A Family Care Plan

In my prior post I talked about the factors to consider when developing a care plan: needs, preferences, personal and community resources. Now we can start to put together the actual care plan keeping those concepts in mind and reminding ourselves that the goal of a good care plan is to promote the highest quality of life possible.

The care plan I think is most useful consists of 5 parts.

  • The care plan states the problems
  • The care plan identifies the goals
  • The care plan lists the solution(s) to address each problem
  • The care plan identifies the person(s) responsible for seeing that each problem is addressed
  • The care plan includes a timeline for the completion

Some goals require more than one solution. All care plans need to be reevaluated after a period of time.  Sometimes the reevaluation must be done because a person’s physical or mental status changes. However, even during periods of stability a person’s needs and the care plan should be reviewed at least every six months.

So let’s use a simple scenario to develop a care plan:

Mom is an 84 year old widow in generally good health. She lives alone and many of her friends and family have either moved away or died. Mom is beginning to have difficulty managing her daily life. Although she had successful cataract surgery she is uncomfortable driving after dark. As a result she is becoming more isolated because she no longer goes out at night unless someone else is driving. She also finds that she has less energy to do the many things she used to do in one day and she has started to become overwhelmed by tasks that used to be easy for her. For example, she can still balance her checkbook but now finds that task stressful. Mom would benefit from some extra help.

Step 1: Talk to Mom. It’s very important to open a conversation. You may think that Mom needs some help—but she may not. However, assuming you have a good rapport and Mom agrees to accept some help let’s see what a care plan for her might look like. A few issues stand out: Mom’s reduced energy and decision not to drive at night limit her social and community life; Mom is getting stressed by tasks that were once easy for her to do. These issues need to be addressed because we know that social engagement and activity are important components of well-being and successful aging while stress is detrimental to health. The care plan needs to support increased social connection and reduce stress.

The Care Plan:

Problem 1: Mom is becoming more isolated due to limited driving and lower energy.

Goal: Maintain the level of social engagement and activity that Mom would like in her life.

Solution 1: Identify transportation options in the area, car services such as Uber or Lyft, taxis, public transportation, a family member, friend or acquaintance who might be willing to drive Mom to activities. Discuss options with Mom. The solution most likely will involve using several types of transportation. Mom might want some help while she tries out these different services and modes of transportation, such as having someone accompany her on her first few rides using public transportation, Lyft or Uber.

Person Responsible: Daughter who lives nearby and Mom.

Timeline: Two months to set up and try out transportation options.

Solution 2: Work with Mom to identify and try new opportunities for social engagement in the community. For example, these may include a local senior center, a university that offers adult learning classes, joining a faith community (if Mom is not already affiliated with one) or other ideas depending on Mom’s interests.

Person Responsible: Daughter and Mom

Timeline: 6 months

Problem 2: Mom is finding it more difficult to manage her household chores due to limited energy.

Goal: Relieve Mom of some of the more demanding household tasks.

Solution: Mom is able and willing to hire a cleaning service to take over heavy cleaning.

Mom feels comfortable hiring someone herself.

Person Responsible: Mom

Timeline: 1 Month

Problem 3: Mom is finding daily money management, i.e., writing checks and balancing her checkbook, stressful but still wants to oversee and control her finances.

Goal: Relieve Mom of the stressful parts of money management in a way that leaves her in control.

Solutions: Various choices include setting up automatic payments for regularly occurring bills, on-line banking, having a family member take over the task, hiring a professional daily money manager or some combination of these options. Mom is most comfortable having a family member take on the task.

Person Responsible: Daughter

Timeline: 1 month

Clearly this is a very simple care plan. Care plans become more complex as physical and cognitive health declines and when there are multiple family members involved. However, the principals and components remain the same. That is, the care plan should take into account to person’s needs, preferences, personal and community resources, to the extent possible, as well as identify the needs, goals, solutions, responsible person and a timeline.

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