You have to take care planning seriously.

Resident assessment, discussed in this column in June, is the first of four critical steps entailed in the delivery of effective long-term care. Care planning, implementation, and follow-up are equally important, perhaps even more so. Indeed, one can legitimately argue that the only real purpose of the resident assessment is to develop an appropriate plan of care. And, just as the interdisciplinary assessment is more than likely to unravel the interlocking mysteries of a resident's condition, so too will it foster the interdisciplinary response. A team of active decision makers will structure the service package oriented toward those needs, delegate responsibility for its delivery, and determine necessary changes over time.

We all know what goes into a basic care plan, right? We know that the care (or service) plan should encompass three basic domains: essential services (e.g., basic housing and security); therapeutic and restorative services (more in nursing homes than assisted living); and preventive and quality of life services (e.g., dining, housekeeping, transportation, financial advice, education, leisure activities, exercise, support groups, etc.).

Of comparable importance are the logistical issues that must be dealt with--the mechanics of service and care delivery: Who does what for whom, when, where, and how often? But without an understanding of all a customer's preferences and needs (medical, mental, psycosocial, environmental), it will be impossible to construct customer-focused responses to those needs, and the plan will ultimately prove inadequate.

How do we construct a strong care plan? Well, obviously, the community team is important, and we all know the importance of collegial effort. But what about the customer? How often do we include the resident (or resident's family, in the case of the cognitively impaired) in our care-planning processes? This broadened involvement is a concept only recently recognized and even more belatedly emphasized. I think that, for many practitioners, it is even somewhat threatening. Why not, they ask, let the professionals construct the service plan? After all, aren't we the ones with the background and training necessary to do it right? But if "right" is meeting customer needs and preferences, who is in a better position to articulate them than the customer?

The typical resident in a seniors' housing and care community can present any number of disparate issues. Social concerns must be dealt with, perceived medical needs must be addressed, and psychological concerns have to be integrated into the comprehensive service package. The successful community will make sure that all of a resident's issues are dealt with both collaboratively and holistically, and that services are delivered in an inter- and multidisciplinary fashion.

The principles of inter- and multidisciplinary involvement are evident in any successful long-term care delivery system. Examples of those who do it extremely well are practitioners in the various Programs of All-Inclusive Care for the Elderly (PACE). A system based on the adult day care center model, PACE has taken the concepts of comprehensive, holistic, and focused assessment and care planning to their highest plateau. Indeed, federal regulations themselves stress the importance of thinking "outside the box" in designating appropriate members of the interdisciplinary team. This includes, interestingly enough, the van drivers responsible for picking up the clients each morning and taking them back to their homes at night.

Recognizing the need for an all-encompassing approach to care, the authors of the PACE regulations anticipated gleaning a wealth of information from the experiences of those who spend as much time as anyone with the client (their lack of professional training notwithstanding) and who work in a somewhat less formally restricted environment than the typical residential center. Simple informal observations and conversations involving these people can add immeasurably to professional determinations of service efficacy: Any changes in the resident's gait or ease of entry into the vehicle? Any discussions overheard about adverse drug reactions that the client might not wish to bring up overtly with center staff? How about the availability of support personnel at home--do they seem up to the task of caring for their loved one once center staff is no longer present?

The good care plan is not just an all-encompassing clinical tool--it is essential to the very management and profitability of the community. This doesn't mean violating the basic purpose of assessment and care planning by allowing financial considerations to determine the services provided. Issues of reimbursement are, of course, critical to the community's financial success. But payment issues must be dealt with, not within the context of assessment and care planning, but subsequent to them. Care planning that reflects only the ability to pay--and not customer needs--can easily move from the financial to the legal arena.

The care plan must therefore be carefully constructed. It must be faithful, within reason, to the wishes expressed by the resident and family. It must be adequately oriented toward the conditions identified in the assessment. If financial considerations are to surface in developing the plan, those considerations, if any, should reflect amenities, not critical services (although one should be careful--one person's "amenity" might prove to be another's "critical essential").

Once developed, the plan must be implemented--and here is where legal issues can again present themselves. Who hasn't heard stories of failure to effectively implement a care plan leading to litigation? All of us can recall cases in which staffing decisions were a function of the need to "make bottom line," not of dealing with the residents' needs as reflected in their collective care plans.

Not only must the plan be implemented, it must be constantly monitored and documented. Here, as with resident assessment, data systems become critical. They address questions such as: What progress are we making, as measured against established benchmarks? Are we achieving our corporate goals? How effectively are we adhering to government standards?

If done within the context of resident preferences, service needs, and fiscal reality, the well-constructed care plan will be buttressed by data-driven management systems--systems that foster staff competencies and capabilities, promote product accountability and improvement, and ultimately impact favorably on the business's profitability.

The well-managed facility reflects well-managed processes adhered to consistently by all members of the community's staff. Absent such a collegial approach to care, the community will fail. That is why there is no better litmus test of a community's ability to serve its residents' needs--and its owners' financial goals--than a well-designed, implemented, and documented care plan.

Paul R. Willging, PhD, was involved in long-term care policy development at the highest levels for more than 20 years. For 16 years as president/CEO of the American Health Care Association, Dr. Willging went on to cofound the successful Johns Hopkins Seniors Housing and Care postgraduate program (cosponsored by the National Investment Center for the Seniors Housing & Care Industries), and later served as president/CEO of the Assisted Living Federation of America. He has enjoyed an equally long-lived reputation for offering outspoken, often provocative views on long-term care.

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