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 determines the content of the care plan. Not all residents 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 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."
Health Care
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 outcomes 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
- ADLS
- 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 R.O. 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
Goals
- 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 i.e. 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 i.e. 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 i.e. hand massages and textured object i.e. soft baseball
- Provide olfactory stimulation i.e. vanilla extract and cinnamon for reminiscing
- Utilize adapted shovel and watering can during HT sessions
- Provide easy grip writing utensils and a variety of greeting cards/stationary
- Involve resident in small sensory groups i.e. SNOEZELEN and Five Alive
- Sear resident near a window
- Provide a variety of independent arts and craft projects
- Provide adapted scissors and paint brush
Exercise
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.
Kimberly Grandal, Founder and Executive Director of Re-Creative Resources, Inc., is a strong advocate for the field of Therapeutic Recreation and Activities, with over fifteen years of experience working with the elderly in numerous management and consultant positions. She is an Activity Consultant Certified and a Certified Therapeutic Recreation Specialist. She is a recipient of the Kessler Institute of Rehabilitation 1997 Triumph of the Human Spirit Award.
Kim is a member of NJAPA, NJ/EPA-TRA and NAAP and serves on the NJAPA board as the Chairperson for the Legislation Committee. She is an NCCAP reviewer and is an active member of the NCCAP and NAAP Government Relation Committees.
Kim is a speaker for various national, state and local activity associations, the Society of Licensed Nursing Home Administrators of NJ, colleges, and community groups. She also provides consultation and support to numerous facilities in the state.
Kim is the editor and writer for the "The Rec-Room", a monthly newsletter published by her company. In addition, she writes monthly articles for Activity Directors Today newsletter, and has contributed articles to Creative Forecasting Magazine, Current Activities in Long Term Care Magazine and The Continuing Care Insite newsletter. For more information visit http://recreativeresources.com
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