Nursing homes, rehabilitation centers, and other long-term facilities that accept Medicaid and Medicare must abide by federal laws governing residents’ rights. One of those rights involves creating a Care Plan for the resident. Federal law provides that, to the extent possible, the resident, the resident’s family, and the resident’s healthcare designee should participate in the development of the Care Plan.
Federal law says that a written Care Plan should be in a resident’s chart within 21 days of admission to the facility. In rehab facilities where stays tend to be shorter, a preliminary Care Plan is often done as early as 24-48 hours after admission. This is usually based on immediate diagnosis, problems and preliminary information. The facility is then expected to later hold an Interdisciplinary Care Plan Meeting with the resident, his or her family, and legal representative.
Every facility has its own interpretation of what a Care Plan Meeting involves, how it’s conducted, and how involved the resident, family members, and designee representatives should be. Don’t be surprised if you find that you need to request to participate in a Care Plan Meeting for your loved one. It’s quite common.
Who will you see in a Care Plan Meeting? A representative from each discipline working with the resident will usually attend. This is known as the care team, and it typically includes nursing assistants, nurses, physicians, social workers, activity staff, and dietary staff, as well as occupational, speech, and physical therapists.
At the initial Care Plan Meeting, the major topic of discussion will likely concern immediate physical goals and the resident’s orientation to his or her new home. Meals, activities, therapies, personal schedules, medical and nursing care, and emotional needs will be topics of discussion. This initial Care Plan Meeting is the time for your loved one to ask questions about how life works in the facility—Where can I get my hair cut? How do I get to the dining room? How do I get the morning paper? How often are showers given? It’s also the time for family members to ask questions and share information to help staff provide care. One of the positive by-products of this meeting will be a reduction in the new resident’s anxiety about what life will be like in his or her new home. Person-centered care is a value that most facilities endorse.
Again, it’s important to remember that not all facilities handle this initial meeting in the same way. Some facilities provide a booklet during the admission process. Others wait a few weeks before calling a meeting. Some will wait until the resident or family members request a meeting. Know that it’s entirely reasonable to request an orientation. Don’t be afraid to ask.
After the Care Plan Meeting is over, follow-up is important to make sure that your loved one’s Care Plan is being followed. Keep an eye out for how the Care Plan is working and talk with staff if questions arise. The social worker assigned to your loved one will be an important ally. He or she will be your advocate, liaison, support, educator, and discharge planner—for your loved one and dozens of other patients at the same time. That’s why it’s important to get to know each member of your care team and speak directly to them about issues involving their areas of expertise. For instance, if you have questions about how often your loved one will get medications or what the schedule will be for changing a wound dressing, your best bet is to speak to the charge nurse.
And finally, a word about expectations. No Care Plan can compensate for unrealistic expectations about the level of service in a long-term care facility. Please remember—and remind your loved one—that living in a rehabilitation facility, assisted living facility, or nursing home is not the same as living at home or being a guest at a luxury hotel. Staff members have a lot of ground to cover. This means that your loved one may have to wait a few minutes for that glass of water. It’s one thing to be proactive. It’s another thing entirely to be overly demanding. You know the difference.
In the second article in this two-part series, we’ll discuss what happens in after the initial Care Plan Meeting.