Transparency
What a care plan actually looks like
“Care plan” shouldn’t be a mystery box. Here’s how ours work: who writes them, what’s inside, how families stay informed, and how the billing maps to the plan, including a realistic example you can read line by line.
How every plan is built
- A nurse assesses in person. The Alberta Maple Care Assessment (our free first visit) isn’t a sales call: a registered nurse looks at health needs, the home itself, routines, and what the family is already carrying.
- The plan is written, not implied. Goals, tasks, schedule, and who does what, including what stays with family and what stays with Assisted Living Alberta clinical visits where those exist.
- Caregivers are matched, then kept. We match for skills, language, and personality. Consistency is the rule, because a rotating cast of strangers isn’t care.
- The nurse stays accountable. Supervision continues after care starts: the plan is reviewed and adjusted as needs change — up, down, or different.
Realistic examples
These are representative examples, not real clients: composites of common situations, written the way our plans are actually written.
“M.”, 84 — home after a hip fracture
Situation: Discharged after surgical repair of a hip fracture. Lives alone in a two-storey home; daughter nearby but working full-time. Assisted Living Alberta home care provides wound checks twice weekly. Goals: recover safely, stay home, protect the daughter from burning out.
The written plan:
| When | What happens | Who |
|---|---|---|
| Mon–Sat mornings (2h) | Personal care: shower with transfer support, dressing, breakfast, medication reminder, prescribed hip exercises | Consistent caregiver pair |
| Tue & Fri (add 1h) | Homemaking: laundry, bathroom and kitchen reset, meal prep for the freezer | Same caregivers |
| Twice weekly | Wound care and clinical checks | Assisted Living Alberta home care (coordinated, not duplicated) |
| Sunday | Family day: no scheduled visits; on-call line available | Daughter, backed by us |
| Every 2 weeks, then monthly | Nurse supervision visit: progress vs goals, falls risk review, plan adjustments | Registered nurse |
Also in the plan: home-safety fixes completed in week one (bathroom grab bars, night lighting, stair rail check) · escalation contacts and “call the nurse if” triggers written down for everyone · a target to step down to three mornings a week as strength returns — plans should shrink when they can, not just grow.
How the family stays informed: visit notes after every shift, a weekly summary to the daughter, and the nurse’s direct recommendation at every review, in plain language, including “you need less care now.”
How billing maps: every invoice line matches a plan line. Where CDHCI funding is approved, those hours are billed straight to Alberta Blue Cross; anything private-pay is visible and predictable. No mystery hours, ever.
Three more — different lives, same skeleton. Open any of them and read it line by line:
“R.”, 79 — moderate Alzheimer’s, hardest in the late afternoon
Situation: Moderate Alzheimer’s; lives with his wife, also in her late 70s, in their bungalow. Wandering has started, and the late afternoons — the sundowning hours — are when the day unravels; his wife is exhausted but certain of one thing: he is not going to a facility. The Assisted Living Alberta case manager’s assessment is done, and the goals are simple — keep his days familiar, give her real rest, and stay ahead of the nights.
The written plan:
| When | What happens | Who |
|---|---|---|
| Mon–Sat mornings (2h) | Personal care anchored to routine: same time, same order — wash, dress, breakfast, medication reminders. With dementia, the sequence itself is the care | Consistent caregiver pair — the same two faces every visit; unfamiliar faces raise distress |
| Mon, Wed, Fri, 3–6 pm | Sundowning window covered: a walk while the light is still good, music from his era, one job he can finish — folding towels, drying dishes. His wife goes off duty in her own house | Same caregivers (respite block) |
| Thursday, 2–8 pm | Protected respite: his wife leaves the house — errands, her sister’s, anything that isn’t caregiving — while the caregiver carries the whole sundowning stretch, supper, and the evening settle | Same caregivers (respite block) |
| Every 2 weeks | Nurse supervision visit: reviews the behaviour log the caregivers keep (wandering episodes, triggers, sleep), adjusts the plan, and updates the Assisted Living Alberta case manager — coordinated, not duplicated | Registered nurse |
| Sunday | Family day: no scheduled visits; on-call line available | The couple, backed by us |
Also in the plan: door chimes on both exits and an ID bracelet with the on-call number, recommended and arranged with the family in week one · the night question answered in writing before it’s urgent — if wandering moves into the dark hours, the next step is overnight care at home (visits are a minimum of three hours), not a facility · a review at eight weeks with a real target: if the sundowning window settles, the afternoon block shortens — plans should shrink when they can.
How the family stays informed: a plain-language note after every visit, the behaviour log open to his wife anytime, and the nurse’s honest read at each review — settling, holding, or building — so nothing about her husband ever surprises her.
How billing maps: every invoice line matches a plan line. Where CDHCI hours are approved, the personal care and respite blocks map to them and bill straight to Alberta Blue Cross, with the family’s share visible beside them; nurse supervision is never a CDHCI item — it’s a private-pay line they can see coming.
