Care Planning - The Secret to Quality of Life

By Mary Jo Johnson, MPA, CMC

During my 34 years in the long-term care industry, I have embraced the value of the care planning process, not because it is a regulation but because it is a vital tool to assure the delivery of person-centered care. 

Transcending the medical-institutional model, person-centered care calls for a more individualized, social model of care that is built around the needs of the resident (person). It is meant to eliminate (or at least reduce) the dictating demands of the care process to one more driven by a person’s voice and choice.

The best way to ensure that your loved one is receiving person-centered care is to play an active role in the care planning process. You may not realize this, but anyone residing in an assisted living or nursing home setting is required by law to have a needs assessment and a written care plan. A care plan is deeply personal. It explains what care is needed, how it can be best accomplished, how the person likes things done, what methods and approaches are most successful, and what modifications are necessary to ensure best results. It takes into account factors such as family support, functional capacity relative to the activities of daily living, physical care needs, medical information provided, cognitive and behavioral impairments, if any, and personal preferences relative to care needs. Once the care plan is developed, professional caregivers then use it as a guide for the delivery of care and services.

If you want to be an active participant in the care planning process, here’s how to do it.

  1. CONNECT: Upon moving your loved one into a long-term care facility, you must connect and learn about the facility’s philosophy of care, performance standards, outcomes, and testimonials. How do they encourage your loved one’s involvement in the direction of his or her own care plan? How do they get you involved? Do they have regular care conferences? How is communication exercised? 
  2. COLLECT:  This about reciprocal information gathering on topics such as habits, routines, preferences, needs, and expectations, and then sharing that information so an individualized care plan can be designed. It is important for your loved one and family to communicate your expectations of the facility and determine if they can be met. 
  3. COORDINATE:  Based on a collective gathering of information, collaboration is communicated and coordinated for optimal development and execution of the care plan.
  4. CREATE PLAN:  The personalized care plan is created and communicated to all caregivers and entire interdisciplinary team.
  5. CARRY OUT PLAN:  The care plan is put into action.
  6. CHECK/MONITOR PLAN:  Family and staff should be in constant communication evaluating plan outcomes. This is most often done on an informal basis, and a more formal basis referred to as a “Family Care Conference.” It is vital for families to request a Care Conference if not offered one, and to certainly attend when invited. With today’s technology, this is made more convenient with video conferencing when attendance is not possible.  This review determines the effectiveness of the plan, as well as your loved one’s well-being.
  7. CORRECT:  This care plan review is an opportunity to make changes and adjustments as needed. Those changes are then communicated to the interdisciplinary team for follow through.
  8. CONTINUE:  The process is continuous as needs and preferences change

What is the common denominator that ties all eight steps together? It’s communication. Person-centered care can’t happen without it.

Need help navigating the eight steps to person-centered care? A Life Care Planning Law Firm can help. Find one near you.

Mary Jo Johnson, MPA, CMC, is a Life Care Coordinator at Kimbrough Law, a Life Care Planning Law Firm with offices in Athens and Gainesville, Georgia.