ABCs of Care Planning

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In February 2013, the Office of Inspector General (OIG) released a report entitled Skilled Nursing Facilities Often Fail to Meet Care Planning and Discharge Planning Requirements, in which they found that 26% of facilities fail to meet care planning and discharge planning requirements. Is your facility meeting federal guidelines for care planning?
Download the ABC’s of Care Planning presented by Beckie Dow, RN, RAC-MT for an overview of Care Planning in the Skilled Nursing Facility. Beckie discusses the important link between the MDS 3.0, the Care Area Assessments (CAAs) and the Care Plan.
Learn the essential components of a resident-centered care plan and how to develop a care plan that supports the clinical care that is provided to the patient. Beckie also discusses strategies for completing the CAAs more effectively and using the CAA process to create a more resident-specific care plan.

Learn How To:

1. Define the purpose of a Care Plan.

2. Define the purpose of the Discharge Care Plan and Summary.

3. Identify the correlation between the MDS 3.0 Assessment, the Care Area Assessments (CAAs), accurate RUG-IV Classification, and the Care Plan.

4. List three components of a Resident-centered Care Plan.

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ABCs of Care Planning

  1. 1. The ABCs of Care Planning HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Beckie Dow, RN, RAC-MT Director of MDS/Nursing Program Development
  2. 2. Speaker Bio Over 20 Years Experience in Long-term Care Clinical and Reimbursement Accuracy in Assessments Quality Assurance Activities Interrelation between MDS, Care Planning, QA and Clinical Excellence at the Bedside AANAC Master Trainer Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  3. 3. Today’s Objectives Define the purpose of the Care Plan Define the purpose of the discharge Care Plan and summary Identify the correlation between the MDS, CAAs, accurate RUG-IV classification, and the Care Plan List three components of a resident- centered Care Plan Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 3
  4. 4. OIG Report February 2013 Used 2009 stay data Sample of 190 stays that projects to 1,104,692 stays in the population For each stay the OIG determined if care plans contained measureable objectives and detailed time frames for the following eight categories of service (see next slide) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 4
  5. 5. OIG Report February 2013 Scheduled toileting plans or bladder retraining programs Parenteral IV or feeding tubes Skin treatments Speech, occupational, and physical therapy Respiratory therapy Restorative nursing services Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 5
  6. 6. OIG Report Findings The OIG found that: 74% of NHs surveyed in 2007 had at least one deficiency related to quality of care SNFs often did not develop appropriate psychosocial services Care Plans or provide all services identified in Care Plans SNFs failed to meet one or more Medicare requirements for beneficiary assessments or Care Plans about atypical antipsychotics Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 6
  7. 7. OIG Report Findings The OIG found that: There were quality-of-care problems with beneficiaries discharged between SNFs and other facilities There were quality-of-care problems within the SNFs, including development of pressure ulcers, malnutrition, dehydration, side effects from not receiving medications, and inadequate staffing levels leading to poor patient outcomes Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
  8. 8. OIG Report Recommendations to CMS Strengthen the regulations on Care Planning and Discharge Planning Provide guidance to SNFs about Care Planning and Discharge Planning Increase surveyor efforts to identify SNFs that do not meet Care Planning and Discharge Planning requirements and hold these SNFs accountable Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8
  9. 9. OIG Report Recommendations to CMS Link payments to meeting quality-of- care requirements Follow up on SNFs who failed to meet Care Planning or Discharge Planning requirements or who provided poor quality care Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9
  10. 10. Medicare Requirements Related to Quality of Care Develop a Care Plan for each beneficiary and provide services in accordance with the Care Plan Provide services to attain or maintain the highest practicable physical, mental, and psychosocial well being of each beneficiary in accordance with the Care Plan Plan for each beneficiary’s discharge to ensure safe transition to next care settings Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10
  11. 11. Steps of the Nursing Process 1. Assess 2. Diagnose 3. Outcomes / Planning 4. Implementation 5. Evaluation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 11
  12. 12. Developing the Care Plan The resident Care Plan should be based on: Resident’s strengths Resident’s weaknesses Health issues and conditions Residents unique characteristics, strengths, and needs Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 12
  13. 13. Developing the Care Plan The Care Plan must: Be based on a thorough resident assessment Evidence effective clinical decision making Be compatible with current accepted standards of practice Will provide a strong basis for optimal approaches to quality of care and quality of life needs of the resident Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13
