Hypertension/ Hyperlipidemia

Any Recent hospital admissions or recent ER Visits? No

• Goal # 1 for normal BMI is < 25, last OV BMI 25.2

ACTIVITY TOLORENCE: independent

Do you need assistance with booking an appointment: No

CARE PLAN DIAGNOSIS: Hypertension/ Hyperlipidemia

Any Recent hospital admissions or recent ER Visits? No

• Goal # 1 for normal BMI is < 25, last OV BMI 25.2

06/28/2023 Irbesartan 300mg Tablet

- Swollen ankles or feet? No

ACTIVITY TOLORENCE: independent

Do you need assistance with booking an appointment: No, does it by herself

CCM INITIAL CALL// care plan 03/20/2023 Gonzalez, Isabel 08/10/1947

CARE PLAN DIAGNOSIS: Hypertension/ DM2

Any Recent hospital admissions or recent ER Visits? No

• Goal # 1 for normal BMI is <25, last OV BMI 22

ACTIVITY TOLORENCE: independent

Do you need assistance with booking an appointment: No

CCM FOLLOW-UP CALL // care plan 03/20/2023 Gonzalez, Isabel 08/10/1947

CARE PLAN DIAGNOSIS: Hypertension/ Hyperlipidemia

Any Recent hospital admissions or recent ER Visits? No

• Goal # 1 for normal BMI is <25, last OV BMI 22

Any changes to your diet? Eating balanced

05/08/2023 Pantoprazole Sodium 40mg Delayed-Release Tablet

- Swollen ankles or feet? No

ACTIVITY TOLORENCE: independent

Do you need assistance with booking an appointment: No, does it by herself

CCM INITIAL CALL// care plan 01/20/2023 Mendez, Elvira 01/25/1950

CARE PLAN DIAGNOSIS: Hypertension/ DM2

Any Recent hospital admissions or recent ER Visits? No

• Goal # 1 for normal BMI is < 25, last OF BMI 27.9

ACTIVITY TOLORENCE: independent

Do you need assistance with booking an appointment: No

CARE PLAN DIAGNOSIS: Hypertension/ Diabetes

Any Recent hospital admissions or recent ER Visits? No

• Goal # 1 for normal BMI is < 25, last OF BMI 27.9

- Swollen ankles or feet? No

ACTIVITY TOLORENCE: independent

Do you need assistance with booking an appointment: No, does it by herself

CCM INITIAL CALL// care plan 01/19/2023 Knox, Reathey M 11/08/1951

CARE PLAN DIAGNOSIS: Hypertension/ Hyperlipidemia

Any Recent hospital admissions or recent ER Visits? No

• Goal # 1 for normal BMI is < 25, last OV BMI 29.7

ACTIVITY TOLORENCE: independent

Do you need assistance with booking an appointment: No

CARE PLAN DIAGNOSIS: Hypertension/ Hyperlipidemia

Any Recent hospital admissions or recent ER Visits? No

• Goal # 1 for normal BMI is < 25, last OV BMI 29.7

06/07/2023 Hydrochlorothiazide 25mg Tablet

- Swollen ankles or feet? Swollen legs

ACTIVITY TOLORENCE: independent

Do you need assistance with booking an appointment: No, does it by herself

CCM INITIAL CALL// care plan 02/22/2023 Mcguire, Dorsey A 07/14/1954

CARE PLAN DIAGNOSIS: Hypertension/ Diabetes

Any Recent hospital admissions or recent ER Visits? No

• Goal # 1 for normal BMI is < 25, last OV BMI 36