Care planning moving from paper to person


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  • The MDS 3.0 has been designed toimprove the reliability, accuracy, and usefulness of the MDS.The MDS 3.0 has been designed to include the resident in the assessment process, and to use standard protocols used in other settings.
  • Federal involvement in nursing homes began with the passage of the Social Security Act in 1935. there were only public poor houses the majority of people were aged. The legislators did not want these places used to care for the elderly. Social Security Act established a public assistance program for the elderly which proliferated the growth of voluntary and proprietary nursing homes.1950, the Social Security Administration required states participating in the program to establish licensing programs, although the requirement did not specify what the standards or enforcement. 1956 were found to be substandard; staff was poorly trained or untrained and few services were provided. 1965 Medicare and Medicaid federally funded programs for nursing homes were significantly expanded; standards were uniformly put in place for nursing homes participating in the federal program.1970 and 1971 front page:fire killing more than 30 residents in Ohio, food poisoning in a Maryland home killing 36 residents, and numerous horror stories about care atrocitie1972comprehensive welfare reform funded state survey and certification activities in an effort to establish and enforce uniform standards and conditions. emphasis was on the institutional framework rather than on the resident’s care70’s and early 80’s, the Patient Care and Services Survey was born to rectify this problem. controversy over the legitimacy. having a policy was no longer enough, it had to be implemented, reviewed and revised to get results; paper compliance in the form of policy and procedure was nearing its end. Use of paper, in the form of a care plan, was the new gage for insuring resident care.The move from paper to person in determining compliance has been a long road of transitions and lessons learned... 20 years.
  • Federal involvement begins with passage of Social Security Act in 1935.
  • What one value would be most important for you if you were living in a nursing home? Why? How could the facility accommodate it?If they could not how would that impact you PMS/E?
  • Discipline Specific ProfessionalsWho will do what, when, how and where regarding the MDS completion and triggered CAA?Have you considered the setting for obtaining data collection?How will the professional team coordinate the information?Wish = desire, hope, yearningPreference = choice, preferred actionAdministration / staff: culture change… A shift in emphasis: Change existing mission and vision statement? “listen, learn, connect”.Regulators: face the same dilemma as the facility. … Black and white may now often be gray.
  • No person-centered planning process should ever be initiated without a commitment from the key stakeholders, including service systems, to honor the process, take action and follow through on agreements. Simply saying that we are being person centered does not make us person centered in our care planning efforts. Person centered care is an empathic, common-sense approach to personalize care and de-institutionalize the environment that has been present in nursing facilities for decades. The irony of mandated requirements has driven facilities into a very structured system centered approach to care in order to remain in compliance. At the same time, these mandates are now requiring flexibility and system changes to meet individual preferences by using the MDS 3.0 as the vehicle for change.
  • Small group discussion Compare and contrast.ResidentProfessionally driven, addresses what the resident needs.Individualized, but not personalizedFacility routineAbout doing things for or to residentPersonResident driven, addresses what the resident preferences related to their needs.Individualized and personalized.Resident routineAbout being with resident
  • Top DeficienciesNot giving care & services to get or keep the highest quality of life possible. Care planning hits:A complete care plan not developed to meet all of a resident's needs, with timetables and actions that can be measured.Not prepared timelyNot created with team, resident, significant others input.Not care plannedwith the care team.Check and updates missing, not timely.Professional services that follow each resident's written care plan not provided.The emphasis on quality of life is designed to give the resident, the human being, the person a say and how they choose to live out their life. Our new mission is PERSON FIRST care planning. Keeping this in mind may lessen the frustrations, anxieties, and regulatory fears we will surely face as we transition into the next generation of care planning.
  • The components of well thought out care plan remain the same. The methods and formats might be different depending on how your organization decides to get the job done.The format most of us our familiar with is the PGI method. Benefit: We are familiar with it.Negative: It lacks personalizationThere is also the emergence of the “I” format which can be seen the PGI format or the narrative.Give me one benefit, one negative?Later we will explore these options more.
  • Purpose of GoalsHow to write: SMARTInfluences on goal dateWhen where how:What to do when not met
  • These need to be based on the scope, severity and stability of the particular problem.
