Basic Care Planning

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Basic Care Planning

Kathy Sanders RN, RAC-CT, DNS-CTSanders Consulting

Basic Care Planning was developed as an educationalprogram and reference for long-term care staff. To thebest of our knowledge, it reflects current federalregulations and practices. However, it cannot beconsidered absolute and universal. The informationcontained in this workshop must be considered in lightof the individual organization and state regulations. Theauthors disclaim responsibility for any adverse effectresulting directly or indirectly from the use of theworkshop material, from any undetected errors, andfrom the user’s misunderstanding of the material.

Disclaimer

The authors put forth every effort to ensure that thecontent, including any policies, recommendations,and sample documents used in this training, were inagreement with current federal regulations,recommendations, and practices at the time ofpublication.

The information provided in this training is subject torevision based on future updates and clarifications byCMS.

Disclaimer Continued

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The learner will be able to:• Describe the relationship between the RAI process,

the care plan, and quality resident care• Discuss the relationship between the MDS, CAT’s,

CAA’s and the care plan• Discus the role of critical thinking in the care

planning process• List the components of an effective care plan• Define “interim care plan”• Give an example of an “I Format” care plan

Objectives

The care planning requirements reflect the facility’sresponsibilities to provide necessary care planningthat results in care and services to attain or maintainthe highest practicable physical, mental andpsychosocial well-being for the resident.

Introduction

Care planning fosters quality resident care by:• Facilitating communication among the

Interdisciplinary Team (IDT) members• Providing staff with consistent information about

the resident's problems, strengths, and needs• Instructing staff on how to meet the individual

resident’s needs• Allowing updates and revisions according to the

resident's changing needs• Including the resident’s voice and choice

Introduction

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I remember once in my career thinking to myself, “Ishould probably go ask the resident what she thinksof this care plan goal that I set for her,” but thendeciding I didn’t have time. Stop and think for aminute – Whose goals are they? Whose care plan isit? Whose life is it? Remember: What happens to aresident always has been and always will be abouttheir life.

- Carmen Bowman, Former Colorado Department of Health Surveyor

Whose Goals Are They Anyway?

The care plan must aim to address the following:

Care Plan Development

• Prevent avoidable decline• Manage risk factors• Address resident strengths• Evaluate treatment

objectives and care outcomes

• Respect the resident’s right to refuse treatment

• Offer alternative treatments

• Use an interdisciplinary approach

• Involve the resident, family, or other resident representative

• Involve direct care staff in the process

• Use current standards of practice

• CMS’s RAI Version 3.0 Manual, Chapter 4

The RAI Process consists of three basic components:• The Minimum Data Set (MDS) Version 3.0• The Care Area Assessment (CAA) Process• The RAI Utilization Guidelines

Resident Assessment Instrument (RAI) Process

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The critical link between the MDS 2.0 and careplanning results from two key areas:• Care Area Assessments• Care Area Triggers

Links in the(RAI) Process

The Care Area Assessment (CAA) Process is guidedby professional standards of practice and regulatoryrequirements.

It is designed to guide the IDT through thecomprehensive assessment of a resident’s functionalstatus.

What are the CAA’s?

There are 20 CAAs

CAAs

• Delirium• Visual Function• Activity of Daily Living (ADL)

Functional/Rehabilitation Potential

• Urinary Incontinence and Indwelling catheter

• Psychosocial Well-Being• Behavioral Symptoms• Falls• Feeding Tubes• Dental Care• Psychotropic Medication Use

• Cognitive Loss/Dementia• Communication• Pain• Return to Community

Referral• Mood Sate• Activities• Nutritional Status• Dehydration/Fluid

Maintenance• Pressure Ulcer• Physical Restraints

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• Care Area Triggers or CATs are the triggeringmechanisms of the MDS 3.0

• They are specific response options that serve asindicators of the twenty care areas that affectnursing home residents.

• When information entered into the MDS 3.0 triggersa response, additional assessment and care areareview is required.

What are the CATs?

