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  • 1. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 1 MDS 3.0 Care Planning Presented by Debbie Ohl RN, M.Msc., PhD. Ohl and Associates Committed to Quality Care & Professional Excellence 613 Compton Road Cincinnati, Ohio 45231 MDSCarePlanBuilder.com From Paper to Person Debbie Ohl RN, M.Msc., PhD Ohl and Associates Long Term Care Consultants Debbie@MDSCarePlanBuilder.com Debbie’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, Big Book of Care Plans. As a nationally recognized expert, Debbie has presented for many prestigious organizations including the National Institute for Health , the American College of Nursing HomeAdministrators, the National Health Care Lawyer’sAssociation, 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 that thoughts, feelings, and actions have on ourselves and those we serve. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Quality … Degree of excellence or worth Life… A manner or way of existing Autonomy… Self-governance, self-sufficiency Quality of LifeQuality of LifeQuality of LifeQuality of Life RAI…The path to improvement.
  • 2. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 2 Getting to the Care Plan MDS 3.0 CATs CAAs Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Program Objectives Identify and discuss 3 to 5 new terms used in conjunction with the MDS 3.0 and how they can be used in care planning. Issue Problem CPS CPGs PHQ-9 BIMS EBPs PCP Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Program Objectives Discuss the expectations of person centered care planning. Discipline Specific Professionals Person / S.O. Wishes/Preferences Administration Staff Regulators Human Being Resident Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 3. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 3 Program Objectives Identify the seven components of the care plan and at least one key factor of each as it relates to RAI expectations. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Program Objectives Discuss the three primary content areas to be considered in care planning. Active Disease CAAs Accommodation of Need • Impact on function • Impact on life style • 18 • 2 • Physical • Cognitive • Psychosocial Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Evolution of Care Planning Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 4. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 4 Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 1935 Poor houses SSA established public assistance For profit homes proliferate 1950 SSA requires States to license NH SSA does not specify enforcement standards 1956 Feds find NH substandard 1965 Medicare/Medicaid programs funded by Feds Standards put in place 1970 NH atrocities hit front page of news papers 1972 ComprehensiveWelfare Reform Act funds state survey and certification to establish uniform standards and conditions. Emphasis is on institutional framework: CAPACITY to deliver care. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Mid 70’s-early 80’s Patient Care & Services Survey born to correct emphasis on capacity to deliver to ACTUAL delivery of care. Controversy over legitimacy. Paper compliance in the form of policies was nearing its end. 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 MDSCarePlanBuilder.com ThinkTheThoughts.com Phase 1 Paper to Person 1976-1987 EVERY resident must have a plan. EACH discipline must have a plan. Every diagnosis must be on plan. All medications must be on the plan. Total Confusion Result: Multi-disciplinary conflict, fragmentation, confusion, many deficiencies. • Care plan content expectations have increasing demanding. i.e. goal measurability. Phase II 1987 InterdisciplinaryTeam Building QUALITY of CARE OBRA solidifies standards and creates a framework for continuity of care. Care plan goals, interventions and target dates progressively used to site deficiencies. Emphasis is on Quality of Care. Unified care planning efforts begin with name change to IDT. 1995 MDS 2.0 Raises the Bar • Assessment process formalized. • Increased expectations in terms of documentation and care delivery. • RAPS about paper not process.