  • Care planning moving from paper to person

    1. 1. Care PlanningMoving From Paper to Person Presented by Debbie Ohl RN, M.Msc., PhD. Ohl and Associates Committed to Quality Care & Professional Excellence 613 Compton Road Cincinnati, Ohio 45231 December 2011
    2. 2. Evolution of Care Planning Look back to see ahead Evolving regulations Progression of care plans Debbie Ohl & Associates LTC Consultants & Educators
    3. 3. 1935 1965 Poor houses  Federal funding for Medicare/Medicaid SSA established public  Standards put in place assistance For profit homes proliferate 19701950  NH atrocities headline newspapers States required to license NH 1972 Enforcement Standards not  Welfare Reform Act funds specify state survey and certification to establish uniform1956 standards and conditions.Feds find NH substandard  Emphasis on institutional framework: CAPACITY to Debbie Ohl & Associates LTC Consultants & deliver care. Educators
    4. 4. Mid 70’s-early 80’s Outcome  Patient Care & Services Survey born Mechanical to correct emphasis on CAPACITY to process with deliver to ACTUAL delivery of care. conflicts, omissions,  Controversy over legitimacy.contradictions  Paper compliance in the form ofand animosity policies was nearing its end. among team members. 1975-76  Use of paper in the form of care plan takes center stage to insure care delivery....or at least begins the process. Debbie Ohl & Associates LTC Consultants & Educators
    5. 5. Phase 1 Paper to Person 1976-1987 EVERY resident must Result: have a plan. • Multi-disciplinary conflict EACH discipline must • Plan fragmentation have a plan. • Mass confusion Every diagnosis must • Mega citations be on plan. • Care plan content All medications must expectations have be on the plan. increasing demands. Total Confusion i.e. goal measurability.Debbie Ohl & Associates LTC Consultants &Educators
    6. 6. Phase II Interdisciplinary Team Building Quality of Care 1987 1995 MDS 2.0 OBRA creates • Assessment process framework for formalized. continuity of care. • Multi-disciplinary POC goals, conflict interventions, target • Increased dates used to site expectations for deficiencies. documentation and Emphasis on Quality care delivery. of Care. • RAPS about paper Debbie Ohl & Associates LTC Consultants & Educators not process.
    7. 7. 1987 to September 30, 2010 MDS 2.0 promoted inter-disciplinary care planning. Quality Indicators and Measures created benchmarks. RAPs provided insurance that at least the obvious was care planned. Clinical assessment skills were maturing. Quality of care the expected norm. Care plans became more resident specific.Debbie Ohl & Associates LTC Consultants &Educators
    8. 8. 2010Quality of Care ActualizedQuality of life comes toforefrontPerson Centered Careemerging as Standard ofPractice.Debbie Ohl & Associates LTC Consultants &Educators
    9. 9. Phase III Intradisciplinary Team Building Quality of Care Meets Quality of Life October 1, 2010 MDS 3.0 promotes resident driven care planning. CAA‟s demand looking beyond the obvious. CAA‟s demand staying current with best practices. Quality of care is the norm. Quality of Life comes to the forefront. HUGE paradigm and culture change shifts further advances the human condition.Debbie Ohl & Associates LTC Consultants &Educators
    10. 10. 1st Program ObjectiveDiscuss expectations of person centered careplanning. Discipline Specific Person and their Professionals Significant Others The Resident A Unique Being Administration Regulators and Staff Debbie Ohl & Associates LTC Consultants & Educators
    11. 11. Discipline Specific Professionals 1. Who will do what, when, how Person and theirand Significant Otherswhere regarding the MDS andCAAs? Wishes: desire, hopes, wants 2. Have you considered the Preference :choice, preferredsetting for obtaining data actioncollection? Maintain Individuality 3. How will the professional teamcoordinate the information? Administration and Staff Regulators Culture change… A shift in emphasis: Change existing Face the same dilemma as themission and vision statement? facility. … Black and white may now often be gray. “Listen, Learn, Connect”.Debbie Ohl & Associates LTC Consultants &Educators
    12. 12. Care Planning TeamsTeam A group of people with a common purposeDiscipline Relating to a particular field of study• Multidisciplinary Many (Isolated, all mine)• Interdisciplinary Between and among (mine, yours. Sometimes ours)• Transdisciplinary Strategy that crosses many disciplinary boundaries to create a holistic approach Debbie Ohl & Associates LTC Consultants & Educators ours) (Integrated,
    13. 13. “ Person-centered planningbegins when people decide to listen carefully and inways that can strengthen the voice of people who have been or are at risk of being silenced. ” John OBrien A Little Book about Person Centered Planning
    14. 14.  Person-centered planning was “invented” in an effort to offer people who request and receive human services the opportunity to describe and define the characteristics and conditions of life that represent for them a desirable present and future. It was “invented” in an effort to offer people who deliver those services an opportunity to learn and to grow alongside the person who is at the core of the planning process.
