LTC Homes: It’s Time to Fix the Care Plan Approval Process

It’s one of the most delicate issues in long term care. In most facilities, there are residents who just don’t have the capacity to make their own personal care decisions.

In these cases, a substitute decision maker must be appointed. This person—whether she’s a family member or some other individual with power of attorney—needs to sign off on all care plan changes.

Of course, there’s good reason for these rules. The goal should always be to get as close as possible to acting in accordance with resident wishes. And when they can’t decide for themselves, residents are best served by the people who have been entrusted with their care.

But reaching a given substitute decision maker isn’t always an easy process. This crucial step in care delivery can eat up a whole lot of time—and resources.

At Aetonix, we’ve spoken to a lot of professionals who work in long term care. And this is one of those issues that keeps coming up, again and again. In this post, we’ll look at what’s wrong with the care plan approval process—and how it can be fixed.

Reaching out to substitute decision makers

Ontario’s Health Care Consent Act is clear. When a patient is incapable of making a crucial care decision, a substitute decision maker must be brought in.

An individual tasked with making health care decisions for another person carries an enormous amount of responsibility. It’s a difficult role to take on, which is why health care professionals should treat those who fill it with sensitivity and respect.

That said, acquiring consent can be difficult for those working on the frontlines. In long term care, problems often occur when a resident’s care plan needs to be changed. A prescription update or treatment modification can lead to countless voice messages. Often, there are rounds of phone tag, numerous faxes, and extended periods of waiting.

For the practitioner or caregiver hoping to take action, this process can be extremely frustrating. These feelings may be compounded by confusion when many care professionals are involved. All too often, an on-duty nurse will find himself waiting to get the go-ahead from a resident’s loved one. When a shift change occurs, the situation may be even more unclear to the worker who takes over. Questions can arise, leading to uncertainty.

Was the right person contacted for consent? What’s the status of the request? Was the most up-to-date information entered into the care plan, or did the nurse from the earlier shift get delayed? If you work in long term care, you know how frequently urgent situations can pull staff away from administrative tasks.

Between even the most dedicated physicians, nurses, and personal support workers (PSWs), miscommunications can occur. Information can get lost in the shuffle. And the care plan approval process can get held up.

This is a fundamental problem with many circles of care. The people who care for a resident aren’t always in sync. And when they don’t have the latest information, t’s difficult for health care practitioners and family members to provide full support.

The true cost of a broken process

Consider this: 90% of Ontario’s long term care residents have some form of cognitive impairment. One in three are severely impaired.

If you manage a home for people who belong to this population, you’re aware of the challenges involved. Caring for those with cognitive impairments can mean struggling to to obtain consent from substitute decision makers. This difficulty isn’t a well known to those outside of the health care field. But that doesn’t mean it’s easy to tackle.

When care plan approval doesn’t come, team members can’t implement crucial changes. As a result, residents must wait to receive beneficial treatments. Unfortunately, the impact of waiting can be significant.

For someone who needs it, consider the difference that switching a pain medication can make.

Of course, it’s not just about individual patients. Delays can hold up care across facilities, slowing down operations. Managers: how much time do you think your staff spends, in total, trying to get hold of substitute decision makers? How often does treatment get held up because caregivers haven’t received care plan approval?

The truth is, you might not even be aware of the extent of the problem.

In order to provide residents with the best care possible, it’s important to allocate resources in the right way. This includes human resources. For workers and practitioners, the extra effort required to communicate with people outside of their work environments can take its toll. It can even contribute to mental and physical burnout—conditions that have serious consequences.

Every long term care professional (including those in management) should care about this issue. Solving it will lead to better resident health outcomes—and make life far less stressful for entire circles of care.

Streamlining care plan approval

How can long term care homes avoid spending massive amounts of time on the care plan approval process? The answer: strengthen resident circles of care. This goal may seem massive in scope and difficult to reach. But it’s far from unachievable.

In long term care, a resident who’s capable of making her own decisions is at the centre of her circle. Her goals and preferences come first during the care planning process. Every time there’s uncertainty about making a change to her plan, she’s the one who has the final say.

When she can’t make these decisions, her circle of care is just as important it otherwise would be—if not more so. But how can the individuals who comprise her circle work together? More often than not, they’re in different locations. And their schedules are bound to be different.

Communication technology holds the key. By bringing everybody together, the right digital platform can streamline the care plan approval process. The result is instant actions that truly benefit the resident.

