Care Planning

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How to care plan: when, where, how, why, who. Learm how to create person centered care plans that imporve quality of life, satisfy regulators, and make areal difference

How to care plan: when, where, how, why, who. Learm how to create person centered care plans that imporve quality of life, satisfy regulators, and make areal difference

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  • Questions were designed to determine: (a) who was included in the multidisciplinary care planning team, (b) the steps and activities specific to the respective facility's care planning process, (c) each member's role related to each activity, (d) the time spent by personnel in each activity, (e) whether other problem-focused meetings were conducted in which decisions were made about an individual resident's care, (f) the personnel and time involved in relevant problem-focused meetings increasing their efficiency and reducing the number of deficiencies related to the care planning process care planning activities rate and problem-focused meeting rate; quality of the care planning process
  • Consider the scope, severity, and stability of the identified problems and needs to facilitate priority problem recognition and balanced care plans. This will help to prevent putting the cart before the horse! We sometimes try to address everything all at once because we are worried if it’s not on the plan we will get a deficiency……..which sets everybody up for failure. Placing too much data on the care plan can doom it to failure. Sometimes you cannot deal with one problem until you have solved another! When this is the case, provide a note of explanation as to your thinking and awareness of the problems to avoid problems with surveyors. Use the same scope and severity scale applied by surveyors (when citing deficiencies) to help you prioritize care planing needs and actions, along with your input on the stability of the problem, goal, and / or plan.
  • General Care Planning Areas Functional status . Compromise will result in some type of care planning dependent on where and how it impacts the person. This is a primary function of the RAPs. Rehab & restorative nursing . Includes potential for improvement, maintenance, slowing of decline and management of complication risk factors. Health maintenance. Monitoring stable and unstable conditions and disease processes. Listing problems that no longer affect the resident, are controlled, or no longer need monitoring is a team decision based on how the problem affects the overall functioning or well being of the person. Discharge Potential. Needs to be assessed at admission, annually and as needed. Focus should center on what needs to happen before the person can be safely discharged and/or adjustment problems related to not being able to be discharged. Medications . Medications can be an intervention for a problem or can be a problem in and of itself. As example the use of an Antipsychotic may be an appropriate intervention to treat a schizophrenic or it may have been inappropriately prescribed and require reduction and elimination and/or producing troubling side effects. Daily Care Needs . Standard practice approaches need not be placed on a care plan. Particularly if they are expected facility actions. Daily care needs that are specific to the resident and are out of the ordinary must be addressed on the care plan.
  • Activities of Daily Living: staff needs to deliver care Immediate and day to day (short term and continuous) to meet professional standards of practice Quality of care
  • Ff know Residents that require supervision, limited assist, extensive assist or total care for any of the activities of daily living
  • MDS Coordinator Note: Review the three previous month’s entries for patterns and relationships to Core (RAP) Plan problems in conjunction with quarterly reviews.
  • The challenge is identify root problems and determine correctability as well as reversibility or modifiability of the outcomes.
  • Newly noted areas of risk such as falls. Skin, dehydration, etc. If the risk does not materialize after the first quarter you can consider moving to the core plan section. Out of control behavior problems, pain management problems, drug reduction, new problems requiring use of psychoactive medication to correct or control. Unstable health conditions, medications with high risk for side effects, or adverse drug reactions. Wounds, pressure ulcers, acute problems such as falls, new pressure sores, unplanned weight loss or gain, elopements, resident to resident abuse, UTI’s, URI’s, etc. Medicare RUGs (reason for coverage) skilling services.
  • Regulations require resident problems and needs to be care planned. The format and method for doing so is an individual facility decision. The intention of the regulation is to insure that the care plan identifies the problems and needs and is known and followed. Too often, acute problems are noted after the fact, if at all. Care planning completed after the fact results in a paper compliant attempt to meet the regulatory requirement. In reality however, it does nothing except take up valuable time in a useless exercise. Outcomes are dependent on caregiver knowledge and use of the care plan. Citations are issued for failing to know and follow the care plan and can result in a deficiency determined to have been avoidable…all because of care plan lack of presence or lack of knowledge and/or lack of use. To be successful care plans must be accessible, used, followed and reviewed. This can only happen when they are readily available, and staff does not have to play seek and find on top of the hectic pace they run each shift, everyday! Immediate Need Care Plans (INPOC) are intended to address the problems and needs that require day to day intervention, monitoring or both. If they are buried in the body of a long term care plan they are not used. The immediate need care plan is designed to readily identify and locate resident plans on a day to day basis, dramatically increasing the rate of use and compliance
  • incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much bladder function as possible.
