Training › For Family Advocates › Coordinating care

Adama's call yesterday changed something: Mrs Diallo had a brief hospital visit and is being sent home with a new mobility limitation for two weeks. After this lesson, you can revise the plan the same week without losing the prior version. You can pick the right cadence for the authorization level. You can recognize the events that should trigger a revision regardless of cadence. You can write a revision note the next advocate can read in thirty seconds.

How versioning works

The care plan editor is versioned. Every revision saves the previous version. The history panel keeps a record of which advocate authored each version and when. Two practical implications.

• You can always see what the plan said before. When a provider asks "is this change new?" you can check.
• The next advocate covering for you can read the trajectory. They open the history and see the last three revisions and what prompted each one. The plan is a story, not a snapshot.
• You never lose a previous version by editing. Save as much as you need. Experiment with phrasing. The prior version is always recoverable.
• Each revision should have a one-line revision note. "Updated mobility watch-fors after Adama call 2026-05-21." Not "edits." The note is what the next advocate reads in the history panel.

Cadence by authorization level

The cadence is a floor, not a ceiling. The events that should trigger a revision (below) override the cadence.

• Guidance. Initial care plan at intake. Light revision at the six-month check-in.
• Coordination. Initial care plan at intake. Revision every three months, or when a meaningful change happens.
• Delegated Authority. Care plan authored before the first visit. Revision every month, or after any incident or hospital event. The plan also carries the delegated-action block.

Events that should trigger a revision regardless of cadence

• A hospital visit, an emergency-room visit, or a significant medical change.
• A fall, even if no injury.
• A change in mobility, sleep, appetite, or mood that lasts more than a few days.
• A change in who is in the household (a family member moves in or out).
• A change in services (a new booking cadence, a removed task, a new provider role).
• A meaningful conversation with the family or the older adult that shifts your understanding.
• A safeguarding event or near-miss.
• An authorization-level change.

The same-week rule

The discipline that holds continuity is the same-week rule. If a conversation, an event, or a phone call changes the plan, the plan changes the same week. Not next month at the regular review. The same week.

• The next advocate covering for you on vacation reads the plan, not your internal notes. Move the change to the plan.
• The provider walking into the home on Tuesday cannot act on something that lives in your head. Move it to the plan.
• If the change is significant enough to need provider-channel messaging too, do both: revise the plan AND message the provider thread with a short summary. Do not message without revising; the message scrolls away, the plan stays.

Writing a revision note

The one-line revision note is what shows up in the history panel. Two parts: what changed and why.

• "Updated mobility watch-fors after Adama call 2026-05-21." Specific. Anchored.
• "Added Coordination delegation: reschedules within 7 days, goodwill within policy." Specific. Action-oriented.
• "Removed closed risk: bathroom rug replaced 2026-04-12." Closes a loop. Future advocates can stop watching for that.
• Not "edits" or "updates" or "see notes." The next advocate scans these and decides what to read. A vague note forces them to open every version.

Common slips

• Letting internal-notes thinking sit there for weeks. A change that lives only in the notes is invisible to the provider and to the next advocate. Move it.
• Enabling a Delegated Authority block on a Coordination plan. The portal will not allow the action even with the block written. Raise the authorization level first (per the Family Assessment module), then add the block.
• Letting the plan grow past one page. When you add, look for what to remove. Closed risks come off.
• Writing revision notes that say nothing. "Edits." "Cleanup." The history panel becomes useless.

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.