Plan for an Effective Senior Facility Care Meeting

Meeting

During the care plan meeting at your loved one's skilled nursing or other care facility, make sure your voice is heard.

When you have a loved one in a skilled nursing facility or assisted living facility, you'll often be asked to participate in a "care plan conference," or a "quarterly care conference." Unfortunately, family members usually go to this meeting with little understanding of what a care plan document should provide, or what the goals of an effective care plan conference should be. This article helps you be prepared.

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 -- 95 percent of all SNFs in the U.S.

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.

Assisted living is a state matter

Assisted living communities are a bit different because they are regulated by each state, not federal law. Most states recognize the value of care planning in the assisted living environment and have implemented their own policies and practices.

For instance, assisted living facilities in California must develop a Needs and Services Plan (NSP) prior to admission, which includes written assessments of a new resident's medical, functional, cognitive, and mental health status, and outlines specific service needs. The care plan team must update all NSPs "as frequently as necessary to ensure its accuracy, and to document significant occurrences that result in changes in the resident's physical, mental, and/or social functioning" (California Code of Regulations, Title 22, Division 6, Ch. 6, 85068.3).

Many assisted living communities schedule regular conferences to update care plans, but this is not as strictly governed as in the SNF setting. Also, residents and their representatives can request a meeting at any time.

In any setting, a good care plan includes:

  • Measurable objectives, with time frames
  • Tasks that have been assigned to specific staff members or other responsible parties
  • Methods of evaluation

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 private nurse or 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. It is also essential that the resident communicates 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 next quarterly 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 an hour or more.

Come prepared

Write up a list of questions, concerns, and observations and bring it to the care plan meeting. (See the sidebar "Care Plan Questions.") If you don't have a copy of the current care plan, ask to see it in advance.

Care Plan 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 her special interests be integrated into the facility's activities calendar?
  • What percentage of the meals and fluids offered is the resident consuming? Have there been fluctuations in weight? Are there particular foods he enjoys, that he 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 her physician? What do 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 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 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 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 dialog in the future.

But, you should come to the meeting with a full knowledge of residents' 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. 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 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.

RESOURCES

California Advocates for Nursing Home Reform -- http://www.canhr.org. Consumer advocacy group for California nursing home residents and their families.

National Citizens' Coalition for Nursing Home Reform -- http://www.ncccnhr.org. National advocacy group for nursing home residents and their families.

National Senior Citizens Law Center -- http://www.nscls.org. Offers useful guide "Twenty Common Nursing Home Problems", which outlines several important nursing home resident rights that are commonly misunderstood.

Nursing Home Regulations Plus -- http://www.hsr.umn.edu/nhregsplus/. Website operated by the University of Minnesota's School of Public Health, where consumers may examine and compare state nursing home regulations.