Care Plans Introduction

Comprehensive Care Plans help clients work with their Care Team to plan, document, and accomplish individualized care goals and healthier outcomes.

Care Plans are also used and reviewed in Care Team Coordination Meetings and medical appointments to ensure clients are keeping up with their health goals.

After reviewing the information and resources below, you will know:

  • How Care Plans are used as part of STEPS to Care
  • Who should create and update Care Plans
  • How to work with clients to create effective Care Plans

Using a Comprehensive Care Plan with Clients

The Comprehensive Care Plan sets client goals, identifies activities or action steps needed to achieve these goals, expected dates for each action step, and any resources or support needed to complete the Care Plan. For each action step on the Care Plan list a responsible party, target date, outcome, and outcome date. The plan also incorporates behavioral health, nursing, and other specialist and allied health professional plans as needed.

Comprehensive Care Plan

The Comprehensive Care Plan is a four-section written plan developed by the client’s medical provider, the Care Coordination Team and the client to help the client achieve his or her treatment goals.

See the SMART Goals training below to learn more about working with clients to create goals and action steps for the Care Plan.

Download the Comprehensive Care Plan

Who Completes and Maintains the Care Plan?

  • All Care Team members are involved in the Care Plan, but the Care Coordinator is primarily responsible for maintaining the plan regardless of which program staff completed it.
  • The Patient Navigator is an active participant in the creation of the Care Plan, ensuring that it is client-centered and incorporates the client’s goals.
  • All Care Team members providing care to the client participate in and contribute to the Care Plan during Care Team meetings.
  • The Primary Care Provider reviews the Care Plan with the client at the end of every primary care visit. The Care Coordinator and/or Patient Navigator should also be part of this review.
  • Any changes to the care plan are also reviewed at the next Care Team meeting. Patient Navigators can also make changes to the Care Plan after client navigation meetings with a client.

Care Plan Life Cycle

Developing an effective Comprehensive Care Plan involves all Care Team members. This graphic explains the stages and cycle of the Comprehensive Care Plan and who is involved each step of the way.

Developing SMART Goals for a Client-Centered Comprehensive Care Plan

Developing SMART Goals Training

The SMART Goals training available below provides an overview of how to work with your clients to set Care Plan goals that are specific, measurable, achievable, realistic, and timely (or SMART).

By the end of this training, you will know:

  • The significance of a SMART goal
  • Strategies and tips for engaging a client in the Care Plan process
  • How to communicate with a client to set his or her own measurable and realistic goals and help him or her work through barriers to success

Jump to the Trainings section below to launch the training.

Estimated time to completion: 30 minutes

Trainings

Developing SMART Goals for a Client-Centered Comprehensive Care Plan

This training provides an overview of how to work with your client to set care plan goals that are specific, measurable, achievable, realistic, and timely or SMART.