Care Plan Examples

 

These are examples of objectives and the interventions used to support them, grouped by area of impairment. CFS 1 - Housing, for example, contains 15 objectives that were written for members who had trouble maintaining housing, along with interventions by each member of the team.

Further down, the interventions from each example are listed separately, by type.

The County has directed us to put headings in front of each type of intervention as highlighted in the Care Plan below.

Headings

Keep in mind, these are examples of objectives and interventions that were right for a specific individual at a certain point in his or her recovery. The objectives may not be appropriate for use in other situations, and may require a different set of interventions if used for someone else. Objectives and interventions must always be personalized to fit the unique wants and needs of the individual they're created for.

Interventions

Interventions are not "matched" to objectives. Instead, they target the specific symptoms and behaviors that are preventing the person from accomplishing the objective. A group of clients with the same objective ("Member will obtain part-time employment") might all need different interventions. If anger is the primary barrier, rehab will involve teaching anger management skills. If disorganized thinking is the biggest obstacle, the focus will be on improving organizational skills. The doctor may be prescribing medications to treat different symptoms, and linkage needs may change as well. Pay close attention to the symptoms and behaviors described on the CFS page in the assessment. These are what your interventions should be targeting.

Objectives

Objectives are concrete, measurable descriptions of progress. They almost always involve a number that increases or decreases. They usually provide a good answer to the question, "How will we know if what we're doing is working?".

Below is a template you can use to help you write objectives. I like it because it creates objectives with built-in baselines, which all objectives must have. It doesn't work for everything but it works for a lot of things. You can use either "increase" or "decrease" in the first line.

Client will increase: The number of hours of restful sleep she gets
from a baseline of: 2 hours per night
to a goal of: 5 hours per night
and sustain this change for: 6 months
as measured by: client self-report

If you're still having trouble understanding objectives, consider this example: Suppose you have a friend named Joe who’s struggling to get through his algebra class. You’re good at math and offer to tutor him for $30 an hour. His parents agree to your fee, but they don’t want to pay for something that isn’t helping. So they ask you to propose a way of showing that what you’re doing is actually moving Joe towards passing the class. What kind of things would you suggest?

Joe will get a “C” or better on every test he takes from here on out. So far, he’s never gotten higher than a “D”.

Joe will turn in 100% of his homework on time. Up to now, he’s only been turning in 50% of it on time.

Joe will get a “B” or better on all his homework assignments. So far he’s never gotten better than a “C”.

By the end of August, Joe will have gotten his class GPA up to 2.0. As of today he’s at 1.0.

These are all examples of well-written objectives. They all have baselines, describing where Joe is now, and targets, which is where Joe will be in the future if your tutoring makes a difference. They all describe something concrete and easy to measure, like Joe's test scores or his GPA. They avoid the use of vague or unmeasurable targets, such as "Joe will be doing better overall" or "Joe will have a better comprehension of algebra."

 

All PHI has been de-identified per HIPAA Privacy Rule