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The Advance Care Plan
Federal law requires every long-term care facility to create a care plan. The care plan begins with a baseline assessment, which should occur within two weeks after a resident moves into the new facility, by a team from the nursing home (which may include a doctor, nurse, social worker, dietician, and physical, occupational, or recreational therapist). This team will use information provided by the resident and the family about the resident’s medical and emotional needs to generate this baseline assessment, which then becomes the yardstick against which the caregivers can measure the resident’s progress.
You can help by making a list of your loved one’s medical, psychological, spiritual, and social needs, as well as his or her preferences and usual routine. For example, you might give the staff the following type of information: “Dad likes to listen to classical music on the radio as he falls asleep” or “Mom’s always been a night-owl; she goes to sleep at around 1 a.m. and wakes up at 10am.” You should also note signs of depression, or symptoms of dementia. Since the assessment team does not know your loved one as well as you do, your input may be invaluable, especially if the resident is not able to provide meaningful input. Although development of a care plan is something required to be done by a nursing home, a care plan can, and ideally should, be created in advance, well before the need for nursing home care. By planning in advance, when you have a clear mind and the ability to communicate effectively, you can much better guarantee that your wishes, lifestyles and desires are documented and will be communicated to your future caregivers, whether these be family members, private nurses, home health aides, or staff in a nursing home.
The easiest way to develop your own care plan is to use a tool such as the Advance Care Plan, created by Advance Care Planning, Inc. The Advance Care Plan is a proprietary document that is created by special software that gathers, organizes, stores and disseminates information provided by you in an interview, in order to better serve your future healthcare needs and to guide those who you will depend or for future care. The Advance Care Plan identifies your specific needs, desires, habits and preferences and guides your caregiver in a unique manner. An Advance Care Plan should be created as part of your basic Estate Plan or as part of your Long- Term Care Plan, because the best person to create a care plan for you is you. The following example is provided by Advance Care Planning, Inc. of how an Advance Care Plan can help improve a day in the life of Lynn, a typical nursing home resident: