Assessment, Planning, and Care Coordination
Core concepts
Distinguish screening from comprehensive assessment. Screening identifies who needs deeper evaluation; comprehensive assessment gathers medical, functional, cognitive, behavioral, psychosocial, environmental, financial, caregiver, and social-determinant data. Validated tools may include PHQ-9 for depression, Mini-Cog for cognition, Katz or Barthel for ADLs, Braden for pressure injury risk, and Morse for falls. Planning should be patient-centered and measurable: goals written in the patient's words, with realistic time frames, assigned responsibilities, and reassessment triggers. Care coordination aligns providers, services, settings, and resources while monitoring progress and revising the plan.
Traps
Screening does not establish a diagnosis. Patient priorities may differ from clinician priorities, and the patient's stated goal usually wins if it is safe. Avoid cookie-cutter plans that ignore culture, literacy, transportation, or caregiver capacity. Also watch for missing reassessment after a change in condition, new medication, or transition. Coordination is not simply making referrals; it includes confirming that services actually started and that information reached the right people.
Worked example
A newly referred patient has three ED visits in six months. The strong first move is a comprehensive assessment covering medications, barriers, caregiver support, housing, transportation, and behavioral health, followed by a shared plan with a specific follow-up date and a named contact. Referring to a clinic without confirming access is incomplete coordination.
Rule of thumb
If the goal cannot be measured or verified by the patient, it is not yet a care plan.