What is a care plan?

A care plan is a written strategy for how a person's care needs will be met each day. Consumer Voice describes a nursing home care plan as setting out what each staff member will do and when, and as a guide for the resident, family members and staff to discuss progress. At home, a written plan does the same job for family members and paid caregivers sharing the work.

For someone with dementia, a care plan should cover thinking and memory, daily function, safety at home and when driving, medications, behavioral symptoms and depression, the caregiver's needs, and advance care planning. The Alzheimer's Association's care planning toolkit lists these as required parts of Medicare's care planning visit, which ends with a written plan shared with the person and caregiver, including referrals to community resources.

A care plan meeting, or care plan conference, is where nursing home staff and the resident or family agree on how staff will help the resident every day. Consumer Voice says the first is held within 7 days of the initial comprehensive assessment, with the doctor, nurse, nurse aide, activities and dietary staff and social worker, and that reviews follow quarterly or after a major change in condition.

A dementia care plan is a written plan to address a person's thinking and memory symptoms, behavior changes, daily needs and safety, and to link the family to support. Medicare Part B covers a separate visit to create one, in which the provider reviews medications, identifies social supports, including what the usual caregiver can provide, helps update an advance care plan and refers to specialists or community resources.

For a person with dementia, a care plan can be written by a doctor, nurse practitioner, clinical nurse specialist or physician assistant during a care planning visit, with input from the family. The Alzheimer's Association toolkit lists these as the practitioners who can provide Medicare's care planning service. In a nursing home, an interdisciplinary team writes it, and a geriatric care manager can also build a long-term care plan.