A care plan has to be clinically appropriate and realistically executable. The diagnosis may be correct, the medication evidence-based, and the follow-up recommendation entirely reasonable. If the patient cannot obtain the medication, reach the clinic, understand the instructions, or complete the next step, the plan begins to fail outside the healthcare setting.
Follow up with primary care within a week. Pick up the new prescription today. Check your weight every morning. Schedule counseling. Return for repeat laboratory testing. Call the specialist if symptoms continue. Each recommendation may make sense individually, but each also depends on resources and circumstances that may never appear explicitly in the plan.
Healthy People 2030 defines social determinants of health as the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect health, functioning, and quality-of-life outcomes. Economic stability, healthcare access, education, neighborhood conditions, and social context can all influence whether patients are able to use the care being recommended (Office of Disease Prevention and Health Promotion [ODPHP], n.d.-c).
Clinical planning therefore includes another question alongside diagnosis and treatment selection: what will have to be true for this patient to carry out the plan after leaving care?
Every Care Plan Contains Assumptions
Clinical recommendations routinely depend on resources that may remain invisible unless someone asks about them. A prescription assumes the medication can be obtained. Telehealth assumes access to appropriate technology and enough privacy to communicate. A referral assumes that the receiving service is accessible and that communication between the patient and service can occur. Daily weights assume access to a scale and a living situation where monitoring is feasible.
Dietary recommendations may depend on food availability, cost, storage, preparation, and control over what is served. Follow-up may require transportation, childcare, time away from work, stable housing, or reliable communication. Healthy People 2030 identifies healthcare costs, transportation, and availability of services among barriers that can interfere with access to care (ODPHP, n.d.-a).
These factors affect whether an intervention is usable. Selecting the clinically preferred plan without examining the conditions required to carry it out can produce recommendations that are sound on paper and inaccessible in practice.
“Noncompliant” Can Hide the Actual Problem
When a patient does not follow a recommendation, the word noncompliant can collapse very different situations into the same label. Contemporary medication-adherence literature recognizes that nonadherence can arise from multiple interacting influences involving treatment, healthcare systems, social circumstances, opportunity, motivation, and patient decisions (Chapman & Chan, 2025).
A patient may knowingly decline treatment after considering the risks and benefits. Another may agree with the plan but be unable to afford the medication. Someone else may misunderstand the instructions, experience intolerable adverse effects, or lack a reliable way to obtain refills. Missed appointments can likewise occur for different reasons, so identifying the barrier is more informative than assigning a broad label.
Precise documentation can preserve that distinction. McArthur et al. (2026) identified multiple forms of stigmatizing language used in electronic health records that can discredit patients through judgmental or credibility-undermining descriptions. Documentation such as “Patient reports taking medication approximately three days per week because of cost” records clinically useful information about the barrier. “Noncompliant with medications” does not explain why the treatment is not being taken and provides less information for the next clinician.
Health Literacy Includes the Design of the System
Health literacy is sometimes discussed primarily as an individual patient characteristic. Healthy People 2030 distinguishes personal health literacy from organizational health literacy. Organizational health literacy addresses the degree to which organizations enable people to find, understand, and use information and services to inform health-related decisions and actions (ODPHP, n.d.-b).
That distinction changes how communication problems can be examined. A patient struggling with a dense discharge packet filled with medical terminology may be encountering information that is unnecessarily difficult to use. Someone who cannot determine which of several phone numbers to call may be navigating a complex process rather than demonstrating an individual knowledge deficit. A referral system dependent on repeated voicemail exchanges may also create greater difficulty for people without reliable phones, stable schedules, or consistent access to private communication.
Usable healthcare depends partly on the demands created by the healthcare system itself. Organizational approaches to health literacy can include clearer communication and processes that make health information and services easier to find, understand, and use (ODPHP, n.d.-b).
Care Coordination Turns Instructions Into a Pathway
Care coordination becomes particularly important when patients move between settings. AHRQ defines care coordination as deliberately organizing patient care activities and sharing information among the people involved in a patient’s care to support safer and more effective care (Agency for Healthcare Research and Quality [AHRQ], 2022).
The distinction becomes visible in discharge planning. “Follow up with cardiology” communicates a clinical recommendation but leaves several operational questions unanswered. Depending on the patient and setting, a more coordinated process may include confirming that a referral was transmitted, verifying contact information, explaining what should happen if contact does not occur, or addressing a known access barrier before discharge.
Appointment assistance, medication-access support, transportation planning, alternate contact methods, and connections with community resources are examples of strategies that may be incorporated when they address an identified barrier. The appropriate response depends on the patient, setting, available resources, and actual point at which the pathway is likely to fail.
Identifying a barrier can also change who needs to be involved. Medication affordability may warrant pharmacy support. Housing or transportation concerns may require social work, care management, or community resources. Behavioral health needs may require a different referral pathway. Care coordination uses available expertise and information to create a more workable route between the recommendation and the next step.
