The Care Plan Life Cycle

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

  • PCP: Referral by PCP with Medical Plan
  • CC: Intake Assessment
  • CC: Outreach and Information Gathering
  • CC/PN: Review with Client and set SMART goals

B) Care Plan Maintenance Cycle (CC, PN, PCP, Other Social Workers):

  • Review when there is a change
  • Review at formal Care Team Meetings
  • Review at PCP Appointments
  • Update the plan every 6 months, returning to part A