Most caregivers with a loved one residing in a skilled nursing facility (SNF) will be asked to participate in a “care plan conference,” or a “quarterly care conference” at one time or another. Family members frequently attend these meetings at the request of the assisted living or skilled nursing facilities where their parent or spouse resides, but with a limited understanding of what a care plan document is intended to provide, or what the goals of an effective care plan conference should be.
A care plan is a road map of sorts, which provides goals – and directives for achieving those goals – for residents, families, and facility staff. Care plans are required by any SNF that accepts Medicare or Medicaid (which includes 95% of all SNFs in the U.S.), per the 1987 Nursing Home Reform Law. An assessment must be completed within the first 14 days of a resident’s stay in a SNF (or within the first seven days, for those whose stay is paid for by Medicare). The assessment is completed using a standardized document called a Minimum Data Set, or MDS. Within seven days of the assessment, a care plan must be completed, and a conference to discuss progress and changes to the care plan must be held at least every three months, or sooner, if the resident’s condition changes significantly.
Individual states regulate assisted living communities, and they are not bound to the same federally regulated, standardized assessment and care plan process. However, most states recognize the value of care planning in the assisted living environment and have implemented their own versions. Although many communities do schedule regular conferences to update care plans, it is not as strictly governed as in the SNF setting. Residents and their representatives can, however, request such a meeting at any time.
In any setting, a good care plan includes a) measurable objectives, with time frames, b) tasks that have been assigned to specific staff members or other responsible parties, and c) methods of evaluation. A care plan should be written in language that everyone involved can clearly understand, and should reflect the specific needs and concerns of the individual resident. Most importantly, a care plan should be read carefully on a regular basis, revised whenever necessary, and followed diligently.
The resident should attend the care plan conference whenever feasible, and the presence of an additional advocate is worth considering. It is important that all of the information shared by staff is heard and understood, and that the resident is not only communicating their needs and preferences clearly, but is being listened to by the staff. If a family member or friend is not available, you may bring in assistance from an outside professional such as a care manager or a private nurse or social worker.
Residents and their representatives will receive a written communication with the date and time for which the next quarterly care plan meeting has been scheduled. Call to reschedule the meeting if that time is not convenient. Ask how much time is being allotted, and feel free to ask for an hour or more.
Come to the care plan meeting with a written list of questions, concerns, and observations. If you do not have a copy of the current care plan, ask to see one. The care plan meeting is your opportunity to ensure that all of your family member’s medical and non-medical needs have been identified and are being addressed in satisfactory ways. Although you may not resolve every concern at the time of the care plan conference, you should walk away knowing that an agreed-upon strategy is in place. Do not accept recommendations unless your loved one or their representative understands and agrees with them. Remember that residents have the right to choose and refuse any form of care or treatment offered to them, and that the facility must identify and present alternatives that will meet the stated goals of the care plan.
When asking questions and communicating your concerns, assume that the facility administration and staff are working with your family member’s best interests at heart, because the majority are. Attempt to communicate in ways that do not generate defensiveness, keeping the lines of communication open in the future. At the same time, come to the meeting with a full knowledge of residents’ rights, and be prepared to defend and protect those rights when necessary. Although residents and their representatives often fear being labeled a “squeaky wheel,” questions can be raised and issues can be addressed in mutually respectful, positive, and productive ways.
The care plan meeting is also your opportunity to provide the staff with important background information that will improve the quality of care that your loved one receives. SNFs are obligated to provide individualized care, and are therefore required to make reasonable adjustments to honor the resident’s needs and preferences. For example, if an individual always enjoyed their bath after dinner, as a means of relaxing to ensure a good night’s sleep, it is not unreasonable to expect the staff to adjust their bath schedules accordingly. When making specific requests, be prepared to explain how the change or adjustment will be of benefit to the resident and improve their quality of life. Laws are in place that protect residents’ rights to receive quality care. You and your family member should determine what “quality care” means to you, and clearly communicate your expectations to those providing that care.
Questions for the care plan conference:
What changes in the resident’s health, functional status, or behaviors have occurred since the last care plan conference? To what are these changes attributed?
How frequently are they participating in activities or social events? Could any of their special interests be integrated into the facility’s activities calendar?
What percentage of the meals and fluids that they are offered are they consuming? Have there been fluctuations in their weight? Are there particular foods they enjoy, that they would like more of?
What is the status of any special therapies that are being provided (physical or speech therapy, etc.)?
When was the last time the resident saw their physician? What do their clinical notes from recent visits indicate?
Have there been any changes in the facility’s administration or nursing staff? Are there new staff members responsible for the care of my loved one that I need to meet?
Are there any items that they need, such as new clothing, personal items, reading material, or stationery? Are their eyeglasses and hearing aids in good repair?
What changes to the current care plan would the staff recommend, and why?