The plan of care serves as a road map; it is a written agreement developed by the participant and the team that defines how and when services will be provided to the client. It is formulated by the Interdisciplinary team after all of the initial medical and psychosocial assessments are completed. The team then integrates goals that the family and client would like to achieve. The care plan is reviewed every six months or if a significant change occurs. Care plans are key in communicating expectations for both the organization and the client.