• CAAs are required for the following comprehensiveclinical assessments• Admission Assessments• Annual Assessments• Significant Change in Status Assessments• Significant Correction of Prior Full Assessments

• CAAs may also be used at any time, not just whenan assessment is due, to provide in-depth review ofa care area condition to assist with developmentof a care plan

Using the CAAs

RAI Process Design

Assessment (MDS 3.0)

Decision Making (CAAs)


Care Plan Implementation

Evaluation

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The Bridge from Assessment to Care Planning

• Collecting assessment data in itself is not sufficientto develop an effective plan of care

• Understanding the relevance of the data to thespecific resident’s situation is essential

Critical Thinking

• Definition of Critical Thinking: The intellectualprocess of reasoning, of logically analyzing allavailable data

• Purpose of Critical Thinking: To explore a situation,phenomenon, question, or problem to arrive at ahypothesis or conclusions about it that integratesall available information and can, therefore, beconvincingly justified (Kurfiss, 1988)

Critical Thinking

Critical thinking includes:• Integrating all available information and

eliminating irrelevant information• Using reasoning processes• Exploring a situation to arrive at a hypothesis• Logically analyzing data• Arriving at reasonable conclusions about the

resident’s status, needs, problems, and strengths inorder to create an effective plan of care

Critical Thinking

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• The process of the RAI assessments is thefoundation of care planning in long-term care

• The full RAI Process is designed to result in a plan ofcare that guides ALL levels of the resident’s caregivers.


The Holistic View:

• The facility is responsible for addressing all needsand strengths of residents regardless of whetherthe issue is included in the MDS or CAAs[42CFR483.20(b)]


• The RAI Version 3.0 guides the nursing home team toview residents as individuals who consider both qualityof care and quality of life as significant and necessary.

• The RAI components promote a resident-valuedemphasis.

• The interdisciplinary approach influences the resident’sexperience of care by impacting work practices of theteam.

• A holistic focus helps the IDT generate individualized,person-centered/directed plans of care that guideday-to-day care for residents

The Holistic View

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CMS has defined six general care planning areas itconsiders useful for nursing homes:• Functional Status• Rehabilitation/Restorative Nursing• Health Maintenance• Discharge Potential• Medications• Daily Care needs


• Functional status limitations are identified using theMDS and CATs

• All conditions requiring intervention must appearon the care plan once reviewed in the CAAsprocess

• The conditions identified by the RAI should beclearly linked to problems addressed on the carplan.

Care Plan Development: Functional Status

• Assess and care plan potential for all types ofrehab needs

• Assess and care plan for risks and complications

• Be alert to the need for referrals

Care Plan Development: Rehabilitation/Restorative Nursing

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• Monitoring of disease processes that currently arebeing treated:

• Include stable and unstable conditions that needmonitoring

• If the resident is taking medications for conditions,regular monitoring of edema, vital signs, bloodglucose, etc., should be care planned

Care Plan Development: Health Maintenance

• Terminal care

• Special treatments such as dialysis or ventilatorsupport

Care Plan Development: Health Maintenance

• Assess at admission, annually, and PRN

• In some cases assessment for discharge potentialmay need to be completed with each MDS

• Focus on what needs to be done in order for theresident to be safely and successfully discharged

Care Plan Development:Discharge Potential

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Care Plan should include:

• Intent for the use of the medication

• Non-Pharmacological approaches

• Potential adverse effects (please do not throw food atme – read F329 instead!)

Care Plan Development: Medications

• Goals or expected outcome for the resident

• How to monitor the resident’s progress relative tothose goals

• What actions to take when the progress is not asexpected


F329: Care Plan should include:

• Potential adverse consequences that• Appear in FDA Black-Box Warning• Resident may be particularly susceptible to• May be rare• May have sudden onset• May be irreversible• Impact physical function• Impact psychosocial status• Other possible effects

• Action to take if adverse consequences occur


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Sedatives / Hypnotics

• Include other interventions, such as sleep &hygiene programs, implemented before and whileusing these drugs

• Methods for monitoring for adverse consequences


Gradual dose reductions

• Timing and method

• What to look for in terms of possible adverseconsequences associated with tapering of theparticular medication


• Daily care needs that are specific to the residentand are out of the ordinary must be addressed onthe care plan

• Nursing home staff must use their professionaljudgment when making these decision

• It is imperative to talk to direct care staff on allshifts to determine the individual resident careneeds for that shift.

Care Plan Development:Daily Care Needs

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In developing the holistic care plan, utilize allavailable assessment data.

