In almost every nursing home, the care each patient receives is governed by a "plan of care." The plan is based on a clear understanding of what the patient's needs or problems are. The plan sets care or management goals for each of these needs. The plan sets out how the staff will proceed in each of these need or problem areas. It says which departments; nursing, dietary or social service, for instance will do that part of the work. Generally, the plan of care is set up within the first two or three weeks of a person's stay. The plan is reviewed and revised every three to six months. Many nursing home invite families to takc part in care planning.

Take part in setting up the care plan.

Plan to take part in setting up the patient's plan of care. You are an expert on the care needs of the impaired person. You know the best techniques for working with this person. Be ready to offer this information to the care planning group. Tell them what you have observed about the person's food preferences, strengths and weaknesses, likes and dislikes, habits and activities. List for the group the problems you have had and how you handle them. Tell them how you divert the person, how you received him or her, and how you communicate with each other. For example, if the person becomes agitated, how do you calm him or her? How do you tell if the person is in pain or unwell? Do certain gestures signal certain needs, such as the need to go to the toilet?

Put your observations down in writing.

Prepare for this planning session by putting your observations down in writing, if you can. Then they can become a permanent part of the patient s medical record and can be referred to as needed. Former doctor's detailed plan of care. Ask the patient's former doctor for a detailed plan of care. Even if this doctor will not attend the impaired person at the nursing home, ask him or her to submit a report to the new doctor. The report should detail what kind of care the former doctor, who knows the patient's situation best, would prescribe.

The Day of the Move

Although emotionally hard, the day of the move itself is not as important as it might seem in ensuring the impaired person's adjustment to his or her new home. Your planning and your future efforts to assure the person's well-being matter much more in the long run. Still, the day itself may be charged with very strong feelings.

Keep in mind that these feelings are normal, but try not to let them get in the way of your task. You want to bring the person to the home and leave him or her there in as cheerful a manner as you can. Your task is to minimize any distress the patient may feel. The following ideas may help.

Plan what to tell or say to the person.

Think about what you want to tell or say to the person in your care about the move. Let your own know edge of what the person can understand be your guide. Discuss the move at the person's level and be truthful. This way you will avoid too complex an explanation. Also you can be easy with yourself about not deceiving the person. If the person still has powers of memory and thought, you can give more details. Tell him or her about the home and what it will be like. If the person's powers have dwindled, just say hat you have chosen a place where he or she will receive good care. In this case, the impaired person will have to adjust to a new home without the information you might like to give in advance. You can still help and reassure, though. Most meaningful will be the emotional tone you use in talking about the new home If you truly feel good about the home, this feeling will come across.

Bring a few favorite things.

If possible, bring a few favorite "things" with the person to his or her new home. Be sure to discuss in advance with the staff any items you wish to bring with the patient. The home may limit the amount and kind of items you can bring. Most nursing homes don't permit large items sofas or dressers, for instance. Almost every home has a rule barring certain kinds of electrical equipment, electric blankets, extension cords. Most require that all other electrical items be checked before use in the patient's room. If you want the person to have a radio or TV, and if you can easily do so, bring the items to-the home before the day of the move. That way they can be checked and placed in the room before you arrive. Prepare the essential clothes the person will need in the nursing home. Additional clothes can be bought at a later time. Make sure that the person's clothes and personal belongings are marked or labeled clearly with his or her first and last name.

Let the Staff take charge . . .

Once you have brought the person to the home, let the staff take charge. They have routines to help a new resident move in and feel at ease. Discuss, in advance, what they will want you to do. They might want you to remain for a while. They might suggest, based on their experience, that the move will be easier for both you and the person in your care if you plan to leave soon after the person's arrival. You chose this home because you believed the impaired person would receive good care here. Trust that choice. Do what the staff suggests. They will be the caregivers now. You may see that the impaired person is confused, frightened, angry, hurt or any mix of these. Keep in mind that the staff remembers how hard it is to adjust. They are skilled in helping people through this period.

Foreseeing this as a hard day for you.

If you foresee that this will be a hard day for you, try to get help. Ask someone else to drive you and the person to the nursing home and to drive you back home afterwards.

Continued role for you

The amount of contact you have with the person and the care team after placement is your choice It is subject to many factors. A big factor is distance between your home and the nursing home Your own health and resources enter into this. Events, demands and interests in the rest of your life will affect your choice. Whatever you choose, your role may be with both the patient and the care team.

Your role with the impaired person.

Contact with the person in the nursing home may serve both your needs. You can see for yourself that the person is well cared for. The person can feel your presence even if other communication is no longer possible.

You may also want to invite the person's family and friends to come visit in the new home Their care and concern for the impaired person doesn't stop with placement. The person can still feel this care. Keep in mind, though, that it may be hard for family and friends to visit the nursing home. They may not be able to handle seeing the person in this setting.

The impaired person's disease will progress and the person's powers will keep on dwindling. If you visit the person once in a while rather than daily you may seem to detect rapid or sudden declines in abilities. This is not because the nursing home placement is speeding up the person's decline. rather, you are now a more distant observer When you were with the person all the time, you were too involved with your care tasks to notice change. Now that you have "stepped back" the changes may be more noticeable.

Your role with the health care team.

Try for a good working relationship with the nursing home staff. Go about this gently and be tactful. Check with the staff to see if there is anything you can do for them when you visit. You play, for instance, be able to understand what the impaired person is asking for and convey this to the staff. You may be able to coach the staff in how to understand the person better. Keep in mind that nursing home staffs work on a tight schedule They may not have time to meet with you every time you visit.

Staff members are professionals and should know their jobs. But if you find a problem in the care the person is receiving, bring this up. If the problem cannot be resolved easily, you may need to go to a staff member's supervisor or to the Administrator. If you become very dissatisfied, you may have to think about moving the person to another home. Discuss this step with your lawyer or financial advisor. You may decide to move the person, but you need to think about the costs involved and the strain it will put on you and the person.