In many Long-Term Care facilities called nursing and rehabilitation centers the care plan meeting has become insignificant and useless to the resident and the resident’s family, surrogate or representative. The resident and the resident’s family, surrogate or representative need to drive the care plan meeting.
Nursing homes are to provide you with a care plan meeting on about the 21st day and every 90 days or so respectively or whenever there is a significant change in condition. They should be notifying you by a letter giving you the day and the time. Nursing homes schedule a block of time 1 or 2 days out of the week when the interdisciplinary team will be available to meet with you for about 15 to 20 minutes to discuss the care of your loved one. They conduct the meetings for several residents and the meetings are usually back-to-back.
When you are unable to make the meeting they usually allow you to reschedule the meeting, however don’t be surprised if only one team member is available for the meeting. Always make sure that the MDS coordinator is present. The MDS is coordinator is a registered nurse and is the one responsible for coordinating the MDS assessment and developing the plan of care. The MDS coordinator should be able to answer any questions related to the plan of care, your resident’s progress or decline, the conditions of your residents disease progression, and therapeutic services and medications your resident is receiving.
Who can come to the care plan meeting? The resident. The resident’s family, surrogate or representative that has been authorized or designated by the resident or the Heath Care Power of Attorney because of the Health Insurance Portability and Accountability Act (HIPAA).
Who do you want at the care plan meeting? Be selective as you want family members or friends of your resident that have an active social and caregiving role in participating in your resident’s facility life with consistancy. Why? Because you want everyone involved on the same page. It is good to have a second pair of hears in case you missed something.
You will want to purchase a small notebook to bring along with you so that you can take some notes. You can also write important questions in the notebook ahead of time that you want to remember to ask.
When you attend your first care plan meeting you will want them to review the complete plan of care with you and the resident so you can have input and help accommodate revisions you feel are necessary for your residents well-being. Some nursing homes like to skip reviewing the care plan with you because it is so timely. Don’t let them get away with it. This is your opportunity find out how they are going to care for your resident and to ask questions about the care they will provide, the condition and the status of your resident. Please keep in mind that your resident has the right to participate in the care planning at what ever level they are capable of. They have the right to understand their plan of care, their condition as well as the right to request or refuse services and treatment. Make the most of this opportunity!
When a person is placed in a nursing home you must anticipate that there will be some changes in their physical, mental and psychosocial well-being as they adapt to new surroundings, new routines, different sound levels, different people, living in a larger community and adjusting to loss. It takes time to adjust. The adjustment period that can last from 3 months to a year or not at all in some cases. Below are a few immediate concerns that you should keep track of for the well-being of your resident.
You will want to know and make a note of what current medications your resident is receiving, what the medication is for and if your resident is accepting the medications. Please pay special attention to pain medications if pain is an issue. Pain is real to the person who is suffering. Pain prevents a person from having any quality of life. If your resident is receiving medication for behavioral symptoms, be sure that these medications are not over sedating. You want to make sure that medications for behavioral management are theraputic and enabling.
Nutrition and hydration is also an important factor to your resident’s well-being. Find out what your resident’s current wieght is and the date he/she was weighed and make a note of it. Probe further to find out if your resident’s has increased or decreased. If there has been weight loss 5% or greater in one month probe further to find out what their lab values are and if they are within normal ranges. Is their weight loss or gain affecting other medical conditions? Find out what interventions they will put into place. How can you help?
Keep on top of their skin integrity. Do they have any pressure sores (pressure ulcers, bed sores)? If so, are the sores healing? How are they being treated? What factors are preventing them from healing? If the have no pressure sores, are they at risk? If they are at risk, what preventions are in place? Make a note of it.
Sometimes care plan meetings are emotional upsetting because we receive unpleasant information or the care is not happening to our expectations. Use the care plan meeting for the benefit of your resident. Do not use the care plan meeting to vent your feelings out on the nursing home and its staff. The care plan meeting is the time to work together for the benefit of your resident. If you have grievences with the nursing home or its staff you should schedule another appointment to address those issues. The care plan meeting is not the place to effectively work out grievences.
Make the most out of your resident’s care plan meeting. Work with the nursing home staff. The nursing home staff know that you love and care for your resident. They truly want to provide the best care. Your presence, believe or not provides the encouragement for them to provide that care!
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