The RAI Process: CAAs, Care Planning and Beyond

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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 Requirements, in which they found that 26% of facilities fail to meet care planning requirements. Is your facility meeting federal guidelines for care planning? This presentation 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, how to develop a care plan that supports the clinical care that is provided to the patient, and how to proactively maintain a care plan that will meet annual survey requirements. The presentation discusses strategies for completing the CAAs more effectively, and how the CAA process can be used to create a more resident-specific care plan. Learn to develop a resident centered known as ( I careplan) through a workshop discussing different elements of the careplan, from profile, interim, and diagnosis.

1. Gain an understanding of the purpose of a Care Plan.

2. Learn to define the purpose of the discharge Care Plan and Summary.

3. Learn to to articulate the link between the MDS 3.0 assessment, the nursing Care Plan, the discharge Care Plan, and accurate RUG-IV classification.

4. Understand the the correlation between the MDS 3.0 assessment, the Care Area Assessments (CAAs), and the Care Plan.

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The RAI Process: CAAs, Care Planning and Beyond

  1. 1. The RAI Process: CAAs, Care Planning and Beyond HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented by: Coleen Deschenes, RAC-CT Regional Consultant and Christine Twombly, RN, RAC-MT, LHRM Regional Consultant / Trainer
  2. 2. Speaker Bio (Coleen Deschenes) Regional Consultant for Harmony Healthcare International, Inc. Over 20 years of experience in Long-Term Care Certified National Coordinator in NASPAC, specializing in Medicare Regulations, Reimbursement, MDS Accuracy, Mock Surveys, Quality Measures, and MDS Mentoring Former MDS Coordinator, Clinical Financial Operations Manager, and Reimbursement Manager Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 2
  3. 3. Harmony Healthcare International, Inc. 3 Speaker Bio (Christine Twombly) Clinical Consultant and Trainer with Harmony Healthcare International (HHI) Over 26 years of experience in Long-Term Care Certified Gerontological Nurse Certified AANAC Master Teacher and Certified Resident Assessment Coordinator (RAC-CT) Licensed Health Care Risk Manager (LHRM) Hands-on experience with MDS assessments and related care planning Extensive experience with SNFs to conduct Medicare documentation and billing compliance assessments and providing assistance with third-party medical review and the appeals process Copyright © 2013 All Rights Reserved
  4. 4. RAI Process: CAAs, Care Planning and Beyond Disclosures: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclose Planners: Elisa Bovee, MS, OTR/L Diane Buckley, BSN, RN, RAC-CT Beckie Dow, RN, RAC-MT Keri Hart, MS CCC, SLP, RAC-CT Kristen Mastrangelo, OTR/L, MBA, NHA Christine Twombly, RNC, RAC-MT, LHRM Presenters: Christine Twombly, RAC-MT, LHRM Coleen Deschenes, RAC-CT Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 4
  5. 5. Harmony Healthcare International, Inc. Communication & Coaching: A Nurse’s Guide to Creating a Harmonious Atmosphere Disclosure Speakers: Christine Twombly, RAC-MT, LHRM Coleen Deschenes, RAC-CT The speaker has no relevant financial relationships to disclose The speaker has no relevant nonfinancial relationships to disclose Copyright © 2013 All Rights Reserved 5
  6. 6. Harmony Healthcare International, Inc. The RAI Process: CAAs, Care Planning and Beyond Criteria for Successful Completion Complete Sign-in and Sign-Out on Attendance Form Attendance for entire session Completion and submission of speaker evaluation form. Copyright © 2013 All Rights Reserved 6
  7. 7. The RAI Process CAAs, Care Planning and Beyond Objectives The learner will be able to define the purpose of the Care Plan The learner will be able to define the purpose of the discharge Care Plan and summary The learner will be able to identify the correlation between the MDS, CAAs and the Care Plan, Discharge Planning The learner will be able to list three clinical areas a resident-centered Care Plan should address Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 7
  8. 8. OIG Report February 2013 In Fiscal Year (FY) 2012, Medicare paid $32.2 billion for SNF services To participate in Medicare, SNFs must meet certain quality-of-care requirements These requirements are essential to ensuring that beneficiaries receive appropriate care and safe transitions Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8
  9. 9. OIG Report February 2013 SNFs must develop a Care Plan for each beneficiary and provide services in accordance with the Care Plan SNFs must plan for each beneficiary’s discharge to ensure a safe transition from one setting to another The Office of Inspector General (OIG) has identified a number of problems with the quality of care provided Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 9
  10. 10. OIG Report February 2013 Used 2009 stay data Sample of 190 stays that projects to 1,104,692 stays in the population Evaluated whether Care Plans contained measureable objectives with detailed time frames and whether services were provide in accordance to the Care Plan for the following categories of service: (see next slide) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10
