Domain II. Establish goals and a plan of care
1. Prioritize areas of concern in collaboration with client and support
system in order to identify potential areas for intervention.
2. Identify service options and resources that address the areas for
intervention, and discuss their advantages, disadvantages, and
costs with the client in order to establish mutually agreed upon
goals.
3. Develop action steps in order to achieve the agreed upon care plan
goals.
4. Document care plan, including formal and informal providers and the
frequency, intensity, duration, cost, and source of payment for
services, in order to develop a baseline for tracking, accountability,
and quality measurement.