Senior Safety: Examples of Effective and Poor Individualized Care Plans

If you’re at all familiar with senior home care, you know how important it is to have an individualized care plan for your loved one. However, not all care plans are created equal. In fact, a poor or mediocre care plan can sometimes do more harm than none at all. But unless you’re a trained nurse, social worker, dietician, or home health aide, how do you know if you’re making a good care plan or a bad one? Read on to see examples of specific care plans in different categories – and which ones you want to model yours after.

Individualized care plans for falls

One of the most common problems for the elderly is falls – this is true for both those living in facilities and in their own homes. The following are two examples of individualized care plans; the first is what not to do, and the second is the appropriate course of action.

• Problem: patient is at risk for falls.
• Solution: patient will try to be careful and not trip over things. Home health aide will assist patient if she falls, and notify emergency facilities, physician, and doctor if fall occurs.

Why is this a bad plan? Goodness – where do I even begin? The problem is identified, but not the underlying factors. Why is the patient at risk for falls? As for the solution, what role does the aide play in assisting the patient not to fall in the first place? Far too much emphasis is placed on what happens after the patient falls, rather than on prevention. Here is a much better plan:

• Problem: patient at risk for falls due to vertigo caused by medication.
• Goal: patient will not have any falls while home health aide is on duty.
• Solution: aide will orient patient to environment (call bell, walker, etc.), request that she ask for help when needed, attend to patient needs promptly, and keep environment free of obstructions.

This plan (although much simplified for the sake of brevity) is more effective because it lists a reason for the fall risk, specifies a goal, and has actionable steps both the aide and patient will take to prevent falls. At certain intervals (monthly, quarterly, or as needed) such individualized care plans are typically reviewed and revised by the health care team, family, and patient, if they are able.

Individualized care plans for infection control

Infection control is another issue one sees a lot of in eldercare, although this is slightly more common in long-term institutions such as nursing homes. However, seniors with wound care issues and similar challenges can easily contract infections at home as well without the appropriate strategy to counteract them. Below is an example of how not to outline a care plan for this issue:

• Problem: patient returning home from sub-acute rehab with diabetic wound on leg.
• Solution: wound will heal in reasonable amount of time.

The wound will heal? How? Will the patient take care of it? If not, who will help and how? What’s a “reasonable amount of time,” and what happens if the wound gets worse instead? Look below for a more detailed explanation:

• Problem: patient returning home from sub-acute rehab with diabetic wound on (right or left) leg (where wound is X inches in diameter).
• Goal: wound will decrease in diameter to (X minus Y) inches) in (Z) weeks (X, Y, and Z will depend on the wound’s severity).
• Solution: Nurse will make home visits two to three times per week to do anti-bacterial treatments, change wound dressing, and monitor wound healing progress.

Start making good individualized care plans today

Individualized care plans are a great preventative measure even if your senior doesn’t have any urgent medical issues at the moment. But if they do, or their physician is concerned they might in the near future, procrastinating can cost them dearly. If you need help crafting ones specifically for your senior, a qualified home health care agency has professionals that can help. Don’t put this one off – start making your senior’s care plans today.
If you are unsure of how to best help an aging loved one, the trained and compassionate staff at the Institute on Aging is here to help you make that decision and gain the best in at-home senior care. Contact us to find out more.