Guide to Creating a Senior Care Plan

A senior care plan is a tool used to identify an older adult’s needs and coordinate their care. A care plan should outline the services and supports a senior needs and who is responsible for providing them. When necessary, a plan should include a senior’s health conditions and specific treatments. It’s also important to make sure a care plan includes a targeted timeframe in which to reevaluate and update the plan.

Care plans vary based on a senior’s needs. Health care professionals, senior living communities, and home care providers all engage in some type of formal care planning process. Families can also use this approach to better manage their aging loved ones’ care.

A senior care plan helps to ensure a senior is receiving the care they need, but the benefits also extend to family caregivers.

Thoughtful senior care planning should:

• Help caregivers efficiently organize their duties
• Give a senior the opportunity to express their care preferences
• Provide a concrete list of tasks and activities that attend to a senior’s specific needs
• Organize a senior’s medications and provides details about when they should be taken or administered
• Facilitate communication between care team members
• Provide opportunities to discuss long-term planning which may include senior living options and estate planning

Caring for a loved one can be complicated, but creating a care plan can help you stay organized and break caregiving down into more approachable tasks. Try to make the processes of creating the care plan a team effort. For the plan to be effective, the plan needs to be realistic and address the needs of both the senior and their caregivers.

Identify your loved one’s needs

The first step in creating a well-rounded elder care plan is to evaluate your loved one’s needs. Work with your loved one to identify the areas where they’re still independent and where they may need assistance.

To determine what should be included in the care plan, assess the following elements of your senior parent’s daily life:

• Ability to perform activities of daily living (ADLs) such as bathing, dressing, and cooking
• Home safety
• Health status and medication needs
• Social interactions such as friend gatherings or community engagements
• Physical fitness
• Intellectual stimulation

When you’re evaluating a senior’s needs, using tools like an ADL checklist can help you document the areas in which your loved one needs assistance.

Determine care and supports

The next step involves identifying the specific care and supports for your loved one based on the findings of the assessment. Establish the goals of the care plan by addressing the following questions:

• Does your loved one prefer to age in place or in a community setting?
• How could outside support help to fill caregiving gaps?
• What activities or care would your loved one like to improve or incorporate into their routine?
• What supports can family caregivers provide, and for what tasks would it be helpful to have a professional caregiver?

Make sure to prioritize your loved one’s health, safety, and quality of life by identifying the care services they need and the frequency. Knowing your loved one’s financial situation will help your family understand your options.

Consider the following examples:

• For a senior who requires regular support with activities of daily living, list the daily tasks they need assistance with and address who will provide help. Family and friends may be the sole caregivers providing this assistance. Some families opt to incorporate the help of in-home care.
• If your loved one requires daily medication, you might start organizing the care plan with daily medication reminders, then identify who will be providing the reminder.
• For a parent who lives alone, ensuring their home is safe is critical. This could be as simple as removing tripping hazards but may also require major modifications, like grab-bar installations.
• Maybe your parent who lives independently no longer drives but would like to meet with friends for a weekly card game. You might list the event on the calendar and then delegate a family member or companion caregiver to provide regular transportation.

Once your loved one’s health and well-being has been addressed, you should move on to other elements identified in the assessment.

Create a senior care plan draft

After you’ve identified the team members, create a draft version of a customized plan for your loved one. Be sure to address concerns with concrete steps. Propose the care task or service needed to address a concern or need, then identify the individual responsible for carrying out or assisting the senior with said task. A senior care plan is a planning and organizational tool for the entire care team, so it’s important that the plan provides specific information about each team member’s contribution.

Before finalizing the care plan, you’ll need to conduct a meeting with the members of the care team to delegate tasks. This will provide an opportunity for your senior loved one and team members to offer input about their role in the care plan and make adjustments as needed.

Let our care assessment guide you

Think of the care plan as a road map that guides you and the other members of the care team. To make sure there’s no lingering confusion on roles and tasks, the care plan meeting should make any final decisions clear. It also offers another opportunity for your parent to be part of the planning process and offer feedback.

Identify who to invite

In addition to the person you’re creating the senior care plan for, the other individuals making up the care team will depend primarily on the senior’s needs as well as familial resources. For seniors who are relatively independent, the care team may consist of family members or friends. The care team may grow to include hired caregivers or medical professionals for seniors who require a higher level of care.

Based on your family’s circumstances, you may invite a social worker or financial planner. Some families may also choose to invite an elder law attorney to help navigate essential medical and legal documents.

Prepare for the meeting

Create an agenda that highlights what will be discussed and the goal of the meeting, as well as the estimated time length for the meeting. Depending on the number of proposed team members and the complexity of the topics to be discussed, you may consider the following tips to help the meeting run more smoothly:

• Choose a neutral facilitator.
• Assign a timekeeper to regulate comments and time spent on particular topics.
• Create and send video conferencing invites for team members who cannot be physically present.
• Record the meeting or assign someone to take notes.
• Arrange a comfortable environment, with food and beverages and comfortable seating where everyone can make eye contact.

Encourage open communication

The point of the meeting is to work together to create a final, working care plan for an elderly loved one who requires assistance. While differing viewpoints may emerge during the meeting, it’s important for each team member to communicate respectfully and maintain a focus on the goal.

Finalize the care plan

Work through the agenda, and at the conclusion of the meeting, create a final draft of the care plan. Each team member should receive a copy of the care plan that explicitly illustrates how and when they’ll provide assistance.

Keep in mind that in some cases, if a senior’s needs are complex, another meeting may be required. However, a drawn out care planning process may cause delays in your loved one receiving the care they need.

Create a backup plan

It’s important to understand that even with the best care plan in place, circumstances for your senior loved one can change quickly. Consider creating a backup plan that addresses both short-term needs and long-term changes.

A short-term plan can help create flexibility and should offer guidance if a care team member is out sick or on vacation. This might include naming a substitute caregiver or designating a senior community that offers respite care.

Planning for long-term changes can be helpful if a caregiver is no longer able to provide care, or if there’s a significant change to the senior’s health status or mobility. This plan may involve finding a replacement caregiver or adjusting the amount of assistance a senior is receiving.

Once a care plan is in place, caregivers can organize their duties and focus on providing their designated tasks. It’s typical that team members provide care at different times. This makes it important to have a system set up for communicating observations and concerns across caregivers, such as a daily log or notes that caregivers can all review and add to.

While changes in a senior’s health changes and safety should be addressed immediately, it’s important to hold regular planning meetings to review and update the care plan. Reviewing the plan will improve your loved one’s quality of care and decrease the likelihood of any mishaps. This also offers the care team the opportunity to share how they’re managing tasks and discuss any challenges they may be having providing care.

Talk with a Senior Living Advisor

Caring for a loved one can be challenging for family caregivers, but there are options to help families both plan and find resources. Local area agencies on aging often have specially trained staff and connections to community resources that can help families planning to care for a senior loved one.

A Place for Mom is a great resource for learning about home care and senior living options in your area. Our Senior Living Advisors can help connect you with local home care agencies, assisted living, and memory care communities that fit your loved ones needs and budget, all at no cost to your family.