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home | Nursing Homes | Preparing For a Care Plan Conference

Preparing For a Care Plan Conference

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If you have a loved one in a nursing home you should be invited to attend a care plan conference on a regular basis. Assisted living facilities may hold care plan conferences less frequently than a medical facility such as a nursing home, but they should also have regular care conferences scheduled.

Every skilled nursing facility that accepts Medicare or Medicaid funds must complete an initial assessment within the first 7 days (Medicare) or 14 days (Medicaid).  Within seven days of this initial assessment the initial care plan must be completed. A care plan conference to review the patient's progress and necessary changes to the care plan must be held at least every three months thereafter and whenever there is an important change in the patient's status.

The care plan is the "road map" document that a care facility uses to keep caregivers on track with a patient's / resident's care. Rather than allowing every discipline to stagger forward without coordinated goals, each discipline participates in assessing a resident's abilities and needs, and the team then prepares a coordinated plan. Ideally all staff members, the patient or resident, and the family then work together to reach their common goals.

Who Attends a Care Plan Conference?

The care plan conference is usually attended by the supervising nurse, the social worker, the physical therapist, the activities director, the dietician, a family representative, and the patient if able. Some families want to include a care manager or the ombudsman, or both, which should be just fine with the facility.

Scheduling a Care Planning Conference

The resident and the family representative should receive a written notice with the date and time of the scheduled care conference. If you are not able to attend at that time you may reschedule. Keep in mind that because of shift schedules and the needs of other patients, some members of the care team may not be able to attend a rescheduled conference.

Many facilities schedule all their care conferences on a specific day of the week. These mass care planning conferences are often extremely short...often as short as 10 or 15 minutes per resident. A good care planning conference should be thorough and in-depth. A comprehensive team conference will require as much as an hour or more.

Experienced care managers and other advocates suggest that you request a specially-scheduled private care conference if this is the case at your loved one's facility.

What Will They Discuss at a Care Plan Conference?

Members of the care team, including the patient and a family representative, should discuss both medical and non-medical concerns. Medical and nursing care, therapies, meals and food service, activities, emotional needs and personal concerns should be addressed. Issues and goals should be written in easily understood language on a dated care plan document, with measurable goals and responsibilities and a timeline clearly defined.

You should receive a copy of the new care plan before you leave.

Prepare for the Care Plan Conference

Request a copy of the previous care plan before the meeting if you don't have one.

Make a written list of your questions and concerns. If you have praise for anything or anyone pertaining to your loved one's care, make sure to include this on your list so you don't forget.

Use the questions below as a guide:

1. Have there been any changes to the resident's health, behavior or physical abilities since the last conference. What are the professionals' assessments of the reason for any changes? What are your thoughts?

2. When was the last time the resident saw his or her doctor? Has the doctor ordered any treatment or medication changes?

3. What are the special therapy goals (physical therapy, occupational therapy, speech therapy), if any? Is the patient making progress toward these goals, or do they need to be modified in any way?

4. Is the patient/resident eating and drinking well? Has the patient's weight changed since the last conference?  Have there been any issues or concerns about the food?

5. Is the resident participating in activities? Are there any activities the resident would enjoy that could reasonably be added to the activity schedule?

6. Does the resident need anything you may not be aware of, such as new clothing, personal care items, reading or craft materials? Are vision or hearing assessments needed? Can these be done on-site?

7. Have there been any important changes in direct care or administrative staff since the last conference?

8. What changes would the staff recommend that have not already been discussed?

9. What changes would you and the resident recommend that have not already been discussed.

10. Praise and compliment any improvements or progress you have noted since the last conference. Nothing is too small.

Mutual Respect is the Key

You catch more flies with honey, and you'll almost always make more progress when you approach care conferences with the assumption that the facility has your resident's best interests at heart. Be fully aware of your resident's rights, but try to avoid putting the facility staff on the defensive if you can. Always do your best to prioritize your concerns, so that the most important are addressed first. 


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