A successful home-based care plan is far more than a static checklist of chores and clinical tasks. It is a living roadmap designed to preserve independence, mitigate safety risks and evolve alongside patients’ and clients’ conditions.

Baseline care plans focus on managing immediate daily needs, keeping clients healthy and avoiding unnecessary trips to the hospital. The most effective care strategies, however, lean heavily into the client’s strengths and autonomy to help them thrive at home, industry leaders told Home Health Care News.

A care plan is a practical roadmap for caregivers to help a patient reach their goals and help mitigate potential safety risks, explains Kimberly Greenberg, director of rehabilitation and home health aide services (HHA) at Innovive Health.

Care plans begin with an intake assessment to determine a patient’s day-to-day support needs, physical and cognitive abilities, routines, risks and preferences and translate that into a plan for caregivers to follow.

Assessments include determining whether a client can engage in instrumental activities of daily living, such as meal preparation, or prevent outcomes that could threaten their health, such as shower-time falls.

“As an occupational therapist, I’m going to be assessing someone’s ability to do functional transfers throughout the home,” Greenberg said. “Are they safely stepping in and out of the shower? Are they engaging in hygiene routines that are appropriate to ensure that they’re not getting infections or to decrease their risk of wounds?”

Medford, Massachusetts-based Innovive Health provides home healthcare and skilled nursing services across Massachusetts, Colorado and Iowa.

Care plans should also recognize what a patient can still do independently, helping clinicians set realistic goals and avoid unnecessarily taking over these activities, said Shadi Gholizadeh, chief quality and compliance officer at TheKey.

“A good care plan should be much more than a task list,” Gholizadeh said. “A really good care plan goes deeper, and asks, ‘How do I provide help in the most acceptable way for this person?’”

TheKey Home Care, based in Delray Beach, Florida, offers in-home care, Alzheimer’s and dementia care, skilled nursing, geriatric care management and other services across 28 states and the District of Columbia.

Setting goals

Goals give the care plan its direction, Tammy Tenton, vice president of clinical and compliance at Avid Health at Home, told HHCN. Clinicians use the plan to identify what progress looks like for a particular patient — whether that means recovering from an infection, safely walking farther or maintaining the highest possible level of function at home.

“Their optimum might not be what their optimum level would have been maybe 10 years ago, five years ago, but what is it for right now?” Tenton said. “Sometimes it’s a small goal. It could be, ‘I want him to walk 20 feet.’ Five years ago that wouldn’t have been a big deal. But for this patient, where they are today, that might be very important.”

Another example is when a client is prescribed an antibiotic. The care plan should reflect that the patient should complete the antibiotic course and that the issue that necessitated the medication is resolved, Tenton said.

Care plans are a collaborative effort based on the expertise of a team of people, Tenton added. While the client’s caregiver typically drives the care plan’s creation, therapists or social workers can provide input on the care plan as well.

That collaboration is ultimately centered on a shared goal — keeping clients safely at home and avoiding unnecessary, costly trips to urgent care or the hospital, Tenton said.

Chicago-based Avid Health at Home provides personal care, respite care, Alzheimer’s and dementia services, private duty nursing and veteran care across Illinois, Kentucky, Michigan, North Carolina and Ohio. 

Evolving the care plan 

Care plans are not static. They should shift as the patient’s care needs evolve, Gholizadeh said. Determining necessary changes requires observing any deficiencies a patient may be struggling with, such as missing medications or falling behind on hygiene, collaborating with the care team and considering new goals.

“You have to observe, communicate, refine, observe, communicate, refine, over and over again, and the care plan is just going to get better and better,” Gholizadeh said.

Some patients may not appreciate the full breadth of their care needs.

For example, a side effect of dementia is anosognosia, a condition where a person cannot be self-aware of their physical impairments. Damage to the frontal lobe, the part of the brain that informs one’s sense of self, can cause the condition, according to the National Alliance on Mental Illness.

In cases of anosognosia, the client may feel fully capable of walking but still be at a significant risk of falling. The care team must work to create as safe an environment as possible, Gholizadeh said.

“A really common example is someone who may be a fall risk, and they’re unsafe walking without their walker, but they don’t think they need a walker,” Gholizadeh said. “Well, how can we make [using the walker] most acceptable?”

Ultimately, care planning is a continuous process of ensuring a patient’s ability to remain at home. The best laid plans ensure that clinicians and caregivers understand the services needed and the best way to deliver them for the patient’s safety and autonomy.

“It’s essential to get a care plan right because, in home health, we are oftentimes the single regular touchpoint for patients,” Greenberg said. “To support patients’ right to live and thrive in their home, you have to get the care plan items right, and that ensures that you’re providing high-quality care across every single clinician [who] comes and works with the patient.”