    15. 15. The FactsPerson-centered care is an idealistic approachto resident care that became common around1985.It was designed to allow people withdevelopmental disabilities to have a voice intheir lives and to facilitate self determination.By the late 1990‟s the concept had filtered intoother areas of health care.Debbie Ohl & Associates LTC Consultants & Educators
    16. 16.  Person-centeredness is about intentionally being with people. It demands a personal commitment to engaging conscious awareness and self-reflection about the relationship between what we are thinking, feeling and actually doing …… Not everyone needs or benefits from a person- centered planning process… Essential lifestyles plans are developed through a process of asking and listening. The best essential lifestyle plans reflect the balance between competing desires, needs, choice and safety ……… It is critically important to remember that a plan is not an outcome.
    17. 17. How does person centered care differ from resident centered care?Debbie Ohl & Associates LTC Consultants &Educators
    18. 18. Person Centered v. ResidentCenteredPerson Centered Resident CenteredStandard of Practice Obsolete Resident driven  Professionally driven Addresses resident  Addresses what the preferences related to resident needs. their needs.  Individualized, but not Individualized and personalized personalized.  Facility routine Resident routine  About doing things for About being with or to resident residentDebbie Ohl & Associates LTC Consultants &Educators
    19. 19. Quality of LifeQuality … Degree of excellence or worth Life… A manner or way of existing Autonomy… Self-governance, self- sufficiencyRAI… The path to improvement.
    20. 20. Our New Mission isPERSON FIRST care planningKeeping this in mind may lessen thefrustrations, anxieties, and regulatoryfears we will surely face as we transitioninto the next generation of care planning.Debbie Ohl & Associates LTC Consultants &Educators
    21. 21. Care Plan Formats1. Common Plan: Problem Goal Intervention The format most of us our familiar with2. I Plan Typically reads like a book or changes language content of PGI plan Often written in 1st person even when person cannot speak for self.3. Suggested format: PNS R/T R/I R/C PCP …which means? Debbie Ohl & Associates LTC Consultants & Educators
    22. 22. Which means?PNS : Problem Need StrengthsR/T : Related toR/I : Resulting InR/C: Risk / ComplicationsDebbie Ohl & Associates LTC Consultants &Educators
    23. 23. 2nd Program ObjectiveIdentify the seven components of the care plan and onekey factor of each as it relates to RAI expectations. 7 5 3 Debbie Ohl & Associates LTC Consultants & 4 Educators
    24. 24. 1st Components of the Care Plan Incorporate PNS R/T R/I R/C PCP PNS Problem, Need, Strengths (& preferences) R/T Related to R/I Resulting in R/C Risk, Complications PCP Physical, Cognitive, PsychosocialDebbie Ohl & Associates LTC Consultants &Educators
    25. 25. Care Plan with Pain as the Root Problem Components of Pain Care Plan: Analgesia, Quality of Life, Ability to Function PROBLEM/NEED GOAL(S) Target APPROACHES/ Res What does the Date INTERVENTIONS Disc /STRENGTH resident want?Problem: Description of 1. Resolve and Medication planpain: type, source, eliminate thelocation, intensity issue if possible Who can do What 2. Pain Relief / WhenRelated to: why pain Control Where How often.Resulting in/ creating 3. Quality of Life -/impacting: affect on What can youfunctional status PCP make better? - What is the best you can expect?Risks / complication(from pain and med used)Strengths/Wishes:
    26. 26. Care Plan ContentSpecific General Person centered  Functional status maintaining and  Rehab and restorative improving quality  Health maintenance of life.  Medication  Daily care needs  Discharge potential Debbie Ohl & Associates LTC Consultants & Educators
    27. 27. Priority Plans1. Unstable health 6. Wounds, pressure conditions. ulcers.2. Pain management. 7. Medicare RUGs3. New areas of risk: falls, (reason for coverage) skin, dehydration, etc. skilling services.4. New problems requiring 8. Acute problems use of psychoactive * Falls medication to correct or * New pressure sores control. * Unplanned weight loss5. Medications with high * Unplanned weight risk for side effects, or gain adverse Associates LTC Consultants & drug reactions. * Elopement Debbie Ohl & Educators * Resident to resident abuse,
    28. 28. 2nd Component of the Care PlanResident Voice  Preferences  Wants  Wishes  AccommodationsDebbie Ohl & Associates LTC Consultants &Educators
    29. 29. 3rd Component of the Care PlanGoals What influences selection of goal dates ?Debbie Ohl & Associates LTC Consultants &Educators