  • 5. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 5 Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 1987 to September 30, 2010 MDS 2.0 promoted inter- disciplinary care planning. Quality Indicators and Measures created benchmarks for outcomes. RAPs provided insurance that at least the obvious was care planned. Clinical assessment skills were maturing. Quality of care was the expected norm. Care plans became more resident specific. 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. 2010201020102010 Quality of Care ActualizedQuality of Care ActualizedQuality of Care ActualizedQuality of Care Actualized Quality of Life Comes to ForefrontQuality of Life Comes to ForefrontQuality of Life Comes to ForefrontQuality of Life Comes to Forefront Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Terms for Care Planning PCP Critical thinking Multidisciplinary Interdisciplinary Transdisciplinary RAI MDS CATs CAAs CPGs EBPs SOP DecisionTrees Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 6. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 6 Terminology RAI ResidentAssessment Instrument MDS Minimum Data Set CATs ClinicalAssessmentTriggers CAAs ClinicalAssessment Areas EBPs Evidenced Based Practices CPGs Clinical Practice Guidelines SOP Standards of Practice PCP Person Centered Planning Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Purpose of Clinical Assessment AreasPurpose of Clinical Assessment AreasPurpose of Clinical Assessment AreasPurpose of Clinical Assessment Areas CAA’sCAA’sCAA’sCAA’s Identify and clarify areas of concern from CATs. Promote identification of underlying cause(s), risks, complications. Consider fixability factors. Establish correlations among multiple triggered CATs. Demands critical thinking skills. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com RAP CAA Possible problems in 18 care areas. Triggers alert to possible issues in care needs. Triggered care area must be thoroughly assessed. Documentation must meet criteria. RAPS must be the tool used for conducting the assessment. Possible problems in 20 care areas. Triggers alert to possible issues in the care needs. Triggered care area must be thoroughly assessed. Documentation must meet criteria. There is no mandated specific tool for assessment. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 7. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 7 CAA ResourcesCAA ResourcesCAA ResourcesCAA Resources RAI • MDS 3.0 tools BIMS CPS PHQ-9 • Chapter 4 Process steps 4-9 POC focus 4-12 20 CAAs 4-17 • Appendix C CAA resources Expert Resources • CPGs • EBPs • SOP • Decision trees • Care paths • Journals, etc. • QIO’s In-Facility • Policy A general plan to guide decisions • • Procedure & protocols Fixed, step-by- step sequence activities or course of action Care plan • Baseline • Review and revisions • SMART goals • Timelines • Resident preferences Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com CAA CompletionCAA CompletionCAA CompletionCAA Completion PsychosocialWell Being Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com CAA DemandsCAA DemandsCAA DemandsCAA Demands Coming off of auto pilot. Problem solving in addition to problem management. Assessment and Care Planning Policies and Procedures. Staying up to date on changing practices. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 8. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 8 CPGsCPGsCPGsCPGs Clinical Practice GuidelinesClinical Practice GuidelinesClinical Practice GuidelinesClinical Practice Guidelines Guidelines developed to help health care professionals and patients make decisions about screening, prevention, or treatment of a specific health condition. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com EBPsEBPsEBPsEBPs Evidence Based PracticesEvidence Based PracticesEvidence Based PracticesEvidence Based Practices 1. Conscientious decision-making based not only on the available evidence but also on patient characteristics, situations, and preferences. 2. Recognizes that care is individualized and ever changing and involves uncertainties and probabilities. 3. A philosophical approach that is in opposition to rules of thumb, folklore, and tradition. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com SOPSOPSOPSOP Standard of PracticeStandard of PracticeStandard of PracticeStandard of Practice A diagnostic and 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 MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 9. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 9 Decision TreeDecision TreeDecision TreeDecision Tree Used in determining the optimum course of action, in situations having several possible alternatives with uncertain outcomes Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Don’t get bogged down!Don’t get bogged down!Don’t get bogged down!Don’t get bogged down! EBP, CPG, Care paths, etc. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Give me a break! 15 minutes
