Person Directed Care Planning

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Person DirectedCare Planning

• Integrating Person Directed Care Principles
• into your
• Care Planning Process

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Maintaining Personhood

• Attachment Bonding to someone
• Comfort The feeling of security
• Inclusion To be part of the group
• Occupation Involved in life in a
• personally
  significant way
• Identity To know ones self
• Book Dementia Reconsidered The Person
  Comes First Tom Kitwood

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Dont Forget The Issues

• Enhancing Opportunities
• for Inclusion
• Building Relationships
• Honoring Uniqueness
• Recognizing Embodiment

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What is a Person Directed Care Planning?

• Directed by the person it is about.
• Written in a language everyone is able to
  understand.
• Focuses on a persons strengths.
• Recognizes the issues of the moment

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Where Do You Start

• Start with your Elders
• Create A Team
• Include Your Surveyors
• Develop a Time Line
• Make it Realistic
• Dont Give Up!

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Step OneA Standard Care Plan
Problem Alteration In Thought Process
RE h/o CVA AMB STM loss
Goal Resident will be oriented to
person, place, time and situation at all times.
Goal Date 2/15/03 Approaches
1. Provide orientation with routine
care. Daily. ALL 2. Invite to
R.O. Activities i.e.holiday parties,
current events group, resident council.
PRN. CNA 3. Place facility
calendar in room. Monthly. RT
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Step TwoIndividualized Care Plan
ProblemCognition RE Cardio Vascular
Accident 1/30/01 AMB
Unable to remember times and places of favorite
activities Goal Frank will use the
activity calendar to remind himself of
daily activities Goal Date-
2/18/03 Approaches 1. Place weekly
calendar in Franks room on the
small Bulletin Board next to his mirror. Weekly.
RT 2. Assist Frank to choose
activities he is interested in
for the day before he goes to
breakfast.
Q am. NAC
3. Remind Frank throughout the day
of the group activities coming up.
Daily. ALL.
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STEP THREEThe I Care Plan

• Problem I have a problem with my memory.
• Related to I have had a stroke about a year
  ago.
• Evidenced By When I wake up in the morning and
  after my nap I
• have trouble remembering where I am.
• Goal I would like to learn to use my calendar
  to get to activities I enjoy.
• The Activity Aide will put a calendar on my
  bulletin board each week. Q week RT
• When I am getting ready in the morning, show me
  my clock and calendar. Q day NAC
• Help me pick out some of the activities
  of interest.
• 3. If I appear a little confused throughout
  the day, help me to get back on Daily
  All
• track by reading my calendar again.
  Remind me of the activities I had
• planned to attend and encourage me to go.

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Step FourPerson Centered Care Planning
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Care Planning List

• Special Considerations/Strengths
• Social History
• Memory Enhancement Communication
• Mental Wellness
• Mobility Enhancement
• Safety
• Vision

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• Dental Care
• Becoming Continent
• Skin Care
• Nutrition
• Fluids
• Comfort
• Activities
• Discharge Plan

