Care plan - when and where?
A care plan outlines healthcare goals and the types of care delivery planned to meet those goals, which involve skilled care (medical) tasks performed by the your loved one together with one or more licensed healthcare professionals - providers, nurses, therapists. Care plans are put in place for your loved one by their primary care provider, their specialist providers, for any outpatient services (such as rehab), for home health care (where your loved one has orders for nursing and/or therapy at home), and for private duty nursing. Therefore, your loved one may have more than one care plan, each with differing but often overlapping goals. Care plans should be regularly reviewed and updated to reflect progress, changes in condition, and evolving needs. Care plans are generally electronic with availability to print out a hard copy.
Service plan - when and where?
A service plan, also sometimes called an "assignment of duties (AOD)", outlines the ADLs and IADLs your loved one needs assistance performing, how much assistance is needed, what type of assistance is provided, how often and for how long. There are no skilled care (medical) tasks involved. A service plan is generated with you and/or your loved one and the home care agency supervisor. Some states require home care agencies to have an RN to oversee service planning and care delivery, even if there are no skilled tasks provided, and in this case the service plan is generated with you and/or your loved one and the home care agency nurse. Service plans specifically state the days of the week and the time period during those days that service will be provided. Sometimes this is written out and sometimes this is done on checkbox form. The service plan may be generated electronically or on paper.
Service plan details
The companion or homemaker will be assigned IADLs, what they are, when they should be done, and how often. For example:
Homemaker scheduled on Tuesdays and Thursdays 8am-2pm
- Fix breakfast and lunch each visit, clean dishes afterward
- Clean kitchen and bathroom, and take garbage can to curbside on Tuesdays
- Vacuum, change linens, and do laundry on Thursdays
The home health aide will be assigned IADLs and ADLs, what they are, when they should be done, and how often. (Home health aides can provide both.) For example:
Home health aide scheduled on Mondays, Wednesdays, and Fridays 8am-2pm
- Fix breakfast and lunch each visit, clean dishes afterward
- Take garbage to the curb on Wednesdays
- Assist with showering each visit, washing hair per client's preference
- Assist with dressing each visit, especially needs assistance with socks and shoes
- Assist with toileting as needed
- Assist with ambulation as needed, noting that client needs one person assistance rising from sitting to standing
Service plan review
The service plan or AID should be reviewed periodically and modified to meet your loved one's evolving needs (more or different assistance). No changes are made to the service plan without your approval. Events that should trigger a service plan review and possible revision:
- After a hospitalization or other extended healthcare facility stay
- After a significant health event not requiring hospitalization (fall, prolonged illness, decline in mobility or function)
- If you or your loved one requests a change
- If agency personnel in the home suggest a change (typically they express this to the agency administrator or nurse, who then discusses with you)
