Care Planning: The Road Map for Individualized Resident Care Kathy - PDF document

6/15/2018 Care Planning: The Road Map for Individualized Resident Care Kathy Sanders RN, RAC-CT, DNS-CT Sanders Consulting kathy@mdshelp.com 1 Disclaimer The Care Planning: Care Planning: The Road Map for Individualized Resident Care was developed as an educational program and reference for long-term care staff. To the best of our knowledge, it reflects current federal regulations and practices. However, it cannot be considered absolute and universal. The information contained in this workshop must be considered in light of the individual organization and state regulations. The authors disclaim responsibility for any adverse effect resulting directly or indirectly from the use of the workshop material, from any undetected errors, and from the user’s misunderstanding of the material. 2 Disclaimer Continued The authors put forth every effort to ensure that the content, including any policies, recommendations, and sample documents used in this training, were in agreement with current federal regulations, recommendations, and practices at the time of publication. The information provided in this training is subject to revision based on future updates and clarifications by CMS. 3 1

6/15/2018 Objectives The learner will be able to: • Describe the relationship between the RAI process, the care plan, and quality resident care • Discuss the relationship between the MDS, CAT’s, CAA’s and the care plan • Discus the role of critical thinking in the care planning process • List the components of an effective care plan • Define “interim care plan” • Give an example of an “I Format” care plan 4 Introduction The care planning requirements reflect the facility’s responsibilities to provide necessary care planning that results in care and services to attain or maintain the highest practicable physical, mental and psychosocial well-being for the resident. 5 Introduction Care planning fosters quality resident care by: • Facilitating communication among the Interdisciplinary Team (IDT) members • Providing staff with consistent information about the resident's problems, strengths, and needs • Instructing staff on how to meet the individual resident’s needs • Allowing updates and revisions according to the resident's changing needs • Including the resident’s voice and choice 6 2

6/15/2018 RAI Process Design Assessment (MDS 3.0) Decision Making (CAAs) Care Plan Development Care Plan Implementation Evaluation 7 Care Plan Development The care plan must aim to address the following: Prevent avoidable decline • Use an interdisciplinary • • Manage risk factors approach Address resident strengths • Involve the resident, • • Evaluate treatment family, or other resident objectives and care representative outcomes • Involve direct care staff in Respect the resident’s • the process right to refuse treatment • Use current standards of Offer alternative • practice treatments • CMS’s RAI Version 3.0 Manual, Chapter 4 8 Resident Assessment Instrument (RAI) Process The RAI Process consists of three basic components: • The Minimum Data Set (MDS) Version 3.0 • The Care Area Assessment (CAA) Process • The RAI Utilization Guidelines 9 3

6/15/2018 Links in the(RAI) Process The critical link between the MDS 3.0 and care planning results from two key areas: • Care Area Assessments • Care Area Triggers 10 What are the CATs? • Care Area Triggers or CATs are the triggering mechanisms of the MDS 3.0 • They are specific response options that serve as indicators of the twenty care areas that affect nursing home residents. • When information entered into the MDS 3.0 triggers a response, additional assessment and care area review is required. 11 What are the CAA’s? The Care Area Assessment (CAA) Process is guided by professional standards of practice and regulatory requirements. It is designed to guide the IDT through the comprehensive assessment of a resident’s functional status. 12 4

6/15/2018 CAAs There are 20 CAAs Delirium • Cognitive Loss/Dementia • • Visual Function • Communication Activity of Daily Living (ADL) • Pain • Functional/Rehabilitation • Return to Community Potential Referral • Urinary Incontinence and • Mood Sate Indwelling catheter Activities • • Psychosocial Well-Being • Nutritional Status Behavioral Symptoms • Dehydration/Fluid • • Falls Maintenance Feeding Tubes • Pressure Ulcer • Dental Care • • Physical Restraints Psychotropic Medication Use • 13 Using the CAAs • CAAs are required for the following comprehensive clinical assessments Admission Assessments • Annual Assessments • • Significant Change in Status Assessments Significant Correction of Prior Full Assessments • • CAAs may also be used at any time, not just when an assessment is due, to provide in-depth review of a care area condition to assist with development of a care plan 14 Critical Thinking The Bridge from Assessment to Care Planning • Collecting assessment data in itself is not sufficient to develop an effective plan of care • Understanding the relevance of the data to the specific resident’s situation is essential 15 5

6/15/2018 Critical Thinking The Bridge from Assessment to Car Planning • Definition of Critical Thinking: The intellectual process of reasoning, of logically analyzing all available data • Purpose of Critical Thinking: To explore a situation, phenomenon, question, or problem to arrive at a hypothesis or conclusions about it that integrates all available information and can, therefore, be convincingly justified (Kurfiss, 1988) 16 Critical Thinking Critical thinking includes: • Integrating all available information and eliminating irrelevant information • Using reasoning processes • Exploring a situation to arrive at a hypothesis • Logically analyzing data • Arriving at reasonable conclusions about the resident’s status, needs, problems, and strengths in order to create an effective plan of care 17 Critical Thinking • The care plan is driven not only by identified resident issues and/or conditions but also by a resident’s unique characteristics, strengths, and needs. • A care plan that is based on a thorough assessment, effective clinical decision making, and is compatible with current standards of clinical practice can provide a strong basis for optimal approaches to quality of care and quality of life needs of individual residents. MDS 3.0 Manual pages 4-9, 10 18 6

6/15/2018 Critical Thinking • A well developed and executed assessment and care plan: • Looks at each resident as a whole human being with unique characteristics and strengths; • Views the resident in distinct functional areas for the purpose of gaining knowledge about the resident’s functional status (MDS ); • Gives the IDT a common understanding of the resident; • Re-groups the information gathered to identify possible issues and/or conditions that the resident may have (i.e., triggers); • Provides additional clarity of potential issues and/or conditions by looking at possible causes and risks (CAA process); 19 Critical Thinking • Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and follow-up; • Reflects the resident/resident representative input and goals for health care; • Provides information regarding how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident’s highest practicable level of wellbeing (care planning); • Re-evaluates the resident’s status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary. MDS 3.0 Manual pages 4-10 20 Critical Thinking • Following the decision to address a triggered condition on the care plan, key staff or the IDT should subsequently: • Review and revise the current care plan, as needed; and • Communicate with the resident or his/her family or representative regarding the resident, care plans, and their wishes. MDS 3.0 Manual pages 4-10 21 7