Integrating Preferences into Care Plans
Why use Preferences for Care Planning
Using the Preferences for Everyday Living Inventory (PELI) to personalize care offers important benefits for residents, families and communities. Understanding and meeting preferences:
- Enhances nursing home residents’ autonomy, quality of life and physical and emotional wellbeing.
- Supports more effective and holistic care planning.
- Increases satisfaction among residents and their family members.
- Strengthens trust and communication among residents, family members and nursing home staff.
- Complies with regulations requiring that care plans reflect residents’ voices and preferences so that each person can experience a meaningful and enjoyable life.
Preparing for the Care Plan Meeting
A PELI interview is just the beginning! The next steps are to summarize resident preferences for the care team and invite key players to the care planning meeting. Before the meeting, one or more care team members can review the resident’s PELI responses and draft simple statements that capture the individual’s preferences for team discussion. One approach for these summaries speaks in the resident’s voice:
- Personal Care Preferences: Consider my most important preferences, such as [choosing what clothes to wear] in order to help me engage positively in care that I can do myself.
- Recreation Preferences: Consider my most important preferences, such as [doing my favorite activities: reading, painting, gardening] in order to help me enjoy my leisure time.
Who should you invite to the care planning meeting? Best practice is to include the attending physician, plus representatives from social services, therapeutic recreation, nutrition services, nursing and a direct care worker. Of course, always encourage the resident and family member, or another person of the resident’s choosing, to attend.
Federal regulations now require the input of a direct care worker in the care plan. The Pioneer Network has developed a tip sheet on Involving CNAs in Care Planning. This excellent resource discusses ways to help direct care workers prepare for and participate more confidently in care planning meetings. Find the tip sheet at https://www.pioneernetwork.net/wp-content/uploads/2016/10/Involving-CNAs-in-Care-Planning-Tip-Sheet.pdf.
Note that you can interview direct care workers to gain their perspective before the care planning session, if they are unable to attend. Ask questions such as: “Has there been any change in cognition or function of the resident?”, or “Mrs. Smith said choosing what clothes to wear was important to her. How has that been going?”
Developing Care Plans that Build Dignity, Pride and Success
Each care plan should reflect and honor the individual’s unique strengths and wishes. The aim of the care planning team is to develop realistic, achievable goals that support the resident’s priorities and account for their unique needs, challenges and strengths. Use language that builds dignity and pride – for the resident to review and approve. Key elements include:
- Tailor activities and services to each resident’s interests and functional abilities. Well-crafted care plans can reduce stress, agitation, depression and other signs of discomfort.
- Look for ways to solve obstacles in meeting preferences. Think creatively and “out of the box” to support the resident’s top preferences and priorities.
- Reassess the care plan at regular intervals or when functional levels change.
- Document the plan clearly and concisely so that team members across shifts can work toward goals consistently.
- Keep care plans open and flexible. Small changes can occur without formal care planning meetings.
To build dignity and promote positive outcomes, use a strength-based care planning approach that addresses functional barriers to preference fulfillment, as shown in the chart below.
| Functional barriers to preferred activities | Strength-based approach | Examples of creative adaptations to encourage participation |
| Physical: Ability to complete task with previous skills has changed. | Use adaptive equipment or approaches | • Provide large print or audio books • Add raised planters for gardening |
| Cognitive: Frustration with complex tasks due to decreased comprehension or problem solving. | Simplify tasks. Increase resident’s confidence through encouragement and small successes | • Offer two outfits to choose from, not three, in order to ease decision making • When asking a question, allow more time for the client to respond |
| Social/Environmental: Prefers privacy and/or quieter environment. | Perform tasks one-on-one or in a small group | • Form small groups for individuals with comparable skills or functional levels |
| Social: Difficulty adjusting to a new environment because prior social supports are less available. | Support adjustment and facilitate social interactions | • Incorporate personal items into the clients’ day (e.g., family photos in room) • Introduce client to peers with similar interests and functional levels |
| Mental health/social: High anxiety, diminished ability to manage stress. | Provide support at a slow pace in synch with resident reactions (i.e., monitor for positive or negative response) | • Whenever possible, bring preferred activity to resident (e.g., knitting) • Introduce relaxation exercises, such as yoga, meditation and other techniques • Provide opportunities for independent leisure and one-to-one interventions • Develop a peer mentoring program, where residents who successfully manage stress assist others dealing with this issue • Play familiar music in the comfort of the resident’s own room. Consider the Music and Memory program (see musicandmemory.org/ |
Staying Alert to Changing Preferences
Keep in mind that using the PELI, and developing preference-based care plans, is an ongoing process, not a one-time task. Ideally, communities use the PELI to assess a resident’s preferences and adjust the care plan at quarterly intervals, along with Minimum Data Set 3.0 (MDS) reviews.
Also, it is important to reassess preferences when the resident experiences a significant change in status, such as an acute illness or a decline in cognition, or when the resident loses interest in a preferred activity. When a resident who has always enjoyed going outside suddenly is no longer interested, explore the reasons. The change may signal a decline in the individual’s physical or emotional wellbeing.
Case Examples
Case Study A: Mrs. Smith has mild cognitive deficits and arthritis that have led her to feel less satisfied with her favorite activity, knitting. In a discussion with her daughter, she shared that she does not like to knit in large groups.
| Client’s priorities and strengths | Goal | Supports for goal |
| Mrs. Smith: I will feel more satisfied with my favorite activity, knitting, when I feel more supported. | I will participate in a smaller knitting group that meets two or three times per week (with more supports). | • Organize a knitting group with a small number of participants. • Offer Mrs. Smith the opportunity to make choices regarding color of yarn or current knitting project. • Adapt the project: use step-by-step tasks, such as winding a ball of yarn for others. • Provide cues in times of confusion. |
Case Study B: Mr. Jones has moderate dementia. While he often exhibits pleasant behavior, he also has episodes of aggression, agitation and disrobing. He is 6’4” tall. The care team has become concerned for their own as well as other residents’ safety during these periods of difficulty. A conversation with his family about Mr. Jones’ preferences revealed that he was an avid wine collector who enjoyed reading about wine and sharing it with others. As one of many interventions, the team developed this plan:
| Client’s priorities and strengths | Goal | Supports for goal |
| Mr. Jones: I will feel less agitated and am less likely to experience the urge to disrobe when my hands and mind are occupied with my genuine interests. | I will look at magazines and documentaries on wine to decrease my feelings of agitation. | • Ensure access to wine magazines. • When agitated, provide with conversation about wine, wine magazines or documentaries about wine. |
Case Study C: Mrs. Washington, a fully oriented resident who requires physical assistance to move through the building, suffers from moderate depression and often refuses to take part in recreational activities. Her interests are keeping in touch with old friends by computer and interacting with children. The facility has Wi-Fi access in only one area.
| Client’s priorities and strengths | Goal | Supports for goal |
| I, Mrs. Washington, am able to pursue my interests with little to no assistance. | By engaging in my preferences of social interaction with old friends and interacting with children, I will have an improved mood. | • Find a young volunteer (who can safely transport her through the building), with whom she can read books or play board games. • Schedule time to use the room with Wi-Fi and interact with friends via email or social media. |
To view the webinar that accompanies this tip sheet, use the link below.