Service/Care Plans
When a person begins to receive long-term care services, an assessment determines their needs and
preferences. The case manager or supervisor works with the client and the rest of the care team to develop a service plan (also called a negotiated care plan). The service plan is a detailed explanation of the client’s needs and the services they will receive. In general, a service plan identifies:
- What tasks the client wants and needs support with;
- Who will support them with each task; and
- How and when the client wants the task to be done. The care team is responsible for keeping the client’s service plan up to date. A client’s needs can change over time, and they may want or need more or less support. One responsibility of a Home Care Aide is to report these changes to the rest of the care team.
Read the client profiles below. What kind of services and support might reach each individual need? What person-centered considerations would caregivers need to be aware of?
Jeff is 33 years old and lives in his own home with his mother.
His mother works days, while Jeff stays home alone.
Jeff has Cerebral Palsy and uses a motorized
chair for mobility.
He works from home and
enjoys many hobbies.
Daisy is 65 years old.
Her partner of 40 years recently died, and she moved into an adult family home a few weeks ago.
She lives with physical limitations, and needs help with mobility, especially when
transferring to bathe.
Daisy is a transgender woman and prefers
female caregivers for help with personal care.
Zainab is 69 years old.
She has lived in an assisted living facility for
two years.
She has progressive dementia, which causes
her to forget where she is and who the people around her are.
Zainab also lives with several chronic conditions that she manages with daily medications.
Bernard is 80 years old.
Last year, he broke his hip and wrist in a fall.
He recently transferred from a nursing home to an assisted living facility.
Since then, Bernard has been experiencing
increasing depression and anxiety.
Bernard lives with emphysema but chooses
to continue smoking.
Bernard prefers to communicate in Spanish,
but speaks English as well.