3 ways to Improve Plan of Care Communication in a Pandemic

Posted by Susan C. Hull on Sep 30, 2020 9:15:00 AM
Susan C. Hull
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Residents, families and care teams in Long Term Care (LTC) facilities need a smart and integrated approach to shared communication about the plan of care with consistent updates and opportunities for shared decision making.

As we move into the start of the flu season and continued coronavirus pandemic, the needs for plan of care communication are heightened, compounded, and complex.

With the co-circulation of influenza viruses and SARS-CoV-2 and new insights into longer term complications of COVID-19 related illnesses, residents in LTC facilities have the potential for prolonged and debilitating course of illness.

“So far, there has been much emphasis on the treatment of acute life-threatening manifestation of COVID-19. However, we are seeing increasing evidence of a “long-tail” of covid-19 related illness, and we need to consider how to support patients with prolonged illness from COVID-19.”

Both influenza and COVID-19 amplify existing care plan needs. Residents and families may have additional questions especially related to pre-existing chronic conditions and health concerns. With dementia and stroke as common reasons for admissions to LTC facilities, complications from diabetes and Parkinson’s disease add additional burden to cognitive, functional, and mobility status. Residents and families may require additional time and support to sort through care plan options and contribute to effective shared decision making. Family members also may experience tremendous anxiety about their resident’s plan of care, given the spread and expected length of the pandemic.

The public health emergency has also added further urgency to resident and family needs for advanced care plan (ACP) discussions. ACP provides the opportunity for discussion and documentation of individual care goals and plans for future interventions. COVID-19 and long-term complications can diminish a resident’s capacity to communicate and limit in person family participation.


All residents and families require:

  • An orientation to how to engage in the care planning process.
  • Expectations for required health assessments, including within 14 days of admission, every 90 days, and ongoing with care and condition changes.
  • Guidance to prepare for care planning meetings, including:
    • What kinds of personal or health care services are needed?
    • What types of staff will provide these services?
    • How often services will be provided?
    • When to expect visits from the assigned physician, nurse practitioner, clinical nurse specialist or physician assistant?
    • How will virtual visits be accommodated?
    • What kind of equipment or supplies will the resident need?
    • What kind of diet is needed and food/eating preferences?
    • What are resident and family care plan goals?
    • What are the goals for returning to the community.
  • Review of Centers for Medicare and Medicaid Services (CMS) requirements for resident and family engagement in the plan of care.
  • Review of CMS data submission requirements for patient level data used for quality measures, nursing home payment and state inspections.
  • Ongoing updates about CMS waivers and flexibilities which are changing plan of care requirements during the COVID-19 public health emergency.
  • Facility-wide plan of care adjustments based on COVID-19 testing and results and contact tracing activities and results.
  • Facility-wide plan of care modifications for influenza prevention.
  • Plan of care modifications personalized for individual residents, based on COVID-19 and influenza status, and relationships to pre-existing chronic conditions.

While plans of care plans have often been routine and standardized based on reimbursement requirements, LTC leaders and clinical teams should expect a new normal during this public health emergency.

LTC leaders and care teams are seeking ways to provide access to resources for residents and family members to understand and engage in the plan of care.


The optimum way to solve for this problem this is to implement an “always on” patient-centric secure and interoperable communication platform to:

  • Consistently communicate to residents, families, and care teams about residents’ plan of care
  • Assure resident safety and peace of mind for family members by providing real time changes in care, conditions, and incidents.
  • Empower residents and families to be more engaged and accountable in care through shared decision making and safe care transitions.
  • Fulfill regulatory requirements, including the plan of care changes during the COVID-19 pandemic.
  • Streamline communication and workflow efficiencies and contribute to patient and family satisfaction.
  • Meet and assure privacy and security standards.

Three Ways to Improve Care Plan Communication

Approaches to streamline both general and personalized family communication to improve engagement and shared decision making are needed for effective plan of care communication.

  1. Broadcast messages enable LTC facilities to provide information and answer questions about care plan communication to residents and families during the pandemic including facility actions taken to keep all loved ones safe. LTC facilities can:
    • Share consistent and accurate information about influenza and COVID-19 outbreaks, testing and contact tracing for all residents and families.
    • Answer specific questions about care plan modifications for infection prevention, including updates about visitation and family-related participation in care plan meeting.
    • Offer virtual visit to support plan of care communication, before, during or after planned meetings.
    • Provide consistent updates about how the facility is adhering to CDC and CMS guidelines for the plan of care for all residents.
    • Push follow-up surveys about resident and family engagement and satisfaction with shared decision making in the plan of care processes.
  1. Personalized messages and resources enable care teams to provide plan of care communication to individual residents and family members about the resident’s specific situation. LTC facilities can:
    • Send attachments or media to provide a complete picture so residents and family can prepare for full participation in plan of care meetings.
    • Send a message about a resident to the family, care team and primary care provider (PCP) to report virus testing or contact tracing results.
    • Respond to resident and family questions about changes in care and condition specific to plan of care updates.
    • Provide resources and communication to prepare for end-of-life care and advanced care planning decision making.
  1. Automated messages with push notifications support real time communication from the care team to family members. LTC facilities can:
    • Push automated updates about the care and conditions of the resident to family members, at scale, with no extra effort on the part of the care team.
    • Provide real time clinical data about the resident, including easy access to up-to-date clinical summary pushed from an electronic health record (EHR).
    • Send automated messages notifying family members about changes in the care plan, including medications, diet and nutrition and lab results.

In Summary, plan of care communication experiences for the LTC resident, families and care teams can be different. The “always on” secure digital communication platform and approach assures and protects resident health, well-being and safety with a shared communication stream.

During these times, these communication practices engage residents and families in shared decision making about the plan of care. These practices bring peace of mind to everyone supporting the resident in the center.

Learn more about how CareLoop helps to streamline family communication about infections in LTC facilities. Free e-book, How to Streamline Long Term Care Communication During a Pandemic.

long term care communication during a pandemic or infectious disease event

Topics: Family Communication, Plan of Care

Susan C. Hull

Written by Susan C. Hull

Susan is a nurse executive, entrepreneur and informaticist passionate about transforming health and care through co-production. Board certified in nursing informatics and advanced nursing executive, her experience spans diverse roles including designing and managing a new children’s hospital emergency service, nursing and health system executive, healthy community partnership and community health information network (CHIN) executive, chief nursing and health informatics officer, consultant and researcher. Her leadership experience builds on participation in the start of the healthy community, population health and learning health system movements.

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