In addition to the RAI Assessments, other assessmentsmay include:

• Admission Nursing Assessment• Hydration / I&O• Fall Risk Assessment• Skin Breakdown Risk Assessment• Restorative Assessment


• Hot Liquid Assessment• Elopement Assessment• Side Rail Assessment• Hospital H&P• SS• Activities• Dietary• Lab & X-ray reports• Discussion with resident and family


The care plan must be prepared by aninterdisciplinary team that includes the attendingphysician, an R.N. with responsibility for the resident,and other appropriate staff in disciplines asdetermined by the resident’s needs, and, to theextent practicable, the participation of the resident,the resident’s family or the resident’s legalrepresentative. [42CFR483.20(k)(2)]

Care Plan Development: Interdisciplinary Team Approach

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• Professional disciplines, as appropriate to theresident, must work together to provide thegreatest benefit to the resident.

• The mechanics of how the IDDT meets itsresponsibility to develop an interdisciplinary careplan are at the discretion of the facility.


• Face-to-face care plans meetings are notrequired.

• The physician must participate, and may arrangefor alternative methods of providing input, such asone-on-one discussions and conference calls.


Resident and family participation

• The nursing home must assist residents toparticipate

• The nursing home must provide enough time toinformation exchange and decision making


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• The nursing home must make an effort to schedulecare plan meetings at a convenient time of theday for residents and their families.

• The resident has the right to refuse specifictreatments and to select among treatment optionsbefore the care plan is implemented.


While federal regulations affirm the resident’s right toparticipate in care planning and to refuse treatment,the regulations do not create the right for a resident,legal surrogate or representative to demand that thefacility use specific medical intervention or treatmentthat the facility deems inappropriate. Statutoryrequirements hold the facility ultimately accountablefor the resident’s care and safety, including clinicaldecisions. [42CFR483.20(k)(2)]


Although federal regulations do not prescribe aspecific care plan format, regulations do mandatethe components to be included in a care plan:

• Problem List / Problem statements / Strengthsspecific to the individual

• Measurable objectives

• Measurable timetables

Care Plan Components

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• Interventions to attain or maintain the resident’shighest practicable physical, mental, andpsychosocial well-being

• Interventions that would be required but are notprovided due to resident’s refusal of treatment

• Date of the entry, signature of the IDT member,discipline responsible for implementation


• Formulated based on critical analysis of the IDTassessments, including triggered CAAs

• Defines the issues specific to the resident’s problemto facilitate effective goal setting anddevelopment of appropriate interventions

• Is NOT a restatement of the medical diagnosis, butusually defines problems arising from the medicalproblem.

Care Plan Components: The Problem Statement

• Medical Diagnosis combined with signs/symptoms exhibited by the resident

• Severe pain with confusion and inability to findown room independently

• Dementia with striking out at care givers

• CHF with SOB after walking 15 feet.

Care Plan Components: Disease-related Problem Statement:

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• In practice, usually combined with etiology tocreate descriptive nursing diagnosis statement

• Confusion, acute

• Violence, directed at others

• Physical mobility, impaired.

Care Plan Components:Nursing Diagnosis Problem Statement:

• Example• Acute confusion related to severe pain and effects

of pain medication as exhibited by inability to findroom independently

• Violence directed at others related to OrganicBrain Syndrome as exhibited by slapping directcare staff while they are giving care

• Impaired physical mobility related to SOB related toCHF as exhibited by unable to walk more than 15feet without tiring, becoming SOB.

Care Plan Components: Nursing Diagnosis Problem Statement

• Shows How:

• The condition is a problem for the resident, NOThow it creates a problem for the staff;

• The condition limits or jeopardizes the resident’sability to complete tasks of daily living; or

• The problem affects the resident’s well-being insome way

Care Plan Components: The Functional Problem Statement

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• Mr. Smith cannot find his room independently

• Mrs. Jones slaps the face of direct care staff whilethey are giving personal care

• Mrs. Brown is unable to walk more than 15 feetbecause of shortness of breath

Care Plan Components: The Functional Problem Statement

• Problem statements should reflect terminology of theMDS

• Etiology & signs/symptoms (s/s) may be added:

• Memory/recall ability deficit related to severe pain &effects of pain medication AEB inability to find ownroom

• Physically abusive behavioral symptoms AEB slappingdirect care staff while they give care

• Shortness of breath with impaired physical mobilityAEB inability to walk more than 15 feet.

