Patient and Caregiver Resources

The Care Plan and Meeting

If your loved one is admitted to a skilled nursing facility, Medicare requires the staff develop an initial, personalized care plan within the first 48 hours. This describes who should be doing what. Then, within the first 14 days, the staff must assemble a comprehensive assessment, which must include your loved one’s needs and strengths. Also their goals of treatment, personal preferences, and a brief life history.

Then, within a week, a formal care plan meeting of all the care team members—including your relative if they are able—is required, to develop a durable roadmap for care based on the assessment. As your loved one’s representative, you have the right to be involved in the plan and meeting.

The care plan lays out what services are needed to support your loved one toward achievable physical, mental, and psychosocial well-being. For example, physical, speech, or occupational therapy sessions. And it identifies dietary guidelines and food preferences. Overall, the plan must tie into and support your loved one’s stated goals.

Here’s how you can help:

  • Before the meeting. Ask your relative what’s going well and what’s not. What do they prefer would happen? Help prioritize their questions and requests.
  • During the meeting. Help the staff understand how best to communicate and work with your loved one. Keep your relative’s goals and preferences at the forefront. You can ask questions or request changes if you don’t understand or don’t agree with staff recommendations. Take thorough notes. You also have a right to a written copy of the plan.
  • After the meeting. Monitor how the care plan seems to be working and definitely talk to staff if questions arise.

Build bridges with a collaborative approach rather than a confrontational mindset. If this sounds daunting, give us a call at 302.478.5707. We can help advocate for your loved one’s wishes.

Has your relative been admitted to a skilled nursing facility?

If so, you have the right to participate in the care plan meetings and in the development of the care plan. As the Delaware, and Delaware and Chester Counties in PA expert in family caregiving, we at Delaware Palliative can help make sure your loved one’s needs and wishes are addressed. Give us a call at 302.478.5707.

Find out how we can help you and your loved ones live comfortably:

Complete an inquiry form online

Print an inquiry form and fax it to our office at 302.479.2597

The region’s leading licensed nonprofit community-based healthcare organization, serving the entire state of Delaware and Pennsylvania’s southern Chester and Delaware counties.

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