  • 10. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 10 Terminology Countdown RAI ResidentAssessment Instrument MDS Minimum Data Set CATs ClinicalAssessmentTriggers CAAs ClinicalAssessmentAreas EBPs Evidenced Based Practices CPGs Clinical Practice Guidelines SOPs Standards of practice PCP Person Centered Planning CT CriticalThinking Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com How does person centered care differ from resident centered care? Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com The identification and evaluation of evidence to guide decision making. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 11. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 11 Critical ThinkingCritical ThinkingCritical ThinkingCritical Thinking 1. Gathers and assesses relevant information. Raises questions and problems States them clearly and precisely Comes to well-reasoned conclusions and solutions testing them against relevant criteria and standards; 2. Thinks open-mindedly within alternative systems of thought, recognizing and assessing: if,then 3. Communicates effectively with others in figuring out solutions to complex problems without being unduly influenced by others' thinking on the topic. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Your Job To interpret and address the CareTo interpret and address the Care Areas identified by the CATs andAreas identified by the CATs and develop an individualized caredevelop an individualized care plan that keeps the person at theplan that keeps the person at the center of all activities.center of all activities. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Summarize your learning ☺ Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 12. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 12 Lunch Time ☺ Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Care Planning Teams Team A group of people with a common purpose Discipline Relating to a particular field of study • Multidisciplinary Many • Interdisciplinary Between and among • Transdisciplinary Strategy that crosses many disciplinary boundaries to create a holistic approach Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 13. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 13 Care Area Assessments Promotes identification of cause and effect relationships, contributing and complicating factors and risk identification Correlates triggering relationships and implications among multiple triggered CATs. Advances recognition of resident strengths,preferences, wishes. Considers correctability. Requires Logical Care Plan Linkage Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com CAA Review 1. Identify relevant triggers. 2. Identify type of trigger. 3. Identify the possible causes, contributing factors, and risk factors . 4. Analyzing and draw conclusions. 5. Develop a personalized, resident-specific care plan based directly on conclusions including insight of IDT members, resident, significant others. 38 Tools, Tips & Clarifications for Care Planning BIMS CPS MMSE PHQ-9 Issue Problem Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 14. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 14 BIMSBIMSBIMSBIMS Brief Interview for Mental Status Interview process used to test the resident’s memory o Repetition of 3 words o Orientation o Recall Residents must be capable of responding. If resident rarely/never understands staff assesses resident based on their observations. CPS Cognitive Performance Scale used in RUGs III to evaluate the level of cognitive impairment MMSE Mini Mental Status Exam questionnaire used to screen for cognitive impairment. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com PHQ9PHQ9PHQ9PHQ9 Resident Mood Interview Patient Health Questionnaire with 9 questions Looking for signs of depression Residents must be capable of responding. Staff PHQ if 3 or more items not completed by resident. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com ISSUE About yesterday and tomorrow. Grey area, intangible. Typically not solvable. PROBLEM About here and now. Black and white, tangible. Something can be done. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 15. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 15 10 Care Plan Must Have’s10 Care Plan Must Have’s10 Care Plan Must Have’s10 Care Plan Must Have’s Debbie Ohl &Associates LTC Consultants & Educators MDSCare PlanBuilder.com ThinkTheThoughts.com Six general care planning areas 1. Functional Status 2. Rehabilitation/Restorative Nursing 3. Health Maintenance 4. Medications 5. Daily Care Needs 6. Discharge Potential Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Priority PlansPriority PlansPriority PlansPriority Plans 1. Unstable health conditions. 2. Pain management. 3. New areas of risk: falls, skin, dehydration, etc. 4. New problems requiring use of psychoactive medication to correct or control. 5. Medications with high risk for side effects, or adverse drug reactions. 6. Wounds, pressure ulcers. 7. Medicare RUGs (reason for coverage) skilling services. 8. Acute problems * Falls * New pressure sores * Unplanned weight loss * Unplanned weight gain * Elopement * Resident to resident abuse, * UTI’s * URI’s * Other Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 16. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 16 Components of the Care Plan 1 2 7 3 6 4 5 Care Plan Statement Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Care Plan Guidance Problem / Need Strength Scope, Severity, Stability CAA 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 Risk Strengths Resident Input 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 What does the resident want?? Delivery means insuring consistent implementation Oversight means monitoring for effectiveness Review Date based on SSS Interim Or Expected to be met Resident Input 3.3.3.3. Developing GoalsDeveloping GoalsDeveloping GoalsDeveloping Goals Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 17. