No matter the name you use or the method to create it, the outcome should be the same; an individualized plan of care identifying the needs of an individual and how to meet them.  

Plan of Care

A Plan of Care incorporates the WHO, WHAT, WHEN, WHERE & WHY (but not necessarily in that order).

• The focus is often a combination of the what and why:
• The WHAT - what is the need? (Example: decline in ADLs - Activities of Daily Living)
• The WHY – why does the individual have the need? (Example: s/p stroke)
• The GOAL (aka the WHEN) - When do we plan to either see improvement or meet our goal? This may include maintaining current status without decline. For example –able to complete daily AM care without assistance in four (4) weeks / able to complete all ADLs in six (6) weeks. The plan must be measurable and should include short and long term goals.
• The INTERVENTIONS – how do we meet the goal associated with the needs (focus) and who is responsible. Each intervention should give specific direction as to interventions/tasks designed to not only meet the goal but also the needs. (Example: assist resident with AM ADLs beginning with cueing allowing resident to choose clothing/ Provide limited hands on assistance of 1 when asked by resident for dressing/ Provide positive reinforcement, encouragement and praise when tasks completed).

The plan needs to include the current WHERE: where the individual is receiving care but also where do we expect the individual to be in the future? We also need to include WHAT is the discharge plan? Discharge planning begins on day one (1) of an individual’s stay in the facility. Most individuals admitted into LTPAC settings do not plan on staying permanently. Our job is to transition everyone to the least restrictive setting possible. The individual’s job is to be as independent as possible.

Writing the Plan of Care

When writing the plan of care, or when joining the care plan meeting, remember that it is not meant to be long or difficult.  What is the problem, how are we going to address it, by whom and when do we anticipate resolution. Ultimately, we need to ask the patient/individual/resident the negotiables and non-negotiables and build them into the plan to aid in success.  If they want to begin their day with breakfast in bed or their am coffee followed by their scheduled exercises, try to accommodate that- this could lead to success.  Think about and ask, what they would set up as their plan if they were home, currently, this is their home so give them as much control as possible.  This personalized plan/approach to meet the individual’s needs is what care planning is supposed to be - not the old nursing school care plans that addressed every little nuance with a very cookie cutter approach.

Need help with developing your Plan of Care approach? Contact Richter Healthcare Consultants today!