This document discusses a study on assessment and care planning tools, processes, and perspectives for older people in long-term care settings in Ireland. The study found that while standardized tools were commonly used for some domains like dependency, other domains relied on clinical judgement. Assessment and planning were primarily done by medical and nursing staff with little input from others. Respondents saw benefits like continuity of care but also drawbacks like the time-consuming nature of care plans. Standardization could improve care quality but a lack of standardization can lead to issues like inadequate or inappropriate care.

1. Caring about care planning: Tools, processes, training and perspectives on assessment and care planning for older people in long-stay settings in the Republic of Ireland. Dr Martin Power, National University of Ireland, Galway. Mr Eric Vanlente, National Perinatal Epidemiology Centre, Cork.

2. Population ageing DoHC, 2008, p. 19.

3. Care for older people: A changing landscape Introduction of National Quality Standards, HIQA, mid-2009. 32 standards – Standard 10: Assessment: Each resident has his/her needs assessed prior to moving into the residential care setting, a full assessment upon admission, and subsequently as required to reflect changes in need and circumstances. Standard 11: The Resident’ Care Plan: The arrangements to meet each resident’s assessed needs are set out in an individual care plan, developed and agreed with each resident, or in the case of a resident with cognitive impairment with his/her representative.

4. Standardisation ‘a new philosophy and approach’ providing a foundation for ‘evidenced-based geriatric assessment and management’ (Bernabei et al., 2008, p. 308) As such, the introduction of standards in Ireland provides both an opportunity for evaluation and comparison and, a mechanism with which to engage in such processes.

5. Method Postal/online questionnaire. Sample – 250 centres . Response rate – 42.5% (106 centres – 53 private / 53 public). Average number of residents 54 (range 9 - 345). Level of dependency (max, high, medium, low) – Public – over 50% max; decreasing by category Private – roughly equal across categories

6. Questionnaire Comprised of four sections: – basic data (number of residents, dependency levels). – Assessment tools in use. – Processes and training (responsibility for completion, updating, revising, professional input) – Respondents’ perspectives (benefits, drawbacks & obstacles).

7. Section A. Assessment tools in use Respondents were provided with a standard set of response options as well as an open-ended ‘other’ option for each of 11 domains This ‘other’ option allowed for recording of the use of a tool(s) not listed in the standard set of responses or where a tool had been developed/devised in-house/ modified.

8. Domains. A- dependency, mobility and activities of daily living. B - skin condition. C – continence and elimination. D – nutritional/oral health. E - Health conditions and risk factors for illness, accident and functional decline F – Current medication use. G- Dental/oral status. H- Visual limitations and abilities. I -Cognitive ability/patterns and organisation of self-care activities J – Communication, hearing and understanding. K- Mood and behaviour patterns / Psycho-social well-being, adjustment and relationships

9. Findings Standardised tools (often more than one) common in some domains A - dependency, mobility and activities of daily living - Barthel Activities of Daily Living (93%). B - skin condition – Waterlow Pressure Ulcer Risk Ass (67%) Braden Scale for predicting pressure sore risk (34%) Professional/clinical judgement or guidelines employed in other domains G - Dental/oral status. H - Visual limitations and abilities. There were (very) limited responses in some domains ? Modification of standardised tools was not uncommon. In a few cases, tools devised in-house were favoured.

10. Recording of information in relation to – Identification and background. Activities and interests. Special treatments, therapies or treatment programmes. Findings. General use of a specific form (eg. NHI ‘resident core details’). Almost no use of off-the-shelf tools (eg. ‘A key to me’).

11. Section B Processes surrounding assessment and care planning Professionals that most often contribute to the average care plan Medical (eg. GP, geriatric nurse) 93% Health care (eg. OT, SLT) 07% Social (eg. Social worker, carer) 00%

12. Staff member co-ordinating completion of care plans Director of nursing 33% Nurse 58% Carer 00% Other 09% Staff member co-ordinating addition of progress notes Director of nursing 13% Nurse 81% Carer 01% Other 05%

13. Frequency of addition of progress notes Daily 55% Weekly 02% Monthly 03% As required 40% Frequency of care plan revision Monthly 28% Quarterly 71% Biannually 00% Annually 01%

14. Care plan availability to resident/representative Always 51% Usually 20% Sometimes 12% Rarely 10% Never 07% Specific care plan related training received Internal/in-house 65% External 36% Both 13%

15. Training courses (most common by staff category)

16. Care plan format Paper based 77% Electronic/computerised 14% Mixture of both 09% Findings Planning largely the preserve of medical/healthcare professionals, with little input from carers. Care document/care lead? – updated daily v as required.

17. Section C Respondents’ perspectives on care planning 3 open ended questions What do you see as the benefits of care plans? What do you see as the drawbacks of care plans? What do you see as the obstacles to completing care plans?

18. Benefits (n=90) Continuity of care (intra-inter-professional working) 47 Promotes person-centredness 41 Promotes structured approach to care process 18 Helps to meet regulatory/legal requirements 15 Improves quality (quality specifically mentioned) 09 Promotes family involvement 08 Improves organisational efficiency 06 Helps to define measurable outcomes 06 Other 04

19. Drawbacks (n=90) Time general 34 Bureaucratic burden (repetitive/boring) 19 Quality (legibility/accuracy/completeness/consistency) 18 Time away from care 13 No drawbacks 11 Appreciation/know-how of staff 09 Time initial (set up) 08 Paper (storage, durability & management) 08 Lack of person-centredness 05 Other 04

20. Obstacles to completing care plans (n=88) Time 52 Lack of appreciation (buy in) and know-how by staff 22 Co-ordination (info to/from residents/MDS/relatives) 19 Lack of resources 14 Accuracy (language/legibility/consistency/completeness) 05 Paper work too Exhaustive 05 Interruptions 05 Updating/changes 04 None 01 Other 06

21. Benefits “Care planning is vital as a way of reflecting on the care needs of our residents. Though there are clear legal benefits the most important issue is caring for a patient's total human needs and not disease specific needs” Drawbacks “nurses find care plans take a lot of time, more often than not aspects of the care plan are omitted, there may be duplication of some information while other relevant information is omitted, the care plan in use is based on a nursing model that may not be appropriate to the individual” Obstacles “Too much writing. Finding time to do so. Interruptions.”

22. Conclusions. Significant variations, with local modification (or devised in-house) common. Absence/lack of specific tools for some domains. Assessment and planning almost exclusive the preserve of medical/nursing staff. Potentially reactive/proactive approaches (updating daily v as required). Significant reliance on paper based approach. General perceived in a positive light, but with necessary evils (time, lack of buy in, bureaucratic burden).

24. - duplication of information (McCormack, 2007).

25. unsystematic care, which does not link assessment and care planning (Stewart, 1999; Hale, 1997).

27. Thank you for you time

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