When an elderly loved one is admitted to a skilled nursing facility (SNF) for rehabilitation after an injury or surgery, the path to regaining independence begins the moment they walk through the door. But how do you, as a loved one, ensure they receive the best care possible? One of the best tools at your disposal is a care plan meeting/conference.

At Senior Industry Services, we find that being proactive at the care plan meeting can make a huge difference between a peaceful discharge and recovery and a demanding, anxiety-filled one. 

We’ve compiled a step-by-step guide on what to ask and why it matters.

Understanding the Care Plan

This is not just paperwork; it is your roadmap to recovery.

• What are the primary goals of the care plan? Ask about short-term and long-term goals like improving mobility, pain control, or regaining independence in activities of daily living (ADLs). This helps to clearly define what success will look like for your loved one.
• How is the care plan tailored to my loved one’s specific needs? Every patient is different, even if they are recovering from similar things. Ask how the care team is addressing your loved one’s medical history, mental wellbeing, and physical condition.
• What is the outlook for achieving these objectives? Recovery does not occur overnight, and is not linear, but how long does it take? Knowing an expected timeline of progress can help you manage expecations and progress.

Be Familiar with The Logistics

Get to know the people who will care for your loved one, what types of therapy or treatment they will be having, and how often your loved one needs treatment.

• Who are the key members of the care team, and what do they do? From therapists and nurses to doctors and social workers, meet the staff so you know who to call with questions.
• What kinds of treatment and therapy are included in the care plan? Will your loved one receive physical therapy? Speech or occupational therapy? Ask how each will help with their specific recovery needs.
• How often will these therapies be administered? Consistency is crucial in rehab. Be clear about how often each service is provided and by whom.

Monitoring and Adjusting the Plan

Rehab and recovery are not always linear. Be sure to ask how the facility will be flexible with lapses in progress.

• How will progress be evaluated and communicated? How can you recieve regular reports? Will it be through emails, phone calls, or some other method? You want to ensure you have a clear line of communication to keep you in the know.
• What if things are progressing more slowly or more rapidly than expected? Ask how therapies and objectives can be modified as your loved one’s status evolves.
• How will pain and discomfort be managed? Ask about pain management options and other strategies they may use for managing discomfort.

Your Role and Advocacy

Your work is not done when you drop your loved one off. Communication with carers, helping make decisions, and showing support and involvement are key.

• How can you stay updated and involved in your loved ones care? How can you support the care team and help contribute to your loved one’s recovery journey? Are you able to attend therapy sessions? Will there be regular care updates? Learn how you can be involved in helping make decisions and planning.
• How do you communicate concerns or provide feedback? What is your preferred method of communication, and who should you contact for specific concerns? Ensure there is a good, responsive system for addressing any issues.

Start Planning for Discharge

Discharge planning begins at admission. 

• What are the discharge criteria? What is the timeline for discharge, and what steps can be taken to prepare for it? Learn the milestones your loved one must reach before they can leave. This enables you to decide if they’re really ready to go home or if additional time is needed.
• What post-discharge care and support will be required? What specific equipment or resources might be needed, such as for in-home care after discharge? Outpatient therapy, home health aides, transportation, and medical equipment may all be needed.
• How do we ensure a smooth transition home? Use the care plan meeting to go over what needs to be arranged: home safety modifications, follow-up appointments, medications, and more. Is all in place?

Clinical Navigation: Why It Matters

The effort of planning, asking questions, and staying on top of things is called clinical navigation. It’s the key to your loved one transitioning safely and successfully from the hospital or rehab back home.

Many find it overwhelming, especially when juggling work, family, and the emotional toll of caregiving.

You should feel empowered, not lost, when you walk into a hospital or rehab meeting. With the right questions, the right support you can make sure your loved one’s care plan isn’t just a formality; it’s a success story in the making.

A Quick Overview:

During a hospital care plan meeting/conference, ask about the care team’s roles, the specific therapies and treatments, how often treatments will occur, the next steps and appointments, how social and emotional needs will be met, and how you can support the care team. Additionally, inquire about the patient’s social and emotional well-being, any necessary equipment or support services, and the process for discharging the patient or making decisions about their care. 

Written for Senior Industry Services by Lauren Hope Bartling

References:

Rothkoff Law Group. (2025, March 20). Five questions to ask at a nursing home care conference. https://rothkofflaw.com/2025/03/20/five-questions-to-ask-at-a-nursing-home-care-conference/#:~:text=How%20is%20My%20Loved%20One’s,Additional%20Questions%20to%20Consider 

What questions should you ask in a care plan meeting? – oasis senior advisors. (n.d.). https://www.oasissenioradvisors.com/locations/fairfield-westchester/blog/what-questions-should-you-ask-in-a-care-plan-meeting/