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.