Questions to Ask at a Nursing Home Care Plan Meeting
For a resident, or the son, daughter or spouse who speaks up for one, with a nursing home care plan meeting coming up; some homes call it a care conference, others a plan of care meeting. The 56 questions run in the order the meeting tends to go: what to settle before you sit down, changes and goals, medicines and medical care, daily care, staff and contact, and the decisions ahead. Put the person's name wherever a question says my relative. How often the plan is reviewed and who has to be invited differ by country and state, so where a note says to ask how it works there, take it literally.
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The questions
Each question, and why to ask it
Before the meeting
Who will be at the care conference, and which of our questions can each person answer?
Why ask it
A care conference usually brings nursing, social work, dietary, activities and therapy to one table, and the doctor is not always among them. Ask ahead who is coming, so a medication question is not put to a room where nobody can answer it.
Can we have a copy of the current care plan a few days before we meet?
Why ask it
Reading it at home lets you arrive knowing which two or three lines you want changed. Hold what it says about bathing, walking and meals against what you see on visits, and mark every gap.
Can my relative be in the room, and how will they be helped to take part?
Why ask it
The plan belongs to the resident, and someone who would tire in a full meeting can often manage the first ten minutes. Ask for an hour of the day when they are at their best, and for hearing aids and glasses to be on before anyone starts talking.
Is this plan of care meeting a routine review, or has something prompted it?
Why ask it
A scheduled review and a meeting called after a fall, a weight loss or a complaint are different conversations. Knowing which one you are walking into tells you whether to bring your whole list or to prepare for a single subject.
How long is the meeting booked for, and can someone join by phone or video?
Why ask it
If the slot is fifteen or twenty minutes, say beforehand which three subjects matter most and ask for longer if you need it. A son or daughter in another city can usually dial in, so find out what the home uses and test it the day before.
Who is on the list to be told about these meetings, and can you add another name?
Why ask it
The invitation sometimes goes only to the first contact in the chart, by a letter that arrives late or a call in the middle of a working day. Check whose name and number are down, and say how you would rather hear: a text, an email or a call in the evening.
Changes and goals
When was the last full assessment done, and what did it find?
Why ask it
The plan is meant to follow from an assessment of the person: memory, mood, mobility, swallowing, skin. How often one is required depends on the country and state, so ask what the schedule is here and whether a hospital stay or a decline brought one forward.
What has changed since the last review?
Why ask it
Go down the list by name: weight, appetite, walking, mood, continence, alertness. A general summary smooths over trends, and small slips in several of those at once are easy to miss when each is reported on its own.
How does this compare with where things stood at admission or a year ago?
Why ask it
Each review is measured against the one before, so a slow slide can go a whole year without anyone remarking on it. Have someone read out what the first assessment said about walking, eating and memory, next to today's.
Has there been a hospital visit, an infection or a new diagnosis since we last met, and what changed in the plan because of it?
Why ask it
Any of the three should leave a mark: a new medicine, a different diet, more help with walking. If the plan reads the same as it did before the ambulance came, ask who went over it when your relative returned.
How are memory and thinking now, and how is that being followed?
Why ask it
A test score says less than what staff see from day to day: finding the dining room, keeping up with a conversation. A change over a few days is a different matter from one over a year, so find out what the nurses would do to look for a cause.
How has mood been lately, and is anyone looking at depression or loneliness?
Why ask it
Withdrawal can pass for tiredness, or for just getting older, and then nobody writes it down. Compare the activities your relative actually went to last month with what was on the calendar, and find out who would arrange for low mood to be assessed.
What are we working toward over the next few months, and what would tell us it is working?
Why ask it
A goal worded as maintaining current function is hard to check later. Press for one or two things anyone could see, such as walking to the dining room or sleeping through more nights.
What does my relative say they want from the next few months?
Why ask it
Staff hear things the family does not, such as a wish to get outside more or to stop an exercise that hurts. If the plan has a line for the resident's own goals, ask to hear it read aloud, then add what you have been told yourself.
Which goals on the plan are being met, and which have stalled?
Why ask it
A plan can carry the same unmet goal from one review to the next because nobody was asked about it. For each stalled one, find out whether the approach will change or the goal will, and who makes that call.
Medical care
Can we go through the medication list one by one and say what each is for?
Why ask it
Lists tend to grow after a hospital stay and are not always cut back afterwards. Go line by line: which of these began in hospital and is still being given, and has a pharmacist looked over the whole list lately?
What has been started, stopped or changed in dose since the last meeting, and why?