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Resident Care Plan
Social History I am Frankford William Fox. My
friends call me Frank. I was born in Fargo,
North Dakota way back in 1910. My parents were
farmers. They raised my six older brothers and
I to have strong work ethics. My parents valued
a good education. All of us boys graduated from
Washington High School in Fargo. Shortly after
graduation I hopped a train to Colorado. I got
off in a town called Marble, way up in the
Rockies...
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Memory Enhancement/Communication
My memory is pretty good. I had a stroke about
a year ago which affected my ability to remember
things which happen day to day. I love to
attend groups and am a very social guy. I
appreciate it if you show me the weekly calendar
in my room near the sink every morning. Review
with me what is going on for that day. I will
tell you what I am interested in. You can remind
me during the day when an activity I enjoy is
going to occur. Goal I want to work with you
daily to learn my calendar so that I will be
able to be independent in getting to
the group activities which I enjoy.
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Memory Enhancement/Communication(Problem Goal
Approaches Divided Out)
My memory is pretty good. I had a stroke about
a year ago which affected my ability to remember
things which happen day to day. I love to
attend groups and am a very social guy. I
appreciate it if you show me the weekly calendar
in my room near the sink every morning. Review
with me what is going on for that day. I will
tell you what I am interested in. You can remind
me during the day when an activity I enjoy is
going to occur. Goal I want to work with you
daily to learn my calendar so that I will be
able to be independent in getting to the group
activities which I enjoy.
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Mental Wellness
After my stroke I could no longer live alone.
Last July I moved to Riverview be near my wife
Marlene who has severe Alzheimer's Disease. We
enjoy our time together. She lives in River
Heights Neighborhood and I live in Melody
Meadows Neighborhood.. We like it this way.
Because of my life changes I sometimes get down
on myself. It helps to visit with the
psychologist when he is here each Monday. I also
like to attend Mens Group on Wednesday to talk
about my issues. Remind me on Wednesday at 2pm
to be in the Garden Room. My faith has always
been strong. I try to visit with the pastor
after Sunday Service. Provide us privacy in my
room so we can talk uninterrupted. Goal I want
to be able to verbalize the positive aspects of
my life when talking one on one with the
psychologist.
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Mental Wellness(Problem, Goal Approaches
divided out)
After my stroke I could no longer live alone.
Last July I moved to Riverview be near my wife
Marlene who has severe Alzheimer's Disease. We
enjoy our time together. She lives in River
Heights Neighborhood and I live in Melody
Meadows Neighborhood.. We like it this way.
Because of my life changes I sometimes get down
on myself. It helps to visit with the social
worker when he is here each Monday. I also like
to attend Mens Group on Wednesday to talk about
my issues. Remind me on Wednesday at 2pm to be
in the Garden Room. My faith has always been
strong. I try to visit with the pastor after
Sunday Service. Provide us privacy in my room
so we can talk uninterrupted. Goal I want to be
able to verbalize the positive aspects of my life
when talking one on one with the social worker.
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Comfort

• Back in 1935 I fell while taking a climb up a
  14,000 foot peak. I cracked a vertebrae in my
  upper spine. Later I developed Arthritis in this
  area. My pain worsens as the day wears on.
  Please remember that if I start getting grouchy
  and short tempered it is because my back hurts.
  Ask me about it. Let the Nurse know I am having
  trouble. I take regular medication for pain.
  Sometimes I need an extra boost of medication. I
  also benefit from a good stretch so I like to
  attend the morning exercise group. The massage
  therapist sees me every Friday for an hour.
  Massage makes all the difference.
• Goal To be free
• Of breakthrough pain
• In my back.
• .

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Comfort(Problem, Goal Approaches Divided Out)

• Back in 1935 I fell while taking a climb up a
  14,000 foot peak. I cracked a vertebrae in my
  upper spine. Later I developed Arthritis in this
  area. My pain worsens as the day wears on.
  Please remember that if I start getting grouchy
  and short tempered it is because my back hurts.
  Ask me about it. Let the Nurse know I am having
  trouble. I take regular medication for pain.
  Sometimes I need an extra boost of medication. I
  also benefit from a good stretch so I like to
  attend the morning exercise group. The massage
  therapist sees me every Friday for an hour.
  Massage makes all the difference.
• Goal To be free from breakthrough pain in my
  back.

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Nutrition

• Ever since my stroke, my appetite just hasnt
  been the same. I have been loosing weight since
  July. It helps to have my special adaptive
  silverware at the table when I eat. I eat better
  when I sit with Marlene. Make sure we have our
  special table set up so we can eat together at
  every meal. I have always been a snacker since
  my hiking days. I especially enjoy Almond Joys,
  Chocolate milkshakes and a burger from McDonalds
  which my daughter brings in. Offer me a snack
  between meals and before bed. Also invite me to
  join in the cooking group. Food always tastes
  better when you make it yourself I always say.
• Goal I want to keep my current weight and
  maybe even gain five pounds.

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Nutrition(Problem, Goal Approached divided out)

• Ever since my stroke, my appetite just hasnt
  been the same. I have been loosing weight since
  July. It helps to have my special adaptive
  silverware at the table when I eat. I eat better
  when I sit with Marlene. Make sure we have our
  special table set up so we can eat together at
  every meal. I have always been a snacker since
  my hiking days. I especially enjoy Almond Joys,
  Chocolate milkshakes and burgers from McDonalds
  which my daughter brings in for me. Offer me a
  snack between meals and before bed. Also invite
  me to join in the cooking group. Food always
  tastes better when you make it yourself I always
  say.
• Goal I want to keep my current weight and
  maybe even gain five pounds.

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RememberThis is a TEAM process.Many people
take a part in making it successful
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providing care is a collaborative art that all
members of the community need to play a role in
improving... Bill
Thomas-Life Worth Living