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What are Nursing Facility Care Plans and Care Planning Conferences?

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When a loved one is first admitted to a skilled nursing facility, family members often have questions about what the next steps will be for their loved one’s care. Many of the answers involving their family member’s care are provided for through care plans and care planning conferences.

Medicare and Medicaid nursing facilities are required under the law to provide services and activities for residents to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well being, regardless of the resident’s payment source, in accordance with a written plan of care.

The written plan is referred to as a care plan. A care plan is a comprehensive, multidisciplinary plan. It involves a team of professionals that can include the resident’s attending physician, nurses, nursing assistants, nutritionist, physical therapy staff, and activity coordinators. A resident’s care plan is developed based on an assessment of the resident’s needs. This assessment of the resident’s health condition must be completed within 14 days of admission to the facility.

Care plans are key to understanding a loved one’s care needs, making sure those needs are met, and setting forth expectations. While a typical nursing facility entrance contract does not have a specific set of services that the facility is promising to a particular resident, the care plan will have this information. The care plan will include critical information as to what types of health and personal services the resident requires, what staff will provide these various services to the resident, what nutritional needs the resident has, and any equipment, such as a wheelchair, that the resident requires. Importantly, a care plan will outline what the resident’s goals are and a plan to reach those goals. This can include whether the plan is for your loved one to stay in the facility long-term, or whether the goal is for the resident to return home or to another community, such as an assisted living facility. The care plan is updated whenever there is a significant change in the resident’s condition and adjusted based on the resident’s changing needs.

Care Planning conferences are held in order to review these plans. The first care planning conference will be held within 7 days of the completion of the assessment. The family members and resident can attend the conference with staff of the nursing facility. These conferences are a great opportunity for the family to understand what the plan for their loved one is, as well as to voice any concerns or questions they may have about their loved one’s care. Care planning conferences must be held anytime there is a major change with the resident. Changes could include a discharge recommendation or a significant change in the resident’s behavior.

While our office always encourages family to be involved with their loved one’s care, including attending care conferences, we understand that there are circumstances where this may not be possible. For instance, children of a resident may live out of town or have their own work or family obligations that prevent them from attending conferences, or a spouse may be stressed by the change in circumstances or facing their own health issues. That is why the care managers through our Care Management Services at Marshall, Parker & Weber are available to attend care planning conferences to advocate for your loved one and make sure that they are receiving the best care possible under the plan.