If you have a loved one in a nursing home, you will soon hear the term “care plan meeting.” Shortly after moving in a new resident, each nursing home is required by the Florida Department of Elder Affairs to develop a plan of care. This helps the facility know what the resident can do for himself or herself, and what other activities they require assistance performing. Of course there is a recognition that all residents will change over time. In some aspects they may improve functioning, and in other areas there will be declines. Due to this changing situation the nursing home must review each resident every three months. Also each resident will be reassessed annually.
NOTE: Bear in mind that due to COVID-19 restrictions, care plan meetings in some facilities will be held virtually (on the telephone or via electronic service such as Zoom.)
So what happens in a care plan meeting?
A plan of care will be set for the resident which will serve as a game plan for how the nursing home staff will help the resident. The plan of care will be in writing. It tells each staff member what to do and when to do it (e.g. dietary aide will place a cup of water on the right side because Mrs. Jones has left side paralysis.) One reason the care plan is so important is because many tasks are performed by aides who do not have the extensive training that is required of doctors and nurses. Without proper instructions in a care plan, the aides might not know what needs to be done.
Care plans must be reviewed each three months (or when there is a physical change to the resident) to make sure they work. They must be revised as needed. The best care plans work to make the resident feel like his or her needs are being met and are consistent with the resident’s goals and values.
In a care plan meeting, staff and residents (and interested family members) will talk about life in the facility-meals, activities, therapies, personal schedule, medical and nursing care, and emotional needs. Residents and their families can bring up problems, ask questions, or offer information to help staff provide care. A representative from each staff group working with the resident should be involved-nursing assistants, nurse, physician, social worker, activities, dietary, occupational and physical therapists.
Federal law provides that, to the extent possible, the resident, the resident’s family, or the resident’s legal representative should participate in the care plan meeting. When you participate, the staff should listen to you and should use language you understand. If you don’t understand something, ask that they explain it to you. If you ask for something and they tell you no, don’t be afraid to ask why. Seek specific answers to your questions.
Residents have the right to make choices about care, services, daily schedule and life in the facility, and to be involved in the care planning meeting. Participation is the only way to be heard.
Before the care plan meeting
Tell staff what you want, what’s working, what’s not working, how you feel, your concerns and what questions you have. Plan your agenda of questions, problems and goals for yourself and your care. Know, or ask your doctor or staff, about your condition, care and treatment. Ask staff to hold the meeting when your family (or our elder care coordinator) can attend.
During the care plan meeting
Discuss options for treatment and for meeting our needs and preferences. Ask questions if you need terms or procedures explained to you. Be sure to understand and agree with the care plan and feel it meets your needs. Ask for a copy of your care plan. Ask who to talk to if you need changes made to meet your needs or desires.
After the care plan meeting
Residents should monitor how your care plan is being followed. Feel free to talk with nurse’s aides or other staff about it. Families should support their relatives’ agenda, choices and participation in the meeting. Even if your relative has dementia, involve him or her in the care planning as much as you can. Always assume your loved one may understand at some level. Also help to watch how the care plan is working and talk with staff if questions arise.
And remember that care plan meetings are your best chance to be proactive in the type of care and support you (or your relative) will receive. Staff may fall into the habit of going through many care plans in a morning to get through the case load. That doesn’t mean that your loved one has to be rushed through with the others. Our elder care coordinator has the goal of attending the first care plan meeting after we are hired to help coach the resident or family members what to expect and how to respectfully get across your wishes. (She may also attend other care plan meetings especially if there is a change in condition or if the resident has been experiencing issues that need to be addressed.) If you have questions about your upcoming care plan meeting, feel free to call Burzynski Elder Law at 239-434-8557.