Care Plan 101 – An Introduction to Care Planning For Activity Professionals

Creating and implementing individualized care plans for residents in long-term care facilities is a very important responsibility of activity and recreation professionals. The activity assessment determinates the content of the care plan. Not all tenants will have an "activity-care plan", but most care plans should have "activity-related interventions" found in the comprehensive care plan. Care plans may be written regardless of if a resident triggers on the MDS 2.0.It is important to set realistic, measurable goals, interdisciplinary interventions, and create care plans that are individualized and person-centered.

What is a Care Plan?
The RAI user manual defines care planning as, "A systematic assessment and identification of a resident's problems and strengths, the setting of goals, the establishment of interventions for accomplishing these goals."

Why write Care Plans?
– Document strengths, problems, and needs
– Set guidelines for care delivery
– Establish resident goals
– Identify needs for services by other departments
– Promote an interdisciplinary approach to care and assign responsibilities
– Provide measurable outputs that can be used to monitor progress
– Meet federal and state requirements
– Meet professional standards of practice
– Enhance the resident's quality of life and promote optimal level of functioning!

What is a Care Plan Meeting?
A forum to discuss and review a resident's status including any problems, concerns, needs, and / or strengths.

Who usually attends a Care Plan Meeting?
– MDS Coordinator
– Nurse (s)
– CNA's
– Dietician
– Rehabilitation Therapist (s)
– Recreation Staff
– Social Worker
– Resident
– Family Member / Guardian

When are Care Plans written?
– A minimum of seven days after the MDS completion date
– Some care plans warrant immediate attention
– As necessary
– Must review at least quarterly

The Role of the Recreation / Activities Department
– Identify the resident's leisure / recreation needs
– Identify barriers to leisure pursuit and help minimize these barriers
– Identify the resident's leisure / recreation potential
– Provide the necessary steps to assist the resident to achieve their leisure / recreation goal / s
– Provide interdisciplinary support by entering a variety of recreation interventions on various (non-activity) care plans
– Monitor and evaluate residents response to care plan interventions

Components of a Care Plan
– Statement of the problem, need, or strength
– A realistic / measurable goal that is resident focused
– Approaches / interventions the team will use to assist the resident in achieving their goal
– Important dates and time frames
– Discipline (s) responsible for intervention
– Evaluation

Target areas for Recreation / Activities
– Cognitive Loss
– Communication
– Psychosocial
– Mood
– Nutrition
– Falls
– Palliative Care
– Activities
– Recreation Therapy
Pain Behavior
– Restraints

Activity / Recreation Care Plan Samples
These are just a few samples. Remember, the most important aspect of care planning, is INDIVIDUALIZATION!

Statements (the resident's name is usually used instead of the word "resident")
– Resident has limited socialization r / t to depression
– Resident prefers to stay in room and does not pursue independent activities
– Resident is bed-bound r / t to stage 4 pressure ulcer and is at risk for social isolation
– Resident demonstrates little response to external stimuli r / t to cognitive and functional decline
– Resident enjoys resident service projects such as changing the RO boards
– Resident becomes fearful and agitated upon hearing loud noises in group activities r / t to dementia
– Resident has leadership abilities
– Resident prefers a change in daily routine and wishes to engage in independent craft projects

– Resident will respond to auditory stimulation AEB smiling, tapping hands, or vocalizing during small group sensory programs in 3 months
– Resident will actively participate in 2 movement activities weekly in 3 months
– Resident will remain in a group activity for 15 minutes at a time 2x weekly in 3 months
– Resident will accept in room 1: 1 visits by recreation staff 2x weekly in 3 months
– Resident will socialize with peers 2x weekly during small group activities in 3 months
– Resident will respond to sensory stimulation by opening eyes during 1: 1 sessions in 3 months
– Resident will actively participate in Horticultural Therapy sessions in the green house, 1x monthly in 3 months
– Resident will continue to assist other residents in writing letters on a weekly basis in 3 months
– Resident will exhibit no signs of agitation during small group activities 3x weekly in three months
– Resident will engage in self-directed arts and crafts projects 1x weekly in 3 months

Interventions / Approaches
– Provide a variety of music ie Big Band and Irish
– Utilize maracas and egg shakers to elicit movement
– Provide PROM to the U / E during exercise program
– Involve resident in activities of interest ie singalongs, adapted blowing and trivia
– Offer 1: 1 visits in the late afternoon to discuss recent Oprah episode
– Seat resident next to other Korean speaking resident during groups
– Provide tactile stimulation ie hand massages and textured object ie soft baseball
– Provide olfactory extraction ie vanilla extract and cinnamon for reminiscing
– Utilize adapted shovel and watering during HT sessions
– Provide easy grip writing utensils and a variety of greeting cards / stationary
– Involve resident in small sensory groups ie SNOEZELEN and Five Alive
– Sear resident near a window
– Provide a variety of independent arts and craft projects
– Provide adapted scissors and paint brush

Imagine that you are a resident in a long-term care facility and you are bed-bound for a health-related condition and are at risk for social isolation and inactivity. Write a goal and at least seven interventions / approaches that are relevant to you.