{ "resourceType" : "CarePlan", "id" : "CarePlanExampleTier2", "meta" : { "profile" : ["https://fhir.heartlandprotocol.org/StructureDefinition/heartland-careplan"] }, "text" : { "status" : "extensions", "div" : "

Narrativa gerada: CarePlan CarePlanExampleTier2

Perfil: HEARTLAND Care Plan

HEARTLAND Facility Implementation Tier: Tier 2 - Standard

HEARTLAND Monitoring Track Assignment: Analog Track B

status: Active

intent: Plan

subject: Rural Patient Example Female, DoB: 1947-06-15 ( https://fhir.heartlandprotocol.org/sid/example-mrn#EXAMPLE-001)

period: 2026-04-16 --> 2026-07-16

activity

Details

-StatusScheduled[x]Description
*Not StartedUma vezInitiate all 4 GDMT classes (ARNI/ACEi/ARB, beta-blocker, MRA, SGLT2i) within 14 days per Tier 2 protocol. Prioritize SGLT2i and beta-blocker first if simultaneous initiation not feasible.

activity

Details

-StatusScheduled[x]Description
*ScheduledUma vezPost-discharge contact within 48 hours by RN champion.

activity

Details

-StatusDescription
*Scheduled7-day in-person follow-up visit at FQHC for vitals, medication reconciliation, and GDMT titration.

activity

Details

-StatusScheduled[x]Description
*ScheduledContagem 4 times, Uma vez por 1 weekWeekly follow-up phone calls x 4 weeks (Track B analog) capturing weight, blood pressure, oxygen saturation, and symptom assessment.

activity

Details

-StatusDescription
*ScheduledFull discharge teach-back covering 8 AHA-aligned domains: (1) daily weight monitoring, (2) sodium and fluid restriction (<=2 g/day Na, 1.5-2 L fluid), (3) medication adherence and timing, (4) symptom recognition (red flags), (5) activity and exercise progression, (6) when to call provider vs ED, (7) follow-up appointment plan, (8) self-care between visits.

activity

Details

-StatusDescription
*ScheduledPatient assistance program (PAP) pursuit + Generic Bridge for medication access. Generic therapy is superior to no therapy; never delay treatment while waiting for paperwork.

note:

Tier 2 protocol: full implementation over 12 months with phased rollout. Quality metrics: dose optimization and 30-day readmission reduction.

\n
" }, "extension" : [{ "url" : "https://fhir.heartlandprotocol.org/StructureDefinition/heartland-facility-tier", "valueCodeableConcept" : { "coding" : [{ "system" : "https://fhir.heartlandprotocol.org/CodeSystem/heartland-implementation-tier", "code" : "tier-2-standard", "display" : "Tier 2 - Standard" }] } }, { "url" : "https://fhir.heartlandprotocol.org/StructureDefinition/heartland-monitoring-track-ext", "valueCodeableConcept" : { "coding" : [{ "system" : "https://fhir.heartlandprotocol.org/CodeSystem/heartland-monitoring-track", "code" : "analog-track-b", "display" : "Analog Track B" }] } }], "status" : "active", "intent" : "plan", "subject" : { "reference" : "Patient/PatientExampleRural" }, "period" : { "start" : "2026-04-16", "end" : "2026-07-16" }, "activity" : [{ "detail" : { "status" : "not-started", "scheduledTiming" : { "repeat" : { "boundsPeriod" : { "start" : "2026-04-16", "end" : "2026-04-30" } } }, "description" : "Initiate all 4 GDMT classes (ARNI/ACEi/ARB, beta-blocker, MRA, SGLT2i) within 14 days per Tier 2 protocol. Prioritize SGLT2i and beta-blocker first if simultaneous initiation not feasible." } }, { "detail" : { "status" : "scheduled", "scheduledTiming" : { "repeat" : { "boundsPeriod" : { "start" : "2026-04-16", "end" : "2026-04-18" } } }, "description" : "Post-discharge contact within 48 hours by RN champion." } }, { "detail" : { "status" : "scheduled", "description" : "7-day in-person follow-up visit at FQHC for vitals, medication reconciliation, and GDMT titration." } }, { "detail" : { "status" : "scheduled", "scheduledTiming" : { "repeat" : { "count" : 4, "frequency" : 1, "period" : 1, "periodUnit" : "wk" } }, "description" : "Weekly follow-up phone calls x 4 weeks (Track B analog) capturing weight, blood pressure, oxygen saturation, and symptom assessment." } }, { "detail" : { "status" : "scheduled", "description" : "Full discharge teach-back covering 8 AHA-aligned domains: (1) daily weight monitoring, (2) sodium and fluid restriction (<=2 g/day Na, 1.5-2 L fluid), (3) medication adherence and timing, (4) symptom recognition (red flags), (5) activity and exercise progression, (6) when to call provider vs ED, (7) follow-up appointment plan, (8) self-care between visits." } }, { "detail" : { "status" : "scheduled", "description" : "Patient assistance program (PAP) pursuit + Generic Bridge for medication access. Generic therapy is superior to no therapy; never delay treatment while waiting for paperwork." } }], "note" : [{ "text" : "Tier 2 protocol: full implementation over 12 months with phased rollout. Quality metrics: dose optimization and 30-day readmission reduction." }] }