Your mom’s medical chart explains when she was diagnosed with osteoporosis, what medications she takes and when her last doctor’s visit was. But what it doesn’t tell you is that she likes to drink chamomile tea before sleeping, wants someone to be around just in case when she gets out of bed and keeps a puzzle on the kitchen counter to stay sharp.
Closing the divide between medical treatment plans and everyday quality of life and functionality is why comprehensive care plans matter.
Ahead, you’ll learn what a care plan is, the difference between an aging plan vs. a care plan and how to take on senior care planning with your loved one.
[READ: 10 Steps to Plan Ahead for Long-Term Care]
What a Comprehensive Care Plan Includes
A comprehensive care plan is a dynamic, written document that turns a care planning session into an actionable guide. Care planning is the process of discussing and agreeing upon a plan of action, while a care plan is the written outcome of the aforementioned process.
For nurses, a care plan is one of the most successful ways to maintain continuity of care.
“An ill-planned care plan frequently is not only out-of-date but also too thin or diagnosis-driven, leaving caregivers to guess at possibilities that can create a patchwork of inconsistency in support,” says Kelsey Pabst, a Warrensburg, Missouri-based registered nurse and medical reviewer at Cerebral Palsy Center. “An organized care plan allows patients to maintain independence.”
Care planning template
Use the following template to guide your care planning discussion and care plan creation. Make sure to include healthcare providers, long-term care facilities, social workers or caregivers as necessary if they are involved with your loved one’s care.
| Type of Information | What to Include |
| Care plan information |
— — — Date care plan was created — — — Next review date — — |
| Personal demographics |
— — — Full name — — — Date of birth — — — Address of residence — — — Phone number — — — Religious affiliation or other affinities, if desired — — — Primary language(s) — — |
| Health demographics |
— — — Primary caregiver or caregiving facility and phone number — — — Preferred hospital address and phone number — — — Preferred urgent care address and phone number — — — Primary care provider address and phone number — — — Insurance and network information — — — Preferred pharmacy — — — The physical location of insurance cards — — |
| Emergency contacts |
— — — Names, relationship and phone number of emergency contacts, when to call each and the order of preference — — — Protocols for emergencies, such as fire escape route, elopement (leaving the home or facility without supervision) or emergencies related to relevant health conditions, like low blood sugar or a seizure — — |
| Legal directives |
— — — Power of attorney information — — — Do Not Resuscitate (DNR) orders, if applicable — — — Living will — — — Orders of life-sustaining treatment, if applicable — — — Locations of all physical documents — — |
| Technology |
— — — Where computer and phone passwords are stored — — — If at home, where computer and phone are located — — — If at home, what the Wi-Fi password is, as well as any other PINs or codes around the house — — |
| Social determinants of health |
— — — Discuss whether any of the following social determinants of health are of concern: food security, medication affordability, medical appointment access, transportation access, financial strain, caregiver burnout, housing stability, environmental toxins or cleanliness, social isolation, literacy (including health literacy and digital literacy), language barriers, neighborhood safety — — |
| Narrative note |
— — — Four to eight sentences describing your loved one and their general health information, mood, needs and goals — — |
| Clinical summary |
— — — — — Diagnoses — — — Diet (normal, pureed, soft mechanical, low-sodium or diabetic-friendly, for instance) — — — Typical appetite and dietary preferences — — |
| Daily care and functional support |
— — — Preferred daily schedule (waking up, meal times, activities, bedtime) — — — Functional baselines for activities of daily living (ADLs), rated from unassisted and standby to light assistance, moderate assistance and total assistance — — — Narrative notes on ADLs that may require clarification, such as “Bathing is standby assist with a shower chair, but without a chair, requires total assistance” — — — Normal walking speed and gait — — — Environmental safety needs, such as a shower grab bar, items that need to remain on the nightstand or a walker in front of the bed — — — Intervention protocols, such as what to do if your loved one with dementia experiences sundowning — — |
| Medications and remedies |
— — — List of all current medications, related diagnoses, dosages, timing and instructions — — — Nonmedical remedies, such as a heat pack helping back pain or chamomile tea at night helping with insomnia — — |
| Physical goals |
— — — Narrative note explaining the physical goals of your loved one, such as being able to get out of bed in the morning or not having any ADLs that are total care for the next six months — — |
| Mental and cognitive goals |
— — — Narrative note explaining the mental and cognitive goals of your loved one, such as being able to complete one sudoku puzzle per day or being able to point out all family member names in a scrapbook — — |
| Social goals |
— — — Narrative note explaining the social goals of your loved one, such as attending a knitting group once per week or calling a family member every other day — — — Social contacts, including names, relationship and phone numbers for your loved one to call if they want to chat — — |
| Follow-ups |
— — — Any upcoming follow-up appointments — — — Upcoming care milestones — — — Triggers to update the care plan, such as a hospital admission or a new diagnosis — — |
A care plan and recommendations that are practical and informed by the family’s experience are more likely to succeed.
