How can I effectively involve family members in the care plan for a frail older adult?

Effectively involving family members in the care planning and management for a frail older adult requires a collaborative, person-centred approach that recognises the vital role of carers ¹,⁴. It is crucial to involve family members and carers in the planning process with the older adult's agreement, acknowledging them as important partners ¹.

Key strategies for involvement include:

• Named Care Coordinator and Multidisciplinary Team (MDT): Ensure the frail older adult has a single, named care coordinator who acts as their first point of contact and liaises with all health and social care services, including the voluntary sector ¹. This coordinator should involve the person and their family in all discharge planning decisions ². Care for frail older patients is often best managed by interdisciplinary teams, which can include doctors, nurses, therapists, social workers, and pharmacists, providing comprehensive support ¹,² (Dyer et al., 2003).
• Collaborative Care Planning and Decision-Making: Develop care plans in collaboration with the older adult, their carers or advocate, and relevant practitioners, ensuring joint ownership and agreement through signatures ¹. Care plans should be tailored to the individual, offering choice and control, and addressing a range of needs including medical, psychological, social, and environmental aspects ¹. Discuss managing medicines with both the person and their carer as part of care planning, including purpose, dosage, and contact details for concerns ¹. When performing structured medication reviews, consider the views and understanding of the person and their family or carer(s) regarding medicines ⁴.
• Comprehensive Carer Assessment and Support: Local authorities must offer carers an individual assessment of their needs, recognising the complex nature of multiple long-term conditions and their impact on wellbeing ¹. Offer family members and carers the opportunity for their needs (e.g., for support and information) to be assessed separately from the person receiving care ³. Support carers to explore the benefits of personal budgets and direct payments, offering help to administer them ¹. Help carers access support services and interventions, including carer breaks ¹. Recognise that the demands of being a carer can sometimes manifest as physical symptoms, such as fatigue or weight loss ³.
• Information Sharing and Communication: Involve carers in decision-making and care planning for the person they care for, keeping them updated with the person's consent ⁴. Explain how the health condition, disability, or needs of the person are likely to progress so the carer can understand potential changes in their role ⁴. Be open and honest, even with difficult information ⁴. Regularly offer carers opportunities for discussion and help them understand information regarding diagnosis and prognosis (with consent) ⁴.
• Training and Practical Guidance: Offer training to carers, such as structured programmes or one-to-one guidance, to enable them to provide care safely ⁴. Ensure carers have access to advice and training on appropriate use of equipment, adaptations, and safe moving and handling techniques ⁴. Examples of training include managing medicines and manual handling courses ⁴. Preventive home care often involves case management, which can include educating carers (Hallberg and Kristensson, 2004).
• Advance Care Planning (ACP): Involve carers in advance care planning if the person gives their consent, and ensure carers understand their role in the plan ⁴,⁵. ACPs should address anticipatory prescribing, psychological and spiritual care needs, and care of the family ⁵.
• Cultural Sensitivity: Be aware that people of different ethnic backgrounds or cultures may have specific preferences regarding family involvement ³.

Continuity of care, by involving the same professional care staff where possible, can also provide valuable support during end-of-life care ⁴.