Developing a Plan of Care

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Developing a Plan of Care

          

After completing a health assessment, you have a baseline for your family member and a starting place for developing a plan of care. A comparison with their baseline can help you determine if they are showing an improvement or decline in their state of health. Your initial comparison looks at what is considered average or “normal” for other people in that age range with the same nationality, gender, and race. If you have access to their prior medical history, you should also compare their current baseline to their past medical history to see what, if anything, changed significantly. After looking at all this data, you can determine what is typical for that person. You can tell the normal range for their vital signs, how often they relapse with any medical condition, and which conditions place them most at risk.  

Why is it important to know someone’s baseline?

Suppose your family member’s lab work usually shows a potassium level that is in the high normal range. When he gets labs drawn, his lab work shows an abnormally low potassium level. Should you be concerned since it’s still normal? Maybe not, but it’s worth watching because there is such a significant drop from very high normal to very low. What’s causing the change? If there is a good explanation, there is nothing to cause alarm. If you do not know the cause, it might be reasonable to look closer. What might be a concern for one patient may be a significant concern for another if it’s a far stray from his standard.

Develop a Problem List

After reviewing your family member’s prior medical history, develop a problem list based on what you learned while doing your baseline health assessment. Include on your list everything causing suffering, requiring medication or special treatment, or having the potential to cause harm. Then, prioritize the problem list based on the effect the problem had on quality of life, safety, or potential for adverse outcomes.  

Sort Your List

Some of the problems on your list are issues that may or may not ever occur. Items such as those related to getting vaccines or completing annual follow-ups. Anything not needing weekly attention goes into a “non-urgent” file. Later, you may want to set up a calendar showing when you want to deal with those issues so you don’t forget them. Keep in mind, however, that anything in the non-urgent file could jump to the front of the line if circumstances exist. Those that don’t need daily attention are placed in a folder to re-evaluate quarterly or more frequently if symptoms develop.

The remaining items are those that need daily or weekly attention. These items become the foundation for your problem list because you will spend most of your time caring for them. Learn about these problems – what is expected (appearance, temperature, lab values, risk factors, treatments, etc.)  

Establish Goals

Caregiving may be a short- or long-term commitment. You may sometimes feel discouraged that nothing changes because you don’t see progress. Often recovery is difficult to see because it comes in baby steps. However, if you jot down a few recovery goals and review them periodically, you may be amazed at how far your family member has progressed.

Create some short and long-term goals that determine your recovery goals. You want some to celebrate immediately and some to work toward achieving. Below are some examples.

Here are examples of goals.

Long-term goals:

    • By Christmas, he will walk with a cane instead of a rollator.
    • He will walk the treadmill for one mile daily by the end of this quarter.
    • He will walk unassisted and without a cane by the end of February.

Short-term goals: 

    • Today, he will sit in a chair for 3 hours instead of two.
    • By the end of this week, he will button his shirt on his own.
    • By the end of the month, he will put his shirt on by himself and button all the buttons himself.
  1. Keep your goals focused on progressing toward recovery with realistic, achievable increases.
  2. Please encourage your family members to do as much independently as possible.
  3. If Physical Therapy (PT) or Occupational Therapy (OT) comes to your house to work with your family, try to get everyone to work on the same goals. For example, OT and PT may both work on independent eating at the table. While OT works on hand-to-mouth strengthening, PT works on core muscle strengthening for sitting up.
  4. Establish your goals on the first day of the week and celebrate your victories at the end of the week. Keep the goals small and measurable. The easier the goals are to achieve, the better they become to provide positive reinforcement and encouragement.
Create Action Steps

Coming up with action steps can be difficult for someone with no experience. You may wonder where to get ideas. Start by looking through some of the topics found on this website. Then, look through some of the organizations found on the Resources pages. Many resources offer guidance documents, toolkits, or other materials for you to consider. Look at several and decide what works best for you.

 Keep your plan simple. Don’t make it elaborate or complicated. Remember that you don’t want to spend time doing busy work. Only add to the plan what is productive and helpful to your family member’s recovery. When one task can address multiple problems, let that one solution solve 15 problems if it can. You don’t have to have a separate action for each problem.

There are no rules for putting your plan together–make it work for you. One approach is to make a calendar of tasks done on certain days of the week. Another way is to plan your activities around similar tasks, such as performing skin or wound care activities at bath time. Use whatever process seems most straightforward or more natural as a workflow.

Implement Your Action Plan

Don’t be surprised if some things you try don’t work. Expect that you’ll need to tweak the plan a lot. Until you get a sense of what works, plan on making daily changes. Keep at it until it feels like you have a plan that you and your family members feel comfortable doing. At that point, you will be in “maintenance” mode rather than design mode. Savor the feeling because something will happen to make you need to change it before too long—it always does. Learn to be flexible.

How is Your Plan Working?

It’s a good idea to periodically check your plan to see if you’ve overlooked anything. You also need to confirm that you’re making progress. You do that by comparing where you are now with your baseline measurements.

Track your progress to determine if you are achieving your goals. Record each treatment that can support progress or the need for a change. For example:

  • Wounds:  Record the measurement of the widest point of the wound, left to right and up and down. Then, using a q-tip, measure how deep it is. Describe the color, smell, thickness, or odor of any drainage.
  • Insulin:  Record the blood sugar readings for the day and the amount of insulin given based on that reading.
  • Vital signs:  Record blood pressure, pulse, respiration, and oxygen saturation for the day. Note any unusual values obtained.

When you see grouped data, analyze the information to see if trends (similar behaviors) emerge over time. If you see improvement, you can call the doctor to discuss changing the treatment plan, or if a doctor’s order is not needed, make the change yourself. If you achieved your goal, take that step away and pat yourself on the back.

On the other hand, if there is no change or a decline, take action to try something else. Let the doctor know your findings and strategize with your family member’s doctor what the next step should be.

 

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