How Team Members Contribute to the Care Plan

Care planning should involve input from the client and/or the family, as well as healthcare professionals.  Healthcare professionals will assess the client’s physical, financial, social, and psychological needs.  After the doctor prescribes treatment, the supervisor, nurses, and other care team members formulate the care plan.

Many factors are considered when formulating a care plan.  These include:

  • the client’s health and physical condition
  • the client’s diagnosis and treatment
  • whether additional services and resources, including transportation or equipment, are needed

For example, a social worker may arrange transportation for the client to and from appointments with his or her physician.

The psychological and socioeconomic status of the client and the family are other important factors. The agency will assess how the client and family are reacting to the medical problems.  Family members may be absent or unavailable for some clients.  For example, a client may have only elderly and ailing relatives to help with care.  Family members may have jobs to go to or children to care for.  Some families may have relatives who are unwilling to assist in care.  For some families, problems like alcoholism and substance abuse can make it difficult to provide care. Housing and financial resources may also be lacking.  A medical social worker may be sent to the home to assess the situation and make referrals.  The medical social worker can assist with long-term care planning.

Input from all members of the care team is needed to develop the client care plan.  For instance, a 250-lb, elderly client requests a tub bath.  The supervisor assigns the tub bath, but the home health aide finds that the client has no adaptive equipment and is unable to move to the tub.  The assignment puts the home health aide and the client at risk of injury.  The home health aide must communicate this. The assignment needs to be changed to a sponge bath or shower, or the client needs to obtain adaptive equipment.  The supervisor is responsible for reassessing the assignment and making necessary changes to the care plan.

Multiple care plans may be necessary for some clients.  In these situations, the supervisor will coordinate the client’s overall care.  There will be one care plan for the home health aide to follow. There will be separate care plans for other providers, such as the physical therapist.

Care plans must be kept up-to-date as the client’s condition changes.  Reporting changes and problems to the supervisor is a very important role of the home health aide.  That is how the care team revises care plans to meet the client’s changing needs.