    30. 30. 4th Component of the Care PlanTarget Dates  MEET GOALS  CHECK PROGRESSTarget Dates Outside of Scheduled Reviews. Who does it? Where will it be documented? What if the plan is off track?Debbie Ohl & Associates LTC Consultants &Educators
    31. 31. 5th Component of the Care PlanApproaches .Debbie Ohl & Associates LTC Consultants &Educators
    32. 32. 6th Component of the Care PlanMonitoringa. Accountability b. ImplementationDebbie Ohl & Associates LTC Consultants &Educators
    33. 33. 7th Component of the Care PlanReview and Revision Care conference scheduled reviews.  Overview  Status of goals  Met  Unmet  Rationale  New areas of concernDebbie Ohl & Associates LTC Consultants &Educators
    34. 34. 3rd Program ObjectivesList the 10 Care Plan Must Haves‟ to Meet Standards ofPractice A standard of practice is a diagnostic and/or treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance. That standard will follow guidelines and protocols that experts would agree with as most appropriate, also called "best practice." Debbie Ohl & Associates LTC Consultants & Educators
    35. 35. 1. Prevent avoidable declines 10 Care Plan Must Haves‟ to Meet2. Manage risk Standards of Practice3. Address resident strengths4. Utilize standards of practice in care planning process5. Evaluate treatment objectives and outcomes6. Respect right to refuse treatment, offer alternatives, adapt.7. Use an inter/trans disciplinary approach8. Involve family and resident representatives9. Assess and plan to meet needs of new admissions Debbie Ohl & Associates LTC Consultants & Educators direct care staff in planning Involve the
    36. 36. Which of the followingCare Plan Format ExamplesDo You Think Best Serve the Residentand Comply with RegulatoryRequirements?Debbie Ohl & Associates LTC Consultants &Educators
    37. 37. Taken from web site on I careplans Sleep medication prn. Discourage napping during the day. Side rails up. IF unable to sleep place in Geri- chair.I „softer‟ PlanI like to walk IF I am walking at night please offerduring the night. to walk with me. Place sashes in doorways of resident rooms who are disturbed by my presence at nite. Offer me snacks. I like to read the sports section of the paper and play solitaire. Debbie Ohl & Associates LTC Consultants & Educators
    38. 38. I-Format Care Plans from http:// “I” care plan sample  I am at risk for skin breakdown because of my decreased mobility. I had an open area on my coccyx, which I obtained while in the hospital. It has improved to just a reddened area. I want to keep healing. Assist me to reposition every two hours if I have not done so on my own. Remind me to keep off my back as much as possible when I am in bed. I have a special pressure-reducing cushion on my chair, which needs to be straightened, before I sit in it every morning. My bed has a pressure- reducing mattress. I take a multivitamin to help with skin healing. I concentrate on making sure I eat proteins at every meal. Remind me that protein will help Ohl &healing. Consultants & Debbie in Associates LTC Educators  GOAL: I wish to remain free of skin breakdown.
    39. 39. Care Plan with Pain as the Root Problem Components of Pain Care Plan: Analgesia, Quality of Life, Ability to Function PROBLEM/NEED GOAL(S) Target APPROACHES/ Res What does the resident Date INTERVENTIONS Disc /STRENGTH want?Problem: Description of 1. Resolve and Medication planpain: type, source, eliminate thelocation, intensity issue if possible Who can do What 2. Pain Relief / WhenRelated to: why pain Control Where How often.Resulting in/ creating 3. Quality of Life -/impacting: affect on What can youfunctional status PCP make better? - What is the best you can expect?Risks / complication(from pain and med used)Strengths/Wishes:
    40. 40. Person Centered Care PlanningWhat do we live for, if itis not to make life lessdifficult for each other? George Eliot
    41. 41. Debbie Ohl RN, M.Msc., PhD Ohl and Associates Long Term Care Consultants Debbie@MDSCarePlanBuilder.comDebbie‟s 30 year consulting practice is an outcome of learning lessons the hard way as a nursing director, sometime nurse‟s aide and behind the scenes administrator. She is a regulatory compliance and interdisciplinary care planning specialist, authoring more than a dozen manuals including HcPro‟s, MDS 3.0 Care Plans Made Easy and Care Area Assessments.As a nationally recognized expert, Debbie has presented for many prestigious organizations including the National Institute for Health , the American College of Nursing Home Administrators, the National Health Care Lawyer‟s Association, and numerous Health Care Organizations, and Nursing Facilities throughout the country.Recently completing her Ph.D in Holistic Life Coaching, Debbie brings a unique perspective on the impact thatDebbie Ohl & Associates LTC Consultants &Educators actions have on ourselves and thoughts, feelings, and those we