  11. 11. 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. 11
  12. 12. Requirements Percentage of Stays in Which SNFs Did Not Meet Requirements Medicare Payments for Stays in Which SNFs Did Not Meet Requirements Care Plan Requirements 25.6% $3.1 billion Service Requirements 15.4% $2.0 billion Total 36.7% $4.5 billion Percentage of Stays in Which SNFs Did Not Meet Care Plan or Service Requirements, 2009 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 12 Source: Office of Inspector General medical record review, 2012
  13. 13. Percentage of Stays in Which SNFs Did Not Meet Care Plan Requirements, 2009 Care Plan Requirements Percentage of Stays in Which SNFs Did Not Meet Care Plan Requirements Care Plans address problem areas identified in the assessments 19.2% Care Plans have measureable objectives and detailed timeframes 6.8% Care Plans are developed by an interdisciplinary team 2.1% Total 25.6% Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13 Source: Office of Inspector General medical record review, 2012
  14. 14. 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. 14
  15. 15. 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 resident outcomes Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 15
  16. 16. 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. 16
  17. 17. 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. 17
  18. 18. 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. 18
  19. 19. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 19 The Interdisciplinary Care Plan
  20. 20. The Interdisciplinary Care Plan Serves as a road map that guides all staff involved in the resident’s care Communicates vital resident care information to the entire interdisciplinary team (IDT) Contains specific detailed instructions for achieving resident goals Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20
  21. 21. Overall Focus of Care Plan Preventing avoidable declines in level of functioning or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end of life situation) Managing risk factors to the extent possible or indicating the limits of such interventions Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 21
  22. 22. Overall Focus of Care Plan Addressing ways to try to preserve and build upon resident strengths Applying current standards of practice in the care planning process Evaluating treatment objectives and outcomes of care Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 22
  23. 23. Overall Focus of Care Plan Respecting the resident’s right to decline treatment Offering alternative treatments, as applicable Using an interdisciplinary approach to Care Plan development to improve or maintain the resident’s functional abilities Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 23
  24. 24. Overall Focus of Care Plan Involving resident, resident’s family and other resident representatives as appropriate Assessing and planning for care to meet the resident’s medical, nursing, mental and psychosocial needs Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 24
  25. 25. Overall Focus of Care Plan Involving the direct care staff with the Care Planning process relating to the resident’s expected outcomes Addressing additional care planning areas that are relevant to meeting the resident’s needs in the long-term care setting Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 25
  26. 26. The Resident Assessment Instrument (RAI) Process Similar to the nursing process Goal: Care delivery aimed at meeting resident’s needs based upon the completion of a comprehensive interdisciplinary assessment, Care Plan development and ongoing evaluation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 26
  27. 27. The Resident Assessment Instrument (RAI) Process Assessment The Minimum Data Set (MDS 3.0) assessment is an initial core set of screening, clinical, and functional status elements which forms the foundation of a comprehensive assessment process know as the Resident assessment Instrument (RAI) process Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 27
  28. 28. The MDS is merely a starting point in the comprehensive RAI process MDS accuracy leads to identifying areas that impact resident care The Resident Assessment Instrument (RAI) Process Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 28 Accurate completion of the MDS assessment is critical to Care Plan development Assessment (continued)
  29. 29. The Resident Assessment Instrument (RAI) Process Decision –Making (CAA Process) Care Area Assessments (CAAs) are the link between the problem identification and the Care Plan development Use the CAA process as a guide to expand your assessment findings from the MDS, and then “chart your thinking” Care Areas triggered during the RAI process must be reviewed to determine Care Planning needs Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 29
  30. 30. Care Area Assessment There are 4 parts to each CAA Section I: The Problem Section II: The Triggers Section III: The Guidelines Section IV: The CAA Key Copyright © 2013 All Rights Reserved 30Harmony Healthcare International, Inc.
