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resident on porchValue Based Care Planning

Transformation asks us to review and alter systems from the medical model that are no longer congruent with a community model of care. Care planning in the third person is one of the systems that need to be changed to reflect a community’s commitment to transformation and person-directed care.

Care plans should be written from the resident’s point of view, in the first person. The goals should be set by the resident or those that know the resident well. It is essential, for anyone, to be involved in the decisions that will affect them; value based care planning embraces this idea by including an interdisciplinary team in the process. This interdisciplinary system is one that includes caregivers, environmental services, maintenance, and the other members that have been traditionally included in the process.

The language of the care plan changes as well, focusing on abilities instead of disabilities. For example a traditional medical model goal may be:

“The resident will walk 30 feet in 14 days by attending PT 3x/week.”

An example of a value based goal would be:

“I am having difficulty walking; I need my team to assist me with walking to and from the bathroom. I will also need my team to assist me with walking the short distance from my room to the dining room for lunch and dinner.”

The goal is the same, the distance is the same. What changes is the inclusion of the resident in the process and the philosophy that therapies do not need to take place at assigned times in assigned areas throughout the day.