A Guide to Creating a Senior Care Plan

A senior care plan is a tool used to identify an older adult’s needs and coordinate their care between different care providers.^[01]

Care plans vary based on the person’s needs. Health care professionals, senior living communities, and home care providers all engage in some kind of formal care planning process. Families can also use this approach to better manage their aging loved ones’ care.

A care plan should include your loved one’s:

• Needs, health conditions, and specific treatments
• Financial assets and accounts
• Legal arrangements

Your care plan should outline the services and supports your loved one needs and who is responsible for providing them. A care plan should also include a targeted timeframe in which to reevaluate and update the plan.

“I think of a family caregiver as the general contractor. They don’t do all the work themselves – they can’t – it’s too much for one person,” explains Leslie Fuller, senior living expert, owner of Inspired Senior Care, a dementia care consultancy, and author of Navigating the Move: A Practical Guide to Supporting Parents in a Transition to Senior Living.

“We have to gather our team of resources, which includes the medical team, but also friends, family members, even home health or an adult day care program,” Fuller says.

A senior care plan helps to ensure a senior is receiving the care they need, but the benefits also extend to family caregivers.

Thoughtful senior care planning should:

• Help caregivers efficiently organize their duties
• Give a senior the opportunity to express their care preferences
• Produce a concrete list of tasks and activities that meet a senior’s specific needs
• Organize a senior’s medications and provide details about when they should be taken or administered
• Facilitate communication between care team members
• Provide opportunities to discuss long-term planning, which may include senior living options and estate planning

Fuller says that one of the most important benefits of a senior care plan is the confidence it provides. “A care plan helps the primary caregiver understand that they don’t have to be the only resource for their loved one. It can defuse anxiety and a sense of overwhelm,” she says.

“If you’re in the habit of looking two steps ahead, it can provide a sense of control, and confidence that you’re prepared. That you can pivot if a twist or curve comes up,” Fuller says.

Creating a care plan can help you and your loved one’s other caregivers stay organized and break caregiving down into more approachable tasks. And research has shown that personalized care plans have an impact on quality of life and positive health outcomes. The more complete a care plan is, the more members of the care team collaborate, and when the primary doctor is involved, the better a person does in managing chronic health conditions.^[02]

Step 1: Identify your loved one’s needs

The first step in creating a well-rounded elder care plan is to evaluate your loved one’s needs. If your loved one’s willing and able to engage in conversations about their care, work with them to identify the areas where they’re still independent and where they may need help.

“This transition affects adult children, but the bottom line is that it’s the parent’s life,” Fuller advises. “Children are affected, of course, but the focus has to be what’s best for their loved one.”

Address the following elements of your senior parent’s daily life:

• Activities of daily living (ADLs). Can your loved one bathe, dress, feed themselves, and complete other personal care tasks?
• Nutrition and accessibility of meals. Is your loved one eating well and often enough to maintain their energy?
• Home safety. Can your loved one navigate their home safely or are modifications needed?
• Health status and medication management. Does your loved one need reminders to take their medication? Do they need help sorting what to take and when?
• Social network. Perhaps your parent would like to meet with friends for a weekly card game but no longer drives.
• Physical fitness. If your loved one still takes daily walks, are you and other caregivers comfortable with them going alone, or would you feel more comfortable if they had a companion?
• Intellectual stimulation. Maybe your parent used to love to read but can’t see well enough to read hard copy books?

When you’re evaluating a senior’s needs, using tools like an ADL checklist can help you document the areas in which your loved one needs assistance.

Step 2: Identify the gaps

It’s likely that you and other caregivers are already meeting at least some of your parent’s needs. The process of creating a care plan includes thinking through whether there are gaps that remain to be filled.

Step 3: Determine care and supports

The next step involves identifying how current care and support is addressing those needs, where more or different help is needed. Questions to consider include:

• What activities and care would your loved one like to stop, start, or add to their routine?
• Who’s in your support system today – family members, neighbors, or friends, perhaps from your or your loved one’s faith community?
• Is more or different help needed to fill caregiving gaps? If so, what kind of help is that?
• If professional help is needed, what’s your loved one’s preference about where that help is provided? If they want to age in place, maybe home care is an option.
• If your loved one wants to move to a senior living community, what pros and cons do they see in that? What concerns do they have?

