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From Paper to Person

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Identify 3 to 5 terms used in conjunction with the MDS 3.0 and how they can be used in care planning. …

Identify 3 to 5 terms used in conjunction with the MDS 3.0 and how they can be used in care planning.

Define the expectations of person centered care planning.

Identify the seven components of the care plan and at least one key factor of each as it relates to RAI expectations.

Determine the three primary content areas to be considered in care planning

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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.
  • Other Patterns: restraints, catheters, medication
  • 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.
  • While we are proficient at developing care plans that address resident needsand sometimes their wants.With the implementation of the MDS 3.0, we are charged with advancing our care planning skills yet again by allowing the resident a real voice in their care. We must honor the resident’s perspective and respect their desires if we are to promote the best quality of life they are capable. It may be helpful in understanding this to look at the difference between care provided and the life being lived. Care provided is a hands on, best practice approach to maintain and improve functional status and medical conditions. The life experienced is the manner and way the person is living.
  • Is an issue or a problem the same thing? CPGs: can perfection be generated?CPS: could you please stopPGQ-9 wrinkle reducing creamEBPs: every body playsBIMS: believe in miraclesPCPA drug that fries brain the cellsA way to remember what needs to be addressed on the pocPerson centered plans
  • 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 actionAdninistration / staff: culture change A shift in emphasis: Change existing mission and vision statement? “listen, learn, connect”.Regualtors: face the same dilemma s he facility. Black and white may now often be gray.
  • 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 familial with is the PGI method. Give me one benefit, one negative?There 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.
  • The final program objective.PCP (cause and impact)= Physical, cognitive, psychosocial or PMS/e =physical, mental, social, emotionalCAA additions: pain, Discharge planning.Accommodation of need: adjust, adapt, modify
  • 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.
  • Result: mechanical process with conflicts, omissions, contradictions and animosity among team members.
  • 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?
  • The shear number of these terms can be overwhelming, confusing and intimidating. The terminology is important to understand in terms of education for new and existing staff and as you begin to change out exiting policies and procedures.
  • CAA process for MDS 3.0 is not that different from the RAP process of MDS 2.0. Since there are no specific forms required with MDS 3.0, the facility has greater freedom to use a wider range of resources when making CAA decisions. However, if facilities are using resources other than those provided by CMS in Appendix C, they must be able to show the resources that were used in this new decision-making process and they must keep up with changing best practices , cpg’s and the like.Promote identification of underlying cause(s), risks, complications: previous baseline, presence of potentially reversible causes, Consider fixability factors: improve, manage, prevent goal driven.Establish correlations among multiple triggered CATs: cause impact PMS/e, associational cases and effects.Critical thinking is essential.
  • When RAPs were triggered a plan was developed or a decision made based on opinion or facts at hand without much further digging. Even when additional information was obtained it was often used or correlated. RAPS were predominantly reactive, spontaneous decisions. If the RAP triggered most often care plan was put in place. We addressed the outward symptom.i.e. IncontinenceCAA’s reflect the next step in our evolution as clinicians. They are more proactive. We talk to the resident rather than at them. We learn to think critically. The CAAs drive home assessment for underlying causes and contributors getting to the root cause.i.e. Incontinence
  • Appendix C CAA resources Although there are no mandated forms, CMS does supply facilities with CAA Resources in Appendix C. The appendix includes care area specific tools that the assessor can use for each of the 20 care areas. Each tool is between three to five pages long, guides the interdisciplinary decision-making, and provides a place to document the process. The benefit of using the tools in Appendix C is that it gives a comprehensive, reliable assessment that has good rater reliability. if facilities are using resources other than those provided by CMS in Appendix C, they must be able to show the resources that were used in this new decision-making process.Considering using forms in appendix C.Let’s look at an example from the RAI manual example. Falls 4-48.SMART: Specific, Measurable. Appropriate, Realistic, Times
  • What is you predominant thought about creating care plans under the MDS 3.0How does this make you feel?
  • Coming off of auto pilot, moving from rote to real, meaning our habit for a very long time has been if it triggers, care plan it just to be safe,Problem solving rather than problem management. Ask why incontinent and can it be reversed or minimized. I.e. Incontinent = reactive plan: toilet plan, fall and skin prevention, smell ok
  • COULD DOOften referred to as best practices they provide instruction on course of action.
