Case Management Initial Assessment

Header Block

Note type: Case Management Initial Assessment | Date/time of assessment: [Date and time] | Setting/location: [Setting/location] | Author: [Name, credentials, role] | Referral source and date: [Referring person/agency and date] | Encounter modality: [in-person / phone / video / chart review] | Participants present: [Patient, caregiver(s), interpreter with language, legal representative] (List names and roles; include interpreter ID if required. If patient alone, state "Patient only.")

Referral Reason & Program Context

[Referral reason in 1-2 problem-focused sentences] (If unclear, state "Pending clarification from [name/role].")

Program type and scope: [Program type, service expectations, eligibility criteria, time horizon, payer/network constraints impacting services]

Consent & Information-Sharing

• Service explanation provided: [Brief description of case management services discussed]
• Consent status: [obtained verbal / obtained written / declined / deferred / unable to obtain / Unknown]
• Coordination permissions: [Permission to contact: PCP, specialists, agencies, family, other] (List specific names/entities and any restrictions. If restricted or declined, describe allowable actions.)
• Preferred communication method: [phone / text / portal / email / mail / other] | Preferred contact times: [times/time zone]

(If consent declined or restricted, subsequent plan must reflect permissible activities only.)

Information Sources & Reliability

• Sources used: [Patient interview / Caregiver interview / Chart review / Outside records / Collateral contacts]
• Collateral contacts made: [Name, role, organization, date/time, outcome] (Add multiple as needed.)
• Reliability statement: [Brief statement of reliability or limitations]
• Unknowns and verification plan: [Key unknown items and how/when they will be verified] (If none, omit.)

Patient Goals & Preferences

• Top goals (patient voice): [Goal 1]; [Goal 2]; [Goal 3] (Quote or paraphrase succinctly. If patient cannot participate, state why and whose goals are represented.)
• Treatment and setting preferences: [Preferences impacting planning, e.g., home vs facility, cultural/faith considerations]
• Definition of success: [What success looks like to patient/caregiver]
• Readiness for specific actions: [Ready / Ambivalent / Not ready] (Specify which actions.)

Clinical Snapshot

(Minimum medical context needed for case management priorities; not a full H&P.)

• Key diagnoses/active issues driving referral: [Concise list]
• Recent utilization: [ED visits, admissions with approximate dates]
• Current care team: [PCP, key specialists, home services]
• Medication management barriers: [cost / cognition / access / complexity / none identified / Unknown] (If medications or allergies unknown and needed for safety, elevate as priority problem.)
• Current symptoms affecting function/safety: [Brief problem-focused items] (If none, state "None identified.")

Functional Status & Safety

• ADLs: Bathing [independent / needs assist / dependent]; Dressing [independent / needs assist / dependent]; Toileting [independent / needs assist / dependent]; Transfers [independent / needs assist / dependent]; Feeding [independent / needs assist / dependent]
• IADLs: Shopping [independent / needs assist / dependent]; Cooking [independent / needs assist / dependent]; Finances [independent / needs assist / dependent]; Medication management [independent / needs assist / dependent]; Transportation [independent / needs assist / dependent]
• Mobility and equipment: [Ambulates independently / cane / walker / wheelchair / bedbound]; [oxygen / other DME]; [homebound status if applicable]
• Cognition/communication: [Memory, orientation, comprehension, speech, hearing, vision concerns] (Document observed or stated concerns; do not infer diagnoses. If none, state "No concerns identified.")
• Falls risk and home safety: [History of falls: Yes / No / Unknown]; [stairs, bathroom safety, ability to summon help, environmental hazards] (Document explicit facts only.)

Behavioral Health & Coping

(Include when relevant to referral, safety, or engagement. If not assessed, state "Not assessed this encounter.")