Why ask it
Families are not always rung about each change, and three small ones can add up between reviews. Ask who ordered each and where the reason is recorded, and say now if you want a call before anything new is started.
Is anything being used to manage behavior or agitation, and what was tried first?
Why ask it
Calming medicines are sometimes prescribed for distress in dementia, and the prescriber is the person to say what the risks are for your relative. Find out what was tried without drugs first, who agreed to it, and when the dose is next due to be looked at.
Could any of these medicines be behind drowsiness, dizziness or confusion?
Why ask it
Put this to the nurse or the pharmacist with the list in front of them, above all if your relative has been sleepier or less steady of late. The answer may be that nothing should change, but it ought to come from someone who has looked at the list with that question in mind.
How is pain being assessed, and what is given when it is not enough?
Why ask it
Three things to pin down: which scale is used, how often, and what the nurse is allowed to give when the regular dose falls short. If your relative cannot say that something hurts, ask which signs the staff read as pain, such as guarding an arm or refusing to stand.
How often is the as-needed medicine actually given, and who decides to offer it?
Why ask it
An as-needed order works only if the resident asks or an aide notices. Ask to see last month's count: none at all for a person with known pain deserves a question, and so does a dose every single day.
What happens when a dose is refused or missed?
Why ask it
One refusal is a person's choice on the day; a run of them should reach a nurse and the family. The useful follow-up is whether anyone has asked your relative why, since a tablet that is hard to swallow can sometimes be given in another form.
Who is the doctor or nurse practitioner now, and when did they last see my relative in person?
Why ask it
Get the date, and whether it was an examination at the bedside or a look through the chart. How often a visit is required varies by place and by who is paying, so ask what the rule is here and how the family can speak to the doctor directly.
When were teeth, eyes, hearing and feet last looked at?
Why ask it
Each of the four touches something bigger: a sore mouth and eating, old glasses and falls, a dead hearing aid battery and joining in at the table. Who books the dentist, the optician, the audiologist and the podiatrist, and how does the family hear what they found?
What therapy is in place, and what happens when the coverage for it runs out?
Why ask it
How long physical, occupational or speech therapy is paid for is set by the insurer or program, so ask the home what applies to your relative and how much warning you would get. Then ask what maintenance program the unit's own staff will carry on once formal sessions stop, and whose job it is.
Daily care
What does a normal day look like now, hour by hour?
Why ask it
Wake time, meals, hours out of bed, hours out of the room and time with other people are the substance of the plan. If the honest answer is a day spent mostly in one chair, have it said out loud at the table so the plan has to answer it.
How much time does my relative spend out of bed and on their feet each day, and who helps with it?
Why ask it
Walking that is nobody's assigned job tends to get dropped on a busy shift. Get a number, such as twice a day to the dining room, and find out whether it sits on a named person's task list or is done when there is time.
Have there been any falls or near falls, and what changed afterwards?
Why ask it
A fall should produce a specific change: footwear, a bed height, a toileting schedule, a medication review. If the answer describes only increased monitoring, ask what the assessed cause was.
Are bed rails, alarms or anything else that limits movement in use, and why?
Why ask it
A chair alarm, a lap tray or a bed pushed against the wall may have been added after a fall and never looked at again. What a home may use, and whose consent it needs, depends on local rules, so ask what applies here, what was tried before it and when it is next reviewed.
Is the wheelchair, walker or cushion still the right one?
Why ask it
Equipment fitted at admission may not suit a body that has since lost weight or strength. A therapist is the one to check the seating and the walker height, so get the date of the last check, and find out who pays for a replacement, which depends on the coverage.
What is the plan for skin care, and how often is repositioning and checking actually done?
Why ask it
Skin can break down fast in someone who sits or lies in one position for hours. Get the turning and checking schedule, hear whether any redness has been noted already, and ask to be rung the same day if a sore appears.
Is my relative eating and drinking enough, and what has their weight done over the last three months?
Why ask it
Three monthly weights side by side say more than one, and a small steady loss is easy to miss between reviews. Ask whether a staff member stays to help at meals and how long that help actually lasts.
Has swallowing changed, or the texture of the food and drink being served?
Why ask it
A move to pureed meals or thickened drinks alters every mealtime, and it should come with a reason and a date for looking again. Whoever did the swallowing assessment can give the reason, and the aides can say whether your relative is eating the new diet or leaving it on the tray.
What help is needed now with dressing, bathing and the bathroom, and how is that scheduled?
