How to Design the Perfect Care Plan for My Mom

August 5, 2019

We’ll share insider tips to designing the perfect care plan for your Mom (or Dad). But, first, you probably want to know why a care plan is so important.

A care plan is a road map for care. It ensures care has direction toward achieving the goals you want. The care plan instructs caregivers or other care providers.

Why does a care plan matter?

It is the job description, therefore it tells those providing care what to do (and, when designed properly, how to do it).
The care plan sets expectations. It communicates what needs to be done, preferences, and key details. When done well, it sets those expectations clearly in specific language, reducing misunderstandings.
It creates a roadmap to successful care. Without it, everyone involved is “wandering aimlessly”, making it unlikely to reach goals or succeed with the care being provided.
It sets priorities and keeps care on track. Caregiving is unpredictable. Mom might have a bad day, life happens. A well-written care plan builds in predictability even to the unpredictable days. Everyone knows tasks that must be done even when time is tight, and aren’t left wondering what to do on days when there is more time. Your Mom won’t feel like she needs to entertain her caregivers; they have guidance about what to do so she doesn’t have that burden of being a manager.
It sets the basis for good communication and feedback. Because it outlines what needs to be done and how, you and the care team can refer to it in evaluating progress and areas that need improvement. It is a concrete means for measuring progress.
Without it, there is no direction…and therefore, no results.

The Care Plan as Job Description for the Caregiver

When designing the perfect care plan, remember it is the caregiver/care team’s job description. It helps to be sure the right caregivers are matched with Mom, that they have the tools they need, and that they understand clearly how to do what you want and what Mom needs.

Here are key components of the “job description”:

What – What do you expect from the caregiver? What would Mom like the caregiver to accomplish during their shift? At EasyLiving, we train our staff to ask for specifics and examples. Further down, you will see tips that help to use the right language to communicate this information clearly.

How – How will the caregiver complete what the client wants? This is especially important when establishing the relationship with the agency/caregiver, to be sure things you want done are within their scope of service and licensing. This also helps identify the right caregiver with the skillset to accomplish what your Mom needs. By looking at the “how”, your care providers can also identify tools or supplies they might need to complete the tasks (for example, a basin for a bed bath or a shower chair for the client who prefers showers; preferred cleaning supplies and tools).

When – When do you want certain tasks done? Is there a set time and day or guidelines, such as breakfast after 9 AM for the non-early riser? Or, should the task be done at Mom’s request? Would Mom prefer the caregiver ask/confirm before starting a task?

Why – The why is important to understand the safety and care goals of the case. Example: Why the floor must be thoroughly dried after mopping is to prevent falls in a susceptible client. Knowing why emphasizes the importance of tasks and details that may not seem so important otherwise.

How to Write a Good Care Plan: Language Tips

To have a proactive caregiver you must write with proactive statements. Here are examples of what not to write, and how to instead write a proactive statement:

Poor care plan language:

Check to see if client is wet and change undergarments.

Occasionally check to see if client is wet and change undergarments.

These statements leave a lot of room for interpretation with their vague language.

A well-written care plan statement:

Check every two hours for bowel incontinence. Change when undergarment is soiled. Undergarments are located in closet by the bathroom.

This statement provides specific direction. It also allows direct measurement of whether care tasks are being performed according to the plan. It doesn’t leave room for confusion. And, it includes the “how” and details.

How can you develop specific action statements?

By asking Mom behavior-based questions, such as:

When you say “x” can you please give me an example of what you mean?

Can you show me how you would like “x” completed?

Can you tell me what you want the caregiver to do when…?

Setting expectations in the care plan:

One essential rule in any care plan is not to make assumptions. Layout specific expectations to avoid misunderstandings. This also ensures there is detailed information for any substitute caregiver to be able to provide consistent care.

This might include everything from tasks to communication. For example, the care plan can give examples of some things caregivers should do when first arriving at Mom’s home and how she wishes to be greeted. This sets things off on the right foot.

Clients often complain that cleaning or some other task isn’t being done properly. In most cases, this is a matter of not setting proper expectations. The specific tasks and way they should be done was not explained, but assumed. For example, one family member said, “It’s not that hard to know when I say I wanted cleaning done, that it includes the baseboards. Everyone who cleans, cleans baseboards.” However, you can’t make that assumption. By writing this into the care plan, the caregiver can do the job the way you want. Caregivers don’t go into the job wanting to fail. They want to do a good job, they just need the information.

Some additional information needed to set expectations:

Schedule/shifts
Are there dogs/pets in the home? Address caregiver safety and any pet care needs.
Meal preparation
Supplies needed/where supplies are located
Process for purchasing Items
Handling breaks, lunch, water, bathroom etc. (the care planning process is a good time to review the importance of providing a comfortable working environment for the caregiver and treating them fairly and kindly)
Issues about the work environment (temperature of the home is one common problem)
Handling transportation needs (what’s needed, will the caregiver be driving Mom’s care or his/her own?)
Handling items breaking in the home

The Care Plan in Action

The well-written care plan is the job description. Now, to implement it in the best way possible, job training is the other key component. Much of that training comes from the caregiver’s professional training and company training. For example, at EasyLiving, we make sure our caregivers are trained in areas such as communicating with older adults, dementia care, food preparation and household chores, and personal care and safety. We provide orientation, continuing education and on-the-job training and supervision. This is something to ask about when you are hiring a caregiver or agency.

However, beyond that type of training, there is the specific training to your Mom’s needs. It starts with the care plan, but then it is important to show the caregiver what you mean and how you want things done. We call this the show and tell method. For example, if you want clothes folded and put in a certain dresser, you talk about that aspect of the care plan while showing the caregiver the dresser. Remember, the way Mom wants things and what she needs may be quite different than a caregiver’s other clients. A caregiver has a lot to remember. They need to get used to how you do things and where you keep things. Showing visually reinforces the information in the care plan. It aids visual learners to better understand and recall.

Feedback and Changes

With a good care plan as your base, feedback is easier. You can point to any specific items that aren’t being done according to the plan and demonstrate how to improve. If you find that something was missing from the care plan or not communicated well enough, you can update the care plan. Care plans are living documents that should be updated when there are client changes of any sort. At EasyLiving, we also review them every 60 days to get specific feedback and check if updates need to be made.

Our team also prepared a list of tips for how to get a positive response when giving caregiver feedback.