  • Decide if you are dealing with an issue or a problem; a core problem or an outcome problem caused by something else. Determine if it impacts the resident, environment or Both
  • Directions 1.) For listed items indicate if the statement, as written, is an issue, a problem or both. For those you identify as problems only write a measurable goal. In the blanks at the bottom, give one example of a problem statement and one of an issue using a care plan example from your facility (a test of your memory!).
  • You will find it difficult if not impossible to develop measurable, do-able, appropriate goals if your problem statement is addressing an issue instead of a problem. If there is ever any doubt about the level of goal development always shoot for the highest goal first. Just be careful not to dis-able the resident or the team with unrealistic, unattainable goals
  • Directions : Indicate if goal is measurable and appropriate. Discuss your rationale. Hint: Involves reviewing the care plan statement.
  • The team must clarify who will hold the accountability for oversight. Don’t assume everyone knows. Consider using the last listed discipline as the vehicle to reflect this. Oversight does NOT mean day to day supervision of implementation. It means periodically checking. If the plan is not being implemented or implemented incorrectly the chain of command must be followed to correct the problem. The last thing people need are more bosses!
  • Target dates are not always three months. Consideration must be given to the scope and severity of the problem. This doesn’t necessarily mean that a team meeting must be held for every goal developed outside of three months. It means that the responsible discipline noted above will check the plan on that date, make a note, and take action accordingly.
  • Monitoring stable and unstable conditions, disease processes, or high-risk areas.
  • Compromise will result in some type of care planning dependent on where and how it impacts the person and the type of support needed. ADL Directive’s The intention of the ADL care plan is to provide ready access and specific information to the primary care giver to meet the ADL needs of the resident while enhancing resident self performance and participation where possible. In order for the ADL Directives to be effective they must be used! Used means accessible and user friendly, with content that provides meaningful, helpful information. This eliminates the practice of keeping them on the chart (too many barriers, too much time to review for the primary care giver).
  • Goals will includes potential for improvement, maintenance, slowing of decline and management of complication risk factors.
  • Medications can be an intervention for a problem or can be a problem in and of itself. As example the use of an antipsychotic may be an appropriate intervention to treat a schizophrenic or it may have been inappropriately prescribed and require reduction and elimination and/or producing troubling side effects.

Transcript

  • 1. Meeting Professional Standards of Practice Care Planning Debbie Ohl RN, NHA, M.Msc. Ohl & Associates Consultant and Educator THINKTHETHOUGHT.com MDSCAREPLANBUILDER.com
  • 2. The Care Plan
    • Thirty years ago regulators began focusing on the idea of care planning.
      • Each discipline was required to develop a care plan whether the resident had a problem or not.
      • All medical diagnosis, medications, etc had to be care planned.
      • Next came the concept of measuring and timing goals
      • Care plans driven by what we thought surveyors wanted to see.
    • In 2008, care plans are expected to be pertinent, individualized, person centered, and practiced.
  • 3. Discuss
    • What is multi-disciplinary care planning?
    • What is interdisciplinary care planning?
    • What is individualized care planning?
    • What is person centered care planning?
  • 4. Principles and values of person-centered care
    • Every person has strengths, gifts, and contributions to offer.
    • Every person has hopes, dreams and desires.
    • Each person is the primary authority on his or her life, along with those who love them.
    • Every person has the ability to express preferences and to make choices.
    • A person's choices and preferences must always be considered.
  • 5. Assessment of Care Plan Activities
    • Acute problems are addressed timely.
    • Care plans geared to preventing avoidable declines?
    • Care plans consistently manage resident risk factors in a timely manner?
    • Care plans recognize and build on resident strengths?
    • Goals measurable?
    • Goals achievable?
    • Goals met ?
    • The IDT work together?
    • Some team members write their own care plans for fear they will otherwise be cited?
    • Documentation reflects status and/or rationale on each care plan goal?
    • Direct care staff on all shifts and units are informed about the care plan goals and interventions?
    • The direct care staff can explain what the goals are and why they are doing what they are do?
  • 6. The Ohl Modified Enforcement Matrix Determining SSS of Problem for care planning Degree of the Problem Isolated Rarely happens or Not very often Pattern Certain times Places Circumstances Widespread Unpredictable Constant Cannot anticipate Out of control Serious Negative outcomes have or are occurring J K L Is a big Deal Significant concerns, negative outcomes / problems have occurred or are occurring but not life threatening G H I Could be a big deal Concern warranted, risk for negative outcome could be likely D E F No big deal Not a true concern A B C
  • 7. General Care Planning Areas
    • Daily Care Needs / Wants
    • Health maintenance.
