More than ever, this year, we receive calls from loved ones wanting help understanding the next steps when family is transferred to a skilled nursing facility. They may tell us they briefly met by phone with a few staff members at the facility where their loved one has just been transferred. When I explain to them that this meeting is called a Care Plan meeting, and that it is their opportunity to set expectations for their relative’s care, they may be surprised or disappointed that they were unaware of just how important this meeting is.

Shortly after you or a loved one enters a skilled nursing facility, either for long-term care or short-term rehabilitation, you will be invited to a meeting to discuss the “plan of care.” This meeting will include a multidisciplinary team from the facility; the patient and/or family are likely to meet with a nurse, physical therapist, occupational therapist, speech therapist, recreation therapist, and dietician. Having these various professionals together in one room to discuss your or your loved one’s care is an excellent opportunity to build consensus and agreement on the goals for the patient’s stay as well as the steps it may take to achieve them.

Many people have questions about the Care Plan meeting. Here are a few of the more common questions and answers:

  • When does this meeting usually take place?
    • It can take place days after admission or up to two weeks after admission.  Additionally, you can and should request one if things are uncertain for you or there has been a significant change in the patient’s condition.
  • How should I prepare for the Care Plan meeting?
    • If the patient has transferred to the facility from a hospital, you should have a copy and be familiar with the hospital’s discharge plan.
    • Bring a list of all medications the patient was taking before hospitalization and/or entrance into the skilled nursing facility.
    • Have the list of all medical diagnoses.
    • Know the patient’s baseline condition: Be ready to describe how your loved one was generally getting around or behaving before the event/s that led to hospitalization or placement in the skilled nursing facility, pain they had/have generally.
    • Know/write down the patient’s favorite foods and ask if the facility can accommodate those preferences.
    • Write down a list of questions before the meeting and bring it with you.
  • What should I do during the meeting?
    • If anything is unclear, don’t hesitate to ask more questions.
    • Write down answers to questions and make a note of any new information.
    • If your loved one has a condition that might prevent them from participating in physical, occupational or speech therapy, make sure that is addressed.
    • Share with the team any special accommodations that might make it easier for your loved one to participate in therapeutic activities such as being given a pain reliever, scheduling therapies in the afternoon for those who don’t function well early in the morning, or bringing in an outside specialist if necessary.

The Care Plan meeting can feel overwhelming. If you are concerned or would like help, consider hiring a patient advocate.  The earlier in the process that you begin asking the right questions, the sooner you will you get answers, and the greater the chance that you or your loved one will experience better outcomes.

  • I have more questions!
    • Call me! I’m happy to answer your questions and help you through the Care Plan meeting and beyond. I can be reached at (516) 584-2007 Ext.1