Overview
The SMART Goals, Interventions, and Self-Management sections form the core of the patient's individualized Care Plan. After documenting the patient's medical history, assessments, Social Determinants of Health (SDOH), and vital signs, care coordinators use these sections to define measurable health objectives, outline the clinical actions required to achieve them, and encourage patients to actively participate in managing their health.
Care Plan 2.0 allows goals, interventions, and self-management tasks to be created manually, populated from reusable templates, or copied from previous care plans, significantly reducing documentation time while maintaining consistency across patient populations.
Before You Begin
Before creating goals and interventions, ensure that:
A Care Plan has been created.
Patient Information sections have been completed.
Assessments and SDOH have been reviewed.
Current vitals and clinical findings are available.
The patient's diagnoses and care priorities have been identified.
Navigation
Log in to the HealthArc Portal.
Navigate to Patients.
Select the patient.
Open the Care Plan tab.
Open the draft Care Plan.
Navigate to:
Preventive Services
SMART Goals
Interventions
Self-Management
Understanding the Care Planning Workflow
These four sections work together to create a comprehensive care strategy:
Section | Purpose |
Preventive Services | Recommend preventive screenings and routine healthcare activities. |
SMART Goals | Define measurable health objectives for the patient. |
Interventions | Document the clinical actions that support each goal. |
Self-Management | Assign activities the patient should complete independently. |
Each section builds upon the previous one to create a coordinated, patient-centered care plan.
Preventive Services
Overview
The Preventive Services section documents routine healthcare services recommended to maintain health, detect conditions early, and reduce the risk of complications.
Preventive services may be manually added or automatically populated from Care Plan templates.
Common Preventive Services
Examples include:
Annual Wellness Visit
Influenza Vaccination
COVID-19 Vaccination
Pneumococcal Vaccine
Diabetic Eye Exam
Foot Examination
A1C Testing
Colon Cancer Screening
Mammography
Bone Density Screening
Tobacco Cessation Counseling
Nutrition Counseling
The available services may vary based on the patient's age, diagnoses, and enrolled program.
Adding a Preventive Service
Select Preventive Services.
Click Add Preventive Service.
Select the appropriate preventive service.
Record any applicable due dates, frequency, or notes.
Save the service.
Repeat these steps for each recommended preventive activity.
Best Practices
Base recommendations on current clinical guidelines and provider recommendations.
Review preventive services during every care plan evaluation.
Update completed services promptly to avoid duplicate recommendations.
Consider age, diagnoses, and patient preferences when selecting preventive services.
SMART Goals
Overview
SMART Goals define the desired health outcomes for the patient and provide measurable objectives that guide ongoing care.
SMART stands for:
Specific
Measurable
Achievable
Relevant
Time-Bound
Care Plan 2.0 allows multiple SMART Goals to be created for each patient and supports the use of standardized templates for common chronic conditions.
Why SMART Goals Matter
Well-defined goals help:
Focus patient care.
Measure progress objectively.
Improve patient engagement.
Coordinate activities across the care team.
Demonstrate measurable clinical outcomes.
Examples of SMART Goals
Examples include:
Maintain blood pressure below 130/80 mmHg within three months.
Reduce A1C to below 7.0% within six months.
Walk at least 30 minutes five days per week.
Lose 10 pounds over the next six months.
Improve medication adherence to greater than 95%.
Monitor blood glucose twice daily for the next 90 days.
Reduce emergency department visits through improved chronic disease management.
Creating a SMART Goal
Select SMART Goals.
Click Add Goal.
Enter the goal title.
Describe the expected outcome.
Define measurable success criteria.
Establish the target completion timeframe.
Save the goal.
Multiple goals may be created within a single Care Plan.
Goal Status
As patients progress, goals can be updated to reflect their current status.
Typical statuses include:
Not Started
In Progress
Achieved
Partially Achieved
Discontinued
Keeping goal statuses current helps evaluate the effectiveness of interventions and informs future care planning.
Best Practices for SMART Goals
Keep goals patient-specific and clinically relevant.
Focus on realistic, achievable outcomes.
Avoid overly broad objectives.
Discuss goals with the patient to encourage participation.
Review and update goals during each evaluation.
