Perform a Comprehensive Assessment of Needs

✅ Reviewed for accuracy and relevance by Deanna Cooper Gillingham, RN, CCM, FCM on June 26, 2025.

Professional case managers perform comprehensive assessments to identify their clients’ physical, behavioral health, and social needs. According to CCMC, assessment is “the process of collecting in-depth information about a person’s situation and functioning to identify individual needs in order to develop a comprehensive case management plan that will address those needs.” The CM gathers information through client interviews, reviews of medical records, and the use of standardized assessment tools. 

Physical function assessment

  • A physical assessment looks at a client’s health and functional status, including:
  • Current health status and conditions
  • Medical history
  • Medications (prescription, over-the-counter, and supplements)
  • Treatment plans and response
  • Nutritional status and body mass index
  • Test results
  • Activities of daily living (ADLs)
  • Instrumental activities of daily living (IADLs)

Tools to assess physical functioning

Activities of daily living (ADLs) and the more advanced instrumental activities of daily living (IADLs) are assessment tools used to evaluate essential areas of function for self-care and independence.

ADLs measure the level of independence in performing six basic activities:

  • Bathing
  • Dressing
  • Toileting/continence
  • Transferring
  • Hygiene/grooming
  • Feeding

ADLs can be remembered by the mnemonic DEATH: Dressing/bathing, Eating, Ambulating, Toileting, Hygiene.

IADLs measure the patient’s ability to perform eight independent living skills that are more complex than the basic ADLs assessment. These include:

  • Shopping
  • Using the telephone
  • Paying bills/budgeting
  • Food preparation
  • Housekeeping
  • Laundry
  • Using transportation
  • Handling medications

Behavioral health assessment

The behavioral health assessment examines psychological and cognitive functioning, including:

  • Current mental health status
  • History of substance use
  • History of depression, anxiety, or trauma and treatment
  • Cognitive functioning
  • Decision-making capacity
  • Learning abilities and preferences
  • Depression and anxiety screening

Tools to screen for depression

The Patient Health Questionnaire-2 (PHQ-2) serves as a pre-screen for depression. Clients who pre-screen positive are further evaluated using the Patient Health Questionnaire-9 (PHQ-9). 

Social assessment

The social assessment looks at:

  • Family dynamics
  • Availability and willingness of caregiver(s)
  • Support system
  • Employment status/work environment
  • Cultural values, needs, and preferences
  • Hobbies, activities, and social interests
  • Neglect, abuse, violence, or trauma
  • Advance directives
  • Social determinants of health
  • Health-related social needs

Assessment best practices

The assessment process must be client-centered, considering each client’s unique cultural background and language needs. Case managers should utilize standardized assessment tools that are appropriate for their practice setting and document the findings in the client’s record. They should ask open-ended questions and demonstrate active listening to encourage clients to share information. A client’s nonverbal cues also provide important assessment data.

This article shares a portion of the information covered on this topic in CCM Certification Made Easy, 4th Edition by Deanna Cooper Gillingham, RN, CCM, FCM (2025). For more details, including tools to screen for health-related social needs and related concepts, purchase your copy at CCMCertificationMadeEasy.com.