Adjusting Care Plans Based on Ongoing Evaluation
Continuously monitor and adjust care plans based on patient progress, changes in cognitive status and feedback from families and caregivers to ensure optimal care.
A care plan that never changes is not being used
The last letter of DWARAA is the one that decides whether the other five were real. Dementia progresses; a plan written on admission describes a person who no longer exists a year later. The review checks for an individualized plan to manage behavior without restraints, collaboration with providers and family in building it, regular team meetings to review progress and adjust, and — the item that is skipped most often — that all staff are trained and informed about the specific resident’s plan.
Families are part of the evaluation loop
The review explicitly checks that families are encouraged to participate in behavior management, are educated on the negative impacts of restraints and the alternatives, and are kept in open communication about strategy. A relative knows what settled this person in 1998, which no assessment tool can recover. For families.
Collaboration & Care Planning, category 30 of 54.
DWARAA is six steps. Back to the overview.
The four items
- An individualized care plan to manage behavior without restraints.
- Built in collaboration with healthcare providers, family members and caregivers.
- Reviewed at regular team meetings, and adjusted.
- Known to all staff who work with that resident.
The last item is the one that fails
A plan the day shift follows and the night shift has never read is not a plan; it is a document. In a building with agency cover, high turnover, or a float pool, the transmission problem is the whole problem. The practical test is not whether the plan exists but whether someone who started three weeks ago can say what settles this resident.
What a review triggers
- A fall, or a near miss.
- A medication change, in either direction.
- A new or worsening behavior.
- A hospital admission and return, which is when medication lists change most.
- A family raising something. Families see change across time that no single shift does.