A care plan is a tool that long-term care providers use to organize and manage patients’ needs and services. Family caregivers can also benefit from using this strategy for providing care, but this is a tool that must be regularly assessed and updated in order to be effective. Once an initial care plan has been established, all aspects of it should be reviewed periodically—especially after certain health events.
Care Plans Are Constantly Evolving
The frequency of evaluation depends largely on the nature of the care recipient’s medical conditions and the level of assistance they require. For example, someone with a progressive condition like COPD or dementia will likely need more frequent assessments than an individual with milder or more stable health issues.
As a point of reference, Medicare requires home health agencies that provide skilled care to review each client’s care plan at least once every 60 days. In Medicare-certified nursing homes, full health assessments and appropriate care plan updates must be made at least once every 90 days. Both of these examples focus on patients with fairly complex medical conditions and care needs, but attention to detail is crucial, even for those seniors who are still fairly healthy and independent.
Identify Important Changes
Picking up on even subtle changes in how a senior is feeling, both physically and mentally, is an ongoing part of providing high quality care. Start by talking with them and, most importantly, listening for any changes or complaints that seem to be new or more serious than usual. If a senior isn’t honest or forthcoming about how they are feeling, you will need to rely on careful observation to detect changes in body language and behavior that can indicate things like pain, discomfort, and confusion.
Changes in any of the following symptoms should be discussed with their primary care physician immediately in order to make the appropriate changes to their care plan:
- Frequent urination or changes in bowel movements
- Itching, wounds, or new skin problems
- Changes in balance, coordination or strength
- Indigestion or nausea
- Thirst, increased hunger or loss of appetite
- Drowsiness, fatigue or insomnia
- Headaches or body aches
- Dizziness, restlessness, or a tendency to stumble or fall
- Changes in mental status
Ensure They Get the Post-Hospital Care They Need
A visit to the emergency room, whether or not a senior is admitted to the hospital, is considered an important development in their condition. Their care plan should always be assessed and updated following a hospitalization.
A transitional care plan should be provided as part of the discharge process. This plan will detail all new prescription doses and frequencies, prescribed medical equipment, such as walking devices, any physical therapy needs, and orders for follow-up medical appointments. Be sure to add to or adapt the existing care plan so that it incorporates these important changes.
The transitional plan could be as simple as adding an antibiotic to their medication regimen for 10 days to clear up at UTI, or it could call for skilled nursing and physical therapy services to help manage a new or worsening chronic condition. Carefully review this plan and decide if you are equipped to handle what it entails on your own or if assistance through a home care company or an inpatient rehabilitation facility will be necessary to meet your loved one’s needs while they recover. If possible, make sure your loved one is involved in conversations with the doctor or other clinicians so they understand that a return visit to the hospital may result if discharge instructions are not followed.
Schedule follow-up appointments as soon as you return home, and make sure to get an appointment with their primary care physician (PCP) within two weeks of the hospital visit. The PCP is familiar with you and your loved one and will help devise a more permanent plan of care and next steps for treating and/or managing their condition.
Set New Health Goals
Sometimes changes to a care plan aren’t made because of a hospital visit or change in health. Certain tweaks can refresh a senior’s daily routine and provide preventative health benefits. Work with your loved one to set personal goals that are based on improving their physical and mental condition as well as their quality of life.
Even small goals, such as walking to the mailbox or emptying the dishwasher, can be motivating short-term or long-term objectives. Incorporate activities that will help them achieve these aims on a daily basis. Small advances can help a senior work up to quite meaningful achievements. When seniors are active participants in their own health and wellbeing, they are usually able to remain independent and safe in their own homes for much longer.
Communicate with All Care Team Members
A comprehensive care plan usually requires a team of family members, friends, professionals and community resources in order to be executed smoothly. Regular communication with all team members is essential. Each person brings a unique perspective and area of expertise to the table, and different people tend to pick up on things others may miss. Interacting with a senior in various situations and different times of day can also reveal a great deal about changes in their health and functional abilities.
Frequent check-in phone calls with other team members, or a log for recording daily observations and activities can ensure the care plan is being followed, keep everyone up to date, and make it easier to recognize patterns in behavior that may need to be addressed.
Take time to find out how the person you're caring for feels about their care routine, too. Let them know that they still have control over their day-to-day life and whom they spend it with. If there is a part of their routine that they aren’t fond of or something they would like to add, work with them to make reasonable and realistic changes. The same goes for members of the care team. If they are not connecting with a particular team member or caregiver, don't be afraid to make a change if you think there might be a better fit.
Make Your Own Health and Happiness a Priority
A care plan is as much for your benefit as it is for your loved one. Each time you evaluate the care plan and team, take inventory of how you are feeling mentally and physically. You may find that you’ve forgotten to schedule this year’s annual physical or that you’re feeling spread too thin. Set goals for your own daily routine and find ways to incorporate them into the plan. This will enable you to make time for yourself so that you can engage in self-care.
Introducing outside help, such as in-home care or adult day care services, even for a weekend or one day a week, can give you a well-deserved break. Home care companies also devise and regularly update a client’s care plan as part of their services. If you could use some extra support and assistance with coordinating care and responsibilities, in-home care is an excellent option.
Be attentive to your loved one’s changing needs, factor yourself into this care plan, and take advantage of all the resources available to you through your friends, family and community.