  31. 31. Harmony Healthcare International, Inc. 31 Care Area Assessment 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 20. Return to Community Referral Copyright © 2013 All Rights Reserved
  32. 32. Care Area Assessment Care Area Trigger (CAT) Specific MDS response indicates that clinical factors are present that may or may not represent a condition that should be addressed in the Care Plan Triggers “flag” conditions for the interdisciplinary team to consider in making Care Plan decisions Copyright © 2013 All Rights Reserved 32Harmony Healthcare International, Inc.
  33. 33. Care Area Assessment The Guidelines The interdisciplinary team reviews the conditions under the CAA guidelines (and other assessment information as needed) to: determine the nature of the problem understand the cause specific to the Resident To get a better understanding of the relationship between the problem conditions and their effects on the Resident Keep asking: how, when and why Copyright © 2013 All Rights Reserved 33Harmony Healthcare International, Inc.
  34. 34. Care Area Assessment Decision Making Determining the severity, functional impact and scope of a Resident’s problems Understanding the causes and relationships between a Resident’s problems Discovering the “what’s” and “why’s” of Resident’s problems Copyright © 2013 All Rights Reserved 34Harmony Healthcare International, Inc.
  35. 35. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 35 CAA Documentation While reviewing each CAA consider: What MDS responses caused this to trigger? What issues or conditions contributed to those MDS responses? Were those issues or conditions addressed in the MDS? Is there a new onset of a problem that the resident did not previously have?
  36. 36. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 36 CAA Documentation While reviewing each CAA consider: Wht MDS responses caused this to trigger? What issues or conditions contributed to those MDS responses? Were those issues or conditions addressed in the MDS? Is there a new onset of a problem that the resident did not previously have?
  37. 37. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 37 CAA Documentation
  38. 38. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 38 CAA Documentation CAA documentation helps to explain the basis of the Care Plan by showing how the IDT determined that the underlying causes, contributing factors, and risk factors were related to the care area condition for a specific resident
  39. 39. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 39 CAA Documentation Documentation for each triggered CAA should describe: The nature of the issue or condition (may include presence or lack of objective data and subjective complaints). In other words, what is the problem for this resident? Causes and contributing factors. Complications affecting or caused by the care area for this resident
  40. 40. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 40 CAA Documentation Risk factors that arise because of the presence of the condition that affect the staff’s decision to proceed to care planning Factors that must be considered in developing individualized Care Plan interventions, including appropriate documentation to justify the decision to plan care or not to plan care for the individual resident Need for referrals or further evaluation by appropriate health professionals
  41. 41. Care Plan Development Care Planning Establishing a course of action that moves a Resident toward a specific goal, utilizing Resident strengths and interdisciplinary expertise Defining the “how” of Resident care Copyright © 2013 All Rights Reserved 41Harmony Healthcare International, Inc.
  42. 42. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 42 Care Planning: Beyond The RAI 42 CFR 483.20(b): Facilities are responsible for assessing and addressing all care issues, regardless of whether or not they are covered by the RAI This includes monitoring the resident’s condition and responding with appropriate interventions
  43. 43. Care Planning: Beyond The RAI The Care Plan should address the following special considerations/strengths, which may or may not be indentified through the CAAS: Copyright © 2013 All Rights Reserved 43Harmony Healthcare International, Inc.
  44. 44. Care Planning: Beyond The RAI Social history Cognitive status and communication Mental well being including mood and behavior issues Mobility issues Vision Dental Improving continence Skin care Nutrition/hydration Comfort Activities Discharge planning Copyright © 2013 All Rights Reserved 44Harmony Healthcare International, Inc.