    • Functional status.
    • Rehab & restorative nursing .
    • Medications .
    • Discharge Planning/implications.
  • 8. Components of the Care Plan
    • ADL: care delivery
    • Day to day: skilled, quality of care and short term
    • Core plans: quality of life and long term
    • Special Focus: rehab and restorative
  • 9. CERTIFICATION REQUIREMENT Activities of Daily Living
    • Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practical physical, mental and psychosocial well being ,
    • … in accordance with the comprehensive assessment and plan of care.
  • 10. ADL Directive’s
    • The intention of the ADL care plan is to provide ready access and specific information to the primary care giver to meet the ADL needs of the resident while enhancing resident self performance and participation where possible.
  • 11. ADL Care Plan Directives User Type of Entries Initiate by Review Update Discont’ Direct Care Giver
    • Behavior & mental status
    • Resident strengths/preferences
    • Risk factors.
    • ADL performance & staff support including task segmentation, special directions.
    • Particulars direct care needs to know on a day to day
    RNAC Unit Nurses with assistance of Nurse Aides Unit nurse & primary care giver In place over the course of the admission
  • 12. Immediate / Day to Day Professional Care Needs
    • As a general guideline, problems that are unstable, high risk, or require a portion of time to determine the scope or stability are addressed initially as immediate needs.
  • 13. Immediate / Day to Day Needs User Type of Entries Initiate by Review Update Discontinue Licensed Nurses Professional staff
    • Acute conditions
    • Acute illness
    • High risk problems
    • (I.e. Falls, skin, restraint use, new psychoactive med, new continence mgt. program).
    • Chronic unstable DX
    • Changes in status
    • Skilling services
    Licensed nurses Professional disciplines  Licensed nurses  RNAC  Supervisor  Other  Licensed nurses  RNAC  Supervisor  Other
  • 14. Sample Day to Day / Immediate Need Problem List
    • Create an index to identify care plan entries.
    • Maintain for short term, acute, and/or chronic/unstable
    • needs/ conditions.
    Date Problem Charting Date Resolved Shift Frequency  Days  Eves  Nites
    • QD
    • QOD
    •  Q wk on ____________
    •  Q mo ____________
  • 15. Comprehensive Core Plan
    • Address problems and needs that are more long term in nature.
    • More quality of life oriented, requiring more staff training to address the particulars for the individual.
    • Content is the outcome of
    • - RAP assessments
    • - professional assessments
    • - immediate need care
    • patterns/trends
    • Overseen by the interdisciplinary team via
    • - admission, - quarterly,
    • - significant change
    • - annual reviews
  • 16. Comprehensive Core Care Plan User Type of Entries Initiate by Review Update Discontinue IDT Team
    • Person centered
    • RAP/QI Related
    • Chronic stable
    • problems
    Individual team member with IDT consensus and/or IDT as group
    • Within 7 days of MDS / RAPs completion
    • Quarterly
    • As needed
    Individual team member with IDT consensus and/or IDT as group
  • 17. Comprehensive Core Plan Review
    • Be sure to critique the other two parts of the comprehensive plan to insure coordination.
      • ADL Directives: status of day to day needs and staff support required.
      • Immediate Need patterns day to day high risk, acute, and chronic medical conditions requiring close scrutiny.
  • 18.
    • The Comprehensive or Core Plan
    • The care plan must focus on resident functional problems, needs and outcomes.
    • For this to occur:
    • Professional assessments must be completed timely.
    • The MDS must be evaluated as a whole, not parts, by the team.
    • The RAPs must be used as intended.
    • Clinical team members must be willing to modify initial plans and work together, not separately.
  • 19. Care Planning Begins At Admission You must address the immediate needs to care for the resident. These include:
            • High-Risk Issues
            • Unstable Health Conditions
            • PPS Related Condition(s)
  • 20. Ongoing Care Planning
    • Required between reviews for such things as UTI’s, URI’s, skin tears, short term reversible problems.
    • Complex issues arising between schedule reviews typically will require a new MDS/RAP review.
  • 21.
    • Restorative programs are indicated for those residents who have decision-making ability and/or the resident or the staff believe the resident is capable of increased performance .
    • A maintenance program is indicated when the resident has no ability to make decisions and/or has severe limitations caused by medical illness.
