Creating a good care plan
If you know that one day you may be caring for someone close to you, having a care plan is a great way to give you both confidence in what may lie ahead.
A ‘care plan’ is a document that outlines how a person might be cared for in a range of scenarios and who will be responsible for that care. It is a collaborative, organic document that can change and adapt with time and circumstances.
A good care plan creates a clear path for everyone involved and can help reduce the stress of deciding what to do if there’s a crisis.
It is an important tool for making sure that the needs of the person being cared for are met in ways that they would want and that their wishes are at the heart of all decisions. It also considers the needs of those taking primary responsibility for caring.
Here’s how to create a good care plan:
Start early.
When it comes to making sure you have good plans in place for someone you’ll be caring for, it’s never too early to begin discussions. Having said that, you might meet with resistance if you try and start planning before first getting agreement on the idea. Make sure they understand they are part of the process and that you want to work with them so that they are able to make their own plan.
Don’t be put off from starting the conversation.
Many elders tend to avoid discussing their own care needs and plans. Broaching the subject can be challenging, but this is an important first step for you both – for their future needs and for your successful caregiving.
Establishing a realistic and well thought through care plan can help make sure their independence and wellbeing are looked after, while allowing you to build support for what you do – with respite care and outside help as part of your regular routine. Be aware that without some structure and assistance from friends, family and elder care professionals, caregivers can leave themselves vulnerable to stress and burnout.
TIP: It can be worth thinking about having an elder care professional participate in the planning – a neutral third party who has experience in the benefits of care planning and knows what to cover.
Start by talking about the benefits of care planning.
Do they know what care planning is? Why do they think it might be a good idea? Talk about how it can help to be ready if things change, how it might help with communication and coordination. Explain that it will help to know what they would want if they weren’t in a position to communicate that at the time.
Take your time.
If they are not ready to have the conversation, then leave it for a while. It is easy to get caught up in the need to get things organised. Try to go at their pace. Seeding the idea and gently bringing it up again another time will usually get things much further than trying to insist on ‘now’.
Imagine the different futures you might need to plan for.
Developing a care plan means talking about the future. The very process of thinking about the changes the future holds can make it easier to cope with those shifts. You can talk about what might need to be different, recognising that some of what you imagine may not happen, but talking things through so you that can make decisions together. They might need care in the future, or more care, or you might not be able to keep caring for them. You can also talk with health care providers and other services to see how they can help.
Agree on who might need to be part of the wider care team.
You will probably need the input and support of wider family members, friends and elder care professionals to create and implement a good care plan. Members of the care team can include:
Family members
Friends and neighbours
Home care and home health care professionals
Care or activity centres
Age Care Professionals
Legal support/planning
Social workers
Doctors (your primary care doctor or specialists)
Financial planners
Members of the local community or religious groups
TIP: Think about the entire team that might ultimately need to be involved in putting your plan in place.
What’s included in a care plan?
A care plan typically covers:
A mutually agreed list of problems that might need to be dealt with
Defined goals for the person or people involved
Views of medical management – including what they do or don’t want in terms of medications and intervention
If and when they want to legally appoint someone else to make decisions – this can be you or another trusted family member or friend
A prioritised action plan/interventions/steps/tasks – based on their changing needs and their carer/support network
Crisis or contingency planning with written information re: early warning signs/red flags and actions to take
Outline of who is responsible for what, with sharing of responsibilities
Key actions and tasks in that person’s preferred language
Time and an agreed method for review and follow-up on the plan. Things can change and reviewing over time is a good idea.
As you talk about what they want to happen, write that down. This forms your plan and the details basically act as instructions from them that are known as an ‘advance care directive’, or a ‘living will’.
When you have a plan written up and agreed on, you should let everyone in the care team and health care team know that a plan exists and either give them a copy or let them know where copies are kept.
TIP: If you want your care plan to be formally recognised, bear in mind that each Country/Province/State has different rules about what documents are needed. So check out your local requirements.
Your changing role as a carer.
As a carer, you will probably experience different stages in your role, usually with increases in terms of time and energy required. As time passes, you might not be able to help the person you care for as much as you did. That can be because of their specific health requirements or your own health, work, financial pressures, family situation or other reasons. That’s why care planning also means thinking about what might change for you.
Consider what might change with your situation.
It’s important to start thinking about what changes might take place for you. Think ahead and ask yourself:
Who will care for the person if I can’t?
Do I have a back-up carer? If my plan was to be the full-time carer could they become the full-time carer instead?
Where will the person live if I am not around? Could they stay in their current home, move in with another family member, or would they need residential care?
Think about how you can get help with your role.
A team approach to caregiving is far more sustainable than a sole caregiver taking on all the responsibilities. For example, if you’re going to be a hands-on carer you might want to choose someone else to have guardianship or power of attorney and start to prepare for that.
You can talk with the person you’ll be caring for to ask what they would like if things did change for you. You can talk with your family and doctor about the options available. You might also want to talk through your options with other carers in online forums.
If you can’t provide care anymore.
For whatever reason, at some time you might not be able to continue to look after the person you care for. If that happens, you have two main choices:
Get help with care in your home
Many organisations have services that provide care in your home. Home care workers can help with all aspects of care, including washing, dressing, moving and meals. Workers might come to your home every day, or they can live with you.
Home care will allow you and the person you care for to stay in your home. However, sometimes the person might need more care than can be provided at home. Then you will need to think about moving them to live somewhere else.
Look at options for moving the person to a residential facility
There are several other places the person you care for could live, depending on their condition:
If you are looking after an elderly person, you can think about moving them to an aged care home
If you are looking after someone with a disability or a mental illness there may be care homes or group homes available
If you are looking after someone who is reaching the end of their life they may be more comfortable in a hospice.
Have an emergency care section in your plan.
An emergency care plan makes it easy for someone to take over from you in a hurry. It has all the information about the person you care for in one place, so you can get it quickly and easily.
The emergency care part of the plan has:
emergency contacts
the detailed care needs of the person you care for
medical information and contacts
a medicine list
carer emergency cards
any legal documents (e.g. Power Of Attorney)
Be flexible when you put your care plan into action.
The reason for having a care plan and a team in place is to help make things work as well as possible for all involved when they’re needed. But keep in mind that your care plan is likely to be an evolving tool. Planning and reality can be different and finding the best solutions may take some trial and error. Don’t be afraid to review and make changes. If things aren’t working as you thought they would, you can change them. Flexibility is key to success.
