Assess the support system and the primary caregiver's capacity, competence, and willingness.
Screen for caregiver strain using burden indicators and direct inquiry about the caregiver's coping.
Evaluate the patient's coping and adjustment to the illness and the care demands.
Screen the social determinants of health — housing, food, finances, transportation, and utilities — and identify unmet needs (aligned with the OASIS-E2 social-determinant items).
Coordinate social work and community resources, address financial barriers to the plan, and screen for abuse or exploitation (reporting handled in Safety).
