AD Waiver Care Plan Example for Home Support

A care plan is where a family’s everyday reality becomes a clear plan for support. An AD Waiver care plan example can help you see how needs such as bathing, meals, medication reminders, safety, and caregiver relief may be written down in a way that supports a loved one’s goal of remaining at home.

For Indiana families using the Aged and Disabled Waiver, the plan is more than paperwork. It helps make sure services fit the person, their home, and the people already helping them. A thoughtful plan protects dignity while giving caregivers practical direction and helping families understand what support may be available.

What an AD Waiver care plan is meant to do

An AD Waiver care plan, sometimes called a person-centered service plan, describes the help an individual needs to live as safely and independently as possible. It is built around the person’s preferences, strengths, health needs, living situation, and personal goals.

The plan may identify services such as attendant care, homemaker support, home-delivered meals, transportation, adult day services, personal emergency response systems, or other approved supports. The exact services and hours depend on eligibility, assessed needs, program rules, and the approval process. A care plan should never be copied word for word from someone else’s situation. It must reflect the individual’s real routines and priorities.

For example, one person may need hands-on help getting dressed and preparing meals each morning. Another may be physically able to complete personal care but need supervision due to memory loss, regular reminders, and someone nearby to reduce the risk of falls. Both may need in-home support, but their plans should look different.

AD Waiver care plan example: a realistic home routine

The following sample is fictional. It is designed to show the level of detail that can make a care plan useful for the individual, family caregiver, service coordinator, and care provider.

Individual profile

Name: Maria S., age 78 Living situation: Lives in her own Indiana home with her daughter, Elena, who provides much of her care. Primary concerns: Arthritis, limited mobility following a fall, diabetes, and difficulty remembering whether she has eaten or taken prescribed medications. Strengths and preferences: Maria enjoys choosing her clothes, listening to church music, talking with neighbours, and having breakfast at her kitchen table. She wants to stay in her home and prefers that Elena remain involved in her care.

Maria’s goals

Maria’s care plan may identify goals that are specific, respectful, and connected to her daily life:

1. Maria will remain safely in her home with the support needed for personal care, meals, mobility, and household routines.

2. Maria will maintain her usual morning routine and make choices about her clothing, meals, and activities whenever possible.

3. Maria will reduce fall risks by receiving assistance with transfers, bathing, and safe movement around the home.

4. Elena will receive dependable support so she can rest, work, and continue caring for her mother without becoming overwhelmed.

These goals keep the focus on quality of life, not just tasks. Help with a shower is not simply a service unit. It allows Maria to feel clean, confident, and comfortable in her own home. Relief for Elena is not an extra - it can be essential to keeping the home care arrangement stable.

Suggested support schedule

Morning support, Monday through Friday, 7:30 a.m. to 10:30 a.m. A trained caregiver assists Maria with getting out of bed, walking safely to the bathroom, bathing, grooming, dressing, and changing clothing as needed. The caregiver prepares a diabetes-conscious breakfast based on the family’s instructions and encourages fluids. The caregiver provides medication reminders and observes for concerns such as dizziness, unusual confusion, poor appetite, swelling, or changes in mobility. Any concerns are documented and reported according to the care provider’s procedures.

Midday support, three days each week, 12:00 p.m. to 2:00 p.m. The caregiver prepares or heats a lunch, completes light housekeeping related to Maria’s care, changes bed linens when needed, and helps Maria complete safe, preferred activities such as folding towels, listening to music, or sitting outside. The caregiver also checks walking paths for clutter and makes sure commonly used items are within reach.

Family caregiver support. Elena remains involved with appointments, grocery shopping, evening meals, and decisions about Maria’s care. If approved through the applicable program arrangement, a family member or trusted friend may be able to serve as a paid caregiver. This can give families a more sustainable way to provide familiar, consistent support while receiving training, employment structure, and administrative guidance.

Safety plan

Maria’s plan should be clear about what keeps her safe without making her feel restricted. It may state that she uses a walker for all walking, requires standby or hands-on assistance for transfers depending on the day, and should not use the shower without support. Throw rugs are removed, pathways are kept clear, and a phone or emergency alert device remains accessible.

The plan can also state what to do when a concern arises. For example, if Maria falls, experiences chest pain, has sudden weakness, or shows a major change in mental status, the caregiver follows emergency procedures and contacts emergency services when appropriate. For non-emergency changes, such as a new skin concern, repeated missed meals, or increasing fatigue, the caregiver informs the designated family contact and supervisor promptly.

Details that make a plan more helpful

A vague plan can leave caregivers guessing. Saying that someone needs help with activities of daily living does not explain whether they need a reminder, supervision, set-up assistance, or full physical assistance. Those differences matter for safety, staffing, and the individual’s independence.

Try to include the person’s normal schedule. Note when they prefer to wake up, whether they eat small meals, what foods they avoid, how they communicate discomfort, and what helps them feel at ease. If a person becomes anxious around unfamiliar people, that belongs in the plan. If they value privacy during personal care, write down how caregivers can offer support respectfully.

The plan should also distinguish between non-medical support and skilled medical care. A caregiver may assist with routine activities, observe and report changes, and provide medication reminders when permitted. Nursing tasks, medication administration, wound care, and other clinical services may require different authorisation or a qualified professional. When in doubt, ask the service coordinator or care provider what is permitted and how the need should be documented.

Questions to bring to the planning meeting

Families do not need to arrive with every answer. Still, a few practical questions can help shape a plan that works at home:

• What tasks are becoming difficult, unsafe, or exhausting for the individual and family?

• At what times of day is help most needed?

• What can the individual still do independently or with a little encouragement?

• What routines, cultural preferences, foods, hobbies, or privacy needs should caregivers respect?

• Who should be contacted if there is a change in condition or an emergency?

• Can a family member or friend be considered as the caregiver under the approved arrangement?

It is also wise to talk honestly about caregiver capacity. Many relatives begin by providing care around the clock because they love the person, not because the schedule is manageable. A care plan that recognizes family responsibilities, work schedules, sleep needs, and burnout risk can prevent a crisis later.

How to use this example without treating it as a template

Use this AD Waiver care plan example as a conversation starter, not a document to submit unchanged. Write down a typical day for your loved one: what happens in the morning, where help is needed, what has become risky, and which moments bring comfort or frustration. Bring those notes to the assessment or planning meeting.

Needs can change after a hospital stay, a fall, a new diagnosis, or a decline in memory. A good plan can be reviewed and adjusted when circumstances change. Families should speak up when approved hours no longer match the level of help required, when a task is missing from the plan, or when the current schedule is no longer safe.

Harmony Care understands that dependable in-home support must feel personal as well as organized. The right plan gives caregivers clear guidance while allowing the individual receiving care to remain at the center of every decision.

The most useful care plan is one that sounds like the person it serves: their home, their routine, their preferences, and the support that helps them live each day with greater comfort, respect, and peace of mind.