Why ask it
Two details settle most of this: how many baths or showers actually happen in a week, and whether help to the toilet comes on a schedule or only when asked for. Waiting for help to the bathroom is hard on anyone's dignity, so have the times written into the plan.
How are the nights going, and how often is my relative woken?
Why ask it
Night staff are seldom at the table, so ask whether anyone read their notes before the meeting. Find out what the checks and changes during the night are for, and whether any could be moved so that your relative sleeps longer at a stretch.
Who spends one-to-one time with my relative, and how often?
Why ask it
A person who cannot follow bingo, or who will not leave the room, still needs company. Find out what a one-to-one visit consists of here, who makes it, and how many there were last week.
How often does my relative get outdoors or off the unit?
Why ask it
Weeks can go by on one corridor without anyone having decided that they should. Ask for it to go into the plan with a number attached, such as the garden twice a week in fair weather, and a name beside it.
Are personal preferences written down, and can we go through them?
Why ask it
Waking time, foods that will actually get eaten, the preferred name, music, a fear of showers: these belong in the record and not in one aide's memory. Have the list read aloud at the table and correct whatever is out of date.
How is my relative getting on with the roommate and the people at their dining table?
Why ask it
A roommate's television at midnight, or a tablemate who shouts, can sour every single day, and the aides see it long before the family does. Hear what has been tried so far, and how a change of room or table is requested.
Staff and contact
Who provides the day-to-day care on each shift, and how many residents does that person have?
Why ask it
Continuity matters as much as the ratio, because the aide who knows someone's habits is the one who notices change first. Ask about nights and weekends separately, when the numbers on the floor can be different.
How does what we agree today reach the aides on nights and weekends?
Why ask it
The people at the conference table are rarely the ones doing the bathing and the turning. Where does an aide actually see the plan: a sheet in the room, a screen, the handover? And how would a temporary worker learn it on a first shift?
How long does it take for a call light to be answered, and what should we do if it is too long?
Why ask it
Some call systems log every response time, so ask whether this one does and what last week's figures were. Ask as well who to raise a long wait with in the moment, rather than saving it for the next conference.
Who do we call for what, and how quickly should we expect a response?
Why ask it
Leave with three names, one each for nursing questions, billing and complaints, and the number that is answered at night and at weekends. A message left with whoever picks up the phone has no owner, so ask how a call is logged and passed on.
What would make you call us, and what would you handle without calling?
Why ask it
Settling this now heads off both kinds of upset: a call at work about a routine matter, and hearing about a hospital transfer the next morning. Have your answer written into the plan, with the hours you can be reached.
Here is what we have noticed on our visits: can we talk about what is behind it?
Why ask it
Bring dates and particulars: unshaven on three Sundays running, a water jug out of reach, a bruise on the forearm. A specific observation tends to get a specific answer, and it shows the family is watching without turning the meeting into a complaint.
What would you like the family to do more of, or do differently?
Why ask it
Staff often have a small, practical request ready: come at supper to help with eating, bring shoes that fit, label the new cardigan. Asking it makes the conference run in both directions, and the answer is usually something you can do that week.
What happens when clothes, glasses, dentures or hearing aids go missing?
Why ask it
Small things vanish in a shared laundry and a busy dining room, and a lost hearing aid changes the whole day. Find out who looks for them, how belongings are labelled and listed, and what the home's policy is on replacing them, which differs from one home to the next.
If something goes wrong between meetings, how do we raise a complaint, and who outside the home can we turn to?
Why ask it
Start with the home's own steps: who receives a concern, how soon they answer, and whether it is logged. Many places also have an independent body, such as the long-term care ombudsman in the US, so ask how that works where you live and where the contact details are posted.
Decisions ahead
What advance directive do you have on file, and does every shift know what it says?
Why ask it
A signed directive filed in a chart is not the same as one the night nurse can find in thirty seconds. Ask where it is kept, whether it is flagged in the electronic record, and what would happen if someone were found unresponsive at three in the morning.
Who is on record as the person who decides if my relative cannot?
Why ask it
Check that the name, the phone number and the paperwork in the chart match what the family believes. What the role is called and which document creates it differ by country and state, so ask what the home needs on file and whether a copy is there today.
In what situations would you send my relative to the hospital, and how are our wishes about that recorded?
Why ask it
For a frail person a night in the emergency room can be the right call or a frightening one with little gained, and that is for the resident, the family and the doctor to weigh together. Two facts help: what the home can treat on site, and where a stated preference is written so the nurse on duty finds it.
