Individualized Care Planning

The Care Planning Process:

1. Admission and Initial Assessment (Within 24–48 Hours):

• Key areas include:
  • Medical condition and diagnosis
  • Medication needs
  • Mobility and rehabilitation goals
  • Dietary requirements
  • Emotional and cognitive status
  • Personal preferences (routines, language, religion)

2. Comprehensive Interdisciplinary Assessment (Within 14 Days of Admission):

• Performed by a care team, including:
  • A member of the nursing team
  • Physical/occupational/speech therapist
  • Social Services
  • Dietary Department
  • Activities coordinator

3. Care Planning Conference:

• Resident and/or Responsible party are invited to a meeting. May have more family members if requested by Responsible party.
• Team reviews assessment findings and goals.
• They co-develop the Individualized Care Plan.
• Topics discussed:
  • Treatment plans
  • Therapy schedules
  • Discharge planning
  • Activity preferences
  • Food preferences
  • Resident preferences and goals

4. Plan Implementation:

• Progress is monitored regularly while the care team follows the plans set up from care plan meeting(s).

5. Ongoing Evaluation and Revisions:

• ICP is updated:
  • Every 90 days
  • After significant changes in condition
  • Based on therapy progress or setbacks
  • Upon resident/family request

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What to Expect as a Resident or Family Member:

What You’ll See	Why It Matters
Regular team meetings	Transparent communication about health status and care
Goal-focused therapy plans	Better chances of recovery or improved function
Input from the resident/family	Care reflects personal values and goals
Documentation and follow-up	Accountability and measurable progress

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