  45. 45. Care Plan Development The facility must develop a Care Plan that meets these guidelines: Individualized Comprehensive Measureable goals Interventions aimed at meeting the desired outcome Timetable to for completion Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 45
  46. 46. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 46 Linking Assessment and Care Plan
  47. 47. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47 Linking Assessment and Care Plan The Care Plan is driven by: Resident issues and/or conditions Resident unique needs Resident strengths Each resident’s unique characteristics
  48. 48. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 48 Linking Assessment and Care Plan The MDS and CAAs re-evaluates the resident’s status at prescribed intervals (i.e., quarterly, annually, or if a significant change occurs( using the RAI manual as a guide) The Care Plan is then modified to provide individualized care the needs of the patient change
  49. 49. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 49 Linking Assessment and Care Plan The Care Plan must be based on a thorough assessment, effective clinical decision making, and must be compatible with current standards of clinical practice Looks at the resident as a whole with unique characteristics and strengths
  50. 50. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50 Care Planning Process The RAI process (MDS and CAAs) along with any other assessments used to accurately assess the resident’s condition are completed as the basis for Care Plan decision making All tasks can be done by the RN Coordinator, by regulation, but ideally is a cohesive effort of the entire IDT
  51. 51. Care Planning Process Interdisciplinary Team includes: Resident and Family Nursing Physician Activities Dietary Social Services Therapy Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 51
  52. 52. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 52 Care Plan Development A new Care Plan does not always have to be developed after subsequent assessments The IDT team may revise an existing Care Plan using the results of the latest comprehensive assessment.
  53. 53. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 53 Care Plan Development The IDT team should evaluate the appropriateness of the Care Plan continuously and update when there is a clinical change Review and update with Quarterly assessments, and modify as needed Sign and date changes made on the hard copy
  54. 54. 4 Parts of the Care Plan Process Assessment – problem identification through RAI process and in-depth review of clinical data Planning – Goal setting, development of individualized interventions Implementation – Putting plan into place Evaluation – Periodically review progress to goals and revision of established goals or interventions as indicated Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 54
  55. 55. Assessment Collecting, organizing and analyzing data Pre-admission information Hospital Discharge Summary Resident’s Medical record Staff Observations Shift to shift report Interviews Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 55
  56. 56. Care Planning Defining the Issue to be Care Planned Problems: Condition, diagnosis, situation, or behavior that negatively impacts the person, requiring assistance, intervention, or correction by the staff Need (Psychosocial): An emotion, feeling, or social interaction that is important to the person and should be recognized. Strength: An ability, skill, characteristic, or trait a person possesses that should be recognized, encouraged, and/or promoted. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 56
  57. 57. Issue Statement Forming the Problem/Need Statement: A statement of an actual or potential health problem identified through the RAI process Can use functional status or need (limitations or strength) or Nursing Diagnosis Resident centered, not staff centered Should be written in simple terms, not medical terminology. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 57
  58. 58. Problem Statement Sample Problem Statements: Requires assistance when ambulating due to gait disturbance resulting in frequent falls Pain related to recent hip fracture interferes with ADL participation Poor appetite due to mouth pain related to poorly fitting dentures Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 58
  59. 59. Problem Statement Sample Problem Statements : (continued) Strong identification with past occupation as a nurse resulting in desire to attempt to assist fellow residents Finds strength in scientology faith and relies on faith to resolve health concerns Self conscious about appearance due to new colostomy resulting in decreased activity participation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 59
  60. 60. Goal Setting Set goals that target either improvement, prevention, maintenance or palliative outcomes Develop goals that are measurable and have a timeframe for completion or evaluation (the subject, the verb, the modifiers and timeframe) Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 60
  61. 61. Problem Statement May be linked to related factors, etiology, and signs/symptoms Problem statement related to (r/t) associated with (etiology related factors) as evidenced by (signs and symptoms Ex: Left hip pain r/t L hip fracture/surgery as evidenced Resident reports of pain which worsens with movement Facial grimace Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 61
  62. 62. Problem Statement Ensure problem statements are written to identify problems for the resident not the staff For example: “Resident strikes out at the staff during care” The problem for the staff is that the resident is striking out at them, but what is the problem for the resident The resident’s problem can only be identified by doing a “root cause analysis” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 62
  63. 63. Problem Statement To identify and address the resident’s problem in this case the IDT must ask “why” until they are able to identify the reason the resident is striking out during care Is the resident experiencing pain? Is the resident cold? Fearful? Modest? The problem statement should be written to address the resident’s issue Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 63
  64. 64. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 64 Goal Setting
  65. 65. Goal Setting Elements of a Goal Goals should be Resident centered Goals established should be a priority for the Resident not just the staff It is important to ASK the Resident what their goals are Ask about their goals for quality of life and activity involvement If Resident is unable to participate involve the family by asking them to identify what they believe the Resident goals would be Copyright © 2013 All Rights Reserved 65Harmony Healthcare International, Inc.
