When and How to Update a Care Plan for a Senior Parent

If you will be a caregiver for your senior parent or another family member or are already serving in this capacity, it is important to have a written care plan. A care plan is a tool that caregivers and long-term care providers use to coordinate and manage a care recipient’s healthcare goals, needs, and services. Family caregivers benefit from this care plan, but it must be regularly evaluated and updated to continue being effective. Once an initial care plan has been established, all aspects should be reviewed periodically. This is particularly important after certain health events occur or transpire.

How Often Should a Care Plan Be Updated?

Care plans are constantly evolving. The evaluation frequency depends largely on the nature of a care recipient’s medical conditions and the level of assistance needed. For example, someone with a progressive condition like chronic obstructive pulmonary disease or Alzheimer’s will likely need more frequent assessments and updates than someone with milder or more stable health conditions.

As a point of reference, Medicare requires home health agencies to review each client’s care plan at least once every 60 days. In Medicare-certified nursing homes, full health assessments and appropriate care plan updates must occur at least once every 90 days. Both these examples focus on patients with fairly complex medical conditions and care needs. With that said, attention to detail is crucial in a care plan. This is true even for older adults who are still fairly healthy and independent.

How to Identify Important Changes Warranting Care Plan Updates

Picking up on even subtle changes in how a senior feels physically and mentally is an ongoing part of serving as a caregiver to an older adult. The first step in identifying potential important changes warranting updates to a care plan is to talk with the care recipient. It is important to listen to the care recipient to pick up on any changes or complaints that appear to be new or more significant than usual. There certainly are situations in which a senior isn’t forthcoming.

There are also instances in which seniors cannot convey their feelings. In such situations, you will need to rely on careful observation to detect changes in body language and behavior that may indicate pain, discomfort, or confusion.

Certain changes warrant immediate contact with an older person’s primary care physician. These are changes that likely will necessitate a care plan alteration. These include:

  • Frequent urination or changes in bowel movements
  • Itching, wounds, or new skin problems
  • Changes in balance, coordination, or strength
  • Indigestion or nausea
  • Thirst, increased hunger, or loss of appetite
  • Fever
  • Drowsiness, fatigue, or insomnia
  • Headaches or body aches
  • Dizziness, restlessness, or a tendency to stumble or fall
  • Changes in mental status

How to Ensure Proper Care Plan After an Emergency Room Visit or Hospitalization

If a recipient of care visits an emergency room or is hospitalized, an existing care plan must be reconsidered.

If a senior is admitted to a hospital, a transitional care plan should be provided as part of the discharge process. This plan will detail all new medications, prescribed medical equipment, such as mobility aids, any therapy needs, and orders for follow-up medical appointments. An existing care plan must be adapted to recognize these transitional necessities.

Remember that a hospital discharge care plan could be as simple as adding an antibiotic to their medication regimen for 10 days to treat a urinary tract infection. On the other hand, a discharge plan could necessitate a short-term stay at a senior rehabilitation facility to address a new or worsening chronic condition.

As a primary caregiver, you must carefully review the discharge and transition plan with a discharge coordinator at the hospital. The coordinator will help you decide if you can handle your senior loved one’s care independently or if in-home care or a rehab stay will be necessary to meet recovery needs, goals, and objectives. If possible, involve your loved one in conversations with healthcare providers so that the care recipient understands what will occur in the future. A senior care recipient also needs to understand that a return visit to the hospital may result if discharge instructions aren’t followed.

Schedule all follow-up appointments as soon as your loved one returns home. As a caregiver, you usually have to make an appointment with a care recipient’s primary care physician within a couple of weeks of a hospital visit. A primary care physician should be familiar with your loved one’s health status and the various sources of support they receive. These details are crucial for coordinating a more permanent care plan for treating and managing a senior adult’s condition.

Setting New Health Goals in a Care Plan

Sometimes changes to a care plan are not made because of a hospital visit or a change in health status. Rather, certain care plan modifications are made to refresh a senior’s daily routine to provide or enhance preventative health benefits. A caregiver can work with an elder care recipient to set personal goals to improve their physical and mental health and overall quality of life.

Revised goals in a care plan need not be major. Even small goals can motivate short-term or long-term objectives. Incorporate daily activities that will help them tackle these objectives. Minor advances can help a senior achieve more meaningful achievements over the long haul. When older adults are active participants in their own health and well-being, they can usually remain independent and safe in their homes for a longer period.

Communicate With All Care Team Members

A typical care plan typically necessitates the involvement of multiple people. These often include:

  • Primary caregiver
  • Recipient of care
  • Primary care physician
  • Other healthcare professionals
  • Other professionals

Regular communication with all team members is vital. Each person brings a unique perspective and area of expertise to the table regarding keeping a care plan current and relevant.  

As the primary caregiver, you can best ensure that a care plan is followed by making frequent check-in phone calls with other team members. These strategies can also keep everyone informed. Regular communication makes it easier to recognize behavioral patterns or symptoms that should be addressed. Regular communication aids in recognizing when a care plan needs to be modified.