A red barn provides a nod to country life in Sudbury/Photo by Douglas Flynn

A care plan is a schedule of routine services that are organized to address some of the care recipient’s most pressing needs like bathing, medication management, grocery shopping, and laundry.

Traditionally the hospital discharge planner or social worker will put this plan of care together before the care recipient goes home from the hospital or from the rehabilitation facility. Case managers also create care plans after assessing if the care recipient is eligible for specific state home care programs and then offer so many hours of service based upon what the program stipulates.

Example of a Traditional Care Plan:

  • Homemaking Services 2 hours per week (grocery shopping and laundry)
  • Personal Care 1 hour, 3 x week (bathing)
  • Physical therapy 3 x week

(There is often an underlying assumption that the family caregiver will fill in all of the other needs.)


Possible Scenario: Widowed elderly woman living alone is hospitalized with a fractured hip. Woman has two daughters, one living in a nearby town and one living out of state.

Important Note: Traditionally, care plans focus on the care recipient and do not address the family caregiver’s health needs. Often the caregiver feels obligated to get everything done at whatever cost to their own health, career and relationships with other family members and friends.

Feelings of guilt may surface if the caregiver feels that they have failed the person they are caring for. Feelings of frustration, anger and resentment may also arise from the losses they are incurring which seem to be invisible to those not in the caregiver role.

SKILL BUILDER: How to create a care plan for both the care recipient and the caregiver

For the Care Recipient – List all of the needs of the care recipient beginning with activities of daily living (ADLs) and instrumental activities of daily living (IADLs), and then continue noting particular interests and goals specific to the care recipient, prioritizing what is most important to them.

For the Family Caregiver – List all of the tasks that the caregiver is responsible for in all aspects of life, not just caregiving. This list usually awakens the caregiver to all that he or she is really doing every day and helps others in the family, as well as professionals working with the family, to understand the load the caregiver is carrying.

Also refer to the Caregiver Checkup to address any areas of health that are being taxed (lack of sleep, not going to medical appointments, lack of exercise, social isolation, etc.).

Review the above list of needs  Review the needs for both the care recipient and the family caregiver and check the tasks that the family caregiver wants to do. Assess if this is a workable load that allows the family caregiver to remain healthy physically and emotionally. If this is still too much, then remove some of the tasks on the list.

Prioritize the unassigned tasks – Can any of those tasks be combined or reduced by how often something is done, or lesser priorities eliminated?

Match the remaining tasks – Match the remaining tasks with the list of people and professional services that you wrote down in the How to Ask for Help? Section.

Example of a care plan for the care recipient and the caregiver:

Care recipient’s unmet needs in the traditional care plan above

Meal Preparation: combination of meals on wheels 5 x week so caregiver (CG) can work, family brings over dinners 3 x week, frozen dinners as back up, friends/neighbors 1 x week,  CG  dinners 3 x week.

Money management: pay bills and balance check book monthly – family

Transportation: doctors’ appointments – CG, friend and taxi service as backup

Medication management: pharmacy service prepackages meds and delivers them

Secretary: scheduling appointments, communicating updates, maintaining the schedule of all the services, family and volunteers coming into the home and keeping track of who is doing what when – CG.

Church service: goal of care recipient (CR) is to return to volunteering at the church – church member will drive CR weekly

Caregiver’s Care Plan

  • Family Meal prep – CG 4 x week, spouse 2 x week, prepared foods & take out as backup
  • Housekeeping – CG, spouse, children
  • Laundry – spouse
  • Grocery shopping – spouse or delivery
  • Driving children to after school activities – CG, school friends’ parents carpool
  • Work responsibilities – CG
  • Helping with homework – spouse
  • School Committee – CG may need to take a short leave of absence
  • Gym – CG 1 hour 3 x week
  • Reading – 1 hour 2 x week
  • Socialization, lunch with friends – 1 or 2 x month
  • Emotional and educational support – CG support group 1 x month

Note: Typically there are more needs, especially over time and less supports and services that the CG knows about or has connections for and relationships to meet needs. Over time the CG needs to learn about what services and programs are available (ASAPs, Councils on Aging, Veterans Affairs).

What does insurance cover (get help from the SHINE program at your local Council on Aging) and are there any benefits that the care recipient is eligible for that can be applied for? All of this takes energy, time and persistence. So prioritize the health needs of the caregiver from the beginning to maximize strength and stamina. Chronic caregiving is a marathon not a sprint.

When to Rewrite the Care Plan

As the needs of the care recipient and the caregiver change and increase over time, the care plan needs to change or it becomes inadequate. Again, it is the care plan that is inadequate, not the caregiver.

Chronic caregiving is extremely challenging. The sooner the caregiver recognizes that the needs are mounting and changes the care plan, the healthier everyone is. Adding more supports to your family structure makes it stronger.

Note:  If physical violence is occurring, the care plan needs to change immediately; call 911 or Psychiatric Emergency Services Crisis Line 800-640-5432.

Contributed by Leslie May-Chibani©2014

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