Care Plan Components:MDS –Related Problem Statement

• The functional problem statement sample for SocialServices: Cognition; Mood; Psych-Well Being; Activities; Psych Drug

• Mr. Smith misses doing things with his wife like theyused to related to (RT) CVA, Hemiplegia, Aphasia, asexhibited by (AEB) loves to play cards and is willing tolearn new card games. He becomes suspicious andparanoid of his wife at times as to her faithfulness tohim. He has a Dx. Of depression and is on scheduledCitalopram.


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• Activities is one area where the resident may notexhibit any “problems”.

• CMS does want Activities to have a plan of carefor each resident.

• Strengths can be worded in a statement.

• “Resident enjoys music programs. She has lovedmusic her entire life and plays the piano andorgan.”

Care Plan Components: Strengths

• Regardless of the working or format, the problemstatement must contain enough information toensure that interventions selected are related to thetrue problem

• Example: For a resident who fell, the problemstatements below would result in differentinterventions:• Fall climbing out of bed unassisted• Slipped on urine walking to bathroom.


Goal: Reasonable expected outcome of care basedon the content of the specified problem whichprovides precise objections for the resident to meet:• Action-oriented• Goal for the resident, not for staff• Measurable• Time-limited• Individualized for each resident

Care Plan Components: The Goal

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According to the RAI User's manual, the goalstatement should include: a subject, a verb,modifiers, and a time frame.


Subject Verb Modifiers Time Frame

Mr. Jones Will walk Up and down five stairs with the help of one CNA

Daily for the next 30 days

Additional Example:Mr. Smith will walk 50 feet with a front wheeledwalked & limited assist of 1 person & gait belt daily forthe next 30 days• Subject: Mr. Smith• Action Verb: will walk• Modifiers: 50 ft. with front-wheeled walker, limited

assist of 1, gait belt,• Time Frame: daily for the next 30 days.


From Previous Examples:• Mr. Smith will find his room independently with

verbal cues within 2 weeks• Mrs. Jones will have <1 episode per shift of slapping

direct care staff while they are giving care by theend of 1 week.

• Mrs. Brown will walk 25 feet with supervision of 1person without s/s of SOB by July 25, 2014.


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Reasonableness of the goal• For Mrs. Jones, “no episodes of slapping with 24

hours” might NOT be a reasonable goalRealistic time frame:• Federal regulations required quarterly reassessment

at a minimum.• Resident-specific assessment data should dictate

how often reassessment should be done• Mr. Smith might need 2 weeks of med changes,

behavior modification, etc., to reachindependence.


• Each problem / strength must have a least one goal

• A problem may have more than one goal

• If Mrs. Brown is unable to walk more than 15 feet RTSOB and hip pain, a second goal would addressthe hip pain

• Related problems may share the same goals andapproaches.


• Example of combined SS goal getting back to Mr.Smith: 2 goals from 1 combined problem

• a. Mr. Smith will participate in an card game with hiswife weekly by 10/01/2016

• b. Mr. Smith will have not adverse drug reactions(ADR’s) from the Citalopram by 10/01/2016


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• Interventions are:• Instructions to the IDT• Developed by correlating assessment data with goals

of care• Specific to the individual’s problems, needs,

strengths, and risks• Interdisciplinary, with assigned accountability• Consistent with the established plan of care• Based on professional standards of quality

Care Plan Components: Interventions

Vary in focus depending on desired outcome• Facilitate improvement in status• Prevent avoidable decline in status• Provide palliative care


Categories of interventions to consider include:• Assessments• Observations and monitoring• Specific clinical approaches designed to

achieve specific outcomes• Resident and family teaching activities


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The instructions to the IDT which should includeconcise, focused action statements of directionregarding the resident’s care:• Action verb: Ambulate• Amount, distance, quantity, such as “30 Feet”• Method of to be utilized, such as “with front-wheeled

walker”• Frequency, when appropriate, such as “TID”.• Additional clarifying information or direction, such as,

“with gait belt and limited assist of 1 person”.


The Care Plan is the tool for providing continuity ofcare:

• All care givers must be informed about the detailsof the plan initially and with any changes

Care Plan Communication

• Goals and interventions must be communicated toall care givers consistently to ensure that everyoneis working with the same outcomes in mind

• Resident and family must be included, and thefinal care plan must be discussed with the residentor the representative.


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• An effective system for consistently communicatingcare planning decision to everyone who needs it isessential to positive resident outcomes.

• It cannot be overstated how important it is toinclude direct care staff in the process.


