Who Creates the Resident Care Plan? A Look at the Interdisciplinary Team

Within 14 days of a resident's admission to a skilled nursing facility, a comprehensive assessment must be completed to begin the process of creating their care plan. This vital document is not created by a single individual but is a collaborative effort involving many healthcare professionals, the resident, and their family, to ensure a truly person-centered approach.

Quick Summary

A resident care plan is developed by an interdisciplinary team (IDT) of medical and supportive professionals, including nurses, doctors, dieticians, and social workers. Most importantly, the resident and their family are key participants in this collaborative process to ensure the plan is personalized and comprehensive.

Key Points

• Team Effort: The resident care plan is created by an interdisciplinary team (IDT), including the resident, their family, and various healthcare professionals like nurses, doctors, and social workers.

• Person-Centered: The resident's personal preferences, goals, and life history are central to the care planning process, ensuring it respects their autonomy and dignity.

• Ongoing Cycle: Care planning is a continuous five-step cycle involving assessment, diagnosis, planning, implementation, and regular evaluation to adapt to the resident's changing needs.

• Legal Rights: Residents and their families have the right to actively participate in meetings, influence decisions, and receive information about their care plan.

• Improved Outcomes: Effective, personalized care plans enhance resident quality of life, reduce hospitalizations, and ensure consistent, high-quality care across all staff.

• Baseline Plan: A baseline care plan is developed within 48 hours of admission to guide initial care until a comprehensive plan is established.

Understanding the Interdisciplinary Team (IDT)

At the core of resident care planning is the interdisciplinary team (IDT), a group of experts from various fields who work together to create a holistic, customized plan for each individual. This approach ensures that all aspects of a resident's well-being—physical, mental, and emotional—are considered. The IDT model contrasts with a multidisciplinary approach, where specialists may treat a patient without the same level of coordinated communication. The collaborative nature of the IDT is what makes it so effective, especially in complex care settings like skilled nursing facilities.

Key Roles on the Care Planning Team

Different professionals bring unique expertise to the table during the care planning process. The composition of the team can vary based on the resident's specific needs, but typically includes:

• Attending Physician: The physician provides the medical diagnosis and orders, guiding the overall medical direction of the resident's care.
• Registered Nurse (RN): As the primary care coordinator, the RN is often responsible for developing and documenting the nursing diagnosis within the plan. They conduct assessments, implement interventions, and evaluate progress.
• Certified Nursing Assistant (CNA): CNAs provide daily hands-on care and offer invaluable insight into the resident's routines, habits, likes, and dislikes, which are essential for personalizing care.
• Social Worker: A social worker addresses the resident's psychosocial needs, connects them with community resources, and provides emotional support to both the resident and their family.
• Dietitian: The dietitian assesses the resident's nutritional needs and preferences, creating a dietary plan that supports their health and well-being.
• Therapists (Physical, Occupational, Speech): These specialists help set goals and develop interventions for rehabilitation, mobility, daily living activities, and communication.
• Activities Director: This team member helps identify and plan social, recreational, and spiritual activities that align with the resident's interests and preferences.

The Resident and Family: The Most Important Participants

Legally and ethically, the resident and their designated representative (usually a family member) are the most crucial members of the care planning team. A person-centered approach dictates that the resident's goals, preferences, life history, and routines should be at the very center of the plan. This ensures that the care provided maintains their dignity and respects their autonomy. Family members can offer historical context and emotional insights that staff may not have, leading to a more comprehensive and personalized plan. Their involvement also empowers them to advocate for the resident's best interests and provides an opportunity for transparent communication with the care facility.

The Step-by-Step Care Planning Process

The creation of a resident care plan follows a structured, continuous cycle:

1. Assessment: Within 14 days of admission, the IDT conducts a comprehensive assessment of the resident's physical, mental, and psychosocial condition. This includes functional ability, strengths, needs, and personal preferences. A baseline care plan is also established within 48 hours to guide initial care.
2. Diagnosis (Nursing): Nurses use the assessment data to make a nursing diagnosis, which identifies the resident's health problems from a nursing perspective.
3. Planning: The team, with the resident and family, collaborates to set specific, measurable goals and identifies the necessary interventions. This person-centered plan is completed within seven days of the assessment.
4. Implementation: The care plan is put into action by the staff, who follow the outlined interventions and strategies.
5. Evaluation: The IDT regularly reviews the plan to evaluate its effectiveness and check if the resident's goals are being met. Reviews happen at least quarterly and whenever there is a significant change in the resident's condition.

