Person-centered care planning principles and standards
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How to care plan: when, where, how, why, who. Learm how to create person centered care plans that imporve quality of life, satisfy regulators, and make areal difference
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Person-centered care planning principles and standards
- 1. Meeting Professional Standards of Practice Care Planning Debbie Ohl RN, NHA, M.Msc. Ohl & Associates Consultant and Educator THINKTHETHOUGHT.com MDSCAREPLANBUILDER.com
- 6. The Ohl Modified Enforcement Matrix Determining SSS of Problem for care planning Degree of the Problem Isolated Rarely happens or Not very often Pattern Certain times Places Circumstances Widespread Unpredictable Constant Cannot anticipate Out of control Serious Negative outcomes have or are occurring J K L Is a big Deal Significant concerns, negative outcomes / problems have occurred or are occurring but not life threatening G H I Could be a big deal Concern warranted, risk for negative outcome could be likely D E F No big deal Not a true concern A B C
- 23. Improving Care Plan Writing Skills
- 29. Issue Based Problem Based Here & Now Depressed, makes negative self statement Exhibits depression as evidenced by: lack of attention to personal appearance, grooming and negative self statements about her appearance. . Agitated during care Agitated during care as a result of poor comprehension creating risk for injury to self or staff and poor hygiene.
- 31. Issue or Problem? Care Plan Statement Issue Problem Both Decompensates and strikes out if feels rushed Constantly complains about roommate. Cries at intervals for no apparent reason. Chronic re-occurring pressure ulcers secondary to left sided dependence and frequent refusal to change positions. Frequent Fecal Impactions R/T chemo therapy and use of narcotics resulting in pain, discomfort & loss of appetite. Inability to be understood.
- 33. Is the Goal Measurable? Appropriate? Care Plan Statement Goal M A Wanders out of activities. I P B Will stay for entire activity. Frequently incontinent of urine. I P B Will not fall, skin will remain intact and free of rash. Brittle diabetic, refuses to comply with diet restrictions Will comply with diet
- 40. Care Plan Content Areas
- 45. Care Plan Guidance Problem / Need Strength Scope, Severity, Stability Built by: MDS worksheet RAP CEA Interventions Approaches Clear Concise Do-able Done Review Dates & Places Nurse’s Notes Progress notes IDT notes Goal (s) Related Linked Measurable Reasonable Do-able Responsibilities Oversight Delivery Content Contains Issue Reason Impact 4 Quadrants Fix ability Fix it Improve it Maintain it Control it Slow the decline Minimize/prevent complications Use the 4 Quadrant What physically mentally socially emotionally? Ask each discipline: what can you offer? Deliver y means insuring consistent implementation Oversight means monitoring for effectiveness Review Date based on SSS Interim Or Expected to be met
- 51. What do we live for, if it is not to make life less difficult for each other? - George Eliot Person Centered Care Planning
Editor's Notes
- Questions were designed to determine: (a) who was included in the multidisciplinary care planning team, (b) the steps and activities specific to the respective facility's care planning process, (c) each member's role related to each activity, (d) the time spent by personnel in each activity, (e) whether other problem-focused meetings were conducted in which decisions were made about an individual resident's care, (f) the personnel and time involved in relevant problem-focused meetings increasing their efficiency and reducing the number of deficiencies related to the care planning process care planning activities rate and problem-focused meeting rate; quality of the care planning process
- Consider the scope, severity, and stability of the identified problems and needs to facilitate priority problem recognition and balanced care plans. This will help to prevent putting the cart before the horse! We sometimes try to address everything all at once because we are worried if it’s not on the plan we will get a deficiency……..which sets everybody up for failure. Placing too much data on the care plan can doom it to failure. Sometimes you cannot deal with one problem until you have solved another! When this is the case, provide a note of explanation as to your thinking and awareness of the problems to avoid problems with surveyors. Use the same scope and severity scale applied by surveyors (when citing deficiencies) to help you prioritize care planing needs and actions, along with your input on the stability of the problem, goal, and / or plan.
- General Care Planning Areas Functional status . Compromise will result in some type of care planning dependent on where and how it impacts the person. This is a primary function of the RAPs. Rehab & restorative nursing . Includes potential for improvement, maintenance, slowing of decline and management of complication risk factors. Health maintenance. Monitoring stable and unstable conditions and disease processes. Listing problems that no longer affect the resident, are controlled, or no longer need monitoring is a team decision based on how the problem affects the overall functioning or well being of the person. Discharge Potential. Needs to be assessed at admission, annually and as needed. Focus should center on what needs to happen before the person can be safely discharged and/or adjustment problems related to not being able to be discharged. Medications . Medications can be an intervention for a problem or can be a problem in and of itself. As example the use of an Antipsychotic may be an appropriate intervention to treat a schizophrenic or it may have been inappropriately prescribed and require reduction and elimination and/or producing troubling side effects. Daily Care Needs . Standard practice approaches need not be placed on a care plan. Particularly if they are expected facility actions. Daily care needs that are specific to the resident and are out of the ordinary must be addressed on the care plan.
