Assessment and Care Planning

To create a truly comprehensive Life Care Plan, you must first understand the senior. That’s why, at LivHOME, our Life Care Management services always start with a comprehensive assessment.

A comprehensive assessment identifies not only physical and functional needs, but also preferences, priorities, social and emotional challenges, and risk factors. LivHOME Life Care Managers have extensive experience in assessing care needs, and they are trained to gather this information with compassion, respect, and discretion.

As a family member, it’s likely that you cannot be as thorough, or as objective, when planning for care. After all, we all view things through the lens of our history and experience. In most cases, families become involved in elder care only after some critical event such as your loved one falls or has a medical diagnosis and more. As a result, you may be in a reactive mode, unable to be as thoughtful as you’d like to be in your decision making.

Having a professional Life Care Manager involved to conduct an assessment and develop a care plan will help you regain perspective and provide the best care for your elderly loved one.

What is Care Planning?

Care planning, or elder care planning, refers to a three-part process that includes: 1) identifying issues that negatively impact an individual’s life, 2) prioritizing desired outcomes, and 3) determining the interventions, services, and resources needed to reach the chosen goals. Based on the information obtained from the initial assessment, the Life Care Plan becomes an agreement between the senior and others involved about how to enhance their quality of life and reduce the risks associated with living at home.

Seniors and their family caregivers benefit from having care plans because they serve as roadmaps, helping all involved to stay focused on the interventions that require attention. However, planning for elder care is an ongoing process, and care plans need to be updated and managed based on real-time and real-life changes.

In addition to being used as a yardstick to measure progress, an elder care plan can be an essential and useful tool to have on hand in the event of a crisis or medical emergency. The elder care plan outlines, in writing, what kind of care the individual wants. Making a directive like this is quite helpful to families, especially if their loved one is not able to articulate their wishes due to a medical condition or cognitive decline.

A Life Care Plan enables family members to make decisions consistent with their loved one’s preferences and values.

Biopsychosocial Assessment

A biopsychosocial assessment is the cornerstone of elder care planning. The goal of the evaluation is to understand the whole person—not just their physical or medical needs, but their emotional, psychological, social, and even spiritual needs, as well.

A biopsychosocial assessment is typically conducted by a credentialed social worker, nurse, psychologist, gerontologist, or another professional who specializes in working with geriatric clients.

Typically, a biopsychosocial assessment takes 1 – 3 hours, and it may be conducted in one or more sessions. Usually, the evaluation takes place in the senior’s residence; however, at times, it may be more feasible to conduct it at a hospital, at a family member’s home, or at the practitioner’s office. During the evaluation, the Life Care Manager will ask questions about:

  • Presenting issues (Why does the senior need help now?)
  • Medical history (current information that is relevant)
  • Medications
  • Current functional abilities (ADLs and IADLS)
  • Social support systems (past and present)
  • Emotional well-being (depression/suicide, anxiety, mood, affect, losses, changes)
  • Risk factors (depression, social isolation, home safety, falls, nutrition, medication adherence, driving, caregiver burnout, substance abuse/misuse, elder abuse, etc.)

Because it covers a wide range of physical and emotional topics, a biopsychosocial assessment results in an understanding of the whole person. That, in turn, results in effective interventions that are chosen based on facts, not just assumptions.


The “bio” part of the biopsychosocial assessment focuses on the senior’s medical, physical, and functional status, including:

  • medical diagnoses/conditions
  • medications
  • sleep habits
  • nutritional and/or digestion issues/weight gain or loss
  • hearing and vision
  • toileting
  • skin condition (rashes, reddening, sores)
  • ambulation/walking
  • pain
  • respiratory issues
  • swelling of extremities
  • management of ADLs and IADLs

Life Care Managers are not physicians; however, they do have the training and experience to gauge symptoms and identify red-flag issues. During the biopsychosocial assessment, a Life Care Manager may determine that specific physical problems should be brought to the attention of a primary physician.

They may also find issues that can be remedied with relatively simple interventions. For instance, if a senior is not remembering to take their medications as prescribed, the Life Care Manager may recommend a system to improve compliance, such as organizing pills in a pill box or setting up a reminder system to alert a caregiver when a dose is missed.


Emotional and psychological well-being are critical to healthy aging. But considering all the changes that seniors experience—with their physical abilities, employment status, living arrangements, losses (of people, pets, and things of value)—it’s quite common for them to feel off balance and out of sorts.

Life Care Managers will ask questions in a manner that feels more like a natural conversation, not an interrogation probing into difficult or emotionally charged areas. The questions asked in the psychological portion of the biopsychosocial assessment typically focus on:

  • feelings and moods
  • appetite
  • sleep habits
  • recent changes
  • energy level
  • thoughts of suicide
  • anxieties
  • coping mechanisms (past and present)
  • pleasurable activities and hobbies
  • history of mental health issues for self, or in family

Once a Life Care Manager better understands a senior’s emotional state, they can suggest interventions to help improve it, if needed. For example, if a senior has recently lost their spouse, moving that person to a new living environment may not necessarily be the best option. While it may solve an immediate concern for family members who are worried about dad living alone, it may compound his grief, as now he has to cope with the loss of his wife, plus the loss of familiar home environment.


Bill Thomas, MD, the founder of the Eden Alternative, proposed that three plagues are affecting older adults: boredom, loneliness, and helplessness. For those who suffer from boredom, the cure is activity—meaningful, purposeful activity. For those who suffer from loneliness, the cure is companionship and social engagement. And for those who suffer from helplessness, the cure comes from opportunities to participate, give back, and reciprocate.

Life Care Managers understand that these issues are genuine for seniors, and that’s why they strive to identify not only what someone needs, but also what someone wants and what is important to them. From there, the Life Care Manager can devise a plan that leads to more meaningful activities, opportunities for connection, and ways for a senior to more actively participate in their world.

In the social part of the biopsychosocial assessment, the Life Care Manager explores the senior’s past activities, hobbies, careers, significant people, valuable lessons learned, what gives them pleasure, and ways to adapt past interests into present-day activities.

Quality of Life Plan

Most people understand the value of meeting with a financial planner to create and maintain a financial plan tied to desired outcomes. Likewise, most people understand the importance of meeting with an estate planning attorney in order to have the right tools in place to protect valuable assets.

A quality of life plan is a similar kind of tool, but it communicates how and where a senior wants to live, what is important to them, what kind of food they like, who they wish to spend time with, what time they like waking up, where they want to get their hair done, etc. While they may seem a bit mundane at first, these are the issues that give people comfort.

At LivHOME, we will meet with the senior client and any available family member to create a Quality of Life Plan. Consider it a practical roadmap that provides basic guiding principles so that care is administered in a manner honoring the senior’s wishes. A quality of life plan may include answers to questions like:

  • If I should require care, who will provide it?
  • What is important to me in selecting the right care provider?
  • Where should my family turn for guidance/support?
  • Where do I want to be living?
  • How will my care be financed?
  • Who will handle paying the bills?
  • Who will make decisions about financial, living, and health care matters?
  • If my family can’t see eye to eye, who will have final authority?
  • How do I want to spend my time?
  • What kind of activities do I enjoy?
  • Who do I want to spend my time with
  • Who will provide transportation?
  • What are my regular routines?
  • What are my medications?
  • Where are my essential documents stored?

Elder care planning can enhance your loved one’s quality of life and reduce the risks associated with living at home. To learn more, please call LivHOME today to schedule a free 30-minute phone consultation.