Create a care plan
Summary
A care plan is an essential caregiver’s tool that details a person’s care needs, organizes a caregiving team, and assigns the caregiving responsibilities. This article describes the typical components of a care plan and suggests a process for creating one.
Care plan elements
A care plan is an essential caregiver’s tool that outlines a person’s care needs, organizes a caregiving team, and assigns the caregiving responsibilities. This is different from a medical plan for care that doctors and nurses create for their patients.
Every care plan will look different, depending on a person’s situation and the people available to provide care. However, most plans include summaries of the following elements:
- A person’s health situation. This includes their physical and mental condition, prescription, treatments, and other medical matters.
- Major care needs and activities of daily living (ADL). Major care needs include things like having catheters changed or bedsores cleaned. ADLs include activities such as dressing, eating, bathing, and going to the bathroom. Transportation needs can go under this heading or be put in a separate section.
- Financial and legal matters. These can include paying bills, managing health insurance, assigning powers of attorney, and drawing up a will and living will.
- Caregiving tasks. These include such items as making meals, assisting with medication, shopping, driving, providing companionship, and driving the person to appointments.
- People on the caregiving team. This can be split into the core team (e.g., spouse/partner, adult children, very close friends) and the supporting team (e.g., casual friends, neighbors, co-workers, out-of-town relatives).
- Schedule of caregiving. This says who will do which tasks when.
- Contact list. This gives the names, phone numbers, and email addresses of everyone on the caregiving team and medical professionals. Everyone on the list should be added to the Maia Care app so that they can access important information and receive updates.
- A care log and calendar. This is a space to note observations about the person’s condition, behavior, medications taken, etc., and to note any doctors’ appointments, adult day care sessions, and so on. Using the Care Notes and Care Events sections of the Maia Care app allows all team members to access this information.
Creating a care plan
Like the care plan itself, the process for creating one will look different for every situation. What’s important is to recognize that a plan is necessary for effective caregiving and to put one together as early in the caregiving period as possible.
Typical steps of creating a care plan include talking to the person receiving care, gathering the core team, naming the primary caregiver, naming area coordinators, creating the supporting team, assigning and scheduling tasks, and setting up a communication system.
- Talk to the person receiving care
This is the starting point for developing a good care plan. Have conversations with the person about areas where they feel they need or want help. Ask who they want as their primary caregiver and which other people they would be comfortable having help with care. Get the names and contact information of all their medical providers, as well as potential members of the care team, such as neighbors or walking buddies. Take notes to share with other team members.
- Gather the core team
Hold an organizing meeting of the core team members. Appoint someone to take notes so that everyone feels listened to and accurately understood. Let each person speak in turn about their availability, feelings about caregiving, strengths they can offer and areas they want to avoid, and personal boundaries and limits. Discuss options for accommodating these as much as possible. Go over the notes from the conversations with the person receiving care.
- Name the primary caregiver
The primary caregiver is often the person who lives closest to the loved one, has the closest relationship with the loved one, has medical power of attorney, and/or has the most time to devote to caregiving. Even when there are enough people to spread the caregiving duties evenly, it is a good idea to name a primary caregiver to act as team lead and first point of contact for medical professionals and the health care system.
- Name area coordinators
It is a good idea to assign a coordinator for each major caregiving area—for example, meals, scheduling, medications, transportation, companionship. This person won’t be carrying out all the tasks in this area, but will be responsible for coordinating and managing that aspect of the care. For instance, the Meals Coordinator might note in the Maia Care Stream, “Dr. says Mom must eat more fiber. Nancy and Ken, could you please switch to whole-grain bread on your lunch-making days?” Try to make the person in charge of scheduling different from the primary caregiver, as scheduling is a very time-consuming element.
- Create the supporting team
People outside the core caregiving team are immensely important. They lighten the load, provide coverage, and give variety to the person receiving care. The supporting team can include neighbors, people from church, friends of the caregivers, community volunteers, out-of-town relatives, and so on. Even those who can’t be there in person can help by joining the person in doing online puzzles and games, offering to watch the same TV shows, and having phone chats about each episode, etc.
- Assign and schedule tasks
With the primary caregiver and area coordinators named, it is time to assign specific tasks and create a daily schedule. This might have entries like, “Wed: 8-10am, Jan at Dad’s, gives meds, helps with breakfast. 10-12, Dad on own. 12-1, Victor visits. 1:30pm, dialysis St. Bart’s (8840 Chester Ave.); Frank driving.”
- Set up a communication system
Communication is the most important component of the care plan. People need to know what’s expected of them, what has happened with the person thus far, and what changes are coming up. Decide on a method and frequency for getting in touch with members of the core and support caregivers. Use both a primary method, such as the Maia Care app, and a backup, such as phone or email, for those who may dislike the primary method.
Review and adjust the plan
Keep the care plan fluid. Once it’s in place, assess how it’s working. Ask the person receiving care and the other caregivers what they like and don’t like, and adjust the plan accordingly. Keep adding members to the supporting team and rotating them into the schedule.
Hold regular meetings of the core team. If the condition of the person receiving care worsens, expect to meet more frequently and revise the plan to provide more coverage.
Related information
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Deal with caregiver burnout
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Find trusted sources of help
Get help and support
Join a caregiver community
Minimize family confusion, disagreements, and frustration
Take care of yourself emotionally
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