In my setting we don't use Care Plans, but we have PCMH through NCQA and TJC, and use motivational interviewing to have patients define their own health goals. We then help patients move toward achieving their goals.
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Lisa Duncan, DNP, MBA, RN, AMB-BC, CIC, NEA-BC
VP, Regulatory and Compliance
Family Health Centers of San Diego
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Original Message:
Sent: 09-30-2025 10:20
From: Stephanie McDowell
Subject: Complex Care Plans in Ambulatory Setting
Good morning! I am a RN in a primary care office which is part of a larger organization. I'm new-ish to the ambulatory world and come from an inpatient setting as well as a quality and patient safety background. We have a few patients that are complex care patients who frequently visit the ED. On the inpatient side, these patients have a complex care plan. I'm reaching out to determine what complex care plans look like in the primary setting in your organizations and the process you have in place to coordinate this. I appreciate the information!
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Stephanie McDowell BSN RN
Yuma AZ
9283366545
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