Whether your loved one is staying at a skilled care facility, also known as a nursing home, for a short term rehabilitation stay or as a permanent resident, you should be asked to participate in a “care plan conference,” or a “quarterly care conference.” Unfortunately, family members attend with little understanding of what a care plan should provide or what the goals of an effective care plan conference should be.

What Is a Care Plan?

A care plan is a road map of sorts, providing goals and directives for achieving those goals for residents, families, and facility staff. A care plan is required by the 1987 Nursing Home Reform Law at any skilled nursing facility (SNF) that accepts Medicare or Medicaid.

The facility’s care plan team must complete an assessment within the first 14 days of a resident’s stay or within the first seven days if the stay is paid for by Medicare. The care plan team uses a standard document called

a Minimum Data Set (MDS). Within seven days of the assessment, the team must complete a care plan and schedule a conference.

Thereafter, a care plan meeting should be scheduled at least once every three months, or sooner if the resident’s condition changes significantly, to discuss progress and changes to the care plan. A family member can also request a meeting at any time.

A care plan should be written in language that everyone can clearly understand and should reflect the specific needs and concerns of the individual resident. If you don’t know exactly what the plan means, ask for

clarification. You should read a care plan regularly and carefully, make sure it is revised whenever necessary, and insist that it is followed diligently.

The resident of the facility should attend the care plan conference whenever feasible, and participation by you or another family member or trusted friend is a good idea. Also, you may bring in an outside professional, such as a care manager or a social worker, to help you work out the best plan. It is important that all of the information from the care plan team is heard and understood by the resident, if possible.

It is also essential that the resident communicate his needs and preferences clearly, and that the team really listens and understands these needs. Residents and their representatives should receive a written communication with the date and time of the care plan meeting. You may call to reschedule the meeting if necessary. You should ask how much meeting time is being allotted and feel free to request additional time, if needed.

Come Prepared

Write a list of questions, concerns, and observations and bring it to the meeting.

A Few Suggested Questions

  • 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 is the resident participating in activities or social events? Could his special interests be integrated into the facility’s activities calendar? Obtain a copy of the calendar so you can help your loved one plan to attend the activities.
  • What percentage of the meals and fluids offered is the resident consuming? What is their diet—general, low salt, mechanical soft, etc? What is the current weight? Have there been fluctuations in weight? Are there particular foods/snacks he enjoys, that he would like more of?
  • What is the status of any special therapies that are being provided (physical, occupational, speech, etc.)? If no formal therapies are being offered, ask that your loved one be in their restorative (or maintenance) program.
  • When was the last time the resident saw his physician? A physician must examine residents at least once every 30 days for the first 90 days after admission and at least once every 60 days thereafter.
  • Obtain a list of all the health care providers, including physicians, physician assistants, advance practice nurses, wound care nurses, etc., involved in caring for your loved one. What do clinical notes from recent visits indicate? Obtain a copy of the current medication list.
  • What is your loved one’s bathing / shower schedule? By law, your loved one is to receive one a week. Most communities offer two.
  • Does your loved one need any special equipment, i.e. weighted silverware, plate guard, mattress pad, positioning cushion, etc.?
  • Podiatry visits. Ask that your loved one be added to the list for the podiatrist. Medicare will pay for podiatry visits as medically needed.
  • Dental care. Does your loved one need to be seen by the dentist? If yes, ask about the provider and when he/ she is coming again. Note, Medicare and Medicaid do not pay for dental visits.
  • Have there been any changes in the facility’s administration or nursing staff? Are there new staff members responsible for the care of your loved one that you should meet?
  • Are there any items the resident needs, such as new clothing, personal items, reading material, or stationery? Are eyeglasses and hearing aids in good repair?
  • What changes to the current care plan would the staff recommend and why?

The care plan meeting is your opportunity to ensure that all of your loved one’s medical and non-medical needs have been identified and are being addressed in satisfactory ways. Although you may not resolve every concern during the meeting, you should walk away knowing that an agreed-upon strategy is in place.

Don’t 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 the care plan team offers. The team must identify and present alternatives that will meet the stated goals of the care plan.

When asking questions and communicating your concerns, you should assume that the facility administration and staff are working with your family member’s best interests at heart, because the majority are. You’ll do best by communicating in ways that don’t generate defensiveness, so you can continue having open dialogue in the future.

You should come to the meeting with a full knowledge of the resident’s rights, and you should be prepared to defend and protect those rights when necessary.

Residents and their representatives can feel intimidated or not want to be pushy, but being a “squeaky wheel” is not a bad practice. Just strive to find mutually respectful, positive, and productive ways to deal with the key questions and difficulties that arise.

Two-Way Communication

The care plan meeting is also your opportunity to provide the facility’s staff with important background information that can improve the quality of care that your loved one receives. Skilled care facilities 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 used to enjoy a bath after dinner to relax for a good night’s sleep, it is reasonable to expect the staff to use a similar bath schedule. 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.

Keep in mind that laws 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 who are providing the care.

This information is not to be considered legal advice. If you have questions about it, please contact us.

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