Person-centered care has been around for almost 20 years as a philosophy placing the elderly nursing home or assisted living client in the center of the care process. It focuses on choice, independence, and quality of life. Some time ago, many healthcare professionals were concerned that person-centered care would not be endorsed by The Centers for Medicare and Medicaid Services and the Department of Health and Human Services. Not only do these governing bodies approve of person-centered care, they endorse person-centered care planning.
Creating Baseline Care Plans
CMS and DHHS recommend developing and implementing a baseline plan of care for each resident that includes guidelines to provide effective and person-centered care as well as meet professional standards of high-quality care. The plan should be developed within 48 hours of the resident moving into the care community. The baseline care plan should include minimum healthcare information to begin with, including the resident’s initial goals based on admission orders, physician and dietary orders, therapy and social services, and PASARR recommendation if appropriate.
The leadership team should then provide a summary of the baseline plan of care to the resident and their representative that includes initial goals of the resident’s care, medications and dietary information, services and treatment administered by the care community and any updates that may occur to the plan.
Creating Comprehensive Care Plans
The leadership team should then create a comprehensive care plan that is person-centered, consistent with resident rights, and include measurable goals and timeframes that will meet the resident’s unique medical, nursing, mental and psychosocial needs. The comprehensive plan should also describe specific and specialized services or rehabilitative care required to attain or maintain the resident’s highest practicable well-being. It should be stated that the resident has the right to refuse any treatment.
The plan must be developed within 7 days after completion of the comprehensive assessment and prepared by the interdisciplinary team (i.e. physician, RN, STNA, dietary staff and the resident or resident representative). The plan should be reviewed and revised as needed based on ongoing assessments. All services provided by the care community and included in the person-centered care plan must meet professional standards of quality, be provided by qualified healthcare professionals, and reflect trauma-informed care and culturally-competent philosophies.
Creating the Discharge Planning Process
Once the resident is ready to return home, a clinically sound and personalized discharge plan should be implemented and focus on the resident’s discharge goals, outline risks for readmission, and effectively switch to post-discharge care. The discharge plan must identify and ensure any discharge needs, changes that require modifications of the discharge plan, and be prepared by the interdisciplinary team.
The plan should also identify resident and caregiver or support person availability, capacity and capability to provide any care required after discharge. It should also identify the resident’s treatment preferences and goals. Ultimately, the person-centered discharge plan should be developed with the resident’s participation and include their representative (i.e. family member) who will help them adjust to their new living environment.
Final Thoughts on Person-Centered Care Planning
Most senior care communities embrace the many philosophies of high-quality person-centered care and have done so for some time now. To better fine-tune a resident’s quality of care and life, person-centered care plans can act as personalized road maps to guide staff in providing for the unique needs of each resident, from the time they walk through the care community’s doors to the time they return home. And, health care leaders can be comforted to know that this plan is endorsed by both CMS and DHHS.
Reference
- Title 42 – Public Health. Chapter IV – Centers for Medicare & Medicaid Services, Department of Health and Human Services. Subchapter G – Standards and Certification. Part 483 – Requirements for States and Long-Term Care Facilities. Subpart B – Requirements for Long=Term Care Facilities. 483.21 Comprehensive Person-Centered Care Planning.