    Special ADL Programs = Restorative Care Planning
  • 22. Restorative Care Plan GOALS
    • To emphasize ability, de-emphasize disability; focus on what is left, not what is missing.
    • To promote self care responsibility.
    • To foster independence.
    • To reinforce skills learned in formal therapy.
    • To teach functional adaptation when complete recovery is not possible.
  • 23. Improving Care Plan Writing Skills
  • 24. Steps to Care Planning
    • Assessments
    • Consensus and interrelationships
    • Clear and connected problem /need/want statements
    • Measurable, reasonable, attainable goals
    • Do-able, discipline defined interventions
    • Oversight accountability
    • Time lines for meeting goals
    • Documentation of rationale, status and outcomes.
  • 25. Care Plan Parts
    • Problem / need statement
      • - Reason why?
    • - Risk factors
    • - Resident strengths
    • Goal development and time frames
    • Interventions
    • Responsible discipline
  • 26. Principles Care Plans that Work
    • Accurate, appropriate, consensus based resident assessment.
    • Well written, clear, and concise care plans that are:
            • known
            • followed and
            • re-assessed for effectiveness
  • 27. Building Effective Care Plans
    • Do Not write or use problem statements that are broad and unfocused. ( issues )
    • Judgments are made by the reader often not intended by the writer .
    • ISSUES are general statements.
      • Lack substance
      • Not based in the present
      • Goals don’t change or are impossible to achieve.
  • 28. Care plan the specific problems that result from the issue
    • What is the issue creating for the person HERE and NOW ? What is the Problem?
      • Is it affecting others?
      • Is it resulting in loss of appetite
      • Does it interfere with activities of daily living, pursuits or interests?
      • Does it act as a barrier, creating avoidance by others?
  • 29. Issue Based Problem Based Here & Now Depressed, makes negative self statement Exhibits depression as evidenced by: lack of attention to personal appearance, grooming and negative self statements about her appearance. . Agitated during care Agitated during care as a result of poor comprehension creating risk for injury to self or staff and poor hygiene.
  • 30. Writing Problem Statements Issue Problem
    • General statement that is past or future oriented.
    • Typically not solvable
    • Almost impossible to develop measurable, achievable goals.
    • I.e. Confused and disoriented
    • Specific statement that is here and now oriented.
    • Typically the impact of the issue.
    • Goal development flows easily.
    • I.e. Confused and disoriented resulting in risk for weight loss from failure to feed self; elopement attempts when seeking to “go to work”.
  • 31. Issue or Problem? Care Plan Statement Issue Problem Both Decompensates and strikes out if feels rushed Constantly complains about roommate. Cries at intervals for no apparent reason. Chronic re-occurring pressure ulcers secondary to left sided dependence and frequent refusal to change positions. Frequent Fecal Impactions R/T chemo therapy and use of narcotics resulting in pain, discomfort & loss of appetite. Inability to be understood.
  • 32. Developing Goals I nsure goal alignment with capabilities
    • Is problem solvable/fixable?
    • Is this something that might be improved?
    • Is this an area where maintenance or control is possible?
    • Can the decline be slowed?
    • Is there nothing that can be done to correct, reverse or retard the problem?
    • What are the complications and risk factors attendant to this un-fixable problem?
  • 33. Is the Goal Measurable? Appropriate? Care Plan Statement Goal M A Wanders out of activities. I P B Will stay for entire activity. Frequently incontinent of urine. I P B Will not fall, skin will remain intact and free of rash. Brittle diabetic, refuses to comply with diet restrictions Will comply with diet
  • 34. Determine Interventions
    • Team member ask:
    • Is there anything I can offer from my discipline to help with this problem?
    • Do I have ideas for others that may be of use?
    • Clarity and connection :
    • Are the interventions related to the problem and connected to goal?
    • Can the staff clearly understand their responsibilities?
  • 35. Deciding on Accountability
    • The discipline with the greatest
    • ownership for the problem holds
    • the accountability for plan
    • implementation and modification
    • between scheduled reviews
    • (established target dates).
  • 36. Time Frames and Review Dates
    • These need to be based on the scope , severity and stability of the particular problem you are dealing with…..
    • ………… ..thus the reason to assign accountability to a particular discipline for reviews that are needed between quarters!
  • 37.
    • Create the Care Plan
    • Care Plan Development Requirements
    • Determine it you are in issue or problem.
    • Use four quadrants thinking to identify impact of issues:
    • Physical/environmental
    • Mental/intellectual
    • Social
    • Emotional
    • Make goals measurable, appropriate, do-able, and linked to the problem/need.
