1. 9/22/2010 From Paper to Person MDS 3.0 Care Planning Presented by Debbie Ohl RN, M.Msc., PhD. Ohl and Associates Committed to Quality Care & Professional Excellence 613 Compton Road Cincinnati, Ohio 45231 MDSCarePlanBuilder.com Debbie Ohl RN, M.Msc., PhD Ohl and Associates Long Term Care Consultants Debbie@MDSCarePlanBuilder.com Debbies 30 year consulting practice is an outcome of learning lessons the hard way as a nursing director, sometime nurses aide and behind the scenes administrator. She is a regulatory compliance and interdisciplinary care planning specialist, authoring more than a dozen manuals including HcPros, Big Book of Care Plans. As a nationally recognized expert, Debbie has presented for many prestigious organizations including the National Institute for Health , the American College of Nursing Home Administrators, the National Health Care Lawyers Association, and numerous Health Care Organizations, and Nursing Facilities throughout the country. Recently completing her Ph.D in Holistic Life Coaching, Debbie brings a unique perspective on the impact that thoughts, feelings, and actions have on ourselves and those we serve. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Quality of Life Quality Degree of excellence or worth Life A manner or way of existing Autonomy Self-governance, self-sufficiency RAI The path to improvement.Debbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 1

2. 9/22/2010 Getting to the Care Plan MDS 3.0 CATs CAAs Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Program Objectives Identify and discuss 3 to 5 new terms used in conjunction with the MDS 3.0 and how they can be used in care planning. Issue Problem CPGs PCP CPS PHQ-9 EBPs BIMS Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Program Objectives Discuss the expectations of person centered care planning. Discipline Specific Person / S.O. Professionals Wishes/Preferences Human Being Resident Administration Regulators Staff Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 2

3. 9/22/2010 Program Objectives Identify the seven components of the care plan and at least one key factor of each as it relates to RAI expectations. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Program Objectives Discuss the three primary content areas to be considered in care planning. Impact on function Active Disease Impact on life style 18 CAAs 2 Physical Accommodation Cognitive of Need Psychosocial Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Evolution of Care Planning Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 3

4. 9/22/2010 1935 1965 Poor houses Medicare/Medicaid programs funded by Feds SSA established public assistance Standards put in place For profit homes proliferate 1970 1950 NH atrocities hit front page of news SSA requires States to license papers NH SSA does not specify 1972 Comprehensive Welfare Reform Act enforcement standards funds state survey and certification to 1956 establish uniform standards and conditions. Feds find NH substandard Emphasis is on institutional framework: CAPACITY to deliver care. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Mid 70s-early 80s Patient Care & Services Survey born to correct emphasis on capacity to deliver to ACTUAL delivery of care. Controversy over legitimacy. Paper compliance in the form of policies was nearing its end. 1975-76 Use of paper in the form of care plan takes center stage to insure care delivery.... or at least begins the process. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Phase 1 Phase II 1987 Paper to Person 1976-1987 Interdisciplinary Team Building QUALITY of CARE EVERY resident must have a plan. EACH discipline must have a plan. OBRA solidifies standards and creates a Every diagnosis must be on plan. framework for continuity of care. All medications must be on the plan. Care plan goals, interventions and Total Confusion target dates progressively used to site deficiencies. Emphasis is on Quality of Care. Result: Multi-disciplinary Unified care planning efforts begin conflict, with name change to IDT. fragmentation, confusion, many deficiencies. 1995 MDS 2.0 Raises the Bar Care plan content expectations have Assessment process formalized. increasing demanding. i.e. goal Increased expectations in terms of measurability. documentation and care delivery. RAPS about paper not process. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 4

