Care management is a service provided to older adults and their families. The purpose of care management is to link older adults with needed services that will help them live independently, or receive quality care if they reside in a long-term care facility. Older adults who live long distances away from their children are some of the individuals who benefit from the services of a care manager.
Developing a Care Management Plan
A care management plan assures that an older adult is receiving appropriate services or treatment. Specifically, the goals and objectives of a care management plan will help assure that a senior's needs are being met. A good care management plan includes goals, objectives and strategies to help meet the objectives. However, the first step in setting up a care management plan is to conduct an assessment to determine a senior's specific needs. Once the assessment is accomplished, goals and objectives can be developed to address issues identified in the assessment.
Conducting the Needs Assessment
When a care manager conducts a needs assessment with the senior, he or she should ask questions about the individual's ability to perform activities of daily living, such as bathing, dressing and eating. The individual's mental status should be assessed to determine if their are issues such as dementia. Other information needed includes support systems that may already be in place and whether the individual is able to live independently, with minimal support, or needs 24-hour supervision. Conducting a thorough assessment will require that the care manager speak with or observe the client, talk with the family, health care professionals or others who can provide relevant information that might impact the senior care management plan.
Writing Goals and Objectives
Senior care plan goals describe the preferred situation that the care manager, family and the older adult hope to achieve. A goal is a broad statement that describes the desired outcome, such as "improved health." Objectives are measurable statements that describe what needs to happen to meet a goal. Strategies are the methods that will be employed to help reach goals and objectives. For example, a goal might be to help an older client manage his diabetes successfully. The Hemoglobin A1c test is a blood test that measures the level of sugar in the blood over a three-month period. Ideally A1c should be under seven. An objective to reach this goal might be stated as follows: "The client's A1c test result will be seven or less at each doctor's visit." This is a measurable objective, because the physician orders the blood test that will return with a specific A1c number. That number will indicate whether the objective is met. If the objective is met, the goal will be achieved. One strategy to reach this objective would be to make sure the client takes his medication as prescribed. Another strategy to reach the objective would be to limit the client to 45 grams of carbohydrate at each meal.
Another example is the long-term care resident whose family does not want her to stay in bed all day. A goal might be to get the client to spend more time out of bed. An objective might be stated this way: "By the end of two months, the resident will sit in a chair at least two hours each day." A strategy might be to encourage the client to sit up for 30 minutes each day, until she can do so comfortably for two hours. The care manager would monitor the client's progress through observation, talking with the client, or with those involved with the client's day-to-day care. If the client is able to increase the time out of bed each day, then she makes satisfactory progress toward her goal.
Senior Care Management Goals and Objectives Should be SMART
The purpose of the plan is to help the older person have the best quality of life possible. Goals and objectives should be SMART which means specific, measurable, attainable, realistic and timely. Encouraging the older adult to spend more time out of bed, the objective is specific -- the adult will sit up -- and measurable -- for two hours -- unless the adult has some physical difficulty, the objective is attainable, since it will be accomplished over time. The individual will sit up for brief periods until the objective is reached. It is realistic, since the adult is not required to sit up all day, but will gradually reach two hours, and it is timely -- within three months.
Senior Care Management Goals and Objectives Should be Evaluated Periodically
When writing senior care management goals and objectives, the care manager, client and others involved should meet periodically to evaluate the plan to determine if the goals and objectives are being achieved. Goals and objectives can be revised or deleted as needed.
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