Dr Kola Tytler MBBS CertHE MBA MRCGPClinical Lead • iatroX
Effectively involving family members in the care planning and management for a frail older adult requires a collaborative, person-centred approach that recognises the vital role of carers NICE NG22,NICE CKS. It is crucial to involve family members and carers in the planning process with the older adult's agreement, acknowledging them as important partners NICE NG22.
Key strategies for involvement include:
- Named Care Coordinator and Multidisciplinary Team (MDT): Ensure the frail older adult has a single, named care coordinator who acts as their first point of contact and liaises with all health and social care services, including the voluntary sector NICE NG22. This coordinator should involve the person and their family in all discharge planning decisions NICE NG27. Care for frail older patients is often best managed by interdisciplinary teams, which can include doctors, nurses, therapists, social workers, and pharmacists, providing comprehensive support NICE NG22,NICE NG27 Dyer et al. 2003.
- Collaborative Care Planning and Decision-Making: Develop care plans in collaboration with the older adult, their carers or advocate, and relevant practitioners, ensuring joint ownership and agreement through signatures NICE NG22. Care plans should be tailored to the individual, offering choice and control, and addressing a range of needs including medical, psychological, social, and environmental aspects NICE NG22. Discuss managing medicines with both the person and their carer as part of care planning, including purpose, dosage, and contact details for concerns NICE NG22. When performing structured medication reviews, consider the views and understanding of the person and their family or carer(s) regarding medicines NICE CKS.
- Comprehensive Carer Assessment and Support: Local authorities must offer carers an individual assessment of their needs, recognising the complex nature of multiple long-term conditions and their impact on wellbeing NICE NG22. Offer family members and carers the opportunity for their needs (e.g., for support and information) to be assessed separately from the person receiving care NICE CKS. Support carers to explore the benefits of personal budgets and direct payments, offering help to administer them NICE NG22. Help carers access support services and interventions, including carer breaks NICE NG22. Recognise that the demands of being a carer can sometimes manifest as physical symptoms, such as fatigue or weight loss NICE CKS.
- Information Sharing and Communication: Involve carers in decision-making and care planning for the person they care for, keeping them updated with the person's consent NICE CKS. Explain how the health condition, disability, or needs of the person are likely to progress so the carer can understand potential changes in their role NICE CKS. Be open and honest, even with difficult information NICE CKS. Regularly offer carers opportunities for discussion and help them understand information regarding diagnosis and prognosis (with consent) NICE CKS.
- Training and Practical Guidance: Offer training to carers, such as structured programmes or one-to-one guidance, to enable them to provide care safely NICE CKS. Ensure carers have access to advice and training on appropriate use of equipment, adaptations, and safe moving and handling techniques NICE CKS. Examples of training include managing medicines and manual handling courses NICE CKS. Preventive home care often involves case management, which can include educating carers Hallberg 2004.
- Advance Care Planning (ACP): Involve carers in advance care planning if the person gives their consent, and ensure carers understand their role in the plan NICE CKS,NICE CKS. ACPs should address anticipatory prescribing, psychological and spiritual care needs, and care of the family NICE CKS.
- Cultural Sensitivity: Be aware that people of different ethnic backgrounds or cultures may have specific preferences regarding family involvement NICE CKS.
Continuity of care, by involving the same professional care staff where possible, can also provide valuable support during end-of-life care NICE CKS.
Key References
- NG22 - Older people with social care needs and multiple long-term conditions
- NG27 - Transition between inpatient hospital settings and community or care home settings for adults with social care needs
- CKS - Palliative care - general issues
- CKS - Support for adult carers
- CKS - Heart failure - chronic
- (Hallberg and Kristensson, 2004): Preventive home care of frail older people: a review of recent case management studies.
- (Dyer et al., 2003): Frail older patient care by interdisciplinary teams: a primer for generalists.