Car e Planning: T HE R E SIDE NT S VOICE Sande r s - PDF document

2/21/2017 Car e Planning: T HE R E SIDE NT ’S VOICE Sande r s Consulting Kathy Sande r s R N, R AC-CT , C-NE 1 Disc la ime r T he Ca re Pla nning : T he Re side nt’ s Vo ic e wa s de ve lo pe d a s a n e duc a tio na l pro g ra m a nd re fe re nc e fo r lo ng -te rm c a re sta ff. T o the b e st o f o ur kno wle dg e , it re fle c ts c urre nt fe de ra l re g ula tio ns a nd pra c tic e s. Ho we ve r, it c a nno t b e c o nside re d a b so lute a nd unive rsa l. T he info rma tio n c o nta ine d in this wo rksho p must b e c o nside re d in lig ht o f the individua l o rg a niza tio n a nd sta te re g ula tio ns. T he a utho rs disc la im re spo nsib ility fo r a ny a dve rse e ffe c t re sulting dire c tly o r indire c tly fro m the use o f the wo rksho p ma te ria l, fro m a ny unde te c te d e rro rs, a nd fro m the use r’ s misunde rsta nding o f the ma te ria l. 2 1

2/21/2017 Disc la ime r Co ntinue d T he a utho rs put fo rth e ve ry e ffo rt to e nsure tha t the c o nte nt, inc luding a ny po lic ie s, re c o mme nda tio ns, a nd sa mple do c ume nts use d in this tra ining , we re in a g re e me nt with c urre nt fe de ra l re g ula tio ns, re c o mme nda tio ns, a nd pra c tic e s a t the time o f pub lic a tio n. T he info rma tio n pro vide d in this tra ining is sub je c t to re visio n b a se d o n future upda te s a nd c la rific a tio ns b y CMS. 3 Ob je c tive s T he le a rne r will b e a b le to : • De sc rib e the re la tio nship b e twe e n the RAI pro c e ss, the c a re pla n, a nd q ua lity re side nt c a re • Disc uss the re la tio nship b e twe e n the MDS, CAT ’ s, CAA’ s a nd the c a re pla n • Disc us the ro le o f c ritic a l thinking in the c a re pla nning pro c e ss • L ist the c o mpo ne nts o f a n e ffe c tive c a re pla n • De fine “inte rim c a re pla n” • Give a n e xa mple o f a n “IF o rma t” c a re pla n 4 2

2/21/2017 Who se Go a ls Are T he y Anywa y? I re me mbe r o nc e in my c are e r thinking to myse lf, “I sho uld pro bably go ask the re side nt what she thinks o f this c are plan go al that I se t fo r he r,” but the n de c iding I didn’t have time . S to p and think fo r a minute – Who se go als are the y? Who se c are plan is it? Who se life is it? Re me mbe r: What happe ns to a re side nt always has be e n and always will be abo ut the irlife . - Car me n Bowman, F o rme rCo lo rado De partme nt o f H e alth S urve yo r 5 I ntro duc tio n T he c a re pla nning re q uire me nts re fle c t the fa c ility’ s re spo nsib ilitie s to pro vide ne c e ssa ry c a re pla nning tha t re sults in c a re a nd se rvic e s to a tta in o r ma inta in the hig he st pra c tic a b le physic a l, me nta l a nd psyc ho so c ia l we ll-b e ing fo r the re side nt. 6 3

2/21/2017 I ntro duc tio n Ca re pla nning fo ste rs q ua lity re side nt c a re b y: • F a c ilita ting c o mmunic a tio n a mo ng the I nte rdisc iplina ry T e a m (I DT ) me mb e rs • Pro viding sta ff with c o nsiste nt info rma tio n a b o ut the re side nt's pro b le ms, stre ng ths, a nd ne e ds • I nstruc ting sta ff o n ho w to me e t the individua l re side nt’ s ne e ds • Allo wing upda te s a nd re visio ns a c c o rding to the re side nt's c ha ng ing ne e ds • Inc luding the r e side nt’s voic e and c hoic e 7 Ca re Pla n De ve lo pme nt T he c a re pla n must a im to a ddre ss the fo llo wing : • • Pre ve nt a vo ida b le de c line Use a n inte rdisc iplina ry • Ma na g e risk fa c to rs a ppro a c h • Addre ss re side nt stre ng ths • I nvo lve the re side nt, • E va lua te tre a tme nt fa mily, o r o the r re side nt o b je c tive s a nd c a re re pre se nta tive • o utc o me s I nvo lve dire c t c a re sta ff in • Re spe c t the re side nt’ s the pro c e ss rig ht to re fuse tre a tme nt • Use c urre nt sta nda rds o f • Offe r a lte rna tive pra c tic e tre a tme nts • CMS’ s RAI Ve rsio n 3.0 Ma nua l, Cha pte r 4 8 4

2/21/2017 Re side nt Asse ssme nt I nstrume nt (RAI ) Pro c e ss T he RAIPro c e ss c o nsists o f thre e b a sic c o mpo ne nts: • T he Minimum Da ta Se t (MDS) Ve rsio n 3.0 • T he Ca re Are a Asse ssme nt (CAA) Pro c e ss • T he RAIUtiliza tio n Guide line s 9 L inks in the (RAI ) Pro c e ss T he c ritic a l link b e twe e n the MDS 3.0 a nd c a re pla nning re sults fro m two ke y a re a s: • Ca re Are a Asse ssme nts • Ca re Are a T rig g e rs 10 5