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 17 2.2.2.2. Resident VoiceResident VoiceResident VoiceResident Voice Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 4.4.4.4. Target DatesTarget DatesTarget DatesTarget Dates Meet Goal or Check ProgressMeet Goal or Check ProgressMeet Goal or Check ProgressMeet Goal or Check Progress Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Consider the Scope, Severity, and StabilityConsider the Scope, Severity, and StabilityConsider the Scope, Severity, and StabilityConsider the Scope, Severity, and Stability Scope Severity Stability Pervasiveness of the problem. Seriousness of the problem. Current status of the problem. Present continuously (3) Intermittent, patterned (2) Sporadic (1) Immediate jeopardy to health & safety of self or others (4) Harm present or eminent (3) Potential for harm (2) Minor (1) To what degree is the problem solved and or what is the likelihood of reoccurrence if interventions are withdrawn? Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 18. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 18 5.5.5.5. ApproachesApproachesApproachesApproaches Determining Interventions & ActionsDetermining Interventions & ActionsDetermining Interventions & ActionsDetermining Interventions & Actions . Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 6.6.6.6. MonitoringMonitoringMonitoringMonitoring a.a.a.a. Deciding on AccountabilityDeciding on AccountabilityDeciding on AccountabilityDeciding on Accountability Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 6.6.6.6. MonitoringMonitoringMonitoringMonitoring b.b.b.b. Implementation Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
  • 19. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 19 Care Plan Formats Common PlanCommon PlanCommon PlanCommon Plan “I” Plan“I” Plan“I” Plan“I” Plan Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com PGI Reads like a book Or Changes language content of common plan “I” care plan samples Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com I-Format Care Plans http://paculturechangecoalition.org SKIN: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 in healing. GOAL:I wish to remain free of skin breakdown. Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com COMMUNICATION/MEMORY:I used to communicate well and enjoy a hearty conversation.Humor has always been a part of my communication style. I have become much weaker as my health has declined. Sometimes I find it hard to even to answer I am tired. Occasionally I have episodes of confusion. Sometimes I do not know where I am and I become frightened. Please provide orientation during these times and when you are providing my care. Let me know who you are and what you are going to be doing. I usually recognize my children and my spouse. Holding m y wife’s hand comforts me.When I am confused and frightened, I may strike out at you. Use calm gentle touch and hand massage while providing me reassurance. *GOAL: I don’t want my memory loss and confusion to interfere with my ability to accept the care I need. I do not want to hurt my caregivers
  • 20. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 20 Comfort (Rhode Island Quality Partners) I take regular medication for pain. Sometimes I need extra boost of medication. I also benefit from stretching so I like to attend the morning exercise group. The massage therapist seems me every Friday for an hour. Massage makes all the difference. Goal: To be free from breakthrough pain in my back Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Sleep medication prn. Discourage napping during the day. Side rails up. IF unable to sleep place in Geri-chair. IF I am walking at night please offer 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. I‘softer’ Plan I like to walk during the night. Taken from web site on I care plans 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/ INTERVENTIO NS Resp. Discip IssueIssue:: why painwhy pain DescriptionDescription of pain:of pain: type, source, location,type, source, location, intensityintensity ResultingResulting in/in/ creating/impacting:creating/impacting: affectaffect on functional statuson functional status PMS/E:PMS/E: Risks / complicationRisks / complication (think about from pain(think about from pain and med used)and med used) ResidentResident Strengths/Wishes:Strengths/Wishes: 1. Resolve and eliminate the issue if possible 2. Pain Relief / Control 3. 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.
  • 21. 9/22/2010 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 21 7. Review and Revision Target dates outside of facility established reviews. Who does it? Where will it be documented? What if the plan is off track? Care conference scheduled reviews. Overview Status of goals Met Unmet Rationale New areas of concern Debbie Ohl &Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Assessment of Care Plan ActivitiesAssessment of Care Plan ActivitiesAssessment of Care Plan ActivitiesAssessment of Care Plan Activities 1. Acute problems are addressed timely. 2. Care plans geared to preventing avoidable declines? 3. Care plans consistently manage resident risk factors in a timely manner? 4. Care plans recognize and build on resident strengths? 5. Goals measurable? 6. Goals achievable? 7. Goals met ? 9. The IDT work together? 10. Some team members write their own care plans for fear they will otherwise be cited? 11. Documentation reflects status and/or rationale on each care plan goal? 12. Direct care staff on all shifts and units are informed about the care plan goals and interventions? 13. The direct care staff can explain what the goals are and why they are doing what they are do? Person Centered Care Planning What do we live for, if it is not to make life less difficult for each other? George Eliot