Issue link: https://www.newlifestylesdigital.com/i/859777
46 The Care Plan Conference: Making Your Voice Heard Most caregivers with a loved one residing in a skilled nursing facility (SNF) will be asked to participate in a "care plan conference," or a "quarterly care conference" at one time or another. Family members frequently attend these meetings at the request of the assisted living or skilled nursing facilities where their parent or spouse resides, but with a limited understanding of what a care plan document is intended to provide, or what the goals of an effective care plan conference should be. A care plan is a road map of sorts, which provides goals - and directives for achieving those goals - for residents, families, and facility staff. Care plans are required by any SNF that accepts Medicare or Medicaid (which includes 95% of all SNFs in the U.S.), per the 1987 Nursing Home Reform Law. An assessment must be completed within the first 14 days of a resident's stay in a SNF (or within the first seven days, for those whose stay is paid for by Medicare). The assessment is completed using a standardized document called a Minimum Data Set, or MDS. Within seven days of the assessment, a care plan must be completed, and a conference to discuss progress and changes to the care plan must be held at least every three months, or sooner, if the resident's condition changes significantly. Individual states regulate assisted living communities, and they are not bound to the same federally regulated, standardized assessment and care plan process. However, most states recognize the value of care planning in the assisted living environment and have implemented their own versions. Although many communities do schedule regular conferences to update care plans, it is not as strictly governed as in the SNF setting. Residents and their representatives can, however, request such a meeting at any time. In any setting, a good care plan includes a) measurable objectives, with time frames, b) tasks that have been assigned to specific staff members or other responsible parties, and c) methods of evaluation. A care plan should be written in language that everyone involved can clearly understand, and should reflect the specific needs and concerns of the individual resident. Most importantly, a care plan should be read carefully on a regular basis, revised whenever necessary, and followed diligently. The resident should attend the care plan conference whenever feasible, and the presence of an additional advocate is worth considering. It is important that all of the information shared by staff is heard and understood, and that the resident is not only communicating their needs and preferences clearly, but is being listened to by the staff. If a family member or friend is not available, you may bring in assistance from an outside professional such as a care manager or a private nurse or social worker. Residents and their representatives will receive a written communication with the date and time for which the next quarterly care plan meeting has been scheduled. Call to reschedule the meeting if that time is not convenient. Ask how much time is being allotted, and feel free to ask for an hour or more. Come to the care plan meeting with a written list of questions, concerns, and observations. If you do not have a copy of the current care plan, ask to see one. The care plan meeting is your opportunity to ensure that all of your family member's medical and non-medical needs have been identified and are being addressed in satisfactory ways. Although you may not resolve every concern at the time of the care plan conference, you should walk away knowing that an agreed-upon strategy is in place. Do not accept recommendations unless your loved one or their representative