MC6 Assessment Example

MC-6 Care Planning and Care Coordination 

Summative Assessment Example: Whole Person Care Plan

Assignment Instructions 

Students should read the case study, then complete a whole person care plan identifying goals, objectives, interventions, and resources based on evidence in the patient case, and by linking the patient case to resources available in a typical agency, clinic or community setting. 

Definitions 

• Goals: A state of mind, body, or behavior the patient hopes to achieve in the near future. 

• Objectives: Practical steps that are likely to lead to achieving a goal and are specific, measurable, achievable, time-limited, and relevant.  

• Interventions: Approaches used by the BHSS to assist the patient with achieving their goals and objectives.  

• Resources: Education, training, and additional support available digitally or tangibly to the patient to assist them in achieving their goals and objectives.  

• Professional writing: Writing that is appropriate to a clinic or agency culture and reflects the mission and purpose of a whole health care team. Additionally, the writing communicates clearly to an adult or adolescent patient of average intelligence.  

Guidance for Instructor 

Whole health care plan is used interchangeably with the terms “treatment plan”, “goal plan”, and “care plan.” The biopsychosocial assessment example provided may be modified to fit the model most encountered by the school’s practicum students.  

Grading Rubric

Skill being assessed	Criteria				Score	Comments
	1  Needs Work	2  Beginning	3  Developing Proficiency	4  Proficient (for a BHSS student)
Goal planning	Written goals are unrelated to the case	Written goals are loosely related to the case	Written goals are relevant and missing a key element discussed in case	Written goals are highly relevant to needs of the case study patient
Objectives	Objectives are unrelated to SMART goal planning	Objectives are missing 2-3 key elements of SMART goal planning	Objectives are missing one key element of SMART goal planning	Objectives include key elements related to SMART goal planning
Interventions	Interventions are not connected to the goals	One of three interventions are appropriate to the goal	Two of three interventions are appropriate to the goal	All interventions are appropriate to the goal and part of BHSS scope of practice
Resources	No resources are appropriate to the goals and objectives	Some resources are appropriate to the goals and objectives	Most resources are appropriate to the goals and objectives	All resources are appropriate to the goals and objectives
Professional writing	Writing is unclear and is an example of poor communication with both the care team and the patient	Writing lacks clarity, conciseness and is less than optimal in some areas of communication with the team and patient	Writing is clear and concise, and less than optimal in some areas of communication with the team and patient	Writing is clear, concise, and consistent with expectations for communicating with a care team and with the patient

Biopsychosocial Assessment Example 

Client Name: Rafael Vargas 

Date of Birth: January 15, 1987 

Age: 38 

Date of Assessment: March 17, 2025 

Gender: Man (He/him) 

Ethnicity: Identifies as Latino and Mexican American 

Occupation: Office Worker 

Marital Status: Divorced 

Living Situation: Lives alone in an apartment 

Referral Source: Self-referred, seeking help for depressive symptoms and concerns about alcohol use.

Presenting Problem: 

Rafael presents with symptoms of depression, including feelings of sadness, lack of energy, difficulty concentrating, and disrupted sleep patterns following a breakup with a significant other three months ago. He reports that he has increased alcohol consumption over the past few months, particularly in the evenings, as a way to cope with his emotions. Rafael describes feeling overwhelmed and stuck in his current situation and is seeking help to address both his mood and alcohol use.  

Biological Factors: 

• Health History: 
  Rafael has no major chronic medical conditions. He reports occasional headaches and low back pain but no significant history of physical illnesses. He denies any known substance use disorders beyond alcohol. 

• Medication History: 
  Rafael is not currently taking any medication. He was prescribed an antidepressant once by a primary care doctor about five years ago. He didn’t like the side effects of the medication and stopped after one dose. Rafael remembers that he was prescribed an SSRI, but he is not sure which drug. He has not previously been prescribed any other psychiatric medication. 

• Substance Use: 
  Rafael reports drinking alcohol regularly (approximately 4–5 drinks Thursday through Sunday). He notes that he sometimes starts work on Monday mornings feeling hungover. He has been alarmed by his own behavior and worries about the trajectory of his drinking. He denies using illicit drugs, though he smokes cigarettes occasionally. 

• Sleep Patterns: 
  Rafael reports difficulty falling asleep and waking up early in the morning, feeling unrested. He estimates getting 4–5 hours of sleep per night. 

• Family History: 
  There is a history of depression in his family, particularly on his mother’s side. His mother has a history of major depressive disorder, and his maternal grandfather struggled with alcohol use. 

Psychological Factors: 

• Mood and Affect: 
  Rafael reports feeling “down” most of the time for the past 6–7 months. He feels a lack of motivation, has lost interest in activities he once enjoyed, and describes himself as feeling “numb.” He often ruminates on feelings of failure and inadequacy, particularly related to his career and personal relationships. Rafael wonders if his mood contributed to the loss of his partner.  

• Cognition: 
  Rafael describes difficulty concentrating at work and often feels mentally foggy. He reports negative self-talk and feelings of hopelessness about his future. He acknowledges that his alcohol use contributes to his poor mental state. 

• Behavioral Symptoms: 
  Rafael has been withdrawing from social activities and avoiding his friends and family. He reports not leaving the apartment on weekends and sometimes isolating himself. Since his relationship breakup, Rafael reports arranging anonymous sex through an app with the goal of feeling better. He reports these encounters reinforce a negative self-concept and finds them unfulfilling. He also notes a significant decline in his personal hygiene and self-care habits. 