5. 9/22/2010 1987 to September 30, 2010 October 1, 2010 MDS 2.0 promoted inter- disciplinary care planning. MDS 3.0 promotes resident Quality Indicators and driven care planning. Measures created benchmarks CAAs demand looking for outcomes. beyond the obvious. RAPs provided insurance CAAs demand staying that at least the obvious was current with best practices. care planned. Quality of care is the norm. Clinical assessment skills Quality of Life comes to the were maturing. forefront. Quality of care was the expected norm. HUGE paradigm and culture change shifts further Care plans became more advances the human resident specific. condition. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 2010 Quality of Care Actualized Quality of Life Comes to Forefront Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Terms for Care Planning RAI MDS PCP CATs Critical thinking Multidisciplinary CAAs Interdisciplinary CPGs Transdisciplinary EBPs SOP Decision Trees Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 5

6. 9/22/2010 Terminology RAI Resident Assessment Instrument MDS Minimum Data Set CATs Clinical Assessment Triggers CAAs Clinical Assessment Areas EBPs Evidenced Based Practices CPGs Clinical Practice Guidelines SOP Standards of Practice PCP Person Centered Planning Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Purpose of Clinical Assessment Areas CAAs Identify and clarify areas of concern from CATs. Promote identification of underlying cause(s), risks, complications. Consider fixability factors. Establish correlations among multiple triggered CATs. Demands critical thinking skills. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com RAP CAA Possible problems in 18 Possible problems in 20 care areas. care areas. Triggers alert to possible Triggers alert to possible issues in care needs. issues in the care needs. Triggered care area must Triggered care area must be thoroughly assessed. be thoroughly assessed. Documentation must meet Documentation must meet criteria. criteria. RAPS must be the tool There is no mandated used for conducting specific tool for the assessment. assessment. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 6

7. 9/22/2010 CAA Resources RAI Expert Resources In-Facility Care plan MDS 3.0 tools CPGs Policy Baseline BIMS EBPs A general plan to Review and CPS guide decisions PHQ-9 SOP revisions Chapter 4 Decision trees SMART goals Process steps 4-9 Care paths Procedure & Timelines POC focus 4-12 protocols Resident Journals, etc. 20 CAAs 4-17 Fixed, step-by- preferences Appendix C step sequence CAA resources QIOs activities or course of action Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com CAA Completion Psychosocial Well Being Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com CAA Demands Coming off of auto pilot. Problem solving in addition to problem management. Assessment and Care Planning Policies and Procedures. Staying up to date on changing practices. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 7

8. 9/22/2010 CPGs Clinical Practice Guidelines Guidelines developed to help health care professionals and patients make decisions about screening, prevention, or treatment of a specific health condition. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com EBPs Evidence Based Practices 1. Conscientious decision-making based not only on the available evidence but also on patient characteristics, situations, and preferences. 2. Recognizes that care is individualized and ever changing and involves uncertainties and probabilities. 3. A philosophical approach that is in opposition to rules of thumb, folklore, and tradition. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com SOP Standard of Practice A diagnostic and treatment process that a clinician should follow for a certain type of patient, illness, or clinical circumstance. That standard will follow guidelines and protocols that experts would agree with as most appropriate, also called "best practice." Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 8

9. 9/22/2010 Decision Tree Used in determining the optimum course of action, in situations having several possible alternatives with uncertain outcomes Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Dont get bogged down! EBP, CPG, Care paths, etc. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Give me a break! 15 minutesDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 9

10. 9/22/2010 Terminology Countdown RAI Resident Assessment Instrument MDS Minimum Data Set CATs Clinical Assessment Triggers CAAs Clinical Assessment Areas EBPs Evidenced Based Practices CPGs Clinical Practice Guidelines SOPs Standards of practice PCP Person Centered Planning CT Critical Thinking Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com How does person centered care differ from resident centered care? Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com The identification and evaluation of evidence to guide decision making. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 10

11. 9/22/2010 Critical Thinking 1. Gathers and assesses relevant information. Raises questions and problems States them clearly and precisely Comes to well-reasoned conclusions and solutions testing them against relevant criteria and standards; 2. Thinks open-mindedly within alternative systems of thought, recognizing and assessing: if, then 3. Communicates effectively with others in figuring out solutions to complex problems without being unduly influenced by others thinking on the topic. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Your Job To interpret and address the Care Areas identified by the CATs and develop an individualized care plan that keeps the person at the center of all activities. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Summarize your learning Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 11

