Using Strong Communication for Effective Care Planning

Having strong communication skills as a dietitian in any setting will set you apart from being just another employee to thriving as a valued member of the healthcare team. In the long-term care setting, the dietitian often ends up being a liaison between the resident and many other people.

In some cases, a resident’s cognition may be impaired, or they may be having trouble remembering both short- and long-term facts. Starting with your initial assessment, it is a good idea to involve the resident’s family members or medical decision-maker—give them a call or visit the resident when they are present. This allows you to gather important information regarding diet history and food preferences from a trusted source who knows the resident better than anyone. By establishing this relationship from the time the resident is admitted, it becomes easier to keep them updated on changes that occur with the resident as time goes on. It is also a valuable opportunity for them to provide you with information along the way that may be helpful as you work with the resident on their nutrition goals.

Be Open and Update Family Often

No one likes surprises when it comes to learning that there has been a change in their loved one’s condition. In terms of nutrition, this includes a weight change, development or progression of a pressure injury, dehydration, loss of appetite, and/or a change in their ability to tolerate certain diet textures. The more open you can be and the more often that you notify families of even subtle changes, the better.

Many facilities have had more restrictive visitor protocols throughout the pandemic, which has prevented families from seeing their loved ones as often as they once did. In other cases, families or medical decision-makers live a significant distance from the facility and rely on phone calls to stay in touch. This makes it even more important for dietitians to communicate and be a strong liaison between residents and their families.

When you are covering at a facility as a consultant dietitian or are starting a new permanent position, you are meeting residents that may have been at the facility for several months or even years. A good time to start open communication with the resident is at the time of their first MDS assessment. To keep yourself organized and your follow-ups timely, use the MDS schedule as your guide. Care plan meeting dates are derived from this calendar and will be held according to the resident’s quarterly assessments or change in condition.

Care Plan Meetings

The care plan meeting in long-term care is an opportunity for each member of the resident’s healthcare team to provide an update on what is going on with the resident. It is important that all areas of care be represented by a spokesperson at these meetings, as well as the resident themselves, and a family member or appointed person. The meetings can take place in-person or via telephone.

Clear and open communication at the care plan meeting should be a priority. This is where the dietitian will go over the resident’s diet recommendations, meal intake, weight status and trends, and any other nutrition-related concerns. Food preferences may be updated at this time as well. As a team, it may be decided to change the resident’s plan of care or continue the current treatment plan, once all information is discussed and input from everyone is considered.

Effective Communication is Imperative Among Every Member of the Team

We are all in this together. Getting to know each person’s individual role in caring for the residents will put you in the best position to know to whom and when to convey important information so that everyone is kept in the loop appropriately. Here are the key members of the healthcare team in long-term care.

  • Activities staff
  • Administration
  • Dietitians
  • Food and nutrition manager                                                  
  • Foodservice staff                  
  • Housekeeping
  • MDS coordinators                                        
  • Nursing staff  
  • Physicians
  • Residents                                                                  
  • Residents’ family members or medical decision-makers
  • Social work staff                                
  • Therapists

After the Care Plan Meeting

Following the care plan meeting, it is always a good idea to continually update the healthcare team and family as things change with the resident. Do not wait until the next meeting if there is something that should be discussed between assessments. A quick update over the phone or a brief e-mail may make all the difference when it comes to providing an excellent experience for your residents, and it all starts with you!

Sarah Hammaker, RDN

Sarah Hammaker, RDN is a clinical dietitian working primarily in long-term care and acute rehabilitation hospital settings in Pennsylvania. Outside of work, Sarah enjoys spending time with her husband and their four children. She loves running and being outdoors. Her hobbies include reading, planting and shopping.

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