Interventions
Overview
Interventions describe the clinical actions that will be taken to help the patient achieve each SMART Goal.
Unlike goals, which define the desired outcome, interventions specify what the care team will do to support the patient.
Each intervention should directly support one or more goals.
Examples of Interventions
Examples include:
Provide medication education.
Review home blood pressure readings weekly.
Coordinate specialist referrals.
Schedule follow-up appointments.
Perform monthly medication reconciliation.
Provide dietary counseling.
Encourage smoking cessation.
Educate the patient on symptom recognition.
Review RPM readings weekly.
Reinforce self-monitoring techniques.
Adding an Intervention
Select Interventions.
Click Add Intervention.
Enter the intervention description.
Associate the intervention with the appropriate SMART Goal.
Save the intervention.
Multiple interventions may support a single goal.
Intervention Review
Interventions should be reviewed regularly to determine whether:
They remain clinically appropriate.
They have been completed.
They require modification.
Additional interventions are necessary.
Best Practices
Keep interventions specific and actionable.
Avoid duplicate interventions.
Update interventions whenever the patient's condition changes.
Ensure interventions address identified barriers to care and SDOH.
Self-Management
Overview
The Self-Management section outlines activities the patient is responsible for completing outside of clinical encounters.
These tasks promote patient engagement and reinforce healthy behaviors between visits.
Purpose of Self-Management
Self-management tasks encourage patients to actively participate in improving and maintaining their health by promoting consistency and accountability.
Examples of Self-Management Tasks
Examples include:
Measure blood pressure daily.
Check blood glucose before meals.
Record daily weight.
Take medications as prescribed.
Perform prescribed exercises.
Follow a low-sodium diet.
Increase water intake.
Stop smoking.
Keep follow-up appointments.
Monitor symptoms and report significant changes.
Creating a Self-Management Task
Select Self-Management.
Click Add Task.
Enter the activity description.
Define any applicable frequency or schedule.
Save the task.
Tasks should be individualized to match the patient's abilities, health literacy, and goals.
Reviewing Self-Management Tasks
During follow-up encounters:
Ask the patient about task completion.
Discuss any challenges or barriers.
Reinforce successful behaviors.
Modify tasks if needed.
Document patient progress.
Patient adherence should be considered when evaluating overall care plan effectiveness.
Relationship Between Goals, Interventions, and Self-Management
These sections work together to create a comprehensive care strategy:
SMART Goal
Reduce A1C to below 7.0% within six months.
↓
Interventions
Review blood glucose logs monthly.
Provide diabetic nutrition education.
Coordinate endocrinology referral.
↓
Self-Management Tasks
Check blood glucose twice daily.
Follow diabetic meal plan.
Take medications as prescribed.
Walk 30 minutes daily.
This structured approach helps both care teams and patients understand their respective responsibilities.
Using Templates
When a Care Plan is created using a template, many preventive services, SMART goals, interventions, and self-management tasks may already be populated.
Before saving the Care Plan:
Review all imported items.
Remove items that do not apply.
Add patient-specific goals and interventions.
Modify timelines as necessary.
Templates improve efficiency but should always be customized to reflect the patient's individual needs.
Best Practices
Limit goals to the patient's highest clinical priorities.
Ensure every intervention supports at least one SMART Goal.
Encourage patients to participate in setting goals.
Keep self-management tasks realistic and achievable.
Review progress during every scheduled evaluation.
Update goals and interventions as the patient's condition evolves.
Celebrate completed goals to reinforce positive health behaviors.
Troubleshooting
I cannot add a new SMART Goal.
Verify that the Care Plan is in an editable state and that you have the necessary permissions.
My template added goals that do not apply.
Templates are designed to provide a starting point. Review and modify all pre-populated content before finalizing the Care Plan.
Can multiple interventions support one goal?
Yes. A single SMART Goal may have several interventions that address different aspects of the patient's care.
Can I remove completed goals?
Completed goals should generally remain part of the Care Plan to preserve the patient's clinical history. Instead, update the goal status to reflect completion.
How often should goals be reviewed?
Goals, interventions, and self-management tasks should be reviewed during each scheduled care plan evaluation or whenever there is a significant change in the patient's health status.