Plans have new focus

   To avoid using technical terms, I will simply remind families of residents in nursing homes about a resident’s care plan. It is a document outlining health services for each resident. The plan is based on an evaluation made of a resident’s condition within 14 days of admission and then quarterly. It explains the resident’s physical and mental state as well as the person’s ability to care for himself. The care plan should identify the services a resident will need daily to remain in the best physical and mental condition.
    The new resident care plan called 3.0 is not as clinical as the old format and is very resident oriented. The focus is to start to assess the residents’ ability to return home or to a less restrictive environment. So many nursing home residents have remained in long-term care facilities based on the residents’ or their families’ lack of knowledge about services available to them. The 3.0 approach gives new admissions hope that they will return home by ensuring they are aware of that option.
    Assessing a resident’s ability to return home is generally the responsibility of the social worker at a facility. Through the social worker’s assessment and the disciplines that make up the nursing home team, a plan is formulated. In the best case scenario, the resident’s name is submitted to the Rhode Island Department of Human Services (DHS) for the next step in the discharge process. A team will meet with the resident and staff to try to come to the best conclusion. If the discharge is realistic, the team from the DHS will start putting community services in place. It may only be a homemaker that is needed to tidy up the house and run errands. It could be the services of a certified nursing assistant that can visit three times a week to help with bathing. There is also the possibility the services of a registered nurse is needed to make home visits.   
    Families are encouraged to participate in the discharge planning and may also play a vital role in assisting their loved one with care issues. What is essential is that the resident has the right to make that choice regardless of what obstacles or fears family members express. If a person has the capacity, the decision of where they want to live is really their choice. Any decision made by any one of the teams is based on careful assessment, planning and safety considerations. No reckless or poorly executed discharges are completed. The role of my office is to intervene when a resident’s wishes are not respected by personnel at a long-term care facility, family members or the DHS staff.
    It is important that residents and their families are prepared and informed of the patients’ rights to return home. There should be no surprises when a staff member of a facility informs you that your loved one wishes to return home. If you are anxious about being a caregiver, learn about resources available to help you.
    For more information on the discharge process, contact the transition team at DHS at (401) 462-6393 or the Alliance for Better Long-Term Care at (401) 785-3340.

    Kathleen Heren is executive director of the Alliance for Better Long-Term Care. You can contact her at (401) 785-3340.