How to Run a Care Plan Meeting

Care Plan Meetings, also called Care Conferences or IDT Meetings with the Resident and/or Family are an important part of your resident’s stay at the facility.  They are necessary to ensure that no communication has been lost and that we are answering all questions and addressing all concerns raised by the resident and/or family.  Also, getting resident and family input into the plan of care is extremely important in order to optimize clinical outcomes.
Different individuals and even companies run the care plan meetings in different ways.  In some facilities, the MDS Coordinator leads the meeting.  At others, the Social Services Director or even the DON may lead it.  Regardless of who leads the meeting, there are several key components you should ensure are included:
  • Your invitations should go out to the family at least 10 days in advance.  One thing many facilities don’t do consistently is invite the resident.  Let’s make sure we don’t forget that.  After all, it is a meeting on the resident’s plan of care.
  • Make sure the resident’s medical record, care plans, ADL sheets, and current therapy progress notes are brought to the care plan.  You will need to refer to these documents at different points during your conversation.  Have them ready.
  • You should introduce yourself to the attendees as well as introduce all the IDT members.
  • Ask if there are any concerns, questions, or complaints they wish to discuss before reviewing the chart and care plans.
  • Your MDS should match your care plans and you should ensure the CNA ADL sheets have been updated to reflect the resident’s current status.  I always instruct my staff to review the care plan interventions for things the CNAs would need to know and then bring those interventions to the CNA ADL sheet so we are sharing it with the people who need it the most.
  • You should review the diagnoses and explain if the resident or family does not understand.
  • You should go over the current physician’s orders and explain what each medication is for.  Include any recent changes of medications.
  • You should review any significant changes with the resident – any improvements or any declines – since the last assessment.
  • Review the nursing care plan, reading the problem, goals, and interventions and discussing with the team, family, and resident.
  • Each IDT member should review their own department’s care plans and answer any questions that may come up.
  • Discuss if additions or changes need to be made to any of the care plans, goals, or interventions.  It is important to ensure the resident, facility, and family have similar goals for the resident’s best outcome.
  • Explain the facility’s regulatory requirements as necessary to indicate why we must attempt restraint reductions or attempt dose reductions on medications.
  • The QI/QM report should be reviewed for any flags and discuss those as well.
  • The communication during the meeting should be focused and stay on the subject.  If an individual tends to drift out on a tangent, reel them back in.
  • If issues come up that need to be addressed by other staff (ie- grievances, work orders), ensure proper follow-up.
  • Take the opportunity to remind residents or family of any specific rules or issues that may violate the facility’s policies to ensure everyone is on the same page. (ie-smoking in room, or keeping uncovered snacks in room, family bringing in food that is not in compliance with physician-prescribed diet, etc.).
  • Reinforce that good communication is required between all parties to get the best outcomes.
  • The resident and family should leave the meeting feeling like all their questions have been answered and that their input was appreciated and considered for any further care plan adjustments.
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2 Responses to “How to Run a Care Plan Meeting”

  • Sylvia Jackson on

    This is exactly how I did my care plan conference as a DON since 1988. When I read it I felt like I wrote it.
    Thanks for putting this in print.
    Sylvia Jackson MSN RN NHA

  • Mark on

    Thanks, Sylvia. Good to know I’m not the only one, Ha!

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