Chapter 7: The Care Plan Conference

1.  The first care plan conference

Within 21 days after your mother enters the nursing home, and at least every 90 days afterward, the nursing home is required to have a "care plan conference" at which she and the staff set measurable, specific "goals" for her to meet during her stay, decide what needs to be done to meet those goals, and, perhaps most important, decide who in the nursing home is responsible for performing each job necessary to help her.  Completing the Minimum Data Set and any evaluations suggested by it gives your mother, you, her doctor and the staff the information necessary to plan her care. 

Your mother and her family are supposed to be told ahead of time, when the care plan conference is scheduled.  The meeting is supposed to be scheduled when it is possible for your mother, her family, and whoever else she wants there, to be present.  In practice, care plan conferences are almost always held between 9 and 5 on weekdays.  A few days after your mother is admitted, you can ask the Director of Nursing when the conference is scheduled.  If she does not yet know, keep asking until you have an answer.


2.  Who should be at the care plan conference

To the extent your mother is able, every decision about what goals to set and what care she is to get, must be made by her and the staff together.  Thus, unless it is impossible, your mother should attend the care plan conference along with all family members or friends who are involved with her and know her circumstances, and whom she wants there.  If she cannot leave her bed, the conference can be held in her room.  

Even if your mother is incompetent or unable to speak, her presence can be helpful to remind people about her actual circumstances, her abilities and limitations.  If part of the discussion is likely to upset her, she can attend the first part, and then leave for the upsetting part. Even a resident with dementia should have the chance to attend the care plan conference.  Someone with dementia may be able to ask or answer some questions,  and have the care plan explained so as to understand at least some of it.

If you have somebody who wants to participate in the care plan conference but cannot be present, consider using some kind of computerized videoconference (such as Skype) or, at the least, setting up a conference call with a speaker phone.

Which staff attend the care plan conference to some extent varies with the circumstances of each resident. People who attend should include the Director of Nursing, the "charge nurse" for the unit or floor on which your mother lives, the aide who generally cares for her, the social worker, activities coordinator and dietitian.  If she is on a special care unit, the unit coordinator should attend.  If your mother is getting or is assessed as needing physical, speech, or occupational therapy, the therapist(s) also should be there. 

Doctors almost never come to care plan conferences.  For this reason, if you want the doctor to order something which is not already being done, or continue an order which might not otherwise be continued, you must talk to the doctor before the conference to make sure that (s)he phones in the order, or personally writes it in the resident's chart before the conference.

If your mother is supposed to get hospice services, call the hospice agency to make sure they know about the conference, and will have someone attend.


3.  At the care plan conference

Bring your list of care plan issues (the list we discussed in Chapter 6) to the care plan conference.  Do not leave until the group has discussed every issue on the list.  It is a lot easier to start out well at the beginning, than to change things that are going badly later on.  

Many nursing homes schedule care plan conferences to last no more than 15 or 20 minutes.  The staff may be shocked if you come fully prepared and wanting to discuss issues that take more than the scheduled time.  That is why we suggested (in Chapter 6) that you give the staff your list of issues in advance, so they can set aside enough time to cover everything.  Sometimes there are families waiting in the hallway for their meeting, as the staff tries to shoo you out because the meeting is taking too long.  You can be polite but firm in insisting that you do not have to be limited by the usual schedule.  If the meeting goes longer than the usual time, you may want to suggest continuing on another day, so long as it is within the 21 day maximum.  

You do not have to know what you want the nursing home to do about all the issues on your mother's list.  Having specialized knowledge about how to address care issues is the job of the staff.  You have a right to expect, however, that the staff will be prepared to create a plan of care for your mother that realistically meets the needs identified by the Minimum Data Set and by her list.  The plan should be in language she (and you) understand and agree with. 

If the staff does not want to care plan an issue that you want addressed, tell them what you want, and ask why they have not brought it up.  The staff might think, for example, that your mother will be too tired after physical therapy to participate in religious services.  If the staff wants to make a decision with which you or your mother disagree, you can each explain to the other why you think as you do.  If the process works as intended, you will learn from each other.  

Your mother has the right to refuse any kind of medical care, once it is explained to her what are the consequences of refusing.  The nursing home may not force your mother to move out because she chooses not to get some kind of care, even care she has agreed to in her care plan, unless her refusal puts another resident or staff person at risk.  If your mother has a contagious disease she can spread by coughing, for example, she does not have the right to leave her room to go to activities without a mask.  If she refuses physical therapy that the staff and her doctor think she needs, however, the “consequences” may be that Medicare will not pay for her care and she will never walk again.  The “consequences may not be that the nursing home discharges her for not “cooperating” with her care. 