  66. 66. Goal Setting Elements of a Goal Who Resident, caregiver, staff What The action the Resident/caregiver/staff will demonstrate or state Frequency How often this action will occur Qualifier – amount of times or number of occurrences How far will the Resident ambulate How many activities will the Resident participate in Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 66
  67. 67. Goal Setting Functional Goals Should clearly identify who will do what, with how much assistance, and why this is important Should contain a qualifier to define when the goal has been met Unmet goals at the time of Care Plan review should be evaluated for their continued appropriateness and updated as needed Copyright © 2013 All Rights Reserved 67Harmony Healthcare International, Inc.
  68. 68. Goal Setting Sample Goals: The Resident will be able to eat 50% of each meal without assistance within two weeks The Resident will be able to ambulate 25 feet to the dining room for lunch with rolling walker and staff supervision within 30 days Mrs. Jones will report pain relief to level of no greater than “2”, 30 minutes after pain medication is given. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 68
  69. 69. Goal Setting Objective Goals Activity related goals tend to be related to attending a specified number of activities per week Resident will participate in activities of preference daily through next review Resident will participate in 2 - 3 activities for mental stimulation and socialization through next review Copyright © 2013 All Rights Reserved 69Harmony Healthcare International, Inc.
  70. 70. Goal Setting Objective Goals (Continued) These goals MAY be measurable but do not focus on the highest practicable level of well being The interpretive guidelines for F248 related to Activities indicates that goals such as those above that merely identify how many group activities a Resident will attend are “old and outdated” Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 70
  71. 71. Goal Setting Examples of Poorly Written Goals Resident’s needs will be met Resident will maintain current functional level Resident will maintain independence Resident will continue to ambulate daily Resident will participate in ADLs as able Resident will communicate wants/needs Resident will consume diet served Copyright © 2013 All Rights Reserved 71Harmony Healthcare International, Inc.
  72. 72. The Care Planning Process Examples of Poorly Written Goals Psychosocial conditions tend to be more difficult to establish appropriate goals. Resident will show decreased signs of depression Resident will not hit more than one staff member per week Resident will express satisfaction with social interaction Allow Resident to verbalize feelings Copyright © 2013 All Rights Reserved 72Harmony Healthcare International, Inc.
  73. 73. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 73 Care Plan Interventions Specific, individualized approaches must then be developed. Serve as instructions for resident care and promote continuity of care by all staff. These instructions should be short and concise so they can be easily understood by all staff.
  74. 74. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 74 Care Plan Interventions Developed in accordance with the MD orders Consistent with current standards of practice Goal directed
  75. 75. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 75 Care Plan Interventions Precise approaches help the staff to understand and implement interventions successfully Goals and approaches should be communicated to any staff members who may not have a direct role in developing the Care Plan
  76. 76. Sample Interventions Pain medications per orders Scale (3-10) Tylenol 325mg 2 tabs po q4hrs PRN for mild pain (2 or less on pain scale) Medicate 1/2hr prior to therapy utilizing pain scale Assess pain level utilizing pain scale every shift Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 76
  77. 77. Sample Interventions (continued) Offer relaxation music of choice, resident prefers Yanni, or Classical Offer whirlpool bath for comfort Educate resident for potential side effects of Percocet, lightheadedness, upset stomach, vomiting, sedation, constipation Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 77
  78. 78. Implementation Put your Care Plan into action Communicate Care Plan goals and interventions to resident and responsible staff on all shifts Update C.N. A. assignment sheets Provide feedback during Care Plan meeting Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 78
  79. 79. Evaluation Critically reviewing Care Plan goals, interventions in terms of achieved Resident outcomes Assessing the need to modify the Care Plan Periodically review goals, approaches and staff/Resident adherence to the Care Plan Monitor the Resident’s response to care on a daily basis Reassess quarterly, annually and when the Resident has a significant change Copyright © 2013 All Rights Reserved 79Harmony Healthcare International, Inc.
  80. 80. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 80 Evaluation Evaluate your interventions. Determine whether goal has been met. If the goal has not been met: Were approaches appropriate? Were the approaches carried out? Was the goal appropriate? Was the time frame realistic? Was this really a problem for this resident.
