“Person-centered”, “Individualized”, “Resident-focused”; whatever you may call it, it’s past time to evolve from the institutionalized, staff-focused care planning we’ve become accustomed to and embrace the requirement that the individual has control over their life and care choices. But you may be thinking, many people make poor choices! That’s the catch. As always, it is imperative to provide ongoing education while politely suggesting less-risky alternatives when the need arises.

What is Person-Centered Care Planning?

The Center for Medicare and Medicaid Services (CMS) describes person-centered care as focusing on the resident as the locus of control and supporting the resident in making their own choices and having control over their daily lives. In short, person-centered care supports each resident’s choice and gives them a sense of control over their life.

Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident’s life before coming to reside in the nursing home. (SOM Appendix PP)

Care plans must still include measurable objectives and timeframes to meet a resident’s medical, nursing, and mental and psychosocial needs identified through the comprehensive assessment process but should also clearly express a resident’s preferences, choices, goals and desired outcomes, not just ours as care providers. It can be difficult to want to accommodate certain choices a resident may make, for example, choosing to decline incontinence checks and linen changes throughout the night in favor of eight hours of sleep. On the surface it seems a reasonable request, but underneath? What about the resident’s frequent incontinence? The risk of impaired skin integrity? Odor? Dignity? Family complaints? Negative outcomes and litigation? Instead of focusing solely on the risks of fewer bed checks, what if we consider the benefits of uninterrupted sleep: feeling more refreshed and alert, increased energy during the day, improved focus, consistent sleep-wake cycle, and improved immunity for starters.

As always, communication is paramount. The concerns listed in the example above are legitimate and worth mentioning. Discuss the risks and benefits of a resident’s choice with the resident and their representative, as applicable. Provide education in a way that the resident will understand and offer a compromise where appropriate. Perhaps this resident will be willing to wear incontinence briefs during the night and agree to be awakened for a check once during night hours (as opposed to every two hours). Honoring the resident’s choice, when able, not only complies with Resident Rights but also promotes self-determination and personal decision-making. As caregivers, we should remember that quality of life is as important as quality of care.


Assessment and Care Planning Essentials:

As stated in the RAI manual, a well-developed and executed assessment and care plan:

  • Looks at each resident as a whole human being with unique characteristics and strengths;
  • Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident’s functional status (MDS);
  • Gives the IDT a common understanding of the resident;
  • Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers);
  • Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process);
  • Develops and implements an IDT care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow-up;
  • Reflects the resident’s/resident’s representative’s input, goals, and desired outcomes;
  • Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident’s highest practicable level of well-being (care-planning);
  • Re-evaluates the resident’s status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary.

Don’t throw out your favorite book of ‘care planning for nurses’ just yet; that resident’s Ineffective Airway Clearance still needs to be addressed, but try asking the resident how they feel, what they think, and what they want to accomplish. Not surprisingly, a resident-centered care plan can enhance quality of life and quality of care for all.



Center for Medicare and Medicaid Services. (2017). State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities. Retrieved from https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf

Center for Medicare and Medicaid Services. (2019). Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual. Ver. 1.17.1 Retrieved from https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual


Blog by Eleisha Wilkes, RN, RAC-CTA, Proactive Medical Review

Learn more about Eleisha and the rest of the Proactive team.