Training › For Family Advocates › Coordinating care

It is Wednesday morning. Mrs Diallo's son Adama called you yesterday with news about a hospital visit. You open the family record drawer to revise the care plan. After this lesson, you can sit down at the editor and write a plan a provider can act on by Friday. You can open with Mrs Diallo, not her conditions. You can structure the body in the four sections that matter. You can keep it under one printed page.

Open with the older adult

The first paragraph of every care plan is who the older adult is, not what is wrong with them. Two or three sentences that the provider can read in twenty seconds and walk in knowing who they are supporting.

"Mrs Diallo is 78. She moved to East Houston from Senegal in 1991. She lives alone in a third-floor apartment with a small balcony she tends in summer. She has two grown children, one in Houston and one in Dakar."

That is the opening. The conditions, the services, the watch-fors come after. The provider reads better when they know who they are walking in to support.

The four sections of the body

After the opening, the body has four sections. Same four for every plan, every authorization level.

• 1. Care goals. What the family is hoping for, in plain language. One or two sentences. "Mrs Diallo wants to stay in her own apartment as long as possible. She wants help with bathing twice a week and a walk around the block on good-weather days."
• 2. Services in place. Which bookings and tasks are part of the plan, at what cadence. "Provider visits Tuesday and Friday afternoons, 90 minutes. One ad-hoc task per week, usually grocery delivery on Sundays."
• 3. Watch-fors. Medical safety items, mood changes, environmental risks the provider should know. Named risks paired with a specific action. "She has fallen twice in the last six months, both in the bathroom. Watch for wet floors. If you see her balance is off, message me same-day."
• 4. Contact preferences. Who to contact when, in what language, at what time. "If something looks off, message the advocate (me) first in English or French. If urgent, call Mrs Diallo's son Adama in English (number in family contact card). Adama is in Houston and reachable until 9 pm Central."

The under-one-page rule

A care plan that runs longer than one printed page is a care plan that does not get read. Providers scan the first page on the way to the visit and act on what they remember. Whatever is on page two might as well not exist.

• Cut, do not append. If a new watch-for needs to be added, look at what is on the plan already that can come off. Closed risks come off. Resolved questions come off. Plans should shrink as the relationship matures.
• Use bullets, not paragraphs. A provider scans bullets faster than they read paragraphs.
• Skip the explanations. "Bathroom floor is uneven" is enough. The provider does not need to know the history of the renovation.
• Save the long version for the internal notes. The notes section of the family record is where context lives. The plan is where action lives.

Authorization-level sections

• Guidance. The four sections, that is it. No special blocks.
• Coordination. The four sections, plus a delegation-preferences block: which decisions the family has pre-authorized you to make on their behalf (within Coordination scope), and which they want consulted on.
• Delegated Authority. The four sections, plus the delegated-action block. This block lists the specific Delegated Authority actions the family has explicitly delegated to you (covered in the Delegated Actions module). The portal enforces this block: the actions listed here unlock for you; actions not listed stay locked.

A short worked example

Here is what a complete Coordination plan body looks like, under one printed page.

• Mrs Diallo is 78. She moved to East Houston from Senegal in 1991. She lives alone in a third-floor apartment with a small balcony she tends in summer.
• Care goals. Stay in her apartment as long as possible. Help with bathing Tuesday and Friday. A walk around the block on good-weather days.
• Services in place. Provider visits Tuesday and Friday, 90 min. Grocery delivery task most Sundays.
• Watch-fors. Two falls in the bathroom in the last six months. Watch for wet floors and for balance changes after meals. Eats poorly when the apartment is cold. Tell me same-day if either.
• Contact preferences. Message me first in English or French. If urgent, son Adama in Houston (English, until 9 pm Central). Other son in Dakar, time-zone difficult.
• Delegation (Coordination). Adama has pre-authorized reschedules within seven days and goodwill credits within standard policy. Anything else, consult Adama before acting.

Finding this again Open Training from your portal any time to come back to this module. A knowledge quiz follows. You pass it once before activating your caseload, and again each year when you renew your certification. The next lesson covers revisions, versioning, and revision cadence.