  • SHOULD DOExamples of a reliance on "the way it was always done" can be found in almost every profession, even when those practices are contradicted by new and better informationelements in using the best evidence to guide the practice of any professional include the development of questions using research-based evidence adapt to minimize consequencesI.e. Non-compliant diabetic = resident center plan says will follow diet Person centered care plan would say? What do you need to know to address this?
  • MUST DO. i.e. coumadin and falls with head bump.
  • Displays the structure of a particular decision, and the interrelationships and interplay between different alternatives, decisions, and possible outcomes.Formal stepwise process used in coming to a conclusion or making a judgment.Schematic way of representing alternative sequential decisions and the possible outcomes from these decisions.A systematic method of managing a problem by graphically organizing the probabilities of outcomes of alternative treatments. At each decision node or branch a possible alternative is matched with its relative worth, quality of life, freedom from disability, and other factors on which a prognosis may be based.
  • Summarize what you have learned so far:
  • RAI x 15 years- paradigm shift 10 years.Define each of these terms in a sentence: collaborate with someone other than facility mate.Get in groups of 3-5 people and compare definitions. What did you learn?Write the first thought that comes into your mind when you think person centered care planning.
  • 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
  • Person-centered care is an idealistic approach to resident care thatbecame common around 1985. It was designed to allow people with developmental disabilities to have a voice in their lives and to facilitate self determination. By the late 1990’s the concept had filtered into other areas of health care.
  • 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.
  • CAA on self> Did you look beyond the superficial to cause?
  • BasicsClarify Your Thinking: look-out for vague, fuzzy, formless, blurred thinking. Stick to the Point:for fragmented thinking, thinking that leaps about with no logical connections. Start noticing when you or others fail to stay focused on what is relevant.Question Questions: Listen to how people question, when they question, when they fail to question. Look closely at the questions asked. What questions do you ask, should you ask?Be Reasonable: Be on the lookout for reasonable and unreasonable behaviors — yours and others. Look on the surface. Look beneath the surface. Listen to what people say. Look closely at what they do. Notice when you are unwilling to listen to the views of others, when you simply see yourself as right and others as wrong. Ask yourself at those moments whether their views might have any merit.Change in habit from RAPs rote to real, problem solving rather than problem management documenting to doing RAP behavior screams all dayCAA screams all day R/T R/I R/F
  • SWOT Plan
  • Multi Isolated, all mineInter Segmented, mine and yoursTrans Integerated, ours
  • Discuss 3 to 5 CAA’s functions of the CAAsPromotes identification of root cause(s), risks, complications. The RAPs did too but we were at the beginning of the learning curve and just adding another step in the assessment process began the shift in the paradigm.Issues verse problemsReactive v. problem solving care plansCorrelates triggering relationships and implications among multiple triggered CATs:Reflects functional impact to encouraging a centralized, more concise care planning process rather than a piece meal plan with multiple duplications, conflicts and stand alone disciplines. Old care planning was fear driven worry about surveyor acceptance. New care planning is person driven. It’s a shift in thinking for EVERONE.CAAs create an opportunity to sort cause from outcome. Contributing to problem identification and therefore a more focus care plan that promotes highest function with added benefit of promoting interdisciplinary rather than a multidisciplinary approach (which was a result of the first care expectations in the 70s)Advances recognition of resident strengths, preferences, wishes.The more focused emphasis of the MDS 3.0 on resident involvement using their voice as part of the process significantly facilitates and gives credence to the decision making process which may be outside the textbook, thus the evidence based practices which consider client wishes in determining the course of action and the goals.Consider correctability/fixabilityCritical thinking is the determinant for effective decision making.CAAs when used with critical thinking establish correlations among multiple triggered CATs: cause impact PMS/e, associational cases and effectsPromote identification of underlying cause(s), risks, complications: previous baseline, presence of potentially reversible causes. Engenders a proactive plan not a reactive plan.Consider fixability factors: improve, control, minimize decline, prevent complicationsSupports logical care plan linkageCoherent, reliable flow that reflect clear relationships between problem goal, interventions, time lines.Let’s take a quick look at the care plan components and how they correlate on the next slide 11.
