Question:  My mother moved into a nursing home recently. The staff invited me to her care plan conference. What is a care plan?

Answer: Developed during the care planning conference, the care plan is an arrangement for how the staff will care for your mother and meet her individual needs and wishes. The nursing home must assess your mother’s needs, interests, and level of care. These assessments are the basis for planning her care. Care plans are reviewed every three months and revised when your mother’s needs change. A properly implemented care plan can improve your mother’s experience at the nursing home.

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Question:  If the nursing home staff has completed the assessments and they have determined what needs to be done to care for Mother, why do Mother and I need to go to a care plan conference?

Answer: Your mother’s role as resident during the conference is to help the staff get to know her. She can talk about her needs, interests, and how she feels about being a resident of the facility. It is important for the staff to understand her strengths (physical, social, spiritual), daily routines, abilities, expectations, and preferences. Sometimes residents are unable to communicate this information during a conference and their family or legal representative is invited to attend the care plan meeting. This is a good time to discuss medications, personal care, staff, activities, food, and restraints. Be sure to talk about what your mother needs and how she feels. A successful care planning conference involves many people including: your mother, you (if your mother would like you to be there), and an interdisciplinary team which includes the physician, nurse, social worker, nurse assistants, pharmacist, therapists, and others as needed. You and your mother can bring up problems, ask questions, or offer information to help staff provide individualized care. You and your mother can review your mother’s assessments and records at the nursing home prior to the care plan conference.

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Question:   Mother has not been happy that the staff wakes her up and gets her out of bed at 5 AM. I’ve mentioned it to the nurses and nothing seems to change. I don’t think they are listening to us. I’m not sure if going to a care plan conference will make a difference. Is there anyone who can help us?

Answer: Yes! The ombudsman can help you. Many residents and families ask the ombudsman to attend the care planning

conference with them. Each resident in the 17 county Bluegrass area of Central Kentucky has access to certified long term care ombudsmen from the Nursing Home Ombudsman Agency of the Bluegrass (NHOA). If you don’t know the ombudsman, just call NHOA toll free at 1-877-787-0077. The ombudsman can meet with your mother and you prior to the conference and help plan a personalized agenda for the meeting. The ombudsman can help review medical records and assessments, formulate questions about prescribed treatments, identify concerns, and goals to be discussed at the conference. The ombudsman can help you and your mother understand her rights as a resident and how to exercise those rights as she participates in the planning of her care. The ombudsman can advocate on your mother’s behalf. Before the end of the care plan conference, remember to ask for a copy of the care plan and the name of the staff member to talk to if something on the care plan needs to be changed.

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Question:   What happens after the care plan conference?

Answer: After the conference, it is important to monitor the implementation of the care plan. Are the activities in the care plan carried out as agreed? Is the plan of care meeting your mother’s needs and goals? Talk with the facility staff or ombudsman if things are not going as planned, there are problems, or the plan needs to be adjusted.

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Question:  Where can I get more information about care planning?

Answer: Just call the Nursing Home Ombudsman Agency toll free at 1-877-787-0077. We have a new guide to long-term care for residents and families and other materials which describe care planning, and rights and problem solving in more detail. Many families and residents utilize our materials. We are happy to send you materials or you may access them at www.ombuddy.org.

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This Column is presented as a public service of this newspaper and the Nursing Home Ombudsman Agency of the Bluegrass. If you have a question, send it to Sherry Culp, NHOA, 1530 Nicholasville Rd., Lexington, KY, 40503.

©2009 Nursing Home Ombudsman Agency of the Bluegrass, Inc.