12. 9/22/2010 Lunch Time Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Care Planning Teams Team A group of people with a common purpose Discipline Relating to a particular field of study Multidisciplinary Many Interdisciplinary Between and among Transdisciplinary Strategy that crosses many disciplinary boundaries to create a holistic approach Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 12

13. 9/22/2010 Care Area Assessments Promotes identification of cause and effect relationships, contributing and complicating factors and risk identification Correlates triggering relationships and implications among multiple triggered CATs. Advances recognition of resident strengths, preferences, wishes. Considers correctability. Requires Logical Care Plan Linkage Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com CAA Review 1. Identify relevant triggers. 2. Identify type of trigger. 3. Identify the possible causes, contributing factors, and risk factors . 4. Analyzing and draw conclusions. 5. Develop a personalized, resident-specific care plan based directly on conclusions including insight of IDT members, resident, significant others. 38 Tools, Tips & Clarifications for Care Planning BIMS CPS MMSE PHQ-9 Issue Problem Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 13

14. 9/22/2010 BIMS Brief Interview for Mental CPS Status Cognitive Performance Scale Interview process used to test used in RUGs III to the residents memory evaluate the level of cognitive o Repetition of 3 words impairment o Orientation o Recall Residents must be capable of MMSE responding. Mini Mental Status Exam If resident rarely/never questionnaire used to screen understands staff assesses for cognitive impairment. resident based on their observations. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com PHQ9 Resident Mood Interview Residents must be Patient Health capable of responding. Questionnaire with Staff PHQ if 3 or more 9 questions items not completed by resident. Looking for signs of depression Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com ISSUE PROBLEM About About yesterday and tomorrow. here and now. Grey area, Black and white, intangible. tangible. Typically not solvable. Something can be done. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 14

15. 9/22/2010 10 Care Plan Must Haves Debbie Ohl & Associates LTC Consultants & Educators MDSCare PlanBuilder.com ThinkTheThoughts.com Six general care planning areas 1. Functional Status 2. Rehabilitation/Restorative Nursing 3. Health Maintenance 4. Medications 5. Daily Care Needs 6. Discharge Potential Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Priority Plans 1. Unstable health conditions. 6. Wounds, pressure ulcers. 2. Pain management. 7. Medicare RUGs (reason for 3. New areas of risk: falls, skin, coverage) skilling services. dehydration, etc. 4. New problems requiring use of 8. Acute problems psychoactive medication to * Falls correct or control. * New pressure sores * Unplanned weight loss 5. Medications with high risk for * Unplanned weight gain side effects, or adverse drug * Elopement reactions. * Resident to resident abuse, * UTIs * URIs * Other Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 15

16. 9/22/2010 Components of the Care Plan Care Plan Statement 7 1 6 2 5 3 4 Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Care Plan Guidance Resident Input Problem / Need Goal (s) Interventions Responsibilities Review Dates Strength Related Approaches & Places Scope, Severity, Linked Clear Oversight Stability Measurable Concise Delivery Nurses Notes CAA Reasonable Do-able Progress notes Do-able Done IDT notes Content Fix ability Use the 4 Delivery means Review Date Contains Quadrant insuring based on SSS Fix it consistent Improve it What physically implementation Interim Issue Reason Maintain it mentally socially Or Control it emotionally? Oversight Impact 4 Quadrants Expected to be Slow the decline means Risk met Minimize/prevent Ask each monitoring for Strengths complications discipline: what effectiveness Resident Input can you offer What does the resident want?? 3. Developing Goals Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 16

17. 9/22/2010 2. Resident Voice Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 4. Target Dates Meet Goal or Check Progress Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Consider the Scope, Severity, and Stability Scope Severity Stability Pervasiveness of the Seriousness of the problem. Current status of the problem. problem. Present continuously (3) Immediate jeopardy to health To what degree is the Intermittent, patterned (2) & safety of self or others (4) problem solved Sporadic (1) Harm present or eminent (3) and or what is the Potential for harm (2) likelihood of Minor (1) reoccurrence if interventions are withdrawn? Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 17

