What Is a Care Plan for Pediatric Home Care?

October 27, 2022

According to the Department of Human Services for Minnesota, a school-age children/young adult’s care plan is “...a written description of each of the medically necessary PCA services a child will need during the school day with specific instruction of how the services should be provided.”

The care plan should be complete within the first week of a PCA starting services, and you should plan to update it regularly if there is a change to your child’s needs or care.

Who Can Create a Care Plan?

A qualified professional (also known as a QP) must develop the care plan within their scope of practice. This QP will also be responsible for the training and supervision of the person who will be providing the service to the child—potentially requiring in-person meetings with school staff.

How to Create a Care Plan

Any care plan needs to be specific to the location of the special education and the child's needs with enough detail to describe each service in full.

A few components of a plan of care include:

Start and end date of the plan of care.
Child’s name, student identification number, date of birth, and demographic information, including the name of the parent, guardian, or responsible party, and emergency contact information
A list of special instructions or procedures required to meet the child’s specific requests or needs—such as meeting the communication needs of the child due to a language barrier or whether the child or family has requested a personal care assistant of a specific gender
A clear summary, including any diagnosis, conditions, signs, or symptoms relevant to the child
Steps to address safety and vulnerability issues, including responding to immediately predictable, identifiable triggers to level 1 behavior episodes
Date, name, and signature of the QP

Example of a Detailed Care Plan

Here’s an example of a detailed care plan from the DHS of Minnesota, which can help to inform your own.

“The child has a traumatic brain injury. Because of the brain injury, the child has tremors and an unsteady gait. The child will need assistance with mobility, eating lunch, and toileting.

Mobility

The child has an unsteady gait and falls frequently.

The child must wear a gait transfer belt when going to the restroom or lunchroom.
The person providing the PCA service will put the gait belt on the child, walk next to the child and hold the belt rather than the child’s hand or arm.

Eating

Tremors interfere with dexterity and the ability to grasp or hold items.

At lunchtime, the person providing the PCA service will escort the child from the classroom to the lunchroom using the mobility instructions.
Assist the child with washing his (or her) hands.
Stay in the lunch line with the child, help with food selections, and carry the tray to the table where the child will eat.
Open any cartons or containers of liquid, insert a straw into the drink, and cut food when applicable.
Sit with the child to assist with hand-over-hand assistance when eating.
After eating, clean the child’s face and hands, inspect clothing, clean up the table, and dispose of or stack dishes as appropriate
Escort the child back to the classroom or the scheduled location (e.g., recess).

Toileting (as needed)

Escort the child from the classroom to the restroom using the mobility instructions.
Unfasten or remove necessary clothing and pull-up. Position the child on the toilet, clean the child after toileting, put on a new pull-up, redress the child, and fasten clothing.
Use hands-on assistance to help the child with washing and drying hands
Escort the child back to the classroom or the next scheduled location.

Note: This is only an example to show the level of specific details required in a PCA plan of care. Certain administrations may follow their school policy or format (i.e., template or form created by the school, bulleted list, etc.). Likewise, follow school policy for documentation and location of the care plan. (In the IEP, IFSP, or a separate document.).