2/21/2017 Wha t a re the CAT s? • Ca re Are a T rig g e rs o r CAT s a re the trig g e ring me c ha nisms o f the MDS 3.0 • T he y a re spe c ific re spo nse o ptio ns tha t se rve a s indic a to rs o f the twe nty c a re a re a s tha t a ffe c t nursing ho me re side nts. • Whe n info rma tio n e nte re d into the MDS 3.0 trig g e rs a re spo nse , a dditio na l a sse ssme nt a nd c a re a re a re vie w is re q uire d. 11 Wha t a re the CAA’ s? T he Ca re Are a Asse ssme nt (CAA) Pro c e ss is g uide d b y pro fe ssio na l sta nda rds o f pra c tic e a nd re g ula to ry re q uire me nts. I t is de sig ne d to g uide the I DT thro ug h the c o mpre he nsive a sse ssme nt o f a re side nt’ s func tio na l sta tus. 12 6

2/21/2017 CAAs T he re a re 20 CAAs • De lirium • Co g nitive L o ss/ De me ntia • Visua l F unc tio n • Co mmunic a tio n • Ac tivity o f Da ily L iving (ADL ) • Pa in F unc tio na l/ Re ha b ilita tio n • Re turn to Co mmunity Po te ntia l Re fe rra l • Urina ry I nc o ntine nc e a nd • Mo o d Sa te I ndwe lling c a the te r • Ac tivitie s • Psyc ho so c ia l We ll-Be ing • Nutritio na l Sta tus • Be ha vio ra l Sympto ms • De hydra tio n/ F luid • F a lls Ma inte na nc e • F e e ding T ub e s • Pre ssure Ulc e r • De nta l Ca re • Physic a l Re stra ints • Psyc ho tro pic Me dic a tio n Use 13 Using the CAAs • CAAs a re re q uire d fo r the fo llo wing c o mpre he nsive c linic a l a sse ssme nts • Admissio n Asse ssme nts • Annua l Asse ssme nts • Sig nific a nt Cha ng e in Sta tus Asse ssme nts • Sig nific a nt Co rre c tio n o f Prio r F ull Asse ssme nts • CAAs ma y a lso b e use d a t a ny time , no t just whe n a n a sse ssme nt is due , to pro vide in-de pth re vie w o f a c a re a re a c o nditio n to a ssist with de ve lo pme nt o f a c a re pla n 14 7

2/21/2017 RAI Pro c e ss De sig n Assessment (MDS 3.0) Decision Making (CAAs) Care Plan Development Care Plan Implementation Evaluation 15 Critic a l T hinking T he Bridg e fro m Asse ssme nt to Ca re Pla nning • Co lle c ting a sse ssme nt da ta in itse lf is no t suffic ie nt to de ve lo p a n e ffe c tive pla n o f c a re • Unde rsta nding the re le va nc e o f the da ta to the spe c ific re side nt’ s situa tio n is e sse ntia l 16 8

2/21/2017 Critic a l T hinking T he Bridg e fro m Asse ssme nt to Ca re Pla nning • T he inte lle c tua l De finition of Cr itic al T hinking: pro c e ss o f re a so ning , o f lo g ic a lly a na lyzing a ll a va ila b le da ta • hinking: T o e xplo re a situa tio n, Pur pose of Cr itic al T phe no me no n, q ue stio n, o r pro b le m to a rrive a t a hypo the sis o r c o nc lusio ns a b o ut it tha t inte g ra te s a ll a va ila b le info rma tio n a nd c a n, the re fo re , b e c o nvinc ing ly justifie d (K urfiss, 1988) 17 Critic a l T hinking Critic a l thinking inc lude s: • I nte g ra ting a ll a va ila b le info rma tio n a nd e limina ting irre le va nt info rma tio n • Using re a so ning pro c e sse s • E xplo ring a situa tio n to a rrive a t a hypo the sis • L o g ic a lly a na lyzing da ta • Arriving a t re a so na b le c o nc lusio ns a b o ut the re side nt’ s sta tus, ne e ds, pro b le ms, a nd stre ng ths in o rde r to c re a te a n e ffe c tive pla n o f c a re 18 9

2/21/2017 Critic a l T hinking • T he c a re pla n is drive n no t o nly b y ide ntifie d re side nt issue s a nd/ o r c o nditio ns b ut a lso b y a re side nt’ s uniq ue c ha ra c te ristic s, stre ng ths, a nd ne e ds. • A c a re pla n tha t is b a se d o n a tho ro ug h a sse ssme nt, e ffe c tive c linic a l de c isio n ma king , a nd is c o mpa tib le with c urre nt sta nda rds o f c linic a l pra c tic e c a n pro vide a stro ng b a sis fo r o ptima l a ppro a c he s to q ua lity o f c a re a nd q ua lity o f life ne e ds o f individua l re side nts. MDS 3.0 Ma nua l pa g e s 4-9, 10 19 Critic a l T hinking • A we ll de ve lo pe d a nd e xe c ute d a sse ssme nt a nd c a re pla n: • L o o ks a t e a c h re side nt a s a who le huma n b e ing with uniq ue c ha ra c te ristic s a nd stre ng ths; • Vie ws the re side nt in distinc t func tio na l a re a s fo r the purpo se o f g a ining kno wle dg e a b o ut the re side nt’ s func tio na l sta tus (MDS); 20 10