Initial Comprehensive Service Plan Development

Service planning is a critical component of the Comprehensive Case Management Model and guides the client and case manager/team with a proactive, concrete, step-by-step approach to addressing client needs.

The Comprehensive Service Plan can serve additional functions, including: focusing a client and case manager on priorities and broader goals, especially after crisis periods; teaching clients how to negotiate the service delivery system and break objectives into attainable steps; and serving as a review tool at reassessment to evaluate accomplishments, barriers, and re-direct future work.

Goals, objectives, and activities of the service plan are determined with the participation of the client and, if appropriate, family, close support persons and other providers.

In programs incorporating a team model, team members other than the case manager may assist in developing a service plan. However the case manager has full responsibility for the process and completed documentation.

Standard Criteria

Client needs identified at Initial Comprehensive Assessment are prioritized and translated into an Initial Comprehensive Service Plan, which defines specific goals, objectives, and activities to meet those needs.

Time Requirement: Comprehensive Case Management Due at completion of Initial Comprehensive Assessment, 60 days from completion of Brief Intake/Assessment.

Time Requirement: Supportive Case Management Not required.

Time Requirement: AIDS Day Health Care Program (ADHCP) Due at completion of Initial Comprehensive Assessment, 30 days from enrollment.

  1. Initial Comprehensive Service Plan includes at the minimum:
    • Goal(s)
    • Activities (work plan, action to be taken, follow up tasks)
    • Inidividuals responsible for the activity (case manager or team member, client, family member, agency representative)
    • Anticipated time fram for each activity
    • Client signature and date, signifying agreement
    • Supervisor's signature and date, indicating review and approval.
  2. The case manager has primary responsibility for development of the service plan.
  3. The Initial Comprehensive Service Plan is in cluded in the case record and completed on forms developed or approved by the AIDS Institute.
  4. The Initial Comprehensive Service Plan is updated with outcomes and revised or amended in response to changes in client life circumstances or goals.


The Initial Comprehensive Service Plan is not required in the Supportive Case Management model, which uses the Brief Service Plan developed at the Brief Intake/Assessment.

In specified Comprehensive Case Management program initiatives, when assessment of the children and collaterals is not required, addressing their needs is optional within the client’s Initial Comprehensive Service Plan.

AIDS Day Health Care Programs are not required to use forms developed or approved by the AIDS Institute.

Best Practices

Service plans developed during face-to-face meetings and negotiated between client and case manager encourage client active participation and empowerment. A copy of the service plan offered to the client reinforces client ownership and involvement in the case management process.

Measurable goals and activities, taking into consideration the client’s cognitive and physical abilities, available resources, support networks and motivation, result in a more realistic, client-specific plan.

Although client signature denotes acceptance of a plan, a client may decline all or any portion of a service plan.

Documenting changes or updates to a service plan as well as actual outcomes provides a simple method of tracking client progress.

Family members and collaterals may assist in ensuring a client receives needed service. They can be included in the service plan to carry out activities.

Additional Resources

Sample Comprehensive Service Plan form is available on the New York State Department of Health web site under the category “Clinical Guidelines, Standards, and Quality of Care.”