After The Move: The Importance of a Care Plan

In long-term care facilities, the staff prepares a care plan that guides and directs the care they deliver to individuals. In last month’s newsletter, I recommended that you, as a family member, participate in the process of care plan development so that you can represent your loved one’s needs, wishes, preferences, and interests.

(In the event you meet resistance about participating in this process, make sure to relay the fact that Medicare stipulates that an individual [if able], family members, or someone acting on behalf of a resident, has the right to take part in planning care along with the staff of the long-term care facility.)

Care plans include a review of an individual’s health condition. The process of collecting that information may begin even before a loved one arrives and continues upon admission. It must be completed within 14 days. After that initial assessment, further assessments must occur at a minimum of every 90 days (more often as a person’s medical status changes). Ongoing assessments, when needed, result in adjustments to the care plan.

What’s in a Care Plan?

Examples include:

  • Personal or health care services needed, such as assistance with bathing or care of a wound.
  • The level of staff required for performing various services (e.g., a nursing assistant can assist with bathing, but a nurse would be responsible for wound care).
  • The frequency of services and necessary equipment. For example, bathing may be four times per week with the use of a shower chair; wound care may be delivered daily.
  • The type of diet as well as any restrictions or preferences.
  • Health goals and plans for future transitions (if any).

Your Role

In our experience, the most successful outcomes in transitioning an older adult to a long-term care facility, result from the active, ongoing and frequent involvement of family members.

Specifically, here are some things you can do to ensure success:

  • Once you’ve participated in the development of the care plan, be sure to obtain a written copy that you can use as a guide in the future.
  • Be present on site, often, and at different times of the day, so that you get to know the routines and all the staff. You’ll be able to observe the things outlined in the care plan in real time and see how they are accomplished.
  • If possible, share these responsibilities with fellow family members, so that the burden does not fall to just one person.
  • Meet often with your family team members to discuss your individual experiences. Designate one or two of you to attend the facility team/care-plan meetings and to provide feedback to the staff.
  • When providing feedback, remember to point out all the things that you appreciate and that are going well with your loved one, in addition to the things that may require improvement.
  • Develop relationships with all the staff involved. Get to know them as well as the administrative team.
  • Remind the staff that they have vast experience caring for older adults and you hope to learn from them. Remind them as well that you have vast experience with your loved one and that they, in turn, can learn from you.
  • Identify the responsible party who will develop a regular meeting schedule with the team. Ask for in-between meetings if issues arise.
  • Prepare for meetings by creating an agenda that you discuss, in advance, with the professional responsible for organizing the event. In our experience, facilities do a good job preparing for and relaying information they would like to share with a family, but not such a good job soliciting agenda items from you for discussion.
  • Outline the length of the meeting and allot specific amounts of time for each agenda item. Families often leave meetings feeling rushed and unsatisfied; your efforts in advance can improve this experience.
  • Take notes during the meeting and summarize the action items at the end. Discussion will often lead to a revision of the care plan, so be specific about that and obtain a revised copy within a reasonable amount of time.


Once you’ve expended the effort it takes to both transition a loved one to a long-term care facility and to assist them through the adjustment phase, it is our hope that you can become less of a caregiver and more of a family member, able to live in the moment with your loved one.

Although your responsibilities never go away, expending effort up front will pay off in the long run as you work within the village you’ve created around your loved one. The goal should be to support your loved one’s adjustment to his or her new home and new extended family.