  81. 81. The Care Planning Process Traditional Care Plans: Diagnosis focused using nursing diagnosis format Written by the staff based on what they believe is best for the Resident Interventions focus on standards of practice for diagnosis Care plan written in third person – “Resident will…” Care plan focuses on adapting the Resident to facility routine Copyright © 2013 All Rights Reserved 81Harmony Healthcare International, Inc.
  82. 82. The Care Planning Process Resident Directed Care Plans: Resident focused Resident, family, and staff develop a Care Plan that focuses on the Residents wishes Individualized interventions to meet the Resident’s needs and desires Care plan written in the first person Care plan focuses on continuing the Resident’s lifelong routines during the nursing home stay Copyright © 2013 All Rights Reserved 82Harmony Healthcare International, Inc.
  83. 83. Traditional Care Plan Problem/Need Goal Intervention Alteration in thought process r/t history of CVA and short-term memory loss Resident will be oriented to person, place, time, and surroundings at all times Introduce self during care Provide orientation to day and surroundings with all daily care Place facility calendar in room Invite Resident to attend activities daily provide reminders to attend prior to scheduled activity Encourage attendance at the current events activity Copyright © 2013 All Rights Reserved 83Harmony Healthcare International, Inc.
  84. 84. Resident Focused Care Plan Problem/Need Goal Intervention Short-term memory problem due to recent CVA Paul will use the activity calendar to select activities of choice daily Place the monthly activity calendar in Paul’s room on the wall near his bed During am care please show him the calendar of events for the day and assist in selecting some that will interest him Throughout the day remind Paul of the activities that he plans to attend for the day and assist with finding event Paul enjoys most activities that offer refreshments but he does not enjoying attending activities that involve music of any kind Religion is very important to Paul –be sure to invite him to the Sunday service Copyright © 2013 All Rights Reserved 84Harmony Healthcare International, Inc.
  85. 85. Traditional Care Plan Problem/Need Goal Intervention Resident wanders due to dementia Resident will not wander into other Residents rooms Redirect to appropriate area within facility Encourage Resident to remain in common areas Teach Resident not to enter other Residents rooms Praise for appropriate behaviors Copyright © 2013 All Rights Reserved 85Harmony Healthcare International, Inc.
  86. 86. Resident Focused Care Plan Problem/Need Goal Intervention I like to walk throughout the home and sometimes wander into other Resident’s rooms I will continue to ambulate freely throughout the home daily through the next review I like to walk with the staff. I will walk with you anywhere. If the weather is nice please take me outside for walks after lunch. I do not like to take naps and I will not sit even when I am tired unless you sit with me for a while. I like to play cribbage and checkers – help me find someone who will sit and play with me after dinner Copyright © 2013 All Rights Reserved 86Harmony Healthcare International, Inc.
  87. 87. Traditional Care Plan Problem/Need Goal Intervention Potential for Impaired social interaction r/t adjustment to unit Resident will participate in 2 - 3 activities weekly for mental stimulation and socialization through next review Introduce to roommate and fellow Residents Provide access to a monthly activity calendar Encourage and assist Resident to 2 – 3 activities for mental stimulation and socialization Provide 1:1 visits as needed Praise for appropriate behaviors and offer opportunities for success Encourage rest periods Copyright © 2013 All Rights Reserved 87Harmony Healthcare International, Inc.
  88. 88. Resident Focused Care Plan Problem/Need/ Interests Goal Intervention Maureen enjoys knitting and needle crafts Maureen will continue to knit daily Encourage family to bring in items from home that Maureen has been working on Provide craft box for storage Invite Maureen to attend activities that involve crafts Introduce to Residents with similar interests and encourage them to meet daily with small group knitting clutch Copyright © 2013 All Rights Reserved 88Harmony Healthcare International, Inc.
  89. 89. Resident Focused Care Plan Problem/Need/ Interests Goal Intervention Potential for alteration in nutrition and hydration Resident will maintain adequate nutrition and hydration as evidenced by stable weight (+/-4%) and no s/s of dehydration Diet and consistency as ordered Set up assist PRN Monitor weights PRN Supplements and fortified food as ordered Labs and meds as ordered Monitor for signs and symptoms of dehydration Offer HS snack Encourage fluids daily Report any significant wt changes to RD Copyright © 2013 All Rights Reserved 89Harmony Healthcare International, Inc.