If there were a further decline, at what point would you raise hospice or palliative care?
Why ask it
Raised at an ordinary review, this gets a considered answer in place of one given in a corridor during a bad week. Listen for whether the home can give comfort-focused care where your relative is, or would send them to hospital for it.
Is going home, or moving to a lower level of care, a realistic goal, and what would have to happen first?
Why ask it
During a rehab stay this is the main business of a plan of care meeting, and for a long-term resident it still deserves asking once. Get the conditions in concrete terms, such as getting from bed to chair with one person's help, and ask who would arrange the equipment and the home care.
Is the level of care, or the way the stay is paid for, about to change?
Why ask it
Greater needs can mean a different unit or a different rate, and coverage can run out on a date nobody mentioned to the family. Those rules belong to the insurer or program and vary by place, so ask who at the home to talk to and how much notice you would be given.
Who writes down what we agree today, and when will we get the updated plan?
Why ask it
Get a name and a date before the meeting ends. When the copy arrives, read it beside your own notes and ring that person about anything that was said at the table and is missing from the page.
When is the next meeting, and can we ask for one sooner?
Why ask it
How often reviews fall due depends on local rules, so get the date now and write it in the calendar. Ask too what would bring one forward, such as a hospital stay or a marked decline, and whether a request from the family is enough.
Care Plan Conferences: How They Work
Practical guidance for the conversation itself
What the Meeting Is For
One meeting, several names
A care plan meeting, a care conference and a plan of care meeting are the same event in most nursing homes: the sitting where the team looking after a resident goes over the written plan with the resident and the family. Hospitals, hospices and home health agencies hold care conferences too, and most of the questions on this page carry over with small changes. If the invitation uses a name you do not recognise, ask what the meeting is meant to decide and who will be in the room.
It is a scheduled review, and you are part of the team
A care plan conference is held soon after admission and again at intervals set by local rules, usually with nursing, therapy, dietary and social work at the table and sometimes the physician. In many places a resident has a right to take part and to bring the people they choose, so ask the home what the rule is where you are. A family can also ask for a meeting between the scheduled ones, and a hospital stay or a marked change is reason enough.
Ask for the meeting to be arranged around you
These conferences are often scheduled during working hours with little notice. It is reasonable to ask for a different time, to join by phone or video, and to ask who will be present so you know which questions can actually be answered.
Bring the resident's own voice into the room
If the resident can attend for part of it, that changes the tone of the whole meeting. If not, bring specific things they have said recently, since a direct quote carries more weight than a summary of preferences.
Ask for the plan in writing afterwards
Request a copy of the updated care plan and read it against what was said. Anything agreed verbally but absent from the document tends not to survive a change of staff.
Choose your questions before you sit down
A list this long will not fit into one care conference. Put the Before the meeting group to the social worker by phone a week ahead, pick the two or three from each later group that matter this time, and take the rest to the charge nurse on an ordinary visit.
What to Bring
- Recent hospital discharge summaries and any new diagnoses.
- The current medication list, including anything started in hospital.
- Advance directives, any resuscitation or treatment order form (a POLST in parts of the US), and the paperwork naming who decides.
- Dates and details of specific incidents you have noticed, written down at the time.
- Two or three questions you will not leave without answering.
- A notebook, and a second person to listen if you can arrange it.
Between Meetings
- Keep a short log with dates: falls, bruises, weight, mood, missed therapy, unanswered call lights.
- Vary your visiting times, including evenings and weekends, since staffing differs by shift.
- Learn the names of the aides on each shift and ask them what they notice.
- Put concerns in writing to the director of nursing when a verbal request has not worked.
- Ask for an interim care plan meeting after any hospital stay or notable change.
- In the US, look up your state's long-term care ombudsman program, which takes residents' and families' concerns at no charge; elsewhere, ask which independent body does that job.
Common Pitfalls
Letting the meeting stay general
Reassurance that everything is fine is not information. Ask for numbers and dates: weight three months ago and now, how many falls, how many therapy sessions completed, how many times out of bed each day.
Not asking who is responsible
A plan without a named role behind each item tends not to happen. For each change agreed, ask which discipline owns it and how it will be recorded on the shift that has to do it.
Raising concerns only at the conference
Most problems are easier to fix the week they occur. Use the conference for patterns and for the plan, and raise individual incidents with the charge nurse at the time.
Leaving the difficult conversations for a crisis
Directives, hospital transfer preferences and the point at which comfort care would be appropriate are far easier to discuss at a routine review than in an emergency at night.