Care plan meetings have always been an essential element for the professional staff to define the care needs of our patients. They are not only essential for the care team, but are mandated by the regulators for licensure.
A meaningful care plan meeting in a nurinsg home should not focus on the Minimum Data Set (MDS) information. The MDS is the standardized, set of data elements that nursing facilities gather and submit for reminbursement. The MDS is mandatory for the facility that receives funding from the government for care of its residents. Neither should the care plan be a regurgitation of clinical terms and language that the family and resident cannot understand.
At a recent care plan meeting, the rehabilitation staff stood at the bedside of the resident. The senior was hard of hearing and no one recognized this difficulty even though the senior asked to have information repeated on multiple occasions. The therapy staff spoke about minimum, moderate and extensive assist. They futher noted that the senior required contact guard assistance and that she could not go home until she was at the level of stand by assistance. The resident had been in the facility for over two weeks and the medications she was being administered were not correct. When the care plan meeting was over, the senior asked me what had gone on at the meeting. She had not been able to hear and said she did not understand what the team was saying. Since they would not speak up, she dismissed the importance of the meeting.
The care plan team did not recongize these deficits. They were simply following the rules. The real issues of the resident were not addressed. She had a fracture and no one asked her if the pain medication she was taking was effective or if she was having side effects from it. No asked her about her food intake which is important to healing. She had refused virtually every tray of food that was delivered to her. No one asked her about her home and the thick, plush carpet that she has in her home. No one asked her about distances that she was going to have to ambulate when she returned home. No one asked her about whether her bathroom was handicapped accessible. There were many important issues that were overlooked that would have provided the team with intimate knowledge about this resident's plan of care.
As a family member, please try to attend care plan meetings. Facilities should do their best to work within your schedule. If facilites recognize the value of the family input, they will be flexible with time and date. Facilties that are rigid about scheduling care plan meetings do not understand their innate value and rationale. They are only looking at the meeting as complying with requirements.
If you do not see the care plan meeting as having value, it is due to the facility's lack of understanding of the process. The care plan meeting is a two way communication tool. The interdisciplinary team at the facility should explain the plan of care. The family brings the unique perspective of the resident so the team can tailor a plan that meets the unique needs of the resident. Be an active member of the advocacy team for your family member. Whether there is dementia or not, we need your input to do our best job for your loved one.