What is a Person-Centered Care Plan?
Federal regulations for nursing homes require that a Comprehensive Person-Centered Care Plan is created for every resident “that is consistent with their resident rights” (CMS § 483.21) and “that includes measurable objectives and timeframes to meet a resident’s needs and describes the resident goals, preferences, and desired outcomes.” (CMS F656)
Unfortunately, all too often these plans are written only to meet the regulations.
They end up being just another piece of paper in a chart and are rarely looked at.
Every nursing home resident has the right to participate in developing their own person-centered plan of care.
This individualized care plan identifies what and how their care is to be provided and incorporates their personal goals, preferences, and how they want to experience their daily life and routine in the nursing center.
Interdisciplinary care planning meetings bring together all care partners, including the resident, to discuss the resident’s unique situation and preferences and work together to decide on a comprehensive plan to make it happen.
This is a very personal, even intimate, encounter.
It results in a commitment on everyone’s part to meet the agreements laid out in the plan.
It is best when the plan is written in the “I” format, as if the resident is speaking directly about their personal preferences.
Care plans help foster relationships and ensure continuity when there are new staff working with a resident.
These plans are living documents and if they are treated as such, can be a powerful tool to guide the entire care team to drive person-centered and person-directed practices.
Just like we use our GPS to guide our travel, when care plans are created and used correctly, they ensure that the resident is providing the care team with the directions for how they want to live their life with dignity.
If you were going to create YOUR person-centered care plan, what would you want your care partners to know about YOU?
Who do you need to share this information with so that they can advocate for you?