  • 1. Identify relevant triggers: what is the relationship of these triggers, ae they related or aren’t they and why. Assess do not assume.Identify type of trigger: potential problem, broad screen, prevention of problem, or rehabilitation potential. Identify the possible causes, contributing factors, and risk factors : Think holistically: PMSEAnalyzing and draw conclusions: Think critically! What are the cause and effect relationships, can they be changed, eliminated, how can they best be addressed? Think in terms of if, then. 5. Develop a PERSONALIZED, resident-specific care plan based directly on conclusions including insight of IDT members, resident, significant others.EXPERIENTIAL EXERCISE:Complete modified CAA on self.Address underlying problemsUnderstand nature of conditionConsider causes and contributorsHighlight and underscore strengthsCome to a decision providing rationale about the need to act or not act
  • What is the relationship between the BIMS, CPS and MMSE?
  • In testing 90 percent of residents were able to complete the BIMS. The CPS will still be computed for purposes of walking back info to RUGs III until 10/2011
  • Used by primary care clinicians in diagnosing depression as well as selecting and monitoring treatmentTwo components of the PHQ-9: • Assessing symptoms and functional impairment to make a tentative depression diagnosis • Deriving a severity score to help select and monitor treatment Complete PHQ on self
  • CAA EXPECTATION #1Promotes identification of cause and effect relationships, contributing and complicating factors and risk identificationCAA EXPECTATION #2Correlates triggering relationships and implications among multiple triggered CATs.
  • Functional Status: The conditions identified by the RAI should be clearly linked to the problematic issues/conditions addressed on the care plan. PROBLEM and Impact2. Rehabilitation/Restorative Nursing: A resident’s potential for physical, occupational, speech, psychological, respiratory, and other types of rehabilitation should be assessed and addressed by care planning. 3. Health Maintenance: monitoring disease processes that are currently being treated. The IDT may also decide whether or not to list on the care plan a problematic issues/conditions that no longer affect the resident, are controlled, or need no monitoring. Other areas of health maintenance may include terminal care and special treatments such as peritoneal dialysis or ventilator support. 4. Discharge Potential: Discharge potential for each resident needs to be assessed at admission, annually, and as needed. 5. Medications: The nursing home initially and periodically must conduct comprehensive assessments of a resident’s needs including ADE and ADR MMR6. Daily Care Needs: needs wants times etcmethods
  • List 4 of 9 content areas for care plan to meet standards of practice.
  • Recent study OIG: Care plans, goals, diagnosis, planned interventions, and projected outcomes were absent between 18 percent and 45 percent of the time. many of the care plans reviewed did not convey the specific information necessary to carry out the necessary care and services.
  • What does this mean? What does your voice say? What would that look like if it were occurring?It’s about being heard.Exercise: last time you had difficulty understanding or being understood.
  • Consider the scope, severity, and stability of the identified problems and needs to facilitatepriority problem recognition and balanced care plans. 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 planning needs and actions, along with your input onthe stability of the problem, goal, and / or plan.
  • Determining interventions. Each team member should ask: Is there anything I can offer to help with this problem? Do I have ideas that may be of use?.Interventions must reflect the relationship to the problem and goal. This is automatic if you have considered the preceding rules.
  • The discipline with the greatest ownership for the problem must take the responsibility to insure the plan is being properly implemented. The discipline should also be evaluatingeffectiveness of the plan between team meetings. The frequency of the evaluation will be dependent on the scope, severity and stability of the problem/need.
  • Before implementing plans consensus must be sought with resident, family, and those responsiblefor implementation. Hopefully that will be a formality if involvement was sought and obtained priorto plan development…….. a feasible plan will most likely have fallen into place.
  • The primary purpose of documentation and recordkeeping systems is to facilitate information flow that supports the continuity, quality, and safety of care. Since recordkeeping systems serve multiple purposes (e.g., legal requirements, regulatory compliance, accreditation, accountability, financial billing, and others) a summary, centralized in one location can keep conflicts to a minimum.
  • Transcript

    • 1. From Paper to Person
      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
    • 2. Debbie Ohl RN, M.Msc., PhDOhl and AssociatesLong Term Care ConsultantsDebbie@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 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 that thoughts, feelings, and actions have on ourselves and those we serve.
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 3. Tennessee’s Top Deficiencies
      Not in handouts
      Given care & services to get or keep the highest quality of life possible.
      Develop a complete care plan within 7 days.
      Prepare care plan with the care team.
      Check and update the care plan.
      Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.
      Give professional services that follow each resident's written care plan.