  90. 90. Resident Focused Care Plan Problem/Need /Interests Goal Intervention Since my recent CVA I have being experiencing a decreased appetite resulting in 10 lb weight loss this month To maintain my current weight and regain 5 lbs It helps to have my special adaptive silverware provided by OT at the table during meals I eat better when I sit with my friends Sally and Sue I do not like to brush my teeth prior to eating since the toothpaste alters the taste of my meal; instead just assist me to rinse my mouth prior to meals and brush them after Weigh me once weekly in the am prior to my bath Copyright © 2013 All Rights Reserved 90Harmony Healthcare International, Inc.
  91. 91. Resident Focused Care Plan Problem/Need Goal Intervention Since my recent CVA I have being experiencing a decreased appetite resulting in 10 lb weight loss this month (continued) To maintain my current weight and regain 5 lbs Keep my physician informed of any significant changes in my weight I prefer not to get up too early for breakfast – I like to eat hot cereal and eggs with coffee around 9:30 am If you notice I am not eating offer me snacks- chocolate is my favorite and I always have M&M’s from my family in my room. I also like chocolate protein shakes My daughter often brings in my favorite foods from home please remind me they are available and assist with prep Copyright © 2013 All Rights Reserved 91Harmony Healthcare International, Inc.
  92. 92. The Care Planning Process Quality Probes: Does the Care Plan address the needs, strengths, and preferences identified in the comprehensive Resident assessment? Is the Care Plan oriented toward preventing avoidable declines in functioning or functional status? How does the Care Plan attempt to manage risk factors? Does the Care Plan build on the Resident strengths? Does the Care Plan reflect standards of current professional practice? Copyright © 2013 All Rights Reserved 92Harmony Healthcare International, Inc.
  93. 93. The Care Planning Process Quality Probes: Do the treatment objectives have measureable outcomes? Corroborate information regarding the Residents goals and wishes for treatment in the plan of care by interviewing Residents especially those identified as refusing treatment. Copyright © 2013 All Rights Reserved 93Harmony Healthcare International, Inc.
  94. 94. The Care Planning Process Quality Probes (continued): Determine whether the facility has provided adequate information to the Resident to enable the Resident to make informed choices regard their treatment. If the Resident has refused treatment, does the Care Plan reflect the facility’s efforts to find alternative means to address the problem? Copyright © 2013 All Rights Reserved 94Harmony Healthcare International, Inc.
  95. 95. Care Plan Should Always: Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 95
  96. 96. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 96 Care Plan Should Always: Be a working tool with highlighted areas of discontinued goals with signatures and dates changes as they occur. Address ways to try to preserve and build on the resident’s strengths Apply current standards of practice in the care planning process Evaluate treatment of measureable objectives, timetables, and outcomes of care
  97. 97. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 97 Care Plan Should Always: Respect the resident’s right to refuse or decline treatment Offer alternative treatments, as applicable Use an appropriate interdisciplinary approach to Care Plan development to improve the resident’s functional abilities Involve the resident as appropriate
  98. 98. Surveyors will Probe… Can the staff describe the care, services, and expected outcomes of the care they are to provide? Do the staff have a general knowledge of the care and services being provided by other team members? Does staff understand the relationship of these expected outcomes to the care they provide? Is the staff actually doing what the Care Plan says? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 98
  99. 99. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 99 Care Plan The Federal requirements for care planning in nursing homes are located at 42 CFR 483.20(k)(1) and (2) and are described in the interpretive guidelines in Appendix PP of the SOM The SOM can be found at: http://www.cms.hhs.gov/Manuals/IOM/li st.asp
  100. 100. 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. 100
  101. 101. 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. 101
  102. 102. 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. 102
  103. 103. Final Thoughts Care Plans ensure that the residents needs are met throughout their stay and after discharge Increased scrutiny on the quality and content of Care Plans, as well as resident outcomes, can be anticipated The SNF is required to develop a Plan of Care in accordance with the resident’s individualized needs Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 103
  104. 104. Questions/Answers Harmony Healthcare International 1 (800) 530 – 4413 www.Harmony-Healthcare.com ctwombly@harmony-healthcare.com cdeschenes@harmony-healthcare.com Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 104
  105. 105. 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 Assess 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. 105Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc.

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