  14. 14. Care Plan to Support Level of Services Care Plan shows how we plan to provide services to the patient Lack of medical record documentation for RUG-IV items on the MDS may create the appearance of fraud Care Planning from our Care Area Trigger (CAT) items will show that we are meeting the clinical needs of our patient in accordance with the plan of care Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14
  15. 15. Harmony Healthcare International, Inc. 15 Goal of the RAI process The delivery of care to meet the needs of a resident is based upon the completion of a comprehensive assessment and the development of a Care Plan based upon the MDS Copyright © 2013 All Rights Reserved
  16. 16. RAI Process The facility must develop a care plan that meets these guidelines: Individualized Comprehensive Measureable goals Timetable to meet the goals KEY POINT: The Goal of the RAI Process is the Care Plan Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 16
  17. 17. Resident Participation in the Care Plan The resident has the right to participate in care planning and treatment or changes in care and treatment The facility should encourage and assist the resident to participate in choosing care and treatment options F-280 Care Plan (broad tag) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 17
  18. 18. Resident Participation in the Care Plan F-280: “The resident has the right to, unless adjudicated incompetent or otherwise found incapacitated under the laws of the State, participate in planning care and treatment or changes in care and treatment” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 18
  19. 19. Resident Participation in the Care Plan Surveyors are instructed to look for evidence that the resident was afforded the right to participate in care planning or was consulted about care and treatment changes Surveyors will ask the resident or their representative during survey Includes attending care plan conferences, if the patient desires Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19
  20. 20. Resident Participation in the Care Plan The resident has the right to refuse treatment and to select among treatment options before the care plan is instituted Facility staff must make the process easy to understand for the resident or family Residents questions and concerns must be addressed by the facility Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20
  21. 21. CAA Process When implemented properly, the CAA process should help staff: Develop, to the extent possible, interventions to help improve, stabilize or prevent decline in physical, functional, and psychosocial well-being, in the context of the resident’s condition, choices, and preferences for interventions Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 21
  22. 22. CAA Process When implemented properly, the CAA process should help staff: Address the need and desire for other important considerations, such as advanced Care Planning and palliative care; e.g., symptom relief and pain management Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22
  23. 23. Harmony Healthcare International, Inc. 23 Care Area Assessments 1. Delirium 2. Cognitive Loss/Dementia 3. Visual Function 4. Communication 5. Activity of Daily Living (ADL) Functional/Rehabilitation Potential 6. Urinary Incontinence and Indwelling Catheter 7. Psychosocial Well-Being 8. Mood State 9. Behavioral Symptoms 10. Activities 11. Falls 12. Nutritional Status 13. Feeding Tubes 14. Dehydration/Fluid Maintenance 15. Dental Care 16. Pressure Ulcer 17. Psychotropic Medication Use 18. Physical Restraints 19. Pain (NEW) 20. Return to Community Referral (NEW) Copyright © 2013 All Rights Reserved
  24. 24. Discharge Planning When the SNF anticipates the discharge of a beneficiary to another care setting or home it must plan for the discharge As part of this planning the SNF must develop a discharge summary to help ensure coordination of care and safe transition to the new setting Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 24
  25. 25. Discharge Planning The discharge summary should include: A summary of the beneficiary’s stay A summary of the beneficiary’s status at the time of discharge A post-discharge Plan of Care, including: Beneficiary’s and family’s preferences How the beneficiary will access services How care will be coordinated among caregivers Discharge education and instructions Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 25
  26. 26. Discharge Planning The discharge summary should provide an adequate clinical picture of the beneficiary and detailed individualized care instructions to ensure that care is coordinated and that the beneficiary transitions safely from one care setting to another The interdisciplinary team, including the physician, should participate Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 26
  27. 27. Questions/Answers Harmony Healthcare International 1 (800) 530 – 4413 Bdow@harmony-healthcare.com www.harmony-healthcare.com Harmony Healthcare International, Inc. 2727Copyright © 2013 All Rights Reserved
  28. 28. Please Join Us! Effective Care Planning August 21, 2013 10:00-11:00 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 28
  29. 29. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Benchmark your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc. 29Copyright © 2013 All Rights Reserved

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