Long & Short Term Care Planning Process

Because every patient’s needs are individual, care planning is used to create a custom experience for each patient. Care planning is the act of planning what kind of diet, care, therapy, and treatment the patient will receive during their short-term or long-term stay.

The care plan serves several purposes:

• Ensures every member of the healthcare team knows the doctor’s treatment plan and is able to carry it out
• Gives family members the opportunity to voice their opinion and make decisions about care
• Fosters communication between the patient, their family, and their care team
• Promotes patient healing, recovery, and safety

The care planning process involves several steps:

1. Patient assessment. Nurses, doctors, social workers, and therapists collaborate to determine how the patient moves, cares for himself/herself, manages health conditions, eats, and speaks.
2. Needs identification. Once the assessment is completed, a list is compiled to address areas of need. This list may include medical diagnoses, limitations in mobility, or any unique concerns.
3. Establishment of goals. For each area of need, the care team establishes an attainable goal for the patient. For example, a patient who is malnourished due to dysphagia, or difficulty swallowing, may establish a goal weight or a daily caloric intake goal.
4. Solution decisions. The care team then meets to consider each area of need and asks the question, “What interventions will create the desired outcome?” For a patient with swallowing difficulty, like in the above example, the solution may be speech therapy or thickened liquids. A solution or solutions are identified for each specific concern.
5. Care plan implementation. Each problem, intervention, and goal is listed in the care plan, and each member of the team providing care is able to access the care plan. They are responsible for ensuring the interventions are completed as scheduled and evaluating the outcome on a periodic basis. On a set schedule, the care planning team (including family members and the patient) meets to evaluate progress and make adjustments to the care plan.

To learn more about the care planning process, contact your local Santé today. We’re here to help provide the care you need.