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The National Association of Professional Geriatric Care Managers (NAPGCM) stipulates
that a care manager, in order “to provide the highest quality of service to clients,
should develop a flexible care plan that is developed in conjunction with the
older person and/or client system.”

A care plan should be comprehensive.  The following are the major subject areas of a comprehensive care plan as outlined by the National Association of Professional Geriatric Care Managers.

1. Reason for Assessing the Care Recipient

2. Demographic Information

3. Medical History/Medical Needs

4. Cognitive Needs

5. Activities of Daily Living & Instrumental Activities of Daily Living

6. Environment

7. Assessment of Care Recipient’s Support Structure

8. Financial

9. Medical Benefit Coverage

10. Legal Needs

11. Emergency Planning

A Care Plan should then provide:

1.  Recommendations, which should include identified areas of concern, in areas of:

Fall/Home safety

Homebound/isolation

Personal care (ADLs)

Household management (IADLs)

Nutrition Cognitive/Memory Impairment

Depression/Mental well being

Medical/Medicine Management

Primary caregiver burnout

2.  Description of Risks, Issues, Problems, or Area of Concerns
3.  Services to resolve areas of concern.
4.  Recommending Next Steps: care manager’s suggestions to accomplish recommendations, including a timeline for accomplishment.