162. CCA Study Notes: The Care-Planning Process in Community Settings

The Big Picture

In community settings, client care usually follows four main steps. These steps help organize what care and services the client needs and how that care will be provided.

A case manager usually coordinates and manages this process. The four steps are assessment, planning, implementation, and evaluation.

Look for Nova Scotia CCA Notes throughout this page for current provincial guidance.

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Course Notes: Key Ideas You Need to Know

What Is the Care-Planning Process?

The care-planning process is the method nurses and case managers use to plan a client’s care with the health care team. It is also known as the nursing process. In community settings, case managers usually coordinate and manage client care.

The process usually has four steps:

1. Assessment
2. Planning
3. Implementation
4. Evaluation

These steps organize how information is gathered, care is planned, services are provided, and progress is reviewed.

Step 1: Assessment

Assessment means evaluating information collected about the client through observation, reflection, and communication. It is the first step in the care-planning process.

The case manager meets with the client and family members to identify the client’s issues and needs. This meeting usually takes place in the client’s home.

If the client is returning home from the hospital, the case manager uses information from the hospital record or from a referral ⓘ sent to the agency ⓘ. Referral information might come from a hospital case manager or discharge planner.

The Family’s Role in Assessment

Family members are an important part of assessment in community care.

Serious illnesses and disabilities can greatly affect family life. Family members take on new roles, including becoming caregivers to a client with an illness or disability.

The case manager considers:

• the needs, health, and well-being of the whole family
• whether family members need help adjusting to the situation
• whether family members need training to help care for the client
• what care and services the client and family need

The case manager, client, and family members decide together what care and services are needed. These might include nursing care, personal care, Meals on Wheels, housekeeping, transportation, or special equipment.

Assessing the Home

The case manager also looks at whether the client’s home provides a safe environment.

The home must be reasonably clean, be free of infestations ⓘ, and have handwashing facilities and adequate heating and cooling systems.

The case manager also assesses whether changes to the home are needed for the client’s safety. Examples include grab bars in the bathroom or a mechanical lifting device in the bedroom.

Other specialists sometimes complete further safety assessments. For example, an occupational therapist might assess wheelchair accessibility.

Team members also have access to assessment tools such as the Resident Assessment Instrument, or RAI.

Step 2: Planning

Planning involves establishing priorities and goals and deciding on measures or actions that help the client meet those goals.

Planning in community care settings might take a long time and involve several parts.

First: the case manager, client, and family members:

• establish priorities
• set goals
• determine available resources

The case manager then develops a master care plan based on those goals and puts together a health care team. A care plan is a document describing the care and services the client must receive.

Looking at Available Resources

The case manager and family members consider the resources available for care.

The case manager determines how much publicly funded home care the client and family are eligible for. The family might choose to pay a private agency for extra care or services.

The Master Care Plan

The master care plan includes care and services provided by family members, outside professionals, and agencies.

Individual professionals and agencies often develop their own care plans. The case manager remains responsible for the master plan.

For example, a nursing care plan might form one part of the master care plan.

Arranging Services

In many jurisdictions ⓘ, the case manager schedules outside services and arranges financing.

When the client needs a support worker, the case manager contacts an agency. A supervisor assigns a support worker to provide care or support.

The support worker might receive the assignment by phone or on an assignment sheet. In other jurisdictions, the case manager also belongs to the home care team.

When Several Agencies Are Involved

A client with several needs might receive services from more than one agency.

For example, one client recovering from a stroke has a primary family caregiver and needs several services:

• 4 hours of nursing care a week
• visits from respiratory, occupational, and speech therapists
• visits from a physiotherapist
• support-worker help preparing for bed when the family caregiver is at work
• Meals on Wheels so the family caregiver does not have to prepare every meal

This shows how several agencies and services may be involved when a client has multiple needs.

When Clients Manage Their Own Care

Some clients in the community choose to coordinate and manage their own care.

They might create a written care plan, or they might have no written directions.

When there are no written directions, the support worker must ask the client for detailed instructions.

Role limit: You must make sure you know exactly what your employer’s policies allow you to do. You must also know what to do when the client expects care that falls beyond your scope of practice ⓘ.

If you are hired privately, you must decide whether you are able to provide the requested care based on your education. In this situation, you are directly liable ⓘ for legal actions.

Step 3: Implementation

Implementation means carrying out or performing the planned care.

Agency staff provide care and services on the dates and at the times arranged by the case manager.

If an unforeseen need arises, the client or a family member contacts the case manager. The case manager assesses the situation and might ask the agency to provide an unscheduled visit.

Step 4: Evaluation

Evaluation means assessing and measuring. In home care, evaluation continues over time.

The case manager periodically meets with the client and family to assess progress.

The case manager also meets with care providers and service providers and receives their reports. These providers continually monitor and evaluate their own care plans.