Why Care Plans Are So Important

A well-executed care plan is more than just a document; it is a critical tool for ensuring high-quality, consistent, and respectful care. It serves as a blueprint for staff, ensuring continuity of care across different shifts and team members. For residents and families, it provides peace of mind that care is organized and tailored to their specific needs. Ultimately, effective care plans can improve resident outcomes, enhance quality of life, and reduce the risk of hospitalizations and medical errors.

Comparison Table: Care Plan vs. Medical Orders

Feature	Resident Care Plan	Medical Orders
Creator	Interdisciplinary Team, Resident, Family	Attending Physician
Focus	Holistic well-being, personal preferences, daily routines, social needs, and overall care strategies	Specific medical treatments, medications, tests, and procedures
Goal	To attain and maintain the highest practicable physical, mental, and psychosocial well-being	To diagnose and treat medical conditions
Review Frequency	Quarterly or with significant change	As determined by the physician and clinical need
Authority	Guides day-to-day care strategies for the entire team	Directs specific medical actions to be performed by licensed staff
Content	Broader scope covering activities, diet, personal goals, and medical needs	Narrower, medically-focused instructions

The Resident's Rights in the Care Planning Process

Residents have significant rights when it comes to their care plan, and facilities are required to ensure they are involved in the process. These rights include:

• The right to participate in the development and implementation of their person-centered plan.
• The right to request meetings and revisions to the plan.
• The right to help establish expected goals and outcomes of care.
• The right to have personal and cultural preferences incorporated into the plan.
• The right to receive advance notice of changes to the plan.
• The right to see and sign their care plan after significant changes.

For more detailed information on resident rights and how to advocate for effective care planning, resources like California Advocates for Nursing Home Reform (CANHR) offer valuable guidance. Visit the CANHR website for resident rights resources.

Conclusion

The resident care plan is a cornerstone of quality senior living, ensuring that care is not only medically sound but also deeply personal. It is created through a collaborative, interdisciplinary process that brings together diverse expertise to address all facets of a resident's needs. The central involvement of the resident and their family is paramount, transforming a clinical document into a living guide that respects individual dignity and promotes a fulfilling life.

Frequently Asked Questions

Who specifically creates the resident care plan?

The resident care plan is developed by a team of professionals, known as the interdisciplinary team (IDT). This team includes a registered nurse, physician, social worker, and other therapists or specialists, in collaboration with the resident and their family.

How often is a resident care plan reviewed?

Care plans are formally reviewed and updated at least every three months. However, if there is a significant change in the resident's physical or mental condition, the plan must be updated sooner to reflect their new needs.

Can a family member participate in creating the care plan?

Yes, family members or designated legal representatives are crucial participants in the care planning process. Their input helps ensure the plan reflects the resident's personal preferences, history, and goals.

What is the difference between a care plan and a doctor's order?

A doctor's order focuses on specific medical treatments and medications, while a care plan is a broader, holistic guide created by the IDT. The care plan incorporates the doctor's orders but also includes daily routines, personal preferences, and social needs.

What if a family member disagrees with the care plan?

Residents and their families have the right to be involved and provide input. If you disagree, you should request a care conference with the IDT to discuss concerns and suggest alternative approaches. The facility must address these concerns and document any changes.

Does a resident have to agree to the care plan?

Under federal law, residents have the right to accept or refuse any care or treatment offered to them. The facility and physician must inform the resident about treatment options and their potential benefits and consequences.

Who coordinates the care plan within the facility?

The registered nurse often serves as the primary coordinator, but a dedicated 'Care Plan Nurse' or care coordinator may also be responsible for organizing the care plan and ensuring the team and resident are aligned.