Once you’ve addressed your loved one’s health and well-being, you can create a draft plan and then share it with your loved one, appropriate caregivers, and family members to ensure their input is considered.

Step 4: Develop a draft of the senior care plan

Prioritize your loved one’s health, safety, and quality of life by identifying which care services they need and how often they need them.

• Document who, what, and by when. For each need, identify the individual responsible for carrying out or assisting the senior with the task and when they’ll do it.
• Use technology to your advantage. The care plan is a tool to help team members organize and communicate. Shared digital documents, such as a spreadsheet or calendar, or even mobile apps, can help minimize confusion and ensure shared understanding.

Let our care assessment guide you

To ensure clarity around roles and responsibilities, the care plan meeting should give each person, and especially your loved one, an opportunity to ask questions, make suggestions, and clarify any final decisions.

“It’s important to let your loved one speak for themselves. You might say ‘Mom, I noticed that your fridge is kind of bare, and you’ve lost some weight. Maybe your nutrition isn’t as strong as it should be. What are your thoughts on doing something to make that better for you,” Fuller recommends. “And then listen to what they say.”

Step 1: Identify who to invite

In addition to your loved one, the care team should include family members and friends, as well as professional caregivers. Based on your family’s circumstances, you may also want to invite a social worker or financial planner. Some families may also choose to invite an elder law attorney to help navigate essential medical and legal documents, such as a power of attorney.

Step 2: Prepare for the meeting

Make an agenda that lists the goal of the meeting and the topics that will be discussed, as well as the estimated time length for the meeting. Share the draft of your care plan with the other members of your loved one’s care team. Consider the following tips to help the meeting run more smoothly:

• Choose a neutral facilitator.
• Assign a timekeeper to regulate comments and time spent on each topic.
• Create and send video conferencing invites for team members who can’t be physically present.
• Record the meeting or assign someone to take notes.
• Arrange a comfortable environment, with food and beverages and comfortable seating where everyone can make eye contact.

Step 3: Encourage open communication

The point of the meeting is to work together to create a final, working care plan for an elderly loved one who needs help. While differing viewpoints may emerge during the meeting, it’s important for each team member to communicate respectfully and maintain a focus on the goal.

Step 4: Finalize your care plan

Work through the agenda, and at the conclusion of the meeting, create a final draft of the care plan. Each team member should receive a copy of the care plan that explicitly illustrates how and when they’ll help.

In some cases, more than one meeting may be needed. That said, it’s ideal to move quickly when creating a senior care plan, as delays in planning may cause delays in your loved one getting the care they need.

Once your care plan is in place, you and your fellow caregivers can organize your duties and focus on completing your designated tasks. Because team members provide care at different times, it’s important to have a system set up for communicating observations and concerns across caregivers, such as a daily log or notes that caregivers can all review and add to.

While changes in your loved one’s health and safety should be addressed immediately, it’s also important to hold regular planning meetings to review and update the care plan. Reviewing the plan will improve your loved one’s quality of care and make mishaps less likely. This also offers the care team the opportunity to:

• Share how they’re managing tasks
• Discuss any challenges they may be having
• Learn from one another
• Address challenges together

Finally, regular meetings of the care team provide an opportunity for members to make plan B for times when plan A doesn’t work as expected.

Talk with a Senior Living Advisor

Even with the best care plan in place, circumstances can change quickly. Consider creating a backup plan that addresses both short-term needs and long-term changes, such as:

• Short-term. If a care team member gets sick or is on vacation, a short-term plan creates flexibility by naming a substitute caregiver or designating a senior community that offers respite care.
• Long-term. If a caregiver is no longer able to provide care, or if there’s a significant change to the senior’s health status or mobility, a long-term plan highlights the need to identify a replacement caregiver or adjust the amount of assistance a senior is receiving.

Caring for a loved one can be challenging for family caregivers, but there are options to help families both plan and find resources.

• Local area agencies on aging (AAA): Every state has at least one AAA that provides specially trained staff and connections to community resources that can help families planning to care for a senior loved one.
• A Place for Mom: Our Senior Living Advisors can help connect you with local home care agencies, assisted living, and memory care communities that fit your loved ones needs and budget, all at no cost to your family.

“It can really help to talk with an expert about these things. Not many people have been in this place before, so trying to do it on your own is a little like doing research without the internet. You can do it, but why would you when the expertise is available?” Fuller notes.