The Importance of A Chronic-Care Plan

By Jane Farrell

Editor’s note: Nobody likes to think about becoming incapacitated, but preparing for the time when chronic care is needed can go a long way toward having peace of mind for both the potential patient and their family. Here, from the experts at Generations Healthcare, a network of skilled nursing, memory care and rehabilitation facilities in California, is an outline for preparing a chronic care plan.

As you get older, it becomes more challenging to do things for yourself. At some point, you may be swiftly forced to rely on your loved ones to assist and take care of you if you ever have a life-changing event like a stroke or a heart attack. That’s why it’s wise to develop a detailed chronic care plan before you ever need it.

As they say, a proactive plan is the most effective plan. A chronic care plan anticipates your needs and lays out a clear vision of your wishes before they actually come up. It can also bring up situations that you have never thought about and make you think through them while you are still at your best, and not rushed for time. Doing so and getting it all gathered in one place gets everyone on the same page so that if the need arises, you can put it into place.

Why Is A Chronic Care Plan So Important?

First and foremost, a chronic care plan relieves stress and gets you prepared for the worst. When you become incapacitated for one reason or another and can’t make proper decisions because of your condition, you have to rely on others to make decisions for you. This can be stressful for them and for you. They may make decisions that you wouldn’t have or send you to a care provider that you wouldn’t have chosen.

Putting a chronic care plan in place keeps you in control of your own well-being. It removes the burden from your family or primary caregiver of having to research, choose and coordinate care for you. Some decisions like choosing to be taken off life support or not can also be devastating for a family member to make.

You’ll avoid the emotional exhaustion and guilt inherent in leaving these critical decisions to someone else. These decisions can cause stress on marriages and families, and can strain relations when your family members don’t agree on a specific plan of care.

A chronic care plan gives everyone a reference point and action plan about what to do.

What Your Chronic Care Plan Should Include

All chronic care plans should include basic information related to care providers you currently go to. You should also look into and research care providers you like best for all areas of your health and any and all you may need in the future.

For instance, think about these medical professionals that you may need care from:

Occupational Therapist

Physical Therapist

Rehabilitation nursing

Speech, language, and/or hearing therapy

Recreational therapy

Physiatrist

Neurologist

Pharmacist

Cardiologist

Pulmonologist

Also, consider any other type of provider you can think of that could relate to your particular situation or might prove necessary down the road. Create a written snapshot of what your ideal care looks like and how your caregiver can best meet your needs.

Past History

Another important piece of the puzzle is your past health history. Write it down and create a reference so that if chronic care becomes necessary, your family has the information readily available to share with your doctors. This way, the best diagnosis can be made and the best treatment plan for recovery can be implemented with no hiccups.

Having all of this information in one place is handy and makes things easier for all involved, especially your doctors . They need to know if there’s something in your history that could affect the outcome of a treatment plan. Things like family history and what medications you might be taking are important so that you aren’t given treatments or medications that conflict with one another.

Financial Planning

This is another important area to consider and plan ahead of time. Write out answers to the questions below, and provide pertinent information like your insurance name and group number, the names, addresses, and phone numbers of facilities that are in-network, and any bank account information required for the person you have chosen to take care of your financial obligations.

Ask yourself:

Do you have medical insurance? What about Medicare?

What does your insurance cover?

What facilities are in your network?

If you have out-of-pocket expenses, how should these be paid?

Do you prefer payment plans or paying up front?

Who will make decisions on financial things for you?

What bills do they need to pay, and how do they pay them?

Legal Plans

Along with your financial planning comes the legal stuff. Who will take care of your estate while you are incapacitated? Who do you want to be in charge while you are recovering? You will need to make these choices and prepare the proper documents to address this need beforehand to make sure this is clear if you ever go into chronic care.

Consider and prepare the following documentation:

A Durable Power of Attorney for Health Care (DPAHC)/Health-Care Proxy

These are flexible and will allow the person of your choice to act on your behalf and make any necessary medical decisions. Who would you like this person to be?

Take care in whom you choose as they are acting in your stead, and you want them to make choices you yourself would make. These can be used any time you become incompetent; however, they aren’t practical for emergency situations as your representative must be present in order to make decisions for you. These are not permitted in every state, so you will need to find out your state’s guidelines too.

A Living Will

Living wills allows you to specify how you want to be cared for if you ever become so ill or incapacitated that you’re unable to make decisions about your health. It can provide direction and reduce ambiguity during a difficult time by clarifying your wishes on the use of feeding tubes, resuscitation, and other procedures that might be needed to prolong your life. If this document is not in place, it can fall on the family to make those decisions, which can be heart wrenching. That is why a living will is important to prepare before a chronic care situation ever presents itself.

Do Not Resuscitate (DNR) Order

This is a common document that is effective in emergency situations. A DNR means you are declining CPR should your heart or breathing fail, and it is only used for cardiac or respiratory arrest. This is something you need to choose before the situation ever comes up.

Also, it is good to check state guidelines because some will only allow them for hospitalized patients. Depending on your state, MedicAlert necklaces, ID bracelets, and wallet cards can be used to indicate whether you have a DNR in place, and you can also make sure your doctor writes it on your chart.

Durable Power of Attorney (DPOA)

This is a low-cost option to implement that decreases the likelihood of court intervention and will allow you to control who acts on your behalf and what they can do with your property. One downfall is that some states won’t allow you to have a DPOA that is effective only after you become incapacitated, so that’s something to keep in mind.

Choose and Prepare for Guardianship Litigation

You may need to prepare for guardianship while you are in chronic care or incapacitated. This is a legal process where a judge will determine whether or not you have the legal capacity to make your own decisions, or if an adult guardianship is necessary. If you are deemed unable to take care of your legal affairs, you will become a ward of your guardian and lose most of your civil rights. It is good to pick beforehand whom you would want this person to be.

Choose and Prepare a Conservator

You may also need to choose a conservator while you are in chronic care. This is a person who the court can appoint to handle your finances and/or personal affairs if you are unable to do so. Sometimes this person can also be appointed as your guardian and serve both the role of guardian and conservator. Other times, these two roles may be filled by two different people. It is also good to plan out who you think would best fit this role.

Overall Thoughts

When it comes to your health, safety, and long-term care planning decisions, it’s best for you and your family to prepare while you still possess the soundness of mind and body to express your wishes.

Making a detailed chronic care plan early on allows you to address relevant issues carefully and ensure you’re not pushed into making hasty decisions. Plus, with your documentation ready to go, your information will be gathered in one place and easy to find. This allows your chosen caregiver to advocate for your best interests, and it will bring you peace of mind.

Though many connect seniors to planning long-term care, it’s smart to set up a plan no matter what age you are. This way, you can rest easy knowing you’re prepared with a chronic care plan before crisis strikes.

Reprinted and abridged courtesy of Generations Health Care. For details on how to set up a form for a chronic care plan, click here.