Many elderly people you’ll know have some form of disease or another, often times more than one. This basically implies that they have a tendency to take several medications and/or treatments at the same time. Unfortunately, there is no universal way for this to occur as each organism reacts in a different way. This is not only applicable to organisms of different people but also in the organism of the same individual. When this happens, it is referred to as comorbidity.
Treating the triggers, not just the symptoms
Chronic conditions are not getting worse at a constant rate. They flare-up. For example, a senior with heart failure and Type 2 diabetes may be going along well for months until a missed medication here, a dietary slip there, or an unusually stressful week serves to push them over the edge into crisis. A good care plan outlines those specific causes – the particular circumstances that have tended to lead to a bad spell in the past – and provides the caregiver with a set of responses to use when things start getting out of hand.
This is where home care truly becomes preventative rather than responsive. When a caregiver knows that a certain client’s blood pressure tends to spike in response to a rough night’s sleep, that’s part of the plan. They’re monitoring for it. They can report it to the family or doctor before it leads to a hospital stay.
Bridging the communication gap between everyone involved
An often overlooked failure within elder care is fragmentation. The primary care physician writes up a treatment plan. The cardiologist makes adjustments to medications. A family member is overseeing the day-to-day. Nobody is regularly communicating with everyone else, and the older adult is stuck in the middle.
A care plan centralizes all of that information – preferably as a shared document that every player (physicians, specialists, a paid caregiver, family) can ideally refer back to. It spells out who’s responsible for what, who needs to be alerted when anything shifts, what decisions need to be made, and how the process of changing the plan works. This isn’t just administrative tidiness. When multiple caregivers are part of the day-to-day, that’s the information that’s making sure nobody doubles up on – or misses – medications or appointments.
Families looking for care options should begin by understanding the types of home care services available, as differences in the kind of personal care, companion care, and skilled nursing care someone requires will directly inform the kind of care plan that needs to be in place.
Beyond medical: the lifestyle layer
An effective care plan must be comprehensive and account for the complete needs of the person. Social determinants of health such as isolation, diet, mobility, and mental engagement must be included in the plan along with clinical needs and medication schedules. Lifestyle prescriptions are critical to maintaining stability and overall health. For seniors with cognitive decline, a routine isn’t just part of the plan, it’s a necessity.
Plans should evolve, not sit in a drawer
A care plan that is established when the senior is diagnosed is the first step in planning care, but it’s not going to cover all the future care needs that senior will have. What a person needs when he or she is first diagnosed varies greatly from what they will need in short order if that condition worsens. The entire point of scalable assistance – the ability to increase or decrease the amount of support the senior is receiving – is that someone goes in and actually does that. They can only do their job if they’re being given the information they need in order to make the right choices.
A functional needs assessment done every six to twelve months provides that information not only to those currently providing care but to the senior and his or her family. It’s the reality check that says whether the current level is still working. Or maybe they need to be doing more. If a functional needs assessment is framed as something that helps people get what they need and when they need it, rather than a test they need to pass, the conversation shifts. Then the concept of “aging in place” isn’t just an unrealistic dream.
This determination needs to include a respite from caregiving, however, or the family caregivers will start losing interest in the project. Burn out is real and most often it’s the people who are providing the care.
The plan is what makes everything else work
While a plan is built on information and informed by communication, it’s more than just a notebook full of instructions. It’s a living, breathing thing that shifts and adapts as something new is learned or a situation changes. A caregiver’s mom might have good weeks and bad weeks as her rheumatoid arthritis flares up, or a son is suddenly able to take over Wednesday night so his sister can have a predictable respite. The more attention they pay to what is and isn’t working, the easier it is to adapt the plan to make things better.