    • 4. Quality … Degree of excellence or worth
      Life… A manner or way of existing
      Autonomy… Self-governance, self-sufficiency
      Quality of Life
      RAI… The path to improvement.
    • 5. Getting to the Care Plan
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 6. 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.
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 7. Program Objectives
      Discuss the expectations of person centered care planning.
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 8. Not on handout
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
      "Person-centered planning begins when people decide to listen carefully and in ways that can strengthen the voice of people who have been or are at risk of being silenced.”
      John O'Brien
      A Little Book about Person Centered Planning
    • 9. 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
    • 10. Program Objectives
      Discuss the three primary content areas to be considered in care planning.
      P
      C
      P
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 11. Evolution of Care Planning
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 12. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
      1935
      • Poor houses
      • 13. SSA established public assistance
      • 14. For profit homes proliferate
      1950
      • SSA requires States to license NH
      • 15. 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
      Comprehensive Welfare Reform Act funds state survey and certification to establish uniform standards and conditions.
      Emphasis is on institutional framework: CAPACITY to deliver care.
    • 16. 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.
    • 17. 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
      Interdisciplinary Team 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.
      • 18. Increased expectations in terms of documentation and care delivery.
      • 19. RAPS about paper not process.
    • 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.
    • 20. 2010Quality of Care Actualized
      Quality of Life Comes to Forefront
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 21. Terms for Care Planning
      RAI
      MDS
      CATs
      CAAs
      CPGs
      EBPs
      SOP
      Decision Trees
      PCP
      Critical thinking
      Multidisciplinary
      Interdisciplinary
      Transdisciplinary
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 22. Terminology
      • RAI Resident Assessment Instrument
      • 23. MDS Minimum Data Set
      • 24. CATs Clinical Assessment Triggers
      CAAs Clinical Assessment 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
    • 25. Clinical Assessment Areas CAA’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
    • 26. RAP CAA
      Possible problems in 18care 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
    • 27. CAA Resources
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 28. CAA Completion
      Psychosocial Well Being
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 29. CAA 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
    • 30. CPGs Clinical 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
    • 31. EBPs Evidence Based Practices
      Conscientious decision-making based not only on the available evidence but also on patient characteristics, situations, and preferences.
      Recognizes that care is individualized and ever changing and involves uncertainties and probabilities.
      A philosophical approach that is in opposition to rules of thumb, folklore, and tradition.
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 32. SOP Standard 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
    • 33. Decision 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
    • 34. Don’t get bogged down!
      EBP, CPG, Care paths, etc.
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 35. Give me a break!
      15 minutes
    • 36. Terminology Countdown
      • RAI Resident Assessment Instrument
      • 37. MDS Minimum Data Set
      • 38. CATs Clinical Assessment Triggers
      • 39. CAAs Clinical Assessment Areas
      • 40. EBPs Evidenced Based Practices
      • 41. CPGs Clinical Practice Guidelines
      • 42. SOPs Standards of practice
      PCP Person Centered Planning
      CT Critical Thinking
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 43. Person Centered Care
      How does person centered care differ from resident centered care?
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 44. Not in handouts
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
      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.
      “When People Matter More Than Systems” Keynote Presentation for the Conference “The Promise of Opportunity”, Albany, NY, March 2000, Michael Kendrick PhD
      Person-centered care is an idealistic approach to resident care thatbecame common around 1985. It was designed to allow people with developmental disabilities to have a voice in their lives and to facilitate self determination. By the late 1990’s the concept had filtered into other areas of health care.
    • 45. Not in handouts
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
      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.
      Introduction to Person-Centered Planning, Cornell University. http://www.ilr.cornell.edu/edi/pcp/course01.html
    • 46. Critical Thinking Underpins the CAA Process
      The identification and evaluation of evidence to guide decision making.
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 47. Critical Thinking
      Gathers and assesses relevant information.
      • Raises questions and problems
      • 48. States them clearly and precisely
      • 49. Comes to well-reasoned conclusions and solutions
      testing them against relevant criteria and standards;
      Thinks open-mindedly within alternative systems of thought, recognizing and assessing: if, then
      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
    • 50. Summarize your learning.
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
      Slide moved forward
    • 51. Your Job
      To interpret and address the Care Areas identified by the CATs and develop an individualized care plan that keeps the person at the center of all activities.