What does this type of solution look like in practice? Let’s say all of the members of a circle of care are connected through the same electronic system. This system would allow everybody—including relevant nurses, physicians, and specialists—to relay real-time information to the resident’s family members (and, importantly her substitute decision maker).

Using their mobile devices, facility caregivers and attendant practitioners could submit requests as they arose. With the tap of a cell phone or tablet screen, the resident’s substitute decision maker could approve requests quickly.

After shift change, new workers could log in to see the status of requests on an as-needed basis. Care would be delivered quickly, and everyone would win—especially residents.

Fortunately, the technology we’re talking about already exists. In facilities that have trouble with care plan approval, it’s time to incorporate an easy communication and information-sharing app.

A win-win  

Operating a long term care home comes with many challenges. With advancements in digital technology, some are easier to overcome than others.

Streamlining the care plan approval process is an efficiency-enhancing measure that benefits all involved. When communication is quick and easy, physicians, nurses and PSWs can focus on what they’re best at—caring for residents.

Feature image courtesy of NEC Corporation of America

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COPD Education – Onboarding


To complete a thorough needs assessment / initial evaluation for a COPD patient of an outpatient clinic

Patient, Educator (Nurse, RT, the Physician could also be the educator)

One 60-90 min session with the Educator

  • This protocol should be established for all COPD patients from a given clinic, independently of whether they are new patients or they are known to the clinic. This protocol is the basis to engage the patient into other protocols such as education, exacerbation follow-up, etc.
  • We need to identify patient goals/concerns to guide the interventions
  • A thorough evaluation is carried on, with the objective of understanding where the patient is on their disease journey and follow-up treatable traits: dyspnea, exacerbation or dyspnea and exacerbation.
  • It includes the use of objective questionnaires such as the mMRC, CAT, HADS, Frailty Scale, etc.
  • Identify if the patient needs to be referred to other resources (e.g. Physiotherapist, social worker, occupational therapist)
  • Once Onboarding is completed, the patient continues to the COPD Education workflow
COPD Education – Continuous Maintenance


To cover in depth all the necessary elements of self-management education as per the LWWCOPD, with priorities based on patient goals and identified treatable traits

Patient, Educator (Nurse, RT or Physician)

A number of “Core” educational modules have been identified which cover the basic COPD education from the LWWCOPD program. Additionally, optional modules can be used to respond to patient needs. The timeline (frequency, number of modules to be covered at a given education session) is fully customizable, although we recommend to have education sessions every 2-weeks during the “active” phase of education. Once this is completed, the patient continues to the Maintenance Mode (see below).

  • Launched at the onboarding protocol
  • Provide basic overview of COPD self-management based on LWWCOPD (medication adherence, inhaler techniques, PLB technique & energy conservation) up to the development of an Action plan for early exacerbation recognition and management.
  • Prioritize self-learning by the patient (e.g. watching videos, reading educational materials, completing homework) in addition to live sessions with the Educator. Educational materials are sent to the patient directly via the platform, and become the patient’s own library. The Educator can customize which “homework” the patient receives.
  • Educators have access to “User guides” to standardise their educational intervention. These user guides include: objectives, interventions, suggested questions, evaluation of self-efficacy, and learning contracts for each module.
  • Once the core education is completed, the patient can continue to the Respiratory Status Follow-up Workflow (run in parallel)

The Maintenance Mode
  • As soon as the maintenance mode is engaged, the frequency of visits Educator/Patient is reduced to once every 6 months.
  • During the Maintenance Mode sessions, the educator has access to all the education modules and can choose any piece of content that needs to covered with the patient. 
  • A streamlined evaluation (similar to the initial eval.) is done during each “maintenance” visit to identify any substantial changes on the patient’s needs that will require some adjustment. The patient could come back to an “active” education mode (more frequent education sessions, e.g. every 2 weeks).
COPD Respiratory Status Follow-up


Monitoring of stable patients from a clinic in order to identify early any aggravation of symptoms (exacerbation) and implement an action plan

Patient, Educator (Nurse, RT or Physician)

Scheduled regular automated follow-up to the patient symptoms. Intensity/Frequency can be adjusted by the Educator depending on patient needs (e.g. daily, every week, etc.). Ongoing through the year.

  • Launch: Patients who have completed the Core Educational including setting-up an action plan.
  • Regular automated questions allow to identify any change in patient’s symptoms and severity.
  • If an exacerbation is detected the patient gets a reminder to engage their self-management strategies while waiting for the Educator to call back.
  • An alarm is generated for the Educator, so they immediately call back the patient. At this call they will evaluate any further intervention required and schedule additional follow-up.
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