Chronic Illness Support:
In Home Plan of Care Examples

Chronic illnesses begin subtly and progress slowly. Oftentimes many of the more insidious problems with this progression are missed due to lack of caregiver consistency and use of specific monitoring techniques. Below are samples of Guided Living’s outcome-based approach to disease support at home built into every plan of care.


• Maintains a safe environment by monitoring potential stressors, triggers or dangers
• Supervises client & assists as appropriate with ADL & IADL activities
• Engages clients in purposeful and enjoyable activities such as rummaging or reminiscing
• Identifies potential problems such as wandering, hoarding or inability to perform aspects of personal care


• Prepare diet conscious meals to help stabilize glycemic levels
• Monitor skin condition to avoid breakdowns with attention to foot care
• Monitor medications to ensure consistency
• Monitor blood glucose readings & keep an accurate log
• Assist client with proper insulin dosage & assist client with proper use of inhalers

Congestive Heart Failure

• Direct supervision of ADL activities with attention to reducing fatigue & SOB
• Monitor daily weight
• Monitor vital signs and assist with telehealth technology in the home
• Promote activities that conserve energy
• Ensure appropriate diet is followed with attention to salt restriction


• Direct supervision of ADL activities with attention to reducing fatigue & SOB
• Transfer assistance for people with low endurance & need to conserve energy
• Assist client with proper insulin dosage & assist client with proper use of inhalers


•    Direct supervision of ADL activities to increase independence & reduce fatigue
•    Transfer assistance for people with paralysis or partial paralysis
•    Support at mealtimes for people with swallowing difficulties or those at risk for chocking or aspiration pneumonia
•    Mobility assistance to prevent falls


• Assist with sewing & other activities requiring fine motor skills
• Assist with laundry to avoid lifting and reduce joint stress
• Monitor medication use by client especially with pain discomfort

Family Testimonials – Complex Care Situations

I am so pleased at how everything has worked out these last few months and now with a trip to the hospital and home again for my aunt and we want to pause for a moment to thank you and your team very much!

My sister and I were just recently saying to one another how fortunate we and my aunt are to have you and your constant care and effort. It is so reassuring!

We know this latest event must have been very scary for all involved – my aunt the most – and it is so great we can all celebrate a return home for her today. Please thank all of the caregivers and nurses!!!!

Thank you Patrick!

Janet B. - San Francisco, CA
Professional, knowledgeable, responsive and caring. Hands down over and above any and all expectations. Available at all times for all questions! I have been so impressed and grateful for the help and guidance through some very difficult times!!
Nancy O. - Plymouth, MA
I am writing to thank you for the wonderful service you have provided for my parents. We greatly appreciate that you were able to provide customized care and rearrange schedules to meet my parents changing needs. We met you in a time of need for my family and you have offered support in every regard and allowed us to feel comfortable and confident that my folks needs were being met. You have gone above and beyond and we are deeply grateful.
Greg D. - South Portland, ME

Offices in Plymouth & Falmouth

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