Understanding the Care Plan

The care plan is the document that guides your person's home care — it specifies what care is to be provided, by whom, how often, and for what goals. Understanding the care plan allows you to participate in it, monitor adherence to it, and advocate when it needs to change.

Section 01

What a Care Plan Includes

Diagnosis and medical history: The conditions being managed and relevant background
Goals of care: What outcomes the care is trying to achieve — return to independent bathing, wound healing, stable vital signs, pain management
Services and frequency: Which services will be provided (nursing, therapy, aide services) and how often
Specific care instructions: Wound care procedures, medication schedules, positioning requirements, dietary restrictions
Safety precautions: Fall precautions, weight-bearing restrictions, aspiration precautions
Family caregiver instructions: What you are expected to do between professional visits

Section 02

The Care Plan Is a Living Document

💡 The care plan should reflect current reality

Care plans are not fixed documents — they should be updated as your person's condition changes. If the care plan no longer reflects what your person needs:

Tell the visiting nurse: "The care plan says to help with bathing twice a week, but he needs it daily now"
Request a care plan review: "I think the goals need to be reassessed — she has not met the walking goal and I am not sure it is realistic"
Document your observations: When you notice that the plan is not working or that needs have changed, write it down and share it with the care team

Section 03

Your Role in the Care Plan

⚠ Family caregiver responsibilities in the care plan

The care plan often includes specific responsibilities assigned to the family caregiver — tasks that the professional team expects you to perform between visits. Read the care plan to understand:

What you are expected to do and how often
What the signs of a problem look like and when to call
What resources are available when you have questions

If the care plan assigns you responsibilities you cannot safely perform, say so immediately. "I am not able to do the wound care — I need training or for the nurse to do it" is an appropriate response. Do not attempt care tasks you are not prepared for.

Section 04

Goals of Care vs. Goals of Treatment

💡 Understanding what the care is for

There is a difference between the goals of treatment (cure, slow progression, manage symptoms) and the goals of care (quality of life, function, comfort, remaining at home). These may not always be the same thing — and as illness progresses, they may diverge.

A family caregiver who understands what the care is trying to achieve can participate in decisions about whether the current approach is serving those goals. If your person's goal is to remain at home in comfort, aggressive treatment that requires frequent hospitalizations may not serve that goal.

Section 05

When to Request a Care Conference

✓ You can request a care conference

A care conference brings together the key members of the care team — nurse, physician, therapists, social worker — to review the care plan, address concerns, and align on goals. You have the right to request one when:

The care plan is not working and needs significant revision
There is disagreement among care team members about the approach
Goals of care have changed significantly (such as a decision to focus on comfort rather than curative treatment)
You feel your concerns are not being heard through normal channels

Request a care conference in writing to the supervising nurse or care manager.