Person-Centered Care Planning and Coordination
What this domain tests
Person-centered care means the resident's goals, preferences, and routines drive the plan - not the facility's schedule. Candidates must know the care-planning cycle: comprehensive assessment (e.g., MDS/R AI in nursing homes, functional assessments elsewhere), problem/goal identification, interdisciplinary care plan (ICP), implementation, and periodic review with the resident and family.
Core concepts
- The resident (or representative) is a partner and, where capable, the decision-maker; autonomy and dignity are central.
- Interdisciplinary team roles: nursing, therapy, social work, dietary, activities, physician, and pharmacy.
- Goal writing: measurable, resident-directed, time-bound; distinguish goals from interventions.
- Coordination: care conferences, discharge planning, transitions, and communication across settings and HCBS providers.
- Cultural, spiritual, and preference-based care; trauma-informed approaches.
Traps
Examiners love the "clinically correct but not person-centered" option - e.g., a schedule that meets a regulation but ignores a resident's stated preference. Another trap: writing an intervention and labeling it a goal. Also watch for bypassing a capable resident in favor of a family member's wishes; capacity and resident rights govern who decides.
Worked example
Resident states a goal to attend church weekly. A weak plan: "Provide spiritual support." A strong goal: "Resident will attend community worship weekly per preference by [date]," with interventions (transport arranged, schedule coordinated, mobility support). The goal reflects the resident's voice; interventions are the how. Review dates and responsible parties must be explicit.