A care plan creates a better quality of life

Regardless of where a senior’s healthcare is delivered, the provider and team will have created a care plan based on his or her conditions. The physician creates one for the senior, which is recorded in the office files.

If a senior is in a hospital, nursing home or an assisted living facility, a care plan is developed to define their care needs and approaches to meet those needs.

For seniors, especially those in longer term settings such as a nursing home and assisted living facility, the tenure of residency is typically longer than at a hospital. The anticipated outcomes based on the stay at the senior residential facility are also different. The interdisciplinary care plan focuses on the entire individual and their needs, rather than the acute clinical condition requiring hospitalization or a visit to a doctor’s office.

Family involvement is the key to an effective care plan

One important element to the success of a care plan in a senior setting is participation by the resident and their family. Often the senior has conditions or diseases that inhibit effective communication with the interdisciplinary team. Even in cases where the resident can participate in the care plan discussion, the presence of family is important. The family knows details about the resident’s life that will help the care plan team develop a tool that reflects the wishes and essence of the senior.

An example of why this inside knowledge is important follows. A senior with dementia was attempting the leave the facility unsupervised after dinner each evening. Because of his mental confusion, this elopement behavior was a substantial risk to his safety. A care plan meeting was called and his wife was asked to attend. In discussion with his wife, the team discovered that before admission, he and his wife had taken a walk each evening after dinner. The resident was simply attempting to continue his life-long pattern. The care plan intervention by the team was to continue the walks either inside or outside the facility, but with a companion. This eliminated a potentially unsafe and psychologically stressful situation for the resident, his wife and the staff of the facility and allowed the resident the exercise to maintain strength and mobility.

The care plan is less individualized when the family is not fully participating in the process. The care plan team does not have information about the resident’s pre-admission routines and wishes unless the senior or their family shares this information. The team will have records from the hospital if the resident was a patient, but these are usually clinical in nature. The physician is often a hospitalist who has not followed the senior across time. Even a physician who has attended a resident for years often does not know intimate details about the senior’s life and wishes. The family is the sole source for this information.

Care plan terminology may differ

The term “care planning” carries different definitions depending on the type of organization. In the hospital setting, the care plan is usually established within each discipline’s notes. The variation to this is when the senior is in a rehabilitation hospital. In this case, the interdisciplinary team meets to establish goals and time lines. While hospitals and nursing facilities call the process care planning, assisted living facilities often use the term “service plan.”

Regulations impact care plans

Regulatory bodies have established care planning frequency for differing admission status. For instance, if the resident is admitted for Medicare skilled services, the expectations are different than if the resident is not receiving Medicare skilled benefits. The general rule of thumb is that the care plan is reviewed and updated on a quarterly basis, or every three months. The exception to the quarterly time line is if a resident experiences a significant change in condition. This change of condition necessitates a care plan review by the team.

All of the data that is collected on admission helps the team establish a temporary plan of care. As the team learns more about the resident a more tailored and extensive plan is created.

What to expect in a care plan meeting

The care plan is a structured document containing data elements that are consistent across the healthcare settings. The care plan lists problems, goals, interventions and time lines for anticipated improvement or resolution.

The ultimate goal is to help minimize the impact of a disease or to slow the inevitable deterioration of a chronic condition. The family’s input is very important in the creation of the goals and interventions relating to the care plan.

Members of the family attending a care plan meeting does not necessarily need to include the person with Power of Attorney (POA) for healthcare. This is the person that the senior has designed as their agent for healthcare decisions when they are no longer capable of self-decision making. The healthcare POA may not have lived near the senior or may not have been an active participant in their day–to-day life prior to admission.

Due to confidentiality concerns, the care plan team may not disclose information to individuals who do not have a right to the senior’s healthcare information. Families or designated decision makers need to have a discussion with the facility staff to assure that care plan attendees are appropriate so that healthcare confidentiality is not breached. These issues can be resolved with phone calls and simple documentation.

One challenge the care plan team cannot resolve on behalf of the resident is when family dynamics become disruptive to the process of planning and care for the senior. Finding a senior advocate or navigator can help minimize, facilitate or resolve these issues for the team and family.

Care plans are not prescriptive documents. Each individual ages in place in a different way. The care plan interventions are both generic and individualized depending on the scope and severity of the resident’s needs and conditions.

Even with a comprehensive care plan, all adverse outcomes and conditions are not preventable. Outcomes like falls, skin break down, difficulty swallowing and deterioration of activities of daily living still occur in senior facilities because of the continued changes from clinical conditions. The admission status cannot always be maintained regardless of the care and treatment that a resident receives.

Routine care plan meetings are usually brief, lasting 15 minutes or less. If as a family you wish to have an extensive conversation, ask the care plan team to schedule a longer meeting. If there are many issues, the meeting may need to be rescheduled to broach these concerns.

The care plan meeting is not a forum for complaints by the family. It is a professional meeting with the entire disciplinary team to discuss the status of the senior resident. That does not mean that service issues and complaints are not important and may have an impact on the care of the resident. The care plan team is open to listening to the issues, but their focus is on the unique care needs and progress of the resident. Discussion of service issues is best addressed by the management team in a meeting designated for that purpose.

The care plan team will typically be open to requests for alternatives to assist families to attend the meetings. Care plan meetings can often be scheduled for time frames that work for the family. With technology, care plan meetings can be conducted via speaker phone or using Skype or other computer tools as an alternative to face-to-face communication. Ask whether these tools are available so that you can participate.

Communication enhances any care plan

By participating routinely, surprises are kept to a minimum. One of the major advantages of care plan attendance and communication is for the care plan team to help the family understand the disease processes and conditions of the senior. Well informed families can plan for contingencies and not be caught in crisis mode.

Care planning is an important element of the care and treatment of the senior in a facility. The family’s input is of the greatest importance. The care plan meeting is a tool for care taker, staff, the resident and the family. The facility needs your help in caring for your cherished loved one.

Mardy Chizek, RN, FNP, BSN, MBA, AAS
President, Charism Eldercare Services, Westmont, Illinois


  • Mardy Chizek, RN, FNP, BSN, MBA, AAS, is President of Westmont, Illinois’ Charism® Eldercare Services. She has 30 years of professional healthcare experience as a nurse/ nurse practitioner, geriatric expert, consultant in legal and insurance issues, clinical risk management, business and an educator.