• Behavioral health diagnoses: Chart-confirmed: [diagnoses]; Patient-reported: [diagnoses]
• Current treatment and access: [Therapy, medications, provider names if coordinating, access barriers]
• Coping strategies and current stressors: [Brief description]
• Substance use: [Type, frequency, patient-reported] (Use harm-reduction language.)
• Suicide/self-harm screening: [Positive / Negative / Not assessed] (If positive, document actions taken and referrals.)
• Impact on care plan: [How behavioral health factors affect engagement, safety, or coordination]

Social Determinants & Support System

• Housing stability/quality: [positive / negative / unknown / not assessed] [Brief details and impact on plan]
• Food security: [positive / negative / unknown / not assessed] [Referrals/resources initiated if need identified]
• Utilities: [positive / negative / unknown / not assessed]
• Transportation access: [positive / negative / unknown / not assessed]
• Interpersonal safety: [positive / negative / unknown / not assessed]
• Additional domains as relevant: [Financial strain/benefits, employment/education, social isolation, health literacy barriers, phone/internet access, appointment availability]
• Household composition: [Who lives in home and relationship to patient]
• Primary caregiver(s) and capacity: [Name, relationship, availability, burden assessment; backup plan if unavailable]
• Decision-maker status: [Guardianship/MPOA status] (If unknown and relevant to planning, elevate as priority to clarify.)
• Insurance and benefits: [Insurance type, coverage barriers, Medicaid/SNAP/SSI/SSDI status, pending applications]

Advance Care Planning

• Advance directive: [Yes - on file / Yes - copy requested / No / Unknown]
• Code status: [Full / DNR / DNI / DNAR-CC / Unknown] (Include only if known and within scope.)
• Healthcare proxy/MPOA: [Name, relationship, contact information] (If unknown and relevant, document plan to clarify.)
• Preferences: [Patient/caregiver stated preferences about hospitalization, SNF, home care]

Risk Stratification

• Risk factors: [Readmission risk, safety risk, treatment adherence challenges, other]
• Barriers to success: [Transportation, cognition, cost, housing instability, access barriers, other]
• Strengths/protective factors: [Engaged caregiver, stable housing, strong PCP relationship, motivation, community supports]
• Program risk tier: [Tier or score if applicable] (Include date and criteria if standardized tool used.)

Assessment Summary

[Synthesis paragraph of 5-8 sentences: who the patient is and why referred; top drivers of risk across medical, functional, and psychosocial domains; patient goals and preferences; 2-4 highest-priority problems to address first; any immediate safety actions taken today] (Do not introduce new facts not documented above.)

Prioritized Problem List

(Number by severity/urgency with safety first, then feasibility and patient priority. Include medical and non-medical problems when they drive outcomes.)

• Problem 1: [Problem title]
  • Key evidence: [Concise supporting facts]
  • Impact: [Why this matters for outcomes/safety]
  • Owner: [Patient / Caregiver / CM / PCP / Agency / Other]
• Problem 2: [Problem title]
  • Key evidence: [Concise supporting facts]
  • Impact: [Why this matters for outcomes/safety]
  • Owner: [Patient / Caregiver / CM / PCP / Agency / Other]
• Problem 3: [Problem title] (Add or remove problems as appropriate.)
  • Key evidence: [Concise supporting facts]
  • Impact: [Why this matters for outcomes/safety]
  • Owner: [Patient / Caregiver / CM / PCP / Agency / Other]

Initial Plan

(Organize by problem. Avoid vague terms like "monitor" or "encourage" without specifying how and when.)

• Problem 1 plan:
  • Goal: [Measurable outcome and target date]
  • CM interventions: [Specific actions: referrals, coordination, applications, scheduling, education with dates and urgency]
  • Patient/caregiver actions: [Agreed tasks with timeline]
  • Responsible party: [Name/role for each action]
  • Contingency/escalation: [Triggers and escalation path]
  • Referrals placed today: [Service, reason, urgency, expected response time] (If none, omit.)
  • Provider communications completed: [Who, method, summary] (If none, omit.)
  • Education provided: [Topics, method, teach-back result, adaptations for barriers] (If none, omit.)
  • Patient refusals: [Refused intervention, rationale discussed, alternative plan] (If none, omit.)
• Problem 2 plan: [Structure as above]
• Problem 3 plan: [Structure as above]

Follow-Up Schedule

• Next planned contact: [Date/timeframe] via [phone / video / in-person / portal message]
• Monitoring targets: [Appointments to complete, referral status, application progress, symptom or safety checks]
• Escalation criteria: [When to contact clinician, ED, APS, crisis services; include after-hours instructions if applicable]

Signature

[Electronic signature], [Credentials], [Date/time]