This becomes especially relevant during emergency and transitional care, where acute illness can intersect with medication access, housing instability, behavioral health needs, limited primary care access, transportation barriers, and fragmented follow-up. An emergency department cannot resolve every social or structural problem during a single encounter, but recognizing conditions that threaten the feasibility of discharge can inform which additional supports or referrals are appropriate.
Two patients with the same diagnosis may therefore require different levels of assistance to accomplish the same clinical goal. A patient with reliable transportation, an established primary care clinician, and dependable communication may need little help arranging follow-up. Another patient without those resources may need a different pathway for the recommendation to become usable.
Reduce Avoidable Friction
Some barriers arise from circumstances that healthcare organizations cannot directly change. Others are created or amplified by the way care is organized.
Reducing avoidable friction may mean completing a referral instead of providing only a phone number, investigating medication affordability before the patient reaches the pharmacy, providing a clear method for reconnecting after an unsuccessful contact attempt, or involving another service when a known barrier falls within that service’s expertise. Other approaches may include clearer instructions, flexible scheduling, outreach, community-based services, or easier re-entry after interrupted care when those strategies are feasible within the setting.
The National Academies of Sciences, Engineering, and Medicine (2021) identifies an important role for nurses in addressing social needs, improving access, collaborating across sectors, and participating in care models intended to advance health equity. Individual clinicians cannot resolve housing instability, poverty, transportation shortages, or every structural barrier encountered during care. Clinical responsibility can still include recognizing when those conditions change what is realistically possible and involving appropriate resources when they are available.
Before finalizing a plan, questions about feasibility can expose assumptions that might otherwise remain hidden. Can the patient obtain the medication? Is the follow-up service accessible? Can the patient get there? Does the receiving service have usable contact information? Is the plan realistic within the patient’s living circumstances? If the first attempt at follow-up fails, is there another reasonable route? These questions help identify barriers most likely to determine whether the particular plan can be carried out.
Repeated Failure Becomes a Systems Problem
When the same step repeatedly fails across patients or encounters, the process itself deserves examination. Recurrent missed referrals, inaccessible follow-up, medication gaps, or failed contact attempts may reveal a pathway that functions reliably for some patients while creating greater difficulty for others.
That pattern changes the question from what happened during one encounter to where the pathway repeatedly breaks. Local data may show that referrals are not reaching the receiving service, patients cannot be contacted, appointments occur beyond a clinically useful timeframe, medication costs remain unresolved, or required steps create unnecessary barriers.
Healthy People 2030 recognizes that healthcare access is influenced by economic, geographic, social, cultural, transportation, and healthcare-system barriers (ODPHP, n.d.-a). The Future of Nursing 2020–2030 likewise calls for nurses to address social needs and social determinants of health and to participate in developing and evaluating care models that improve access and advance health equity (National Academies of Sciences, Engineering, and Medicine, 2021).
Repeated failures may justify examining referral processes, care navigation, discharge workflows, pharmacy involvement, communication systems, community partnerships, or follow-up models. The appropriate intervention depends on the local problem and on evidence about why the process is failing.
Evidence-based guidelines help identify care likely to improve outcomes, while clinical judgment determines how those recommendations apply to an individual patient. Effective care planning adds the practical requirement that a realistic route exists between the recommendation and its completion. A prescription that cannot be obtained cannot produce its intended pharmacologic effect, and a referral that cannot be completed cannot create follow-up. The strength of a care plan therefore depends partly on whether it remains clinically sound and usable after it encounters the circumstances of the patient’s life.
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References
Agency for Healthcare Research and Quality. (2022, September). Care coordination. https://www.ahrq.gov/ncepcr/research/care-coordination/index.html
Chapman, S. C. E., & Chan, A. H. Y. (2025). Medication nonadherence: Definition, measurement, prevalence, and causes: Reflecting on the past 20 years and looking forwards. Frontiers in Pharmacology, 16, Article 1465059. https://doi.org/10.3389/fphar.2025.1465059
McArthur, A., Ahmad, A., Links, A. R., Warner, K. R., Drew, P., Beach, M. C., & Saha, S. (2026). How words discredit: A taxonomy of stigmatizing language in the electronic health record. Patient Education and Counseling, 147, Article 109520. https://doi.org/10.1016/j.pec.2026.109520
National Academies of Sciences, Engineering, and Medicine. (2021). The future of nursing 2020–2030: Charting a path to achieve health equity. The National Academies Press. https://doi.org/10.17226/25982
Office of Disease Prevention and Health Promotion. (n.d.-a). Access to health services. Healthy People 2030, U.S. Department of Health and Human Services. Retrieved August 17, 2026, from https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/access-health-services
Office of Disease Prevention and Health Promotion. (n.d.-b). Health literacy. Healthy People 2030, U.S. Department of Health and Human Services. Retrieved August 17, 2026, from https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health/literature-summaries/health-literacy
Office of Disease Prevention and Health Promotion. (n.d.-c). Social determinants of health. Healthy People 2030, U.S. Department of Health and Human Services. Retrieved August 17, 2026, from https://odphp.health.gov/healthypeople/priority-areas/social-determinants-health