    • Think about the scope, severity, and stability of the problem when determining target dates, interventions, and oversight needs.
    • Incorporate interdisciplinary approach into the residents problems/needs; NOT creation of a care plan to cover a particular discipline .
  • 38. Care Plan with Pain as the Root Problem Components of Pain Care Plan: Analgesia , Quality of Life, Ability to Function PROBLEM/NEED /STRENGTH GOAL(S) What does the resident want? REVIEW Date APPROACHES/ INTERVENTIONS Resp. Discip Issue : why pain Description of pain: type, source, location, intensity Resulting in/ creating/impacting: affect on functional status PMS/E: Risks / complication (think about from pain and med used) Resident Strengths:
    • Resolve and
    • eliminate the
    • issue if possible
    • Pain Relief /
    • Control
    • Quality of Life, - What can you make better?
    • - What is the best you can expect?
    Medication plan Who can do What When Where How often.
  • 39. Progress Notes / Nurses Notes
    • Notes are essential to support your actions and thinking regarding the care plan and the outcomes you are or are not achieving.
  • 40. Care Plan Content Areas
  • 41. Health Maintenance
    • CHF creating risk for fluid overload, and risk for dehydration from lasix. I P B
    • Bilateral leg amputation. I P B
    • Since death of spouse has poor appetite, social withdraw & lack of motivation I P B
  • 42. ADL’s and RAP’s
    • Unsteady gait from old stroke. Walks unassisted, self-toilets with frequent urge incontinence after meals. I P B
    • Urge incontinence and unsteady gait when self- ambulating. I P B
    • Inability to make decisions; no initiation of activities of daily living I P B
  • 43. Rehab & Restorative Nursing
    • Recent prolonged hospitalization resulting in weakness & inability to walk unassisted .
    • Alert, able to follow direction, motivated to improve.
  • 44. Medications
    • Intervention for a problem
    • OR
    • Medication is the problem/risk
    • I.e. Started on Lexapro for depression with past history of lethargy & appetite loss on start of antidepressant, at risk for weight loss, falls.
    • I.e. Paranoid schizophrenic
    • I.e Dementia with behavior disturbance using prn ativan when combative.
  • 45. Care Plan Guidance Problem / Need Strength Scope, Severity, Stability Built by: MDS worksheet RAP CEA Interventions Approaches Clear Concise Do-able Done Review Dates & Places Nurse’s Notes Progress notes IDT notes Goal (s) Related Linked Measurable Reasonable Do-able Responsibilities Oversight Delivery Content Contains Issue Reason Impact 4 Quadrants Fix ability Fix it Improve it Maintain it Control it Slow the decline Minimize/prevent complications Use the 4 Quadrant What physically mentally socially emotionally? Ask each discipline: what can you offer? Deliver y means insuring consistent implementation Oversight means monitoring for effectiveness Review Date based on SSS Interim Or Expected to be met
  • 46. Reasons for Citations
    • FAILURE TO ACCURATELY ASSESS.
    • MAKING ASSUMPTIONS RATHER THAN EVALUATING.
  • 47. Reasons for Citations
    • FAILURE TO DEVELOP A CARE PLAN
    • OR
    • FAILURE TO APPROPRIATELY ADDRESS THE PROBLEM.
    • Plan does not address the specific problem or need and/or identify resident strengths.
    • Specific goals to manage and prevent risk factors from materializing are not present.
    • Clear, appropriate interventions and approaches are not identified or fail to identify who is responsible for implementation.
    • Target dates are absent or inappropriate.
  • 48. Reasons for Citations in
    • FAILURE TO IMPLEMENT THE PLAN
    • Written and not used
    • Written and not known.
    • Written and not followed or not followed consistently.
    • Lacks individualization.
    • Inappropriate interventions.
  • 49. Reasons for Citations in
    • FAILURE TO
    • REVIEW PLAN
    • FOR
    • EFFECTIVENESS
    • AND
    • OUTCOMES.
    • When is the last time you discussed the status or outcomes at care conference?
  • 50. AVOIDABLE MEANS
    • Resident was appropriately assessed.
    • The care plan was developed and reflective of status, risk, measurable, appropriate, do-able goals with reasonable time frames.
    • Care was implemented consistently in keeping with standards of practice
    • Resident outcomes were reviewed & care plan revised as needed.
  • 51. What do we live for, if it is not to make life less difficult for each other? - George Eliot Person Centered Care Planning