1) Each intervention must be written in straightforward and objective language so the person carrying out the plan can understand
Unskilled caregivers need simple straightforward language
2) Intervention can have a timeline and measurable goals
Problem-Loneliness- Mrs. Appletree recently lost her husband of 50 years
Intervention- GCM will visit weekly for 1 month to help Mrs. Appletree accept community services to relieve some of her loneliness
Measurable goal- in one month outside services should be set up to help Mrs. a better deal with her loneliness
Creating the care plan
¨ Start with problem you were called in to solve
¨ Can follow by a problem that you see as just as important or more important
¨ List all the problems gather in your assessments
List problems of client – most important to least important
4) Next to each problem, list the intervention you will suggest
5) Each intervention must have a clear plan of :
a) Who will carry it out?
b) How it will be carried out
c) Number of times it will be carried out.
Impaired Home management-Mrs. Tornado cannot do her laundry
Intervention: Care provider to do laundry once a week on Tuesday
Problem- Self-care deficit-Mrs. Hurricane cannot shop weekly because she cannot drive
Intervention – Care provider to shop weekly by driving Mrs. Hurricane, with grocery list , Mrs. Hurricane gives care provider, to Safeway.
Just as I say in my Geriatric Care 1 You Tube Channel- you cannot create a Jaguar care plan for a Hundi budget. Your care plan must be something that the older person’s assets and income can afford or that the family is willing to pay for. If your client has a self-care deficit, cannot bathe or groom without assistance, and requires ongoing oversight to remain safely in her home, you may recommend 24-hour care. However, if the client cannot afford 24-hour care, you must offer other, cost-effective solutions, such as having the client move in with a family member or be cared for by the informal support system. This is why a financial assessment is needed before you can prepare your care plan. Financial resources should be investigated on the psychosocial intake form.
Consider this example: Mrs. Paul is unable to get to Heaven Can Wait assisted living dining room every night. GCM Solution: Daughter will hire a care provider from a home health agency to take Mrs. Paul to the dining room 7 nights a week.
However, the family says they cannot afford a care provider. You may have to ask the assisted living facility if it provides a free service to transport clients or ask a neighbor in the assisted living facility, thus her informal support system, to escort Mrs. Paul to the dining room. Finding an affordable solution is one of the challenges to the creativity of the GCM in preparing the care plan.
The Geriatric Care Manager can recommend more than one intervention to solve a single problem. For example, an additional intervention to assist our GCM You Tube client, Mrs. Sterling to accept care could be as follows: The problem of Mrs. Sterling is resistant to care: Mrs. Sterling needs care but has resisted care because she wants her daughter to do the care and wants to save her estate for her special needs son
The multiple interventions the Sterling family problem are
a. Geriatric care manager to hold family meeting in one week to discuss this problem with adult children and discuss hiring financial planner and elder law attorney to help solve problems and accept older son’s offer to pay for mother’s care if paid back after her death.
b. If siblings accept plan for involvement of financial planner and elder law elder, they will prepare financial plans and legal documents to have Bob, willingly lend his mother the money for care on the condition he will get it back in his inheritance.
c. Elder law attorney to meet with Mrs. Sterling and with her consent set up a Special Need’s Trust for son Michael.
Because older clients often have chronic disease, the absence of disease or cure for problem or return to normal is rarely a goal. Mrs. Sterling’s problem for paying for needed care takes multiple, creative interventions to create a care plan for the family. These interventions are written in a way that the GCM ,Mrs. Sterling the client and her family can measure whether they were completed and doable.