abcs of care planning

The ABCs of Care Planning

HARMONY UNIVERSITYThe Provider Unit of

Harmony Healthcare International, Inc. (HHI)

Presented by:

Beckie Dow, RN, RAC-MTDirector of MDS/Nursing Program Development

Speaker Bio

Over 20 Years Experience in Long-term CareClinical and Reimbursement Accuracy in AssessmentsQuality Assurance ActivitiesInterrelation between MDS, Care Planning, QA and Clinical Excellence at the BedsideAANAC Master Trainer

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Today’s Objectives

Define the purpose of the Care PlanDefine the purpose of the discharge Care Plan and summaryIdentify the correlation between the MDS, CAAs, accurate RUG-IV classification, and the Care PlanList three components of a resident-centered Care Plan


OIG Report February 2013

Used 2009 stay dataSample of 190 stays that projects to 1,104,692 stays in the populationFor each stay the OIG determined if care plans contained measureable objectives and detailed time frames for the following eight categories of service

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OIG Report February 2013

Scheduled toileting plans or bladder retraining programsParenteral IV or feeding tubesSkin treatmentsSpeech, occupational, and physical therapyRespiratory therapyRestorative nursing services


OIG Report Findings

The OIG found that:74% of NHs surveyed in 2007 had at least one deficiency related to quality of careSNFs often did not develop appropriate psychosocial services Care Plans or provide all services identified in Care PlansSNFs failed to meet one or more Medicare requirements for beneficiary assessments or Care Plans about atypical antipsychotics


OIG Report Findings

The OIG found that:There were quality-of-care problems with beneficiaries discharged between SNFs and other facilitiesThere 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


OIG Report Recommendations to CMS

Strengthen the regulations on Care Planning and Discharge PlanningProvide guidance to SNFs about Care Planning and Discharge PlanningIncrease surveyor efforts to identify SNFs that do not meet Care Planning and Discharge Planning requirements and hold these SNFs accountable


OIG Report Recommendations to CMS

Link payments to meeting quality-of-care requirementsFollow up on SNFs who failed to meet Care Planning or Discharge Planning requirements or who provided poor quality care


Medicare RequirementsRelated 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 PlanPlan for each beneficiary’s discharge to ensure safe transition to next care settings


Steps of the Nursing Process

1.Assess2.Diagnose3.Outcomes / Planning4.Implementation5.Evaluation


Developing the Care Plan

The resident Care Plan should be based on:

Resident’s strengthsResident’s weaknessesHealth issues and conditionsResidents unique characteristics, strengths, and needs


Developing the Care Plan

The Care Plan must:Be based on a thorough resident assessmentEvidence effective clinical decision makingBe compatible with current accepted standards of practiceWill provide a strong basis for optimal approaches to quality of care and quality of life needs of the residentCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 13

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 fraudCare 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 careCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 14

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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

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RAI Process

The facility must develop a care plan that meets these guidelines:

IndividualizedComprehensiveMeasureable goalsTimetable to meet the goals

KEY POINT: The Goal of the RAI Process is the Care Plan


Resident Participation in the Care Plan

The resident has the right to participate in care planning and treatment or changes in care and treatmentThe facility should encourage and assist the resident to participate in choosing care and treatment optionsF-280 Care Plan (broad tag)



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


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 changesSurveyors will ask the resident or their representative during surveyIncludes attending care plan conferences, if the patient desires



The resident has the right to refuse treatment and to select among treatment options before the care plan is institutedFacility staff must make the process easy to understand for the resident or familyResidents questions and concerns must be addressed by the facility


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


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


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Care Area Assessments

1. Delirium 2. Cognitive Loss/Dementia3. Visual Function4. Communication 5. Activity of Daily Living (ADL)

Functional/Rehabilitation Potential

6. Urinary Incontinence and Indwelling Catheter

7. Psychosocial Well-Being8. Mood State9. Behavioral Symptoms10. Activities

11. Falls12. Nutritional Status

13. Feeding Tubes

14. Dehydration/Fluid Maintenance

15. Dental Care16. Pressure Ulcer

17. Psychotropic Medication Use

18. Physical Restraints

19. Pain (NEW)20. Return to

Community Referral (NEW)

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Discharge Planning

When the SNF anticipates the discharge of a beneficiary to another care setting or home it must plan for the dischargeAs part of this planning the SNF must develop a discharge summary to help ensure coordination of care and safe transition to the new setting


Discharge Planning

The discharge summary should include:

A summary of the beneficiary’s stayA summary of the beneficiary’s status at the time of dischargeA post-discharge Plan of Care, including:

Beneficiary’s and family’s preferencesHow the beneficiary will access servicesHow care will be coordinated among caregiversDischarge education and instructions


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 anotherThe interdisciplinary team, including the physician, should participate


Questions/Answers

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Effective Care PlanningAugust 21, 2013

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