• Stressors: 
  Rafael identifies ongoing stress from his work, including increased workload and tension with coworkers. He also feels the effects of his recent break-up with his partner, which has led to feelings of loneliness and sadness. Financial stress is also an issue, as he struggles to meet bills and maintain his living situation. 

• Past Trauma: 
  Rafael does not report a history of significant trauma, though he mentions that his childhood was marked by emotional neglect, which he feels may have contributed to his current emotional

Social Factors: 

• Social Support: 
  Rafael reports limited social support. He reports superficial conversations with his family with the exception of one sister, and his social circle has dwindled in recent months. Rafael occasionally does talk with a sister out of state; however, he has noticed he is cutting the conversations short to avoid talking about himself. Rafael mentions that his family who live on the other side of the country will tell him about their day-to-day lives, but don’t appear to be interested in him. His ex-partner has cut him off from communication, although he remains in contact with a few friends he and his partner had in common. Rafael does meet one or two friends from his recreational sport teams for a drink occasionally on the weekends.  

• Work and Occupational History: 
  Rafael works in an office environment and reports moderate job stress. He feels unfulfilled and disconnected from his career, mentioning that he does not see any prospects for advancement. He believes his performance is suffering due to his mood and alcohol use. 

• Social/Community Involvement: 
  Rafael has limited involvement in social or community activities. He used to enjoy playing in a recreational soccer league, a softball league and volleyball league, but stopped attending due to his low energy and lack of motivation. 

• Cultural/Spiritual Beliefs: 
  Rafael identifies as culturally Christian but does not actively engage in religious practices. He feels disconnected from any spiritual or community-based support networks.  

Summary of Assessment: 

Rafael is a 38-year-old male presenting with symptoms consistent with major depressive disorder (MDD) and mild alcohol use disorder. His depressive symptoms have led to significant functional impairment, including decreased motivation, withdrawal from social interactions, and impaired work performance. He is also struggling with increased alcohol consumption, which appears to be both a coping mechanism for his emotional distress and a contributing factor to his mood and behavioral difficulties. 

DSM-5 Diagnosis: 

• Major Depressive Disorder, Recurrent, Moderate (F32.1) 
  Criteria: Rafael meets the criteria for MDD, as evidenced by persistent low mood, diminished interest in activities, fatigue, and difficulty concentrating. His symptoms have been present for over six months and cause significant distress and functional impairment. 

• Alcohol Use Disorder, Mild (F10.10) 
  Criteria: Rafael exhibits a pattern of alcohol consumption that negatively impacts his daily life. He meets the criteria for mild alcohol use disorder due to drinking at least 4–5 drinks four days per week with evidence of a pattern of negative consequences (i.e., mood disturbances, impaired functioning, and unfulfilling sexual relationships). 

Whole Health Care Plan Assignment 

Goal 1

Objective 1

Objective 2

Resources

Recommended Intervention

Goal 2

Objective 1

Objective 2

Recommended Intervention

Resources

Goal 3

Objective 1

Objective 2

Recommended Intervention

Resources

Whole Health Care Plan Assignment Answer Guide Example 

Goal 1 Improve perception of self and decrease negative thinking associated with depressed mood.

Objective 1 Record one observation per day M-Th prior to dinner for one week of positive interactions at work or socially and bring homework to session.

Objective 2 Rafael will call his sister and share one goal he has to improve himself and one concern. He will first text his sister to schedule a time to talk and plans to talk with her this weekend.

Resources Rafael received information about the cycle of depression, the diagnosis of major depression and available treatment options including cognitive behavioral therapy and behavioral activation. Rafael understands that the option to talk with the PCP or agency Psychiatric provider about medications to alleviate depressed mood is available and may be scheduled within one to two weeks.

Recommended Intervention Eight weeks of behavioral activation treatment followed by an evaluation of Rafael’s symptoms.

Goal 2  Reduce potential harm from alcohol use and evaluate impact of alcohol use on mood.

Objective 1 Rafael will increase days of abstinence from alcohol from M-W to M-Th starting this week.

Objective 2 Rafael will eat a large meal after work on Friday which he believes decreases his interest in drinking to intoxication and evaluate the effectiveness of this strategy.

Recommended Interventions Motivational interviewing and harm reduction strategies for alcohol use for eight weeks followed by evaluation of symptoms.

Resources Rafael is familiar with AA and does not believe he needs AA at this time. He does believe he needs to modify his choices about how he recreates and whether to include alcohol. Rafael received information on the effects of alcohol on the body and recommended alcohol intake for a male his age and weight.

Goal 3 Improve sleep without the use of sleep aids.

Objective 1 Decrease caffeine use and alcohol use M-Th to help support quality sleep. Rafael will decrease caffeine use from four to three cups of caffeinated coffee in the morning T, W, and Th for one week. Rafael reports he does avoid alcohol consumption M-W and plans to add Th as part of reduction effort.

Objective 2 Enact additional sleep hygiene practices. Rafael will decrease screen time in the evening and replace reading a book for fifteen minutes prior to bed T, W, and Th for one week.

Recommended Intervention Brief cognitive behavioral interventions for sleep.

Resources Rafael accepted referral to online, asynchronous sleep education classes provided through Cleveland Clinic. He also accepted information about sleep hygiene from BHSS and is open to discussing new behaviors to support quality sleep.