Your care plan is a living document

Once a care plan is approved, services begin according to the schedule established in the plan. But a care plan is not permanent. It can — and should — be updated as needs change.

Many families are surprised to learn that CLSC services are not automatically adjusted as a person's health declines. Families often need to proactively request reassessments when they notice things have changed.

Your care coordinator

A care coordinator is assigned to manage your case within the CLSC system. They are your primary contact for:

• Questions about services
• Scheduling concerns
• Requesting changes to the care plan
• Coordinating between multiple health professionals
• Reporting problems with service delivery

Keep the name and phone number of your care coordinator somewhere accessible. When in doubt, contact them first.

What your care plan should include

Ask for a written copy of the care plan. It should specify:

• The services approved (type, frequency, duration)
• The professionals responsible for each service
• The goals of the care plan
• The review timeline (when the plan will next be formally reviewed)

If you did not receive a written plan or cannot locate one, ask your care coordinator for a copy.

Your rights

As a user of the Quebec health system, you have the right to:

• Be informed of the services you are entitled to and the reasons for any decisions
• Participate in decisions affecting your care
• Be treated with dignity and respect at all times
• File a complaint if you are dissatisfied with services or decisions
• Request a review of any care plan decision

These rights apply equally to family caregivers acting on behalf of a person who cannot advocate for themselves.

When to contact your CLSC

Contact your care coordinator (or the CLSC directly) in the following situations:

• The person's health has changed significantly (new diagnosis, hospitalization, surgery)
• Daily activities have become more difficult or unsafe
• There has been a fall or a series of falls
• The primary caregiver's situation has changed (illness, returning to work, moving)
• You are dissatisfied with the level of care being provided
• A service has been reduced or cancelled without explanation

What if the care plan is not sufficient?

If you feel the current level of service is not meeting the person's needs, you can request a reassessment. Document specific examples of what has changed — this is far more persuasive than a general statement that things have gotten worse.

The Knowledge Centre's Increasing Hours and Documentation sections explain how to prepare for this conversation effectively.