A care plan is written at the start of a package. It is thorough, it reflects the assessment and everybody signs it.
Eight months later the person needs more help with mobility, has new medication and has stopped eating properly at lunchtime. The plan still describes the person who was assessed.
Carers adapt informally, which they always do, and the plan no longer matches what happens. Nobody has reviewed it because nothing dramatic occurred.
Step 1: write it around the person rather than the tasks
What matters to them, how they like things done and what they can still do themselves. A task list produces task focused care and a person centred plan produces something better.
Step 2: record preferences in real detail
How they take their tea, which side they prefer to be helped from, what they like to watch, what upsets them. These details are what distinguish good care and they are what new carers most need.
Step 3: record what the person can do independently
Explicitly, so that carers support rather than take over. Doing too much is a common and well intentioned failure that accelerates decline.
Step 4: record the risks and what to do
Falls, choking, skin integrity, medication and anything specific. A risk recorded without an action is an observation rather than a plan.
Step 5: involve the carers who deliver it
A plan written centrally without the people doing the work is frequently impractical. Carers know what actually happens and they should shape it.
Step 6: set a review interval and keep it
At defined intervals regardless of events. A plan reviewed only when something goes wrong is always behind the person's actual needs.
Step 7: review immediately after any significant change
Hospital admission, a fall, new medication or a noticeable deterioration. These are the moments when a plan most needs updating and when everybody is most distracted.
Step 8: give the family access to it
Families want to see what is planned and frequently never do. Sharing it prevents a great many questions and builds considerably more confidence than a summary.
Step 9: record changes rather than rewriting silently
So that everybody can see what changed and when. A plan that changes without a record produces carers working from different versions.
Step 10: make the daily notes connect to the plan
What was done, what was declined, what was noticed. Notes disconnected from the plan are a log rather than a feedback loop.
Step 11: act on what the notes are saying
Repeated entries about a refused meal or increasing difficulty are a review trigger. Somebody has to be reading them for that to work.
Step 12: keep the family informed between reviews
Not only when something is wrong, which is the communication question families care about most.
Step 13: explain how the arrangement can change
Increasing hours, adding a visit or moving to a different model, which is the ground in live in care versus visiting care questions.
Step 14: answer the family's questions about the plan at any hour
An assistant that explains what a care plan contains, when it is reviewed, how to request a change and how a family can raise a concern means the plan is something a family understands rather than a document they signed once. Handled with the care in how to handle sensitive questions in your chatbot, alongside care fees and funding questions families ask and the daily detail in visiting and daily life questions about care homes. See features, start at try, and the sector view sits under senior care.