Rural Life360 and Success Life360 clients will develop an individualized person-centered action plan (PCAP) facilitated by their care coordination coach or community partner organization to address health needs and HRSN. The PCAP will be updated regularly to reflect goals met, new circumstances or needs, annually at a minimum. The PCAP must describe the client's strengths, preferences, and HRSN as identified by the HRSN screen as well as needs for linkage with medical providers. The plan must include short-term (less than 6 months) goals, a crisis plan, and longer-term goals (more than 6 months). Each PCAP must include goals in areas identified through screening and ongoing interaction with the client, including but not limited to:

Maternal Life360 will implement the approaches of the evidence-based model selected and/or processes set by the program that utilize best practices and tools for quality and effectiveness of home visits and to document observations and assessments of maternal/child health and any other family outcomes included. Therefore, a separate PCAP will not be required.