Whether you are providing care or in need of care, a care plan is crucial to ensuring all preferences and expectations for care are known, understood, and respected. Without a plan, doctors and/or family members may end up dropping the ball or making decisions that don’t align with what the patient would have wanted. Starting the care planning conversation ahead of time is a normal and healthy part of future planning.
What is Care Planning?
Care planning is the process of planning and coming to an agreement about how the care recipient’s health and personal needs can be met and supported.
A care plan is a written record of the negotiated plan of action to meet the care recipient’s health and social needs. It is built using the conversations and perspectives of the care recipient, family caregivers, and medical professionals.
More specifically, a care plan describes, in simple terms, the needs of the care recipient, their preferences, choices, goals, beliefs, etc., and any actions that need to be taken by family, caregivers, and the medical team to meet these. This includes both day-to-day micro-level goals and longer-term macro-level goals.
It is one of the most important documents these three stakeholders will share and is a means of communicating the agreed-upon approach, needs, services, treatments, etc. between everyone involved.
How Do You Start a Care Plan?
To start a care plan, begin:
- Gathering perspectives.
Consult all involved when gathering perspectives. This includes the care recipient, caregivers, family, and the professional care team and doctors. Start with an informal set of conversations to ensure you don’t miss anything when setting goals and coming to an agreement.
- Reviewing needs.
Consider the care recipient’s needs both as they stand now and how you expect they will change in the future.
- Setting expectations.
Once you understand everyone’s concerns and have come to terms with what the care recipient needs, it’s time to set expectations. This means setting clear goals, creating responsibilities, and formalizing expectations for all involved.
- Discussing choices.
There are many scenarios for how the future may unfold. Discuss choices, decide on a hierarchy of decision-makers, and plan for these scenarios ahead of time. While no care plan can be perfectly respected, (a care plan is not a contract), this discussion will give the involved parties an idea of how to proceed at a crossroads with a clear conscience.
- Writing it all down.
Take these informal discussions and formalize them in a care plan as discussed next.
The Process of a Care Plan: How is a Care Plan Structured?
To structure a care plan you should write out:
This summary should include a history of basic information such as:
- Contact information
- Blood pressure
- Heart rate
- Medications and supplements
- Significant family history notes
- Past hospitalizations
- Religious or spiritual considerations
- Cultural considerations
- And anything else you find relevant to the patient/care recipient
Care Team Summary
Who will be taking care of this person, and which tasks should each caregiver handle? What is the backup plan if someone is unable to fulfill an obligation from time to time, (if they’re sick, for example)? Formalize these roles and set expectations on the care plan.
This section should include all signs, symptoms, behaviors, etc. of note (whether or not they seem immediately related to one another). Examples include:
- Current medical diagnoses
- Past diagnoses
- Past or planned surgeries
- Behavioral issues
- Mood issues
- Cognitive concerns
- Environmental concerns
- Side effects experienced
- Aches and pains
Next, you should set goals for both care and quality of life. Setting goals will help you monitor progress and make adjustments where needed down the line. For example, you could create goals about:
- Maintaining independence, and how to know when independence is no longer an option
- Physical exercise
- Social interaction
- Symptom and pain management
- Home environment changes
- Mental health and resilience
- Kicking bad habits
- Creating good habits
- Reducing weight, cholesterol, blood pressure, etc.
Set both short-term/benchmark goals and long-term/macro-level goals. For example, if the long-term goal is to lose 30 pounds through walking, you could set benchmarks for every 5 pounds or every 2 months.
Instructions & Interventions
This is where you start adding the formal instructions for care as well as the more theoretical things (such as the care recipient’s hopes for care).
Instructions can include:
- How to care for a condition
- How to respond to a side effect
- The amount of sleep they should get
- How they like to/should be eating
- How to keep your loved one hydrated
- When to give medications
- The types and amounts of exercise they should get
- How to limit bad habits
- What to do at home
- When to call for help
- How to give medication
- Which symptoms require intervention
- What services are available to help in an emergency
- How to calm the care recipient when needed (for example, if the patient has dementia)
In the event they are needed, how does the care recipient feel about:
- Resuscitation – do you need a DNR?
- Responsibility – who is tasked with decision-making?
- Medical procedures – are there any procedures they would not want to have performed?
A care plan should get as detailed as you want and cover as wide a range of topics as you’d like. There are no rules or limits to the depths and details of the plan – the most important thing is just to have one.
The role of caregiver is always tough, but you’re part of a large, strong, and helpful community of people who have been in your shoes. We created the California Caregiver Resource Centers with you both in mind and at heart to be a free resource as you navigate the challenging role you’re in. We would love to connect you with your local Center, which can talk more about local programs and support groups for caregivers, answer your questions, and explain how they can best support you.Share this post: