To achieve the best possible results and improve the quality of life of the home care client, the plan of care importance in homecare should not be understated. The plan of care is a road map that includes the homecare client’s goals, wishes and values, along with pertinent medical history, doctors’ order, end of life planning, and more.

It’s best if the plan of care is based on information from the client, family, members of the care team and is monitored by a nurse care manager. Each member of the care team follows the plan of care to ensure client’s wishes are met. 

In care management, a plan of care should be client or patient centered, meaning the client gives as much input at possible, based on the client’s competence.  It’s often said that competent people have the right to make poor and unwise health decisions, but those unwise decisions appear in a different light if the client suffers from Alzheimer’s/dementia. 

End of life wishes are integral parts of the plan of care.  These decisions include naming a power of attorney, deciding whether the client wishes to have CPR if breathing stops, or would rather not.  A religious client should have their faith respected, including arranging for spiritual care that meets their needs. 

A good plan of care includes a home safety evaluation, medication review and check for interactions and treatments or services requested by the physician or by the client in order to live a better life at home.  Emergency planning should be incorporated to the plan of care, such as where the client would evacuate in case of a wildfire or earthquake.  

Clients who need care with activities of daily living, but not medical care, can still have a plan of care when physician orders are not needed.  Those non-medical plans of care should highlight the social/emotional/physical needs of the homecare client including help with activities of daily living, community events, meal planning and preparation, incidental transportation, light housekeeping and constant safely monitoring if appropriate. 

Clients have the right to review their plan of care and request changes.  They can also update the plan of care as circumstances change, and alter their mind when it comes to choices such as whether to have CPR.  

At Home Nursing Care creates a thorough plan of care based on an RN evaluation and meeting with the client and family.  If you need help, call us at 888-634-8004.