Client Education

Care Planning

Why Plan for Care?

By: Dennis Arp, Special to AccentCare

As a home-care nurse, Mary Mickelson has received hundreds of panicked calls from seniors or their loved ones over the years. But none hit so close to home as the one she received last December.

That's when she learned that her 93-year-old father had slipped and broken his ankle in his San Diego home. That's also when she began to fully realize the importance of having a plan for her father's in-attendant & personal care.

Over the next five weeks, Mickelson, the former owner of Senior Home Care, came to depend on that care plan. She trusted it to help her coordinate the visits of 11 different care professionals, from X-ray technicians to podiatrists to medical-supply delivery people to trained caregivers, as her dad progressed from the ankle injury to pneumonia and a bladder infection.

She and her mother, 87, leaned on the plan to chart her father's use of medications, to monitor the housecleaning they could no longer do and to alert the caregivers to his special needs.

Mickelson's goal was to keep her father out of the hospital. "Had he gone in and then developed pneumonia and a bladder infection, he may not have gotten out at all," Mickelson said. "Probably not in less than two months, anyway."

Her father's goal was to get well enough to visit his 89-year-old sister, who was dying of cancer in a convalescent hospital.

Missions accomplished.

"Because of my experience, I knew a care plan was useful," Mickelson said. "Now more than ever, I know why it's important to have that plan in place."

For many people, a crisis is the first time they recognize the need for a plan of care. "Then it? a scramble to find services," said Virginia Pinkerton, director of quality management and regulatory affairs for AccentCare. "But a care plan is really one great tool for planning ahead, for being prepared when a crisis hits."

A good care plan is more than just a listing of services an older adult needs to live independently at home, said Monique Snyder, a certified geriatric care manager based in Carmel, Calif. "It considers the whole person, from emotional and physical state to likes and dislikes to how that person? life experiences have helped shape them."

Without a plan in place, care can be fragmented, and small problems can get overlooked—until they become big ones, Snyder said.

"The two main reasons seniors end up in the emergency room are poor nutrition and not taking medications correctly," Pinkerton said. "You may have a caregiver helping Mom with the bath or getting dressed, but if that caregiver isn? also aware that Mom has been depressed and hasn? been eating, she might miss a chance to help keep her health from deteriorating."

Then there's the emotional support a good care plan provides. Members of the senior's family may live across town or across the country, but when they receive ongoing reports that show that all aspects of the senior's care are accounted for, "the value in terms of peace of mind is immeasurable," Snyder said.

Here? how the care-plan process generally works:

A geriatric care manager will visit the senior's home to compile information on his background and current living situation. From that information, the care manager will create a care plan.

This service can cost several hundred dollars but may be well worth the price. The local agency on aging should have more information on care managers in the senior's area and on whether financial assistance is available.

To simplify the care-planning process, this Web site offers a free assessment tool you can fill out for yourself or the senior in your care and then receive a comprehensive plan created to meet his specific care needs.

Whether it's done in person or online, a good care plan will feature a summary of the senior's situation and then suggest changes that would benefit him. It will coordinate events, such as doctor's appointments and visits by home health aides, while suggesting tools to keep the senior on schedule, such as day planners and reminder calls.

It will detail his medical conditions and list the medications he? taking, while pointing out any potentially dangerous drug interactions. If the senior is having trouble taking medications, it will offer solutions, such as using a weekly pill box or getting larger print on the prescription label.

It will also identify potential health problems, such as diabetes or depression, and suggest preventive steps.

The report will evaluate the risk of dementia or Alzheimer's disease and suggest ways to protect the senior. It will offer tips on home safety and basic self-care, such as using bigger buttons or Velcro to help the senior dress himself, or hiring a house-cleaning service to clear clutter that could lead to a fall.

It will evaluate the senior's diet and in many cases suggest services such as Meals on Wheels or a home health aide who prepares meals, to ensure proper nutrition.

The report will also point out any legal documents the senior is missing or financial steps he should take.

"The more closely the plan reflects who the senior is, the better it will serve him, " AccentCare Pinkerton said.

"We don't want to deal just with the part of the person that is ailing," Pinkerton said. "We want to deal with the whole person abilities as well as needs."

That means the client will have to answer some personal questions. The more honest the answers, the more thorough and effective the care plan will be, Pinkerton said.

Here are some of the potentially sensitive areas the senior may be asked about and why the answers are important:

The first step in assessing a senior? situation is to find out if he lives at home alone, with others or in an assisted-living setting. Knowing what care is already being used will help determine what options to recommend.

"What is your marital status? If widowed, how long ago did your spouse die? What is your level of education? What are your hobbies? Do you have pets? Do you attend church?"

These might seem like overly personal questions, but the answer to each plays an important role in building a care plan.

If the senior is recently widowed, it will likely take an emotional toll, and he may want to get counseling. If the senior attends church or has social engagements, the plan might need to include transportation arrangements. In addition, the church he attends could offer senior services he can tap into. If he has a pet, he may need someone to shop for cat food or to take Bootsy to the vet.

In addition, there may be social groups in the senior's area that reflect his hobbies and/or past occupation.

"If I have a client who's a Harvard graduate and is lacking stimulation, I may choose to look into the local college for some senior courses," Snyder said. "By the same token, a lack of education could impact the plan. I once had a client who was a migrant worker and never went past the second grade. When the hospice team left notes, he wasn't able to follow them. So we used a tape recorder to leave directions."

"What is your monthly income? Does anyone help you with finances? Do you have a power of attorney?"

The answers to these and other questions will help determine what financial steps the plan addresses. The report may suggest that the senior speak with an attorney or financial planner, or that he set up a living will or advanced directives.

If his monthly income and level of insurance coverage are limited, he may qualify for financial assistance.

"Are you depressed? Anxious? Alert? Sad? Suicidal?"

A range of mental-health services may be available to help the senior cope. This also is one of many areas in the plan where categories of questions and care might overlap. The senior? hobby may have been playing bridge, but since he lost his partner, he no longer plays. Which has led to depression, a loss of appetite and nutrition-related health problems.

Just by suggesting he get involved with a bridge club, the plan could positively affect the senior? mental and physical health.

"This is what we mean when we say it's important to have a plan that considers the whole person," Snyder said.

Seniors who have a care plan find it's easier to cope with a crisis because all they need to do is update their plan instead of starting from scratch, said Carol Marshall-Shoup, director of Care Coordination for AccentCare. The plan should be updated once a month or after each hospital stay or change of orders by a doctor, she said.

"Then we can look back at the plan, at what we're done before, the same way a doctor looks at your chart before he recommends new treatment," she said.

Now that Mary Mickelson's caregiving crisis has passed and her 93-year-old father has recovered from his broken ankle, pneumonia and bladder infection, she still relies on her updated care plan.

There are still appointments to juggle, deliveries of medical equipment to arrange and visits by home health aides to stagger.

Caregivers help maintain a calendar, with notations each time Mickelson? dad eats, takes medication, etc. Even children and grandchildren who live outside the area are called on to assist. They are assigned certain times during the week to call their dad or grandpa to make sure he? OK.

"Now everyone feels as if they're contributing to Dad? care," Mickelson said. "He looks forward to the calls, and they look forward to making them.

"We even pulled my dad into it. He will look at the schedule and say, " time for my exercises," or "forget my medication." He has gradually moved to a more independent state."

Mickelson said she still worries about her father.

"But at the same time, I know he? where he wants to be," she said. "And he? as safe as he can be."

Dennis Arp is a freelance journalist who writes about health-care-related issues for newspapers, magazines and the Web.