Federal regulations link timing with assessments

• Within 7 days of completion of the initial AdmissionAssessment

• Quarterly

• With Significant change in status

Care Plan Time Frames

Exception: The nursing home is responsible foraddressing resident’s needs from the moment ofadmission by developing an interim care plan.[483.20(b)]

Care Plan Time Frames

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Initiation of Care Planning process upon admission:

• Utilize hospital discharge/transfer orders, SNFadmission orders, initial nursing assessment.

• Should also include enough information about ADLstatus for staff to safely care of the resident

Care Plan Time Frames: The Interim Care Plan

• Include routine car instructions to maintain orimprove functional abilities until comprehensiveassessment is complete.

• Conduct an initial CAA review for identifiedproblem or potential problem, such as restraint,incontinence, dehydration, falls, or psychotropicdrug use

Care Plan Time Frames: The Interim Care Plan

• Care plan must accurately represent the care tobe delivered at any given point in time.

• Should be re-evaluated & revised on an on-goingbasis to reflect changes in the resident and carethe resident is receiving (RAI user’s Manual, p. 2-17)

• Services provided or arranged must be inaccordance with each resident’s written plan ofcare.

Care Plan Time Frames: Significant Change in Status

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• Culture Change is about transforming nursing homes forboth residents and staff. It creates “home” within thenursing home through designation of neighborhoods,rather than units, with consistent assignments andresident-directed care.

• Care planning is a practice being influenced by CultureChange. Two newer types of care plan formats are:• I Format Care Plan• Full Narrative Format Care Plan

Care Planning and Culture Change

‘I Format’ Care Plans are the most popular of the newformats. They are:• Written in the voice of the residents, actually using the

individual’s own statements• Written so that care givers can hear the resident

speaking when they read the care plan• Used for cognitively impaired residents by interviewing

family or surrogates to learn the wishes and lifepreferences of the resident

• Able to mesh with both the RAI’s MDS 3.0 CAAs and theQuality Indicator Survey (QIS) interview processes.

I Format Care Plan

Problem / Need Goal Approaches

I am at risk for skin breakdown due to my incontinence

I want to remain free of any skin problems

1. Keep me clean and dry

2. I prefer to turn every hour while I am awake

3. Do not wake me at night to turn me.

4. I do not want to wear briefs, but I will wear a smaller pad in my underwear

5. I take Ditropan for bladder spasms to cut down on leaking.

I Format Care Plan

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• Full Narrative Care Plans are written in paragraphswith resident-specific information that is easy toread.

• When read from start to finish, a full narrative careplan is similar to reading a story about the resident.

Full Narrative Care Plan

All About Me – My Social History:

My name is Julianne Wellington, and I prefer to be calledJulia. I was born on a farm near Lewiston, NE onDecember 8, 1930. My parents were immigrants fromScotland. My childhood was simple and fun, andalthough life was tougher then, it didn’t seem like it. Igraduated from college and became a teacher at acountry one-room school house southeast of Lewiston. Imarried Peter Wellington in 1948 and we had 4 children,all who live nearby. Holidays and birthdays are importantto my family, and I want to participate in them.


Communication / Memory

Goal: I want to keep my mind stimulated to maintainmy memory, I like eye contact, so please look at mewhen you speak to me. I like discussing currentevents, so feel free to ask me my opinion.


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Mental Wellness

Goal: I want to feel like I am important and needed.I have always been very involved in my surroundingsand would like to keep it that way. I sometimes getdiscouraged and may feel like keeping to myself.Don’t take this as a problem unless it lasts more thana week or so. Don’t schedule appointments or bathsfor me during these time.s


Personal Care ADLs

Goal: I want to do as much as I can for myselfHearing: My hearing is good


Where to get more information

MDS 3.0 Manual V1.13 10/01/2015

MDS 3.0 Manual V1.14 DRAFT 10/01/2016

AANAC: AANAC.org

State Operations Manual, Appendix P-PP, Survey Guidance to Surveyors• http://www.cms.hhs.gov/manuals/Downloads/som107ap_p_ltcf.pdf• http://www.cms.hhs.gove/manuals/Downloads/som107ap_pp_guidelines_ltcf.pdf

Information Sources

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Questions?

THANK YOU

Kathy Sanders RN, RAC-CT, DNS-CTSanders Consulting630 N. 3rd. St.Tecumseh, NE 68450Hm: (402) 335-2736Cell: (402) 921-0250Email: kathy @mdshelp.com

THANK YOU

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