Comprehensive Care Plan Life Cycle

The comprehensive care plan is a key part of STEPS to Care and its three strategies. It is a vital tool that requires effort from all members of the care team. The care plan makes sure the patient’s treatment goals remain at the forefront of their care. The flowchart shows the lifecycle of a care plan, from initial referral into the program by the Primary Care Provider to ongoing review by the care team and the patient.

Staff Responsible

  • Primary Care Provider
  • Care Coordinator
  • Patient Navigator

A) Use the following information to complete sections of the plan:

  • Referral by Primary Care Provider with Medical Plan
  • Intake Assessment from Care Coordinator
  • Outreach and Information Gathering from Care Coordinator
  • Care Coordinator/Patient Navigator review plan with Client and set SMART goals

B) Care plan maintenance cycle (Care Coordinator, Patient Navigator, Primary Care Provider, and other Social Workers are responsible for continual review and updates):

  • Review at formal Care Team Meetings
  • Review at Primary Care Provider appointments
  • Review when there is a change
  • Update the plan every 6 months (return to part A)