Care planning is the process of formally understanding your loved one’s goals and creating a concrete plan, (including tasks and due dates) so that those goals can be accomplished. A care plan is crucial to ensure that your loved one’s preferences are respected and that all actions align with what your loved one wants. To plan for the future, it is both necessary and normal to start the conversation early. In this article, we will define what a care plan should include and how to get started creating your own.
What Should a Care Plan Include?
Beyond its intent as a goal setting and achieving tool, a care plan can also help to get a new doctor or caregiver up to speed quickly to allow for consistency of care. Imagine that you find yourself in an emergency situation and your loved one is hospitalized. In this event, a care plan can give a care team everything they need to understand the patient in front of them as quickly as possible, even as nurses change shifts. Another common situation is moving your loved one into a care facility. In this scenario, the care team will quickly be able to get to know their new resident and have what they need to respect their wishes.
A care plan should include five main categories. A patient summary, a care team summary, any health concerns and diagnoses, patient goals, instructions and interventions. Let’s break down a few examples of what should be placed in each category.
Patient Summary
The patient summary should include your loved one's basic information and medical history. This includes things like their most recent height, weight, blood pressure, medications and prescriptions, allergies, religious or cultural considerations, family history, and any recent hospitalizations. You can get as in-depth as you’d like with the section, the important thing is that someone else could pick it up and quickly learn what they need to know about your loved one.
Care Team Summary
The care team summary should go over the basics about anyone providing care to your loved one. For example, name anyone who is expected to take care or participate in care for your loved one, emergency contact information, and backup plan information. Answer questions like,
Who will step in and handle a task when the designated caregiver is unable to?
Who is responsible for which tasks?
What level of detail is each person privy to? For example, some family members may help with care but should be left off financial discussions.
Health Concerns and Diagnoses
This section should include all diagnoses, behaviors, symptoms, and concerns of note. For example, include any current diagnoses, past diagnoses, mood or behavioral issues, planned or past surgeries, side effects or allergies to medication, aches and pains, and more.
It’s important to include all relevant information, even if it doesn’t seem relevant or immediately related to one another. Having everything all on the table can help paint the picture for any future diagnoses or treatment plans.
Goals
The fourth section is all about your loved one's goals, both for their quality of life and care. In the section, create goals about things like physical exercise, social interaction, maintaining independence, nutrition, sleep, mental health, habits bad or good, reducing metrics such as weight, blood pressure, or cholesterol, etc.
To create goals that are achievable, make sure that they are SMART goals:
Specific, Measurable, Achievable, Realistic, and Timely.
For example, don’t say, “Mom wants to lower her cholesterol” instead, say “We are going to work together to lower mom‘s cholesterol by 20 points in January 2022 by cutting out red meat and having a meatless Monday each week.”
It is the same goal, but now you can have a specific and measurable way to tell whether or not you have achieved it. You have defined how you will achieve it, kept it realistic, and set a date for when it will be accomplished.
The most important thing for the section is that you regularly update and check in on it. You may need to adapt some goals, adjust your goals, add new goals, or eliminate some of them entirely over time. As time passes, continue to modify your goals to stay on track.
Instructions and Interventions
In this section, start adding official instructions for how to accomplish the goals set and the care plan in general. You should also include intervention instructions such as, how to calm the care recipient when needed if they have erratic behavior or symptoms (for example, dementia patients).
An example of how to accomplish lowering mom’s cholesterol by 20 points….
“We will prepare a weekly Monday meatless meal plan.” Or “We will request dietary referral from a Physician.”
Other examples of things to include are instructions for caring for their condition, when to call for help, which symptoms require intervention and what types of intervention are needed, how to give medication, what they like to and should be eating, etc.
Also, in the event these questions come up, would your loved one:
Need a DNR (Do Not Resuscitate)?
Who is tasked with decision-making?
Are there any procedures they would not want to have performed?
Imagine handing this booklet to someone who doesn’t know your loved one–can they step in to help/follow your loved one’s wishes after reading your care plan?
Where Should You Start With Care Planning?
Conduct an Interview
To get started with putting this document together, the first step is to conduct an interview with your loved one. Put together a list of questions and consider your loved one’s interests, personal goals, physical and mental health, and care preferences.
Create a Plan
Once you have considered the plan from their perspective, work through how you’re going to implement any changes. For example, do you need to get a power of attorney or another advanced directive put in place? If they want to walk 5KM per day, how can you make that happen?
Write it Up
Once you’ve considered goals and implementation, now it’s time to put it all into a formal document. Gather the information you have and the preferences provided by your loved one and write it up in the order described above.
Put it Into Practice
Then, you’ll need to put it into practice. Work with any outside care providers and start gathering the resources needed to make these goals come to life.
Reflect & Review
As time goes on, continue to check in on your care plan. Over time goals may change, preferences may change (perhaps a change of heart on a DNR, for example), etc. It’s important to revisit and keep the plan current so that everyone is on the same page about the best path forward.
Closing Thoughts: Creating a Care Plan
These conversations can be challenging to hold, but you’ll be grateful to have done them. Understanding and respecting your loved one’s wants and needs without worry can make caring a much less stressful experience when the harder days come.
If you provide regular care to your loved one, we at CRC OC are here for you. We invite you to check out our library of information for family caregivers by clicking here for further reading and resources. You are also welcome to give us a call at 800-543-8312 to find out more about how we can support you in your caregiving journey.