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Individual Service Plans (ISPs)
An Assisted Living Care Plan Defines a Resident's Needs & Services

The core of assisted living care is individual support. Facilities use an Individual Service Plan (also called a care plan) approach based on the person's daily care requirements. Before move-in, a resident and their family meet with the selected assisted living facility staff to develop a comprehensive, customized care program based on the individual's interests, needs and desires - many times referred to as an assessment.

The Individual Service Plan helps define the services provided, in addition to the costs associated with such services. Understanding the specific services offered and the costs associated with each service will help you make a more informed decision when selecting a facility.

What is a Care Plan Assessment?

Care assessment

A care plan evaluation is key to quality care and the strategy for how the staff helps the individual. It lays out what type of care and the time increments administered by each staff member, in addition to additional costs associated with the services. An assessment regularly reviews the resident's care and revised as needs change. It gathers information about how well the resident is able to care for oneself. It measures the person's functional abilities: how well a person walks, talks, eats, dresses, bathes, sees, hears, communicates, comprehends, and recalls.

The assessment also defines a person's habits, activities and relationships so that the staff can better assist the resident in living comfortably and feel at home. If staff finds a problem during the care assessment, they can determine its root cause. For example, medications could produce poor balance or could signify weak muscles weak muscles or ill-fitting shoes, or a urinary infection or an ear ache. The assessment determines the cause so that proper treatment is given by the facility's staff.

It's best if an assessment and meeting occur on a quarterly basis or when there is a big change in a resident's physical or mental condition. Many states have specific regulations that address the assessment. Typically, within one week after assessment, the plan takes effect.

A care planning meeting is held between the staff, the resident, and their family. They discuss the life at the facility: the meals, activities, therapies, personal schedule, medical and nursing care, and emotional needs. It's the opportunity for each person to bring up problems, ask questions, give information, and discuss resources. All staff members involved in the resident's care may attend the meeting; nursing assistant, RN, physician, social worker, activities staff, dietician, occupational and physical therapists.

Care plans are popular and used by most of the assisted living facilities. As you can see from the CDC National Survey of Residential Care Facilities in 2010, 94% of facilities developed a formal individual service plan for the residents.

An individual service plan details the personalized services needed by the resident and what will be provided to him or her by the facility. Does this facility develop formal individual service plans?
Responses of don't know (< 1%), and not ascertained (< 1%) and are not shown.
Source: 2010 CDC National Survey of Residential Care Facilities Survey (Facility Responses)

How to Participate in a Care Planning Meeting

Each resident has the right to make choices about the care, services they receive. These personal care services may include:

  • Medication administration;
  • Resident-focused activities;
  • Assistance with activities of daily living;
  • Supervision and support of residents; and
  • Serving meals, but not meal preparation.

Tips in Preparing for a Care Plan Meeting

Be prepared for the care plan meeting
Care Plan Preparation

Prepare for a care plan meeting by understanding all the assistance the resident may need, in addition to those additional services the resident may request.

Some specific suggestions:

  • Write out your concerns, what you need, the problems, and the questions you have. Be open with your feelings and the goals you've set for your care.
  • Ask your doctor and the staff, about your health condition(s) and treatment(s).
  • Schedule a meeting with your family and the staff to discuss the assessment.
  • Discuss options for treatment and how the staff plans to meet your needs and preferences.
  • Learn the procedures the staff will execute.
  • Make sure you understand (and agree) with the care plan.
  • Obtain a copy of the plan.

Ultimately, the Care Plan meeting is responsible for assessing and documenting the individual's:

  • Personal choices and preferences; choice means a resident has viable options that give them greater control over his/her life. Their choice supports sufficient private and common space within a facility that allows residents to select where and how to spend time and receive personal assistance.
  • Significant health care, mental health or behavioral needs and related maintenance needs.
  • Safety and financial skills.

The care team/staff translates this information into goals and objectives of the plan that supports what is most important to and most important for the individual in their daily life.

How Family Members can Participate

Design the care plan

It is important for residents and family members to become involved. During the search for housing, prepare a list of all daily living activities and health care assistance that the resident requires. This list of items will help design their care plan. Make sure the resident and the family agree on the services needed. Make sure the staff follows through.

Additional ways family should become involved:

  • Support the loved one's preferences and choices.
  • Actively participate in the meeting.
  • Be available to the staff and help them find ways to better care for your relative.
  • Keep a watchful eye out for your loved one and do your own assessment of how the plan is working.
  • Speak out to the staff, ask questions or state your opinion.

The Specifics of a Good Care Plan

  • Written in common language; easy for the resident and family to understand.
  • Mirrors the individual's concerns and supports their well-being, functioning and rights. The plan sets a schedule for the resident and staff to review questions like: Am I getting what I need? Am I satisfied? Does anything need to change?
  • The plan lays out a team approach and use outside referrals when needed.
  • Revised quarterly or on a consistent basis.
  • The assisted living facility must have policies and procedures in place that describe the process used to monitor and carry out the care plan.

Benefits of an Individual Service Plan

  • Gives a clear understanding each resident's needs and preferences.
  • A guide for staff members to deliver consistent quality care and service.
  • Permits staff to adapt if a resident's physical or mental condition changes.
  • Offer peace of mind for residents and their families.

Monitoring a Care Plan

The recurring assessments should help the facility monitor a residents needs to ensure the care plan is effective. However, it's important that the resident and the resident family stay involved, and log all reactions to the service plan, prescribed medications, or other treatments. In addition, consult with the resident's doctor about the plan. If it's not working, ask to schedule another meeting.

Carol Marak
Carol Marak

After seven years of helping her aging parents, Carol Marak has become a dedicated senior care writer. Since 2007, she has been doing the research to find answers to common concerns: housing, aging and health, staying safe and independent, and planning long-term.