Nursing Home Social Services Reference/Flow of Care/Adjustment and Transitions

Adjusting to the routine and rules of a facility are difficult for many new residents. Allowances and encouragements should be offered to these residents for at least three to six months or longer. Particular issues wil arise commonly and offering appropriate resources will greatly help new residents in this transition. These should be included in a new resident's care plan for this time with criteria for adjustment. A sample care plan for new residents is included in the Sample Care Plan section. A resident's needs for association, use of his or her skills and talents, as well as physical and mental engagement should be addressed in helping them find activities, friends and community connections. The goal is to have the new resident engaged in the facility community as much as they are able. Interventions will include support and encouragement for residents to try activities, reach out to other residents and to find community resources that interest them. Reviewing the activities calendar, introducing them to tablemates, other residents of similar backgrounds or interests, and providing community resources to try will support them in finding those doings and cliques/cohorts in the facility community that interest and engage them. Community resources include library books, books on tape, volunteer visitors, church communities that offer visits or transportation to services and meetings, virtual club meetings, political organizations that visit or meet virtually, service organizations that will visit, offer resources or engage in virtual meetings or presentations. The facility may have games, puzzles, a library of donated books and magazines, computer labs and other areas dedicated to giving residents wholesome and engaging individual and group activities. Other transitions also occur in a resident's life. These transitions may include: loss of a loved one, change in mobility or cognition or other functional losses, added and more complicated diagnoses, disruptive med changes, and changes in stable care staff. IN some cases, more than one change may occur at a time. Many of these may cause enough disruption or behavioral changes that they will trigger an added care plan section. As always the goal should be some form of well-being or avoidance of an adverse event / condition. Care Plans for many of these transitions are included in the Sample Care Plans section.