What Is a Care Plan?

When a family engages Cambridge Caregivers for in-home care, the priority is creating a care plan.

That’s the road map that allows us to deliver highly personalized care rather than a one-size-fits-all approach.

All licensed in-home care agencies create care plans for clients; it’s a requirement of Texas Health and Human Services regulations. But at Cambridge Caregivers, we strive to create care plans that help ensure caregivers, family members, and the entire Cambridge Caregivers team are aligned on a client’s needs, preferences, goals, and safety.

“In our work, communication is everything,” said Lisa Kramer Morgan, Community Liaison at Cambridge Caregivers. “Every single care plan is different, because every single client is unique and different.”

A care plan is a structured, individualized digital document that outlines exactly what supportive services a client and his or her family need to help the client safely maintain independence at home. It is also a living document that is continually updated as needs change.

The process begins with a family’s first phone call to Cambridge Caregivers. Each client works closely with a Community Liaison, who serves as a primary point of contact throughout the relationship.

“We are with our clients from that first phone call,” said Cindy Greenberg, Community Liaison with Cambridge Caregivers. “They can reach out to us at any time if they have questions or concerns. There’s no calling around trying to get the right person on the phone.”

Building the Care Plan

The care plan is further developed through the onboarding process, and an assessment is performed in the client’s home. During that visit, the Community Liaison observes, asks questions, and gathers information about the client’s physical abilities, cognitive status, routines, living environment, and goals. The client and/or family members share the client’s daily routines, preferences, and concerns.

The resulting care plan outlines exactly what caregivers are expected to do, whether that involves assistance with bathing, dressing, transferring, meal preparation, medication reminders, companionship, transportation, or light housekeeping. It also establishes goals for care.

“For a client who’s recovering from surgery, the goal may be to get that client back to health and fully functioning,” Cindy said. “For a client with a serious health condition, the care plan might be focused more on keeping them comfortable.”

Safety considerations may also be part of a care plan, including fall prevention strategies and emergency procedures.

When applicable, the care plan also serves as a platform to help coordinate care with other providers, such as private duty nurses, home health, hospice care, or others.

Details Matter

One of the most valuable aspects of a care plan is its specificity.

“Say the caregiver is expected to feed the client,” Lisa said. “For one client that might mean the caregiver needs to cut up the food and assist with eating. For another, it might just mean meal preparation.”

Care plans also include seemingly mundane but critical details.

“A caregiver needs to know if there is a large golden retriever named Rusty in the home, whether the client prefers oatmeal every morning, or how to input the correct code to access the garage,” Cindy said. “Those are the kinds of details that help caregivers walk into a home prepared and confident, creating a smoother experience for everyone.”

The care plan also helps Cambridge Caregivers’ scheduling team match caregivers with the right skills and personality for each client. If a client has a dog, for example, we will assign a caregiver who is comfortable around pets. If a client requires specialized assistance, such as transfers using a Hoyer lift, schedulers identify caregivers with the appropriate training and experience.

A Living, Evolving Document

Perhaps the most important thing to understand about a care plan is that it is never finished.

Clients recover from surgeries, health conditions progress, mobility changes, and new safety concerns emerge. As those changes occur, the care plan changes as well.

“As each client’s care needs change over time, we adjust the care plan accordingly to ensure the appropriate level of support,” Lisa said.

Caregivers play a critical role in keeping care plans current. Before accepting an assignment, each caregiver reviews the client’s care plan. After each shift, they document observations and notes through Cambridge Caregivers’ online reporting system. Those observations may lead to conversations with families and, when necessary, adjustments to care. A client who becomes more prone to falls, for example, may need additional assistance, a walker, a wheelchair or new safety protocols.

Because Cambridge Caregivers employs caregivers as W-2 employees and invests heavily in training, the company can also respond when a client’s needs become more complex.

“Clients often ask for continuity of care — having the same caregiver for every shift,” Cindy said. “We do our best to accommodate that whenever possible.”

“Sometimes a client’s condition changes and new skills are needed, such as using a Hoyer lift,” she said. “When that happens, we can often train the established caregiver to meet those needs. We have the resources and expertise to provide that training.”

Ultimately, a care plan creates a shared understanding among clients, families, and the caregiving team. It helps ensure that everyone is working toward the same goals while allowing care to evolve as a client’s needs change.

“We are a high-touch business,” Lisa said. “Constant communication is the key to making sure that each client gets the best possible care.”

A strong care plan can make all the difference in helping a loved one remain safe and comfortable at home. If you have questions about in-home care, Cambridge Caregivers is here to help. Contact our office at (972) 423-3600.