- Activities of Daily Living: staff needs to deliver care Immediate and day to day (short term and continuous) to meet professional standards of practice Quality of care
- Ff know Residents that require supervision, limited assist, extensive assist or total care for any of the activities of daily living
- MDS Coordinator Note: Review the three previous month’s entries for patterns and relationships to Core (RAP) Plan problems in conjunction with quarterly reviews.
- The challenge is identify root problems and determine correctability as well as reversibility or modifiability of the outcomes.
- Newly noted areas of risk such as falls. Skin, dehydration, etc. If the risk does not materialize after the first quarter you can consider moving to the core plan section. Out of control behavior problems, pain management problems, drug reduction, new problems requiring use of psychoactive medication to correct or control. Unstable health conditions, medications with high risk for side effects, or adverse drug reactions. Wounds, pressure ulcers, acute problems such as falls, new pressure sores, unplanned weight loss or gain, elopements, resident to resident abuse, UTI’s, URI’s, etc. Medicare RUGs (reason for coverage) skilling services.
- Regulations require resident problems and needs to be care planned. The format and method for doing so is an individual facility decision. The intention of the regulation is to insure that the care plan identifies the problems and needs and is known and followed. Too often, acute problems are noted after the fact, if at all. Care planning completed after the fact results in a paper compliant attempt to meet the regulatory requirement. In reality however, it does nothing except take up valuable time in a useless exercise. Outcomes are dependent on caregiver knowledge and use of the care plan. Citations are issued for failing to know and follow the care plan and can result in a deficiency determined to have been avoidable…all because of care plan lack of presence or lack of knowledge and/or lack of use. To be successful care plans must be accessible, used, followed and reviewed. This can only happen when they are readily available, and staff does not have to play seek and find on top of the hectic pace they run each shift, everyday! Immediate Need Care Plans (INPOC) are intended to address the problems and needs that require day to day intervention, monitoring or both. If they are buried in the body of a long term care plan they are not used. The immediate need care plan is designed to readily identify and locate resident plans on a day to day basis, dramatically increasing the rate of use and compliance
- incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much bladder function as possible.
- Decide if you are dealing with an issue or a problem; a core problem or an outcome problem caused by something else. Determine if it impacts the resident, environment or Both
- Directions 1.) For listed items indicate if the statement, as written, is an issue, a problem or both. For those you identify as problems only write a measurable goal. In the blanks at the bottom, give one example of a problem statement and one of an issue using a care plan example from your facility (a test of your memory!).
- You will find it difficult if not impossible to develop measurable, do-able, appropriate goals if your problem statement is addressing an issue instead of a problem. If there is ever any doubt about the level of goal development always shoot for the highest goal first. Just be careful not to dis-able the resident or the team with unrealistic, unattainable goals
- Directions : Indicate if goal is measurable and appropriate. Discuss your rationale. Hint: Involves reviewing the care plan statement.
- The team must clarify who will hold the accountability for oversight. Don’t assume everyone knows. Consider using the last listed discipline as the vehicle to reflect this. Oversight does NOT mean day to day supervision of implementation. It means periodically checking. If the plan is not being implemented or implemented incorrectly the chain of command must be followed to correct the problem. The last thing people need are more bosses!
- Target dates are not always three months. Consideration must be given to the scope and severity of the problem. This doesn’t necessarily mean that a team meeting must be held for every goal developed outside of three months. It means that the responsible discipline noted above will check the plan on that date, make a note, and take action accordingly.
- Monitoring stable and unstable conditions, disease processes, or high-risk areas.
- Compromise will result in some type of care planning dependent on where and how it impacts the person and the type of support needed. ADL Directive’s The intention of the ADL care plan is to provide ready access and specific information to the primary care giver to meet the ADL needs of the resident while enhancing resident self performance and participation where possible. In order for the ADL Directives to be effective they must be used! Used means accessible and user friendly, with content that provides meaningful, helpful information. This eliminates the practice of keeping them on the chart (too many barriers, too much time to review for the primary care giver).
- Goals will includes potential for improvement, maintenance, slowing of decline and management of complication risk factors.
- Medications can be an intervention for a problem or can be a problem in and of itself. As example the use of an antipsychotic may be an appropriate intervention to treat a schizophrenic or it may have been inappropriately prescribed and require reduction and elimination and/or producing troubling side effects.