“S.”, 81 — a plan built around her daughter’s calendar
Situation: Two years after a stroke left her with left-side weakness, S. needs steady help with transfers, bathing, and meals; her daughter lives with her and has carried nearly every hour of care since, around a full-time job. Her Assisted Living Alberta file is quiet — no ongoing clinical visits needed right now. In this family, the plan’s first job is the daughter: keep S. safe and content at home, and give her daughter back her office days, her choir night, and a full night’s sleep.
The written plan:
| When | What happens | Who |
|---|---|---|
| Tue & Thu, 8:00am–2:00pm (her daughter’s office days) | Respite block: morning transfer and shower, dressing, breakfast and lunch, medication reminders, kitchen reset, company for the afternoon — S.’s personal care folds into the same visit, nothing extra to arrange | Consistent caregiver pair |
| Wednesday, 5:00–9:00pm (choir night) | Evening respite: supper together, evening routine, settled safely before the daughter gets home | Same caregivers |
| Saturday, 9:00am–1:00pm | The daughter’s morning fully off — out of the house, phone optional; caregiver covers the whole morning routine plus a walk or visit S. enjoys | Same caregivers |
| One night a month, 10:00pm–6:00am | Overnight respite (overnight visits are a minimum of three hours — this is a full night): repositioning, bathroom transfers, breakfast started, so the daughter sleeps properly — extra morning hours are bookable when she’s away for the night | One of the same caregivers |
| Monthly | Nurse supervision visit: S.’s mobility, skin, and swallowing reviewed — and an honest look at how the daughter is holding up — sleep, energy, whether the time off is actually being taken | Registered nurse |
| All other times | Mother and daughter’s own rhythm: no scheduled visits; on-call line available, extra respite bookable when a hard week comes | The daughter, backed by us |
Also in the plan: transfer safety arranged in week one (bath bench and grab bar, a transfer pole beside the bed, clear approaches on her weaker left side) · escalation triggers written down for everyone — sudden new weakness or slurred speech means call 911 first, then the on-call line, and “I can’t do this week” from the daughter counts as a trigger too · a three-month review target that asks whether the daughter is recovering — sleeping through, back at choir, actually leaving the house on Saturdays — not just whether S. is stable; blocks move until the answer is yes, and shrink later if it stays yes.
How the family stays informed: visit notes after every shift, plus a one-glance weekly summary written for the daughter — what happened, what changed, what to watch — so her hours off aren’t spent wondering.
How billing maps: every invoice line matches a plan line — where CDHCI respite hours are approved, those blocks bill straight to Alberta Blue Cross with the family’s share of each hour shown plainly, and any private-pay hours are just as visible and predictable. No mystery hours, ever.
“J.”, 88 — independent at home, and staying that way
Situation: Widowed, sharp, and proudly independent in her own apartment; both children live out of province. Nothing is wrong, exactly — meals have shrunk, the laundry piles up, she has stopped driving, the days run long and quiet, and there was one stumble last winter. Goals: keep her independent in her own home, put good food and good company back into the week, and give her children eyes on the quiet things.
The written plan:
| When | What happens | Who |
|---|---|---|
| Tue & Thu late morning (2h) | Meal prep and a shared lunch at the table, medication reminder, kitchen restocked and reset | One consistent caregiver — the same face every visit |
| Saturday (2h) | Drive to groceries, errands, or an appointment; laundry and a light tidy while the kettle’s on | Her caregiver |
| Sunday evening | Standing phone check-in — a real conversation, not a checklist (part of the plan’s follow-up, not a billed visit) | Her regular caregiver |
| Monthly | Nurse supervision visit: appetite, steadiness, mood, and whether the plan still fits | Registered nurse |
| All other days | Her days, her way: no scheduled visits; on-call line available | J., backed by us |
Also in the plan: small home-safety fixes recommended and arranged in week one (a grab bar by the tub, brighter bulbs in the hallway, the loose rug retired) · “call the nurse if” triggers written down — appetite slips further, another stumble, or a change the caregivers notice · a three-month review with the target that this plan stays exactly this size — it grows only if J. needs it to, and that’s the point.
How the family stays informed: a short note after every visit and a monthly nurse summary to both children — out of province, but never out of the loop.
How billing maps: every invoice line matches a plan line. a plan this light is straightforwardly private-pay — visible, predictable, no mystery hours. (CDHCI funds personal care, with homemaking only alongside it — if J.’s needs ever grow in that direction, the nurse’s monthly visit is where that conversation starts.)
Your plan will look different — that’s the point
You’ve just read four plans that share nothing but their skeleton — a recovery, a dementia afternoon, a caregiver’s calendar, a fiercely independent apartment. What never changes: a registered nurse writes it, consistent caregivers deliver it, the family can read it, and the billing matches it. Start with a free in-home visit, or take the one-minute care check first.
Care that comes home
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