“Unfortunately, our healthcare system is fragmented, so families often encounter several different care plans across providers,” says Michelle Feng, a licensed psychologist and chief clinical officer of Executive Mental Health, a provider of integrated mental health services in Los Angeles. “A strong care plan is centered around the family, practical and easy to follow.”
[READ: Understanding Home Health Care Service Options]
When Should Changes Be Made to a Care Plan?
A care plan should be updated often.
“Care plans for chronic conditions should be treated like a living document,” Feng says. “(They) should be updated with feedback from patients and family, whenever there are meaningful changes in health, medications, living situations or caregiving support.”
Care plans particularly need updating after a major trigger, such as:
— A fall
— A hospitalization
— A new diagnosis
— A medication adjustment
— Changes in mood, appetite or sleep
— Memory changes
— Functional or physical changes
However, the care plan is most useful when monitored regularly and not just after a major health event occurs.
“The care plan is not just a clinical document, but rather a guide that helps everyone provide care with respect to the wishes and preferences of the person receiving that care,” Pabst notes.
[READ: How to Know Your Loved One Is Getting the Senior Care They’re Paying For]
Steps to Create and Finalize Your Senior Care Plan
Follow these five steps to build and maintain a successful care plan for your loved one.
1. Gather documentation and baseline data. Collect medical history, diagnoses, health insurance cards, financial accounts, legal directives and household passwords.
2. Meet with the professional team. Schedule a visit with your loved one’s primary care provider for a functional assessment. Ask the primary care provider if anyone else on the care team, such as a social worker, geriatric care manager, caregiver, nurse or specialist, should be consulted as well.
3. Conduct medical and functional assessments. Evaluate your loved one’s safety risks, current baseline for all ADLs, dietary requirements, medications and interventions needed for their diagnoses.
4. Hold a mediated family discussion. Convene a family meeting to discuss family delegation, how to communicate and keep one another informed, and go over hypothetical scenarios with your loved one and how they would like those to be handled. If your loved one is already at a senior living community, the director of nursing or another employee can assist with creating and maintaining the care plan with your family.
5. Publish and maintain the plan. Formalize the care plan into a written document and distribute it to family members, caregivers and the healthcare team. Ensure there is a process to update the plan regularly, as well as when there are changes.
Real-World Scenarios and Care Plan Examples
The following real-world scenarios show how specific life circumstances alter the care plan.
Scenario 1: Aging in place with home care support
Your 81-year-old mother with mild osteoarthritis lives alone in her two-story home. She recently had a minor fall, and she struggles with housekeeping and cooking. She manages to take all her medication on time when she has phone reminders, and her medications are close by in a pill organizer.
— Care plan considerations: This care plan will focus on environmental safety needs and ADLs. It also needs to include primary caregivers or home health aides, as your mom would benefit from help around the house with light chores, cooking and setting up medication reminders. If your mom does not want to move to a senior care community, the plan should also include comprehensive fall prevention and an emergency alert system so if she does fall, she’ll receive immediate medical care.
Scenario 2: Transitioning to an assisted living community
Your 72-year-old older brother has Type 2 diabetes and early stage Parkinson’s disease with frequent tremors. He lives in a rural area and recently decided to move to an assisted living community.
— Care plan considerations: This care plan needs to focus on care coordination, such as ensuring that your brother has access to the right specialists in his insurance network. It also needs to describe how he manages his diagnoses and the type of assistance he would prefer from the assisted living community.
Scenario 3: Managing progressive cognitive decline (memory care)
Your 91-year-old grandmother has moderate Alzheimer’s disease and frequently wanders and has sundowning episodes. She lives in a secure memory care unit.
— Care plan considerations: This care plan requires expanded information on the intervention protocols and emergency contacts and communication fields. Because your grandmother is not able to communicate her needs, her clinical baseline for both physical and cognitive function needs to be very detailed. The mental and social goals will pivot away from individual achievements to sensory-based activities, like sorting familiar objects.
As every care plan is different, “Older adults and their loved ones can ask their clinicians to run through the care plan with them,” Feng says. “Don’t be afraid to ask questions like ‘What does a safe discharge look like’ or ‘What symptoms should I be looking out for?’ If there is something important to you, ask them to include it in the care plan and have a copy sent to you.”
Frequently Asked Questions
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What Is a Care Plan? Definitions, Examples and Key Components originally appeared on usnews.com
