A Care Plan for Multiple Needs

I’ve written a lot about care planning in general. A care plan is a good way to organize, and wherever possible, distribute tasks to ease the burden of caregiving. I’ve covered how to set up a care plan and gave an example of a simplified one. But as we know, life is complex, and many care receivers have multiple needs.

Here, I will outline how to set up a more complex care plan.

Similar to a simple one, we always start with an assessment in which we identify the needs, preferences and resources of the care receiver. Your planning process must include direct input from the person receiving care. Talk to them about where they want to live and who they want taking care of them. Most people prefer to be cared for at home by family, although this is not always the case.

The next step is to identify the kind of help the person will need if they opt to live at home and the type of support that exists for this person. Are there family members the care receiver likes who can help? Are there agencies or services within the community that can be used? Is there money to pay for services? Ideally, of course, all of the above exists. The fewer the resources, the greater the burden on the primary caregiver.

Let’s dig into a complex care plan using an example. David is a 79 year old man who has had multiple health problems. Most recently he suffered a stroke.  Happily, he is back home now with Sharon, his wife and primary caregiver.

David’s preferences:

  • David has stated clearly that he wants to remain at home.
  • David wants his wife, Sharon, to be his primary caregiver.

David’s medical needs:

  • Takes multiple medications four times a day.
  • Pills have to be crushed and mixed in with something easy to swallow such as applesauce or yogurt.
  • David is currently unable to organize and prepare his medications.
  • David requires physical and occupational therapy.
  • David needs someone to oversee his medical care and to take him to medical appointments.

Care plan tasks:

  • Organize David’s pills in a pill box and see that he gets them on time. Who: Sharon
  • Therapy three times a week. Who: A local home health agency. Note that the physical therapist has instructed Sharon so that she can help David practice his physical therapy exercises daily.
  • Manage medical appointments, transportation to and from medical appointments, communication with all doctors regarding his care. Who: Sharon

Note that in this example, Sharon is David’s second pair of ears, his note taker and advocate. There is also a home health agency in his community, and he has medical insurance to cover the cost of this care.

David’s needs for assistance with activities of daily living:

  • Medication preparation.
  • Assistance with bathing.
  • Assistance with dressing.
  • Assistance with grooming.
  • Standby assistance when walking.

Care plan tasks:

  • Crush medications and mix with applesauce or yogurt. Who: Sharon
  • Some assistance with bathing. Who: Primarily son Bob who comes over to help with a shower twice a week.
  • Some assistance with dressing. Who: Sharon.
  • Assistance with grooming. Who: Sharon
  • Standby assistance when walking. Who: Sharon

David’s needs for assistance with the tasks of daily living:

  • Cleaning
  • Cooking
  • Grocery shopping
  • Transportation
  • Yard and household maintenance

Care plan tasks:

  • Cleaning. Who: Sharon with help from cleaning person who comes every other week.
  • Cooking. Who: Sharon
  • Grocery shopping. Who: Sharon uses a delivery service for staples and shops for perishables.
  • Transportation. Who: Sharon
  • Yard and household maintenance. Who: Sharon with help from Bob, who mows the lawn and attends to other yard work on one of the two days he visits. Bob is also able to help with small household talks.

David’s needs for social interaction:

  • Weekly interactions with family members, other than Sharon, and friends:

Care plan tasks:

  • Weekly interactions with family other than Sharon. Who: Two daughters and son. Each daughter comes over one day each week for a few hours at an assigned time. They keep him up to date on their lives, talk about what is going on in the world, play cards together or sometimes just reminisce about family history. They also give Sharon some ‘hours off’ to see a friend or just take time for herself. Son, Bob, comes over 2 times a week to assist with David’s care, to visit with him and to help with yard work. Note that as David’s health and stamina improve Sharon will facilitate visits from friends to provide additional socialization.

As you can see from our example, each component of the care plan considers the care receiver’s preferences, needs, identifies solutions and specifies a person responsible for implementing tasks. Everyone has their days and hours set so that Sharon and David can count on help—and their adult children plan for the time.

Sharon takes advantage of every resource she has—in her family (her 2 daughters and a son) and her community (a home health agency and grocery delivery service), as well as the family’s financial resources (a cleaning person)—to see that David’s needs are met and that she is supported during this demanding time. This care plan does not have a time frame since the ‘solutions’ are ongoing. As David’s needs change, the family will reassess the situation and adjust the plan.

Comments

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