National Association
of
Professional Geriatric Care Managers
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Geriatric Care Management Care
Plan Outline
Introduction:
The following
Care Plan Outline was developed by the National Association of Professional
Geriatric Care Managers (NAPGCM) as a guide to care managers seeking to provide
their clients with the highest possible quality of service. This Outline
represents the collective experience of care managers practicing during the
past 25 years. It meets Standard 7
of NAPGCM’s Standards of Practice for
Professional Geriatric Care Managers: “Development of Plans of Care: The
PGCM should strive to provide quality care using a flexible care plan developed
in conjunction with the older person and/or client system”. The term “care recipient” is used
throughout this document to refer to the individual to whom services will be
provided. This Outline is comprehensive in scope. Any particular Care Plan may not include all
of the information included here.
However, a comprehensive assessment/care plan should touch on all of the
topics listed below.
1. Reason for Assessing the Care Recipient
State the primary reason for the
visit/assessment. Include the name and relationship to the care recipient of
the person who requested the assessment/plan and the primary reason that the
assessment/plan was requested. Include
the date and place in which the assessment was conducted and how any additional
information was gathered.
2. Demographic Information
Thoroughly document the demographic characteristics
including vital statistics or quantifiable characteristics of the care
recipient. These would include gender, date of birth, age, ethnicity, language
spoken, living situation, marital status, income, family size, occupation, and
or educational level. Other specific
information can be included such as interests or goals, spirituality,
socialization, activities, and the general personality of the care recipient.
3. Medical History/Medical Needs
Document care recipient’s primary medical
diagnoses. Include the care recipient’s current or past diagnosis(s), current
medication regiment, and how the care recipient’s medical needs impact their
quality of life. Include the care recipient’s primary physician’s name,
address, and phone. Other medical specialist
can be listed also.
4. Cognitive Needs
Document care recipient’s cognitive
abilities and ability to function in his/her day to day life. Document any cognitive tests if you conduct
any, describing the test used and the results, or any tests available in the
medical record. Be sure to discuss how the results impact the care recipient’s
daily activities and socialization. Include in the discussion the perception
the care recipient has of his or her life.
5. Activities of Daily Living (ADL) and
Instrumental Activities of Daily Living
(IADL)
Document the level of assistance the care
recipient needs with ADL’s including bathing, grooming, toileting, dressing,
and eating. Document the level of assistance the care recipient needs with
IADL’s including shopping, preparing meals, housework, money management,
transportation, use of telephone, and ability to make and keep appointments.
Explain how ADL’s and IADL’s were measured such as observation, conversation,
or if a specific test was administered.
6. Environment
Document the care recipient’s environment
including the condition of the living quarters.
If there are possible safety hazards that would cause harm to the care
recipient document them here.
7. Assessment of Care
Recipient’s Support Structure
Provide detail information about the care
recipient’s support structure. Include
their level of commitment to the care recipient and their ability to manage the
needs of the care recipient. Also, document if the care recipient receives
support from religious or other community groups.
8. Financial
Assessment of the care recipient’s financial
situation is very important in order to recommend services that would be cost
effective and affordable. Document the care recipient’s economic status and ability
to pay for care and support. If the care recipient has other financial needs or
issues document them here.
9. Medical Benefit Coverage
Document the any medical benefit coverage
and long term care insurance, if any.
10. Legal Needs
Review and document the care recipient’s
legal needs including a power of attorney for
health care and finance, need for
guardianship, or will.
11. Emergency Planning
Review any need the care recipient may have
regarding planning for any natural disaster such as hurricanes, tornados, snow
storms, etc., and/or the emergency plans that may be in place.
The following information should be documented in the
recommendations section of the assessment:
A. Introduction
Below is a list of possible areas that need
to be addressed to improve a care recipient’s quality of life. Using a list
such as this highlights concerns that where identified in the assessment. Reminder: If areas of concern are identified
in this section your plan for addressing them needs to be in the
recommendations that follow.
Fall/Home
safety
Homebound/isolation
Personal
care (ADLs)
Household
management (IADLs) Nutrition
Nutrition
Cognitive/Memory
Impairment
Depression/Mental
well being
Medical/Medicine
Management
Primary
caregiver burnout
B. Description of Risks,
Issues, and Problems
Areas of Concern
Each risk, issue, problem or area of concern
the care recipient is experiencing should be described in this section. Include
a potential goal or objective which the care recipient has agreed to in the
assessment interview, or which the care manager believes the care recipient
desires to achieve. List the risks, issues, problems or concerns by order of
importance from the highest priority to the lowest. Reminder: If areas are
identified above they should be described in this section.
C. Services
Document any services that may be of
assistance to the care recipient to resolve the risk, issue, problem or area of
concern identified in the sections above. Services may include community
programs, support groups, educational materials, counseling, or adaptive
equipment. All services recommended should include contact information and the
cost of the service, which should be affordable to the care recipient. Reminder: Each area of concern should be
accompanied by services to resolve the concern.
D. Recommending Next Steps
This section should include the care
manager’s suggestions on what steps are needed to accomplish the above
recommendations and a timeline to do so. If on-going care management services
are recommended, they should be explained here, with an estimate of the time
needed to accomplish the care management interventions and the estimated cost
for this time.
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National Association of Professional Geriatric Care Managers
phone 520.881.8008 ¤ fax 520.325.7925 ¤ www.caremanager.org