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.

DoHC, 2008, p. 19.

Population ageing

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.

‘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.

Standardisation

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 categoryPrivate – roughly equal across categories

Method

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).

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.

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 declineF – Current medication use.G- Dental/oral status.H- Visual limitations and abilities.I - Cognitive ability/patterns and organisation of self-care activitiesJ – Communication, hearing and understanding.K- Mood and behaviour patterns / Psycho-social well-being, adjustment and relationships

Findings

Standardised tools (often more than one) common in some domainsA - 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 domainsG - 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.

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’).

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%

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%

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%

Care plan availability to resident/representative

Always 51%Usually20%Sometimes 12%Rarely 10%Never 07%

Specific care plan related training received

Internal/in-house 65%External 36%Both 13%

Training courses (most common by staff category)

COURSE DON NURSE CARER

Care plan related 1 1

Dementia related 3 3 2

Documentation (general) 2 1 2

Gerontology related 4

Medication management 3

Nutrition

Saturn/Catoelectronic system 4 3

Manual handling 3 3 1

Fire fighting 3

FETAC 1

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.

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?

Benefits (n=90)

Continuity of care (intra-inter-professional working)47

Promotes person-centredness41

Promotes structured approach to care process18

Helps to meet regulatory/legal requirements15

Improves quality (quality specifically mentioned) 09Promotes family involvement

08Improves organisational efficiency 06Helps to define measurable outcomes

06

Other 04

Drawbacks (n=90)

Time general 34Bureaucratic burden (repetitive/boring)

19Quality (legibility/accuracy/completeness/consistency)

18Time away from care 13No drawbacks

11Appreciation/know-how of staff

09Time initial (set up) 08Paper (storage, durability & management)

08Lack of person-centredness 05

Other 04

Obstacles to completing care plans (n=88)

Time 52Lack of appreciation (buy in) and know-how by staff

22Co-ordination (info to/from residents/MDS/relatives)

19Lack of resources 14Accuracy (language/legibility/consistency/completeness)

05Paper work too Exhaustive 05Interruptions 05Updating/changes 04None 01

Other 06

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.”

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).

Benefits of standardisation include:- concise timely identification of needs (Fries et al., 1997),- accurate recording of data, continuity of care (Hawes, 1997; Souder & O’Sullivan, 2000; Voutilainen, 2004).- facilitation of evaluation (Carpenter et al., 1997; Slater et al., 2005)- identification of inequities in service provision (Morris et al., 1990; DoH, 2001; Stozs

et al., 2008; Evans, 2008).- prediction of resource demands (Slater et al., 2005; Voutilainen, 2004), - preparation of standardised datasets for research, (Bernabei, 2008) - measurement of quality of care (Rantz, 2004; Butler, 2006).

A lack of standardisation can result in- inadequate care (Hancock, 2006; Worden et al., 2008).- inappropriate care, poor communications (McCormack, 2007).- - duplication of information (McCormack, 2007). - unsystematic care, which does not link assessment and care planning (Stewart,

1999; Hale, 1997).- lack of integration of health and care (Andrews et al., 2009)

Good care

Poor care

Poor documentation Good documentation

Thank you for you time

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