Assessment and Care Planning Tools

Brother and sister in park

Data Collection

Gathering information directly from the patient and family is vital, and requires compassion, humility, and patience.

Resource Assessments should use a strengths-based, patient-centered approach which focuses on successes without minimizing challenges.

Avoid Yes/No questions.  Questions which require short answers or explanations yield more information and foster trust.

The Resources/Strengths Assessment Can Include The Following:

  • Reason for visit or referral   While you may already have the reason why the family was referred, ask the patient or family member why they believe they are there.
  • Social connections  Identify friends, extended family, others who provide emotional or other support.  What other agencies or organizations are involved?
  • Financial resources  This includes income from work, organizations, friends and family, disability, etc.  Does the family have a bank account? What money do they have set aside in case of an emergency?
  • Physical/health resources  What is the overall health of other family members, not merely the patient?  How do they access a medical home and to appropriate care?
  • Other resources  There are a variety of topics to cover in this category:
    • What is the housing situation? How stable is it?
    • How often does everyone have enough to eat?
    • How is food  prepared?
    • How do they get to the store? How did they get to your appointment?
    • Other considerations include access to clean water, appropriate clothing, safe sleeping arrangements, as well as space and time for schoolwork and for play
  • Educational resources  What is the highest grade completed by the patient?  The caregivers?  Are there older siblings or other family members as well?
  • What’s important to the family?  The reason for your meeting may not necessarily be the reason for the presenting problem or something important to the family.  Take time to learn what’s important to them.

The Care Plan is developed in collaboration with the patient and the family. It is guided by information from the Resource Assessment and by conversations with the patient, the family, and others.

An Effective Care Plan

  • Includes basic information on the patient and the family,
  • Clearly states the goals of the group,
  • Specifies who has agreed to accomplish each task (it’s never only the family)
  • Provides dates for follow-up

Once everyone has agreed on the Plan, be sure the patient or the family gets a copy of the Plan as well.


  • Follow-up keeps all parties on task, and encourages families to take the “driver’s seat”
  • Contact the family on the dates agreed upon in the Plan to ask for an update.  Provide your own update to them.
  • The family may have met the goal, may have made progress, or  may not have made any progress at all.
  • Discuss the progress, including barriers which may have arisen, and how they want to proceed.
  • If necessary, set the next follow-up date before the meeting is over.