Success Story Creation Template

Use this template to capture a recent successful interaction you had with a patient. Please use the Success Story Work Aid: Staff Responsibilities document for detailed instructions in completing this form. When you’ve finished the template save a version for your personal reference and email the completed template to your supervisor.

Note: keep in mind how your success story ties into the Triple Aim:

Improved health – including social determinants of health and overall well being

Patient satisfaction – exceptional patient experience

Affordability of care – lower health costs for patients

Name of Case Manager/Care Coordinator/CHN/SWC: Free text

Supervisor Name:

DCM Type:

Case Status at time story submitted:

PATIENT INFORMATION

Demographic information:

Age, gender, language/culture Free text

Patient Name: Free text

Member ID: Free text

Employer Group/Coverage: Free text

Primary Clinic/Primary Provider Name/Care System: Free text

STORY INFORMATION

Please keep story information to a few sentences or bullet points.

Patient History: Include diagnosis and social determinants related to story.

Free text

Barriers/Obstacles: What needs were not being met, barriers to care, etc.?

Free text

Interventions/Collaboration: What did you do to improve the patient’s situation? How did you successfully collaborate with the care team?

Free text

Successful Patient Outcomes: Keep in mind Triple Aim when completing this portion.

Free text

Additional Comments: Any positive comments on success of collaboration with care delivery partners, vendors, or other internal/external partners. May also include feedback from patient, family or physician, etc.

Free text

SUMMARY OF SUCCESS

Success #1:	through

If other chosen, please describe:

Free text

Success #2:	through

If other, please describe:

Free text

Success #3:	through

If other, please describe:

Free text

Other Comments:

Free text