Ongoing assessment is a key component of social work services. Social workers should assess clients at every opportunity to meet or communicate, focusing on progress towards goals, adherence to prevention plans, and new medical, social, or mental health needs. Reassessment helps monitor effectiveness and determine if goals or plans need updating. It is an ongoing process, not a single event, and includes revisiting initial needs and priorities identified. Domains of ongoing assessment include patterns of service use, living situation, communication preferences, literacy, culture, strengths, family relationships, functioning, independence, needed resources and supports, ability to access services, health conditions, and safety.

1. P H I L A D E L P H I A D E P A R T M E N T O F P U B L I C H E A L T H
A I D S A C T I V I T I E S C O O R D I N A T I N G O F F I C E
C L U B 1 5 0 9 N A V I G A T O R S T R A I N I N G
UNIT 3: ONGOING ASSESSMENT

2. ASSESS AND THEN ASSESS AGAIN,
THEN REPEAT
• Ongoing assessment is a key component of social work
services
• Every opportunity to meet or otherwise communicate with the
client is an opportunity for assessment
• The assessment is revolving around client progress towards
items on their action plan, client adherence to HIV prevention
plans including PrEP, and new/emerging client medical,
social, or mental health needs
• Assessment can also come through third party observation

3. NATIONAL ASSOCIATION OF SOCIAL
WORKERS STANDARD 5: ASSESSMENT

4. NASW STANDARDS ON ONGOING
ASSESSMENT
• Assessment is an ongoing activity, not a one-time event
• During the reassessment process, the social work case manager and
client (and, if appropriate, other members of the client system) revisit the
needs, assets, and priorities identified in the initial assessment and
discuss the client’s emerging concerns.
• Reassessment serves both monitoring and evaluative functions,
enabling the social worker and the client to determine whether services
have been effective in helping achieve the client’s goals.
• On the basis of such reassessment, the case manager and the client
may determine that case management goals or service plans need to be

5. SOME DOMAINS OF ONGOING
ASSESSMENT
• patterns of service over- and underutilization
• motivating factors in seeking services
• living arrangements
• vocational history
• language preferences and proficiency levels
• preferred methods of communication and
learning
• degrees of literacy, including health, behavioral
health, and financial literacy
• cultural values, beliefs, and practices
• effects of culturally based discrimination
• psychosocial strengths, protective factors, and
points of resilience
• family composition, structure, roles, and
communication
• physical, cognitive, and psychosocial
functioning
• desire and capacity for independence
• need for economic or other psychosocial
resources, supports, and services
• ability to navigate relevant service systems
• health conditions
• risk of abuse, neglect, or exploitation of or by
the client
• client’s perceptions of changes needed to
improve her, his, or their situation

6. WENGER CLEMONS SYSTEM S5
ASSESSMENT GUIDE FOR SOCIAL WORK
Ongoing Assessment Questions
Situation What brings the client(s) for services today?
Who makes up the client system?
Safety Determine if safety is an issue for the client system.
Immediately provide resources, support and assistance if safety is an
issue.
Survival Needs/Other Needs Are basic needs being met for the client system?
What are other issues to be addressed?
Supports/Strengths What supports are in place?
What strengths does the client system bring to this process?
How were challenges dealt with previously?
What resources are needed?
Short term or crisis work Which treatment modality is appropriate with this client system today?
How imminent and immediate is the need?
Is there time for an ongoing process?

7. THE SURVEY SAYS…