What some might view as an extra bureaucratic layer of corporatized long-term care, care plans are actually an incredibly useful tool for ensuring high-quality and person-centered care. A care plan isn't just a document; it's a roadmap that ensures everyone involved in a person’s care is aligned, informed, and prepared.
What is a care plan?
A care plan is a living document that outlines a person's needs and preferences with the goal to maintain (or improve) quantity and quality of life. It can include information on everything from medical conditions and medication schedules, to whether or not they like to use a nightlight. The exact notes within a care plan will vary as it's developed specifically for a single individual's unique supports.
Quantity vs quality of life
Every care plan should be developed in collaboration with the person being supported (care consumer) and the person(s) supporting (care partner), with personal preferences and goals in mind. This document will help serve as a reference point when balancing decisions between quantity and quality of life. We can also describe these concepts as what is important for (quantity of life) and what is important to (quality of life).
For example, when a person is lactose intolerant it could be important for them to not have ice cream. Ice cream might also be their favorite food, and thereby important to them. A care plan might note both of these facts about the consumer, and may even list some strategies to navigate this conflict of care. Maybe they take a lactose medication with ice cream, or maybe they only eat ice cream every so often.
I once knew a consumer who was prescribed a pureed diet due to difficulties chewing and swallowing, but adamantly refused to eat anything other than regular texture on grounds of quality of life. In this case there was no compromise to be made. They have the right to make that conscious decision about their care. The important thing is to ensure there's a conversation about risks and rewards, and ensuring informed decision making.
What goes into a care plan?
- Demographic details & contacts
A care plan might begin with demographic details, such as name, age, weight, and contact information for both the consumer and the important people involved in their care. This might be emergency contacts, primary care physician, medical and financial representatives, and case managers.
- Medical status & baseline
The care plan might contain a list of current diagnoses, medications, and recent medical procedures. There can also be notes on physician-recommended lifestyle changes, such as diet. Do they have any concerning allergies? Any health risks such as cardiovascular concerns or seizures? Descriptions of the individual at baseline can also be helpful - are they alert and oriented? How do they do with ambulation or transfers?
- Support needs
You'll then want to provide details about the specific supports that are being provided. If the supported person is receiving assistance with showers, what does that look like? Do they wash their own hair and upper body, but receive assistance with lower body? Or do they just need assistance transferring in and out, and the care provider waits in the next room until they're finished?
- Emergency procedures, notes & trackers
You can then add any emergency procedures, whatever additional notes you'd like to document such as preferences or values, and trackers such as medication administration, bowel and urinary care, mood, or pain.
- Task lists
Consider who is responsible for specific aspects of care, like making sure the bathroom is cleaned, or doing the shopping. Creating a list of support tasks and naming who the delegated responsible party is can help ensure the workload is clearly defined, and one person isn't taking on too much.
Care plan complexity
Keep in mind, too many details might make the document challenging to read from the overwhelming amount of information, but too few notes can make it hard to communicate the full scope of care. Striking the balance by sharing the most important notes, or having two versions - one an abbreviated reference, and one in-depth, could be the way to go.
Consider the audience of the document: this might be shared with current and new caregivers, medical professionals, and case managers. This document also becomes a snapshot in time to help keep an eye on symptom development and areas of decline. Remember: a care plan isn’t static—it should be reviewed and updated regularly to reflect changes in health, goals, and circumstances.
Why a care plan matters
- Improves communication
With multiple doctors, specialists, and caregivers often involved in a person’s health, a care plan keeps everyone on the same page. It reduces confusion and ensures consistent treatment across settings.
- Supports person-centered care
Each person has unique needs, preferences, and goals. A care plan honors those by tailoring interventions and support accordingly—whether it’s managing diabetes, navigating dementia care, or planning end-of-life comfort. It also catalogs those preferences, so there can be less guessing as to what the consumer wants.
- Enhances continuity of care
Transitions between home, hospital, acute rehab, and long-term care settings can be difficult. A care plan ensures critical information isn’t lost in the shuffle, helping avoid unnecessary hospital readmissions or medical errors.
- Empowers families & caregivers
Caring for a loved one can be overwhelming. A care plan provides structure, roles, and clarity—helping caregivers understand what to expect, how to respond, and when to ask for help. For family caregivers in particular, it can help define when they're wearing the "care partner" hat and when they can take it off to be family.
- Encourages proactive health management
Rather than reacting to crises, a care plan helps individuals manage their health actively. When care consumers and care partners sit together to collaborate over a care plan, they're creating an open and safe space for dialogue about preferences, needs and balance.
Who needs a care plan?
While everyone can benefit from having some form of health planning, care plans are especially important for:
- Older adults or folks living with physical disabilities
- Those with complex medical conditions or chronic health conditions
- People recovering from major surgery or illness
- Individuals living with cognitive impairments such as Allzheimer's
- Anyone receiving support from multiple caregivers or health providers
If you or a loved one doesn't already have a care plan in place, it might be time to get one started. You can work with a professional such as a care planning consultant, care manager, or social worker. You could also reach out to your primary care physician for assistance, but it never hurts to get started with drafting one on your own.
