A dietitian’s guide to care planning in long-term care 

Dietitians play a vital role in the care planning process and discharge documentation. When thinking about the dietitian’s primary goal in long-term care, these areas are often overlooked as part of the daily tasks the RD is responsible for. When done well, they can take a considerable amount of planning and time to implement effectively. The time is well spent though, as these are areas that can significantly impact a resident’s quality of life.  

Understanding care planning in long-term care 

Care planning in long-term care involves a collaborative effort among healthcare professionals to identify and address the specific needs, goals and preferences of each resident in the facility. The care plan is resident-centered and individualized, intended to provide a comprehensive overview of a resident’s healthcare needs. The care plan serves as a roadmap for the interdisciplinary team so that a resident’s care is consistent and communicated well among the team as well as with the resident’s family.  

The dietitian’s role in care planning is the portion of the plan that addresses whether or not a resident is at nutritional risk and why. This can include the need for a therapeutic and/or mechanically altered diet, the risk or actual existence of a significant weight change (loss or gain), and specific dietary requirements or restrictions. The nutrition portion of the care plan is designed to help monitor a resident’s progress as well as develop an appropriate discharge plan while ensuring optimal nutrition while they are a resident in the facility.  

Importance of discharge notes in long-term care

A discharge note in long-term care is a document that includes input from all disciplines as a guide to explain specific instructions, therapies, medications, and treatments the resident should follow after leaving the facility. It is used as a continuation of care that bridges one place of residency to the next.  

 The dietitian’s role in discharge documentation is to recommend an appropriate diet following their stay at the facility. This is usually the same diet they have been receiving while in the facility. The RD should be specific in including any therapeutic recommendations as well as texture modifications, adaptive equipment, supplementation and post-discharge guidance. Post-discharge guidance may include anything to do with managing the resident’s care after discharge such as diet instruction, medication management, follow-up appointments and community referrals. 

Best practices for care planning and discharge documentation  

To create effective care plans, a comprehensive nutrition assessment should be completed first. This is where the dietitian should set realistic and measurable goals for the resident so it’s clear what needs to be monitored and whether or not the resident is progressing toward their goals. The care plan is most effective when it is reviewed on a regular basis and updated or revised according to changes made to the resident’s care. Examples of this are any new orders, changes in condition or preferences that have occurred since the last update.  

Best practices in discharge documentation include identifying essential information to include in the note, clear and concise communication, and easy to understand post-discharge follow-up instructions and resources. It is not always applicable, but when needed, it can be helpful to verbally review your portion of the discharge documentation with the resident and their family prior to discharge so that you can address any questions they may have before they leave. 

Common challenges and strategies for success 

As with anything healthcare related, time can become a factor, especially during busy times when there is a high census or multiple admissions/discharges on the same day. Plan to give yourself adequate time to ensure your documentation is accurate and of good quality even if it means asking for help. 

Communication and collaboration can be challenging, too, which can lead to miscommunications. This can negatively affect continuity of care, so be aware that effective communication is critical in promoting quality outcomes.  

When a resident has complex medical issues, a multidisciplinary approach to care planning and discharge documentation should be implemented so that important information does not get inadvertently omitted.  

There are several strategies for overcoming the challenges mentioned above. Regular team meetings, open communication and shared document templates can help maintain consistency and streamline processes in order to save time and enhance quality of care. Ongoing training and education keep staff up to date on the latest best practice guidelines. Continuous quality control monitoring establishes systems to ensure regular evaluations are being performed and adjustments are made to areas that have been identified as needing improvement.  

Conclusion 

In summary, a dietitian’s role in care planning and discharge documentation in a long-term care setting is crucial to a resident’s successful long-term care stay in terms of quality of care and optimal quality of life, starting at admission and lasting through discharge and beyond. Despite challenges around time constraints and miscommunication, it is up to every member of the healthcare team to do their part when it comes to developing, following, and monitoring an effective care plan. Discharge documentation is just as important as the resident transitions from one residence to another.

A multidisciplinary approach is best when it comes to setting the resident up for success as they leave the facility. Ongoing and continuous professional development helps healthcare employees stay up to date with the latest information and best practice guidelines. We owe it to our residents to make care planning and discharge documentation a priority.  

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References: 

What’s a Care Plan in a Nursing Home? Available at  https://www.medicare.gov/what-medicare-covers/what-part-a-covers/whats-a-care-plan-in-a-nursing-home. Accessed on 5/24/23. 

Nutrition Care Plans: How Do I Build One? Available at https://longtermcarerd.com/nutrition-care-plans/. Accessed on 5/26/23. 

Dietitian Charting Guidelines for Ling-Term Care. Available at https://dakotadietitians.com/dietitian-charting-guidelines-ltc/, Accessed on 5/26/23. 

Discharge Planning and Disease Management. Available at https://study.com/academy/lesson/discharge-planning-disease-management.html. Accessed on 5/26/23.