If the list you prepared for the care plan conference includes arranging for your mother to see outside medical professionals such as a dentist, ask the staff at the care plan conference how they can help.  Tell them if there is a particular professional you want her to see, if she already has an appointment, or if she has a schedule of appointments she is supposed to make.  Give them the names, addresses and phone numbers of professionals she is supposed to see.  Ask if they (usually the social worker) will make appointments with these providers, and arrange for any necessary transportation and for someone to go with your mother if she should not go alone and you or another family member cannot go with her.  

If the staff agrees to make these arrangements, the care plan should include a schedule for each anticipated appointment.  If you need the staff to find a particular specialist, make sure they agree that they will do this.  If the care plan says the staff will make arrangements, you will need to follow through to make sure they do.  Remember that, even if the staff makes the appointments, your mother will be responsible for paying for any care she receives, either through Medicare Part B or otherwise.  

If your mother is planning to return home during the 90 days covered by the care plan, the plan should include discharge planning.    “Discharge planning” means making the arrangements, such as for home health care, that are necessary for her to move back home.  Discharge planning should include any suggestions the occupational therapist has made when (s)he visited your mother’s home.  Therapy goals set in the care plan should reflect the occupational therapist’s assessment of what your mother must be able to do to return home.

If you think your mother is going to have a hard time getting the nursing home staff to write the care plan she needs, or she is already having difficulty getting the care and services the nursing home is supposed to provide, you may want to ask the nursing home resident ombudsman to be at the care plan conference to advocate for your mother.


4.  Future care plan conferences

The nursing home is required to complete a short version of the Minimum Data Set and have a care plan conference every 90 days.  The purpose is to see if any basic information about your mother has changed.  Every future care plan conference should be a complete discussion of whether any goals set at the last meeting need to be changed – because they have been met, are now impossible, or your mother no longer wants to meet them –  and if new goals need to be set.  The people at the meeting also are supposed to talk about whether the staff are actually doing the tasks they were assigned at the last care plan conference, and if what they are doing meets your mother’s needs.

If your mother has a “significant change in condition” in between care plan conferences, the nursing home is required to redo her Minimum Data Set within 14 days after the change occurs,  and hold a new care plan conference within the next 7 days.  A “significant change in condition” includes:

  • your mother has lost some ability to do two activities of daily living;
  • your mother has lost some ability to do two or more areas of activities of daily living,communication, and cognitive abilities.  For example, she loses the ability to walk by herself, or use her hands to hold small objects, and thus feed and groom herself;
  • your mother’s behavior or mood have changed so as to create daily problems or damage relationships, and the staff believes her situation will not change without staff intervention;
  • your mother’s health becomes so much worse that her life is in danger, for example from a stroke, heart disease, or cancer that has spread;
  • your mother’s health becomes worse, and this change is associated with a serious healthproblem.  Examples of a serious health problem are a new stage 3 pressure sore, prolonged delirium, or a repeated decline in her level of consciousness;
  • your mother’s health becomes worse, and this change is associated with a new disease that islikely to affect her physical, mental or psychosocial well-being for a long time.  For example, she has developed diabetes or dementia;
  • your mother has lost a significant amount of weight;
  • your mother’s mood, behavior or functional status improve to the extent that her care plan nolonger meets her needs, and she has stopped improving.

Not all changes, even if they are dramatic, require a new care plan.  A new assessment and care plan is not required if the change in your mother’s condition is temporary.  If she cannot get out of bed and has no appetite because she has a cold and fever, for example, the staff need to use common sense and their nursing expertise to make sure she does not become seriously ill, but they do not need to formally reassess her or write a new care plan.  

A new care plan is not required if the significant change in your mother’s condition is easily reversible, or if it is already anticipated in her current care plan.  A new care plan is required if the change is an improvement in her health, but she has now stopped improving.

If your mother is readmitted to the facility after a hospital stay, she will need a new assessment and new care plan if she has had a significant change in her condition.

Finally, if your mother is in the last stages of a terminal illness, the staff will not necessarily be required to do a whole new reassessment and care plan, even if she does have a significant change in condition.  The test is whether the resident would benefit from the reassessment.  So long as the staff identify and met any new needs your mother has as a result of her illness getting worse, they are not required to do a formal reassessment.  For example, if your mother can no longer feed herself or get out of bed because her cancer has spread and she is too weak, the staff must make sure that she is fed nutritiously and gets enough fluid, assuming she wishes to eat or drink and can swallow or chooses to use a feeding tube.  They must make sure that she is kept clean and dry.  They must do what they can to keep her from suffering pain.  But they do not need to go through the formality of determining why her health has deteriorated, or try to reverse what is not reversible.  This subject is discussed at greater length in the next chapter, Working with a Hospice.