Creating a Person-Centered Care Plan

By Shannon Harshman, Flourish Care Manager

Independence, dignity, and quality of life. The manifestation of these three goals differs with each client, and it is the CICOA Flourish Care Manager’s role to address individual needs for clients in achieving these goals. But, we don’t stop there. We “step it up a notch” to devise a plan of care for each client that is person-centered.

We include clients in their own care, asking them what their goals are and how they can be accomplished. This can be multi-faceted and includes collaboration with other community agencies, creativity to find imaginative solutions at times, patience, confidence, reality, empathy….this list could go on and on. It’s not always easy to have a conversation with a client about a goal that’s not realistic to achieve. For example, one of my clients wanted to return home from a nursing facility providing rehabilitation for the client; however, he could not feasibly care for himself even with in-home services. In these cases, Care Managers are required to “think outside of the box” in assisting their clients.

Not all situations are identical as each client has his or her own goals/aspirations. I recently had a client who, due to being immobile, simply wanted to wash her hair. I was able, with the help of other care managers, to secure a shampoo bowl for her.

That same client recently had lost her husband (primary caregiver). This raised many questions about how she could remain in the home without him and still raise their young daughter, given her medical condition. She receives home-delivered meals through CICOA and home-delivered groceries when needed. She has the option of getting her medications delivered and transportation to get herself and her daughter to appointments. My client is continuing to gain strength with new medical treatments, which will allow her to become ambulatory. With the help of many others in the community (including providers, neighbors and family friends), the client continues to live in her home and raise her daughter.

Many of our clients simply want to maintain their health and remain in their home.  For some, the solution may be as simple as obtaining a ramp for safe and easy access to and from their home, a bathroom modification that allows a non-ambulatory client who has received only “bed baths” to enjoy a bath or shower, or connecting a client with resources so that they can get out of their home and feel a sense of belonging in their community.

This is all part of a very rewarding role that Flourish care managers play in the lives of our clients. In addition to the goals of independence, dignity and quality of life that are listed in CICOA’s mission statement, we also empower our clients to continue on in the face of adversity.  We provide the support, optimism and—most importantly—belief in each client to pursue and achieve his or her own happiness.