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 52. Lunch Time 
    • 53. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 54. Care Planning Teams
      Team A group of people with a common purpose
      Discipline Relating to a particular field of study
      • Multidisciplinary Many
      • 55. Interdisciplinary Between and among
      • 56. Transdisciplinary Strategy that crosses many disciplinary boundaries to create a holistic approach
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 57. Care Area Assessments
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 58. CAA Review
      Identify relevant triggers.
      Identify type of trigger.
      Identify the possible causes, contributing factors, and risk factors .
      Analyzing and draw conclusions.
      Develop a personalized, resident-specific care plan based directly on conclusions including insight of IDT members, resident, significant others.
      42
    • 59. Tools, Tips & Clarifications for Care Planning
      BIMS
      CPS
      MMSE
      PHQ-9
      Issue
      Problem
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 60. BIMS
      Brief Interview for Mental Status
      Interview process used to test the resident’s memory
      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
    • 63. PHQ9
      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
    • 64. 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
    • 65. 10 Care Plan Must Have’s
      Preventing avoidable declines.
      Managing risk.
      Addressing resident strengths.
      Using standards of practice in the care planning process.
      Evaluating treatment objectives and outcome.
      Respecting right to refuse treatment; offering alternatives.
      Using an inter/trans disciplinary approach.
      Involving family and other resident representatives.
      Assessing and planning to meet the needs of new admits.
      Involving the direct care staff with care planning.
      Debbie Ohl & Associates LTC Consultants & Educators MDSCare PlanBuilder.com ThinkTheThoughts.com
    • 66. Six general care planning areas
      Functional Status
      Rehabilitation/Restorative Nursing
      Health Maintenance
      Medications
      Daily Care Needs
      Discharge Potential
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 67. Content areas for Compliance
      Maintaining and enhancing quality of life as defined by the resident.
      Unstable health conditions.
      Pain management.
      New areas of risk: falls, skin, dehydration, etc.
      New problems requiring use of psychoactive medication to correct or control.
      Medications with high risk for side effects, or adverse drug reactions.
      7. Wounds, pressure ulcers.
      8. Medicare RUGs (reason for coverage) skilling services.
      9. Acute problems
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 76. Components of the Care Plan
      Care Plan Statement
      1
      7
      6
      2
      5
      3
      4
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 77. 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 4Quadrants
      Risk
      Strengths
      Resident Input
      Fix ability
      Fix it
      Improve it
      Maintain it
      Control it
      Slow the decline
      Minimize/prevent complications
      What does the resident want??
      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
      Oversightmeans monitoring for effectiveness
      Review Date based on SSS
      Interim
      Or
      Expected to be met
      Care Plan Guidance
      Resident Input
    • 78. 3. Developing Goals
      Goals must be measurable enough to readily identify if the plan is working.
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 79. 2. Resident Voice
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
      What I see as my main problem.
      What I need to do.
      Why it’s important to me.
    • 80. 4. Target Dates Meet Goal or Check Progress
      These need to be based on the scope, severity and stability of the particular problem.
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 81. Consider the Scope, Severity, and Stability
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 82. Not in handouts
      The Ohl Modified Enforcement MatrixDetermining SSS of Problem for care planning
    • 83. 5. ApproachesDetermining Interventions & Actions
      Interventions must reflect the relationship to the problem and goal.
      Each team member should ask: Is there anything I can offer? Do I have ideas for others that may be of use?
      What does the resident want?
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 84. 6. Monitoring a. Deciding on Accountability
      The discipline with the greatest ownership for the problem holds the accountability for plan implementation and modification between scheduled reviews.
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 85. 6. Monitoring b. Implementation
      Before implementing, consensus must be sought with resident, family, and those responsible for implementation.
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 86. Care Plan Formats
      Common 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
    • 87. “I” care plan sample SKIN
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
      I-Format Care Plans http:// paculturechangecoalition.org
      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.
    • 88. 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 my 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.
    • 89. 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
    • 90. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
      Taken from web site on I care plans
    • 91. Care Plan with Pain as the Root Problem
      Components of Pain Care Plan: Analgesia, Quality of Life, Ability to Function
    • 92. 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
      • 93. Status of goals
      Met
      Unmet
      Rationale
      • New areas of concern
      Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com
    • 94. 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?
    • 95. Person Centered Care Planning
      What do we live for, if it is not to make life less difficult for each other?
      George Eliot

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