STEPS to Care: Care Plans

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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. Each action step on the Care Plan should 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
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.

[PDF - 499 KB]

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.
  • 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.

From client, I need: General review. Confirmation that the multiple pages I compressed into fewer pages works. Meta data. I need to: Figure out navigation. 4th level? Standardize modules for downloads. Make images links. Figure out H1 title style. Sometimes there are problems, such as STEPS to Care Care Plans 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.

Care Plan Life Cycle  [PDF – 92 KB]

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