18. 9/22/2010 5. Approaches Determining Interventions & Actions . Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 6. Monitoring a. Deciding on Accountability Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com 6. Monitoring b. Implementation Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 18

19. 9/22/2010 Care Plan Formats Common Plan I Plan PGI Reads like a book Or Changes language content of common plan Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com I care plan samples I-Format Care Plans http://paculturechangecoalition.org SKIN: I am at risk for skin breakdown because of my decreased mobility. I had an open area on my coccyx, which I obtained while in the hospital. It has improved to just a reddened area. I want to keep healing. Assist me to reposition every two hours if I have not done so on my own. Remind me to keep off my back as much as possible when I am in bed. I have a special pressure-reducing cushion on my chair, which needs to be straightened, before I sit in it every morning. My bed has a pressure-reducing mattress. I take a multivitamin to help with skin healing. I concentrate on making sure I eat proteins at every meal. Remind me that protein will help in healing. GOAL: I wish to remain free of skin breakdown. Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com COMMUNICATION/MEMORY: I used to communicate well and enjoy a hearty conversation. Humor has always been a part of my communication style. I have become much weaker as my health has declined. Sometimes I find it hard to even to answer I am tired. Occasionally I have episodes of confusion. Sometimes I do not know where I am and I become frightened. Please provide orientation during these times and when you are providing my care. Let me know who you are and what you are going to be doing. I usually recognize my children and my spouse. Holding m y wifes hand comforts me. When I am confused and frightened, I may strike out at you. Use calm gentle touch and hand massage while providing me reassurance. *GOAL: I dont want my memory loss and confusion to interfere with my ability to accept the care I need. I do not want to hurt my caregivers Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.comDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 19

20. 9/22/2010 Comfort (Rhode Island Quality Partners) I take regular medication for pain. Sometimes I need extra boost of medication. I also benefit from stretching so I like to attend the morning exercise group. The massage therapist seems me every Friday for an hour. Massage makes all the difference. Goal: To be free from breakthrough pain in my back Sleep medication prn. Discourage napping during the day. Side rails up. IF unable to sleep place in Geri-chair. I softer Plan IF I am walking at night please offer to walk I like to walk with me. during the night. Place sashes in doorways of resident rooms who are disturbed by my presence at nite. Offer me snacks. I like to read the sports section of the paper and play solitaire. Taken from web site on I care plans Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Care Plan with Pain as the Root Problem Components of Pain Care Plan: Analgesia, Quality of Life, Ability to Function PROBLEM/NEED GOAL(S) APPROACHES/ Resp. REVIEW Discip /STRENGTH What does the INTERVENTIO Date resident want? NS Issue: Issue: why pain 1. Resolve and Medication plan eliminate the Description of pain: Who can do issue if possible type, source, location, What intensity 2. Pain Relief / When Control Where Resulting in/ How often. creating/impacting: affect 3. Quality of on functional status Life, - What PMS/E: can you make better? Risks / complication - What is the (think about from pain best you can and med used) expect? Resident Strengths/Wishes:Debbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 20

21. 9/22/2010 7. Review and Revision Target dates outside of facility established reviews. Who does it? Where will it be documented? What if the plan is off track? Care conference scheduled reviews. Overview Status of goals Met Unmet Rationale New areas of concern Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com ThinkTheThoughts.com Assessment of Care Plan Activities 1. Acute problems are addressed 9. The IDT work together? timely. 10. Some team members write their own 2. Care plans geared to preventing care plans for fear they will avoidable declines? otherwise be cited? 3. Care plans consistently manage 11. Documentation reflects status resident risk factors in a timely and/or rationale on each care plan manner? goal? 4. Care plans recognize and build 12. Direct care staff on all shifts and on resident strengths? units are informed about the care 5. Goals measurable? plan goals and interventions? 6. Goals achievable? 13. The direct care staff can explain what the goals are and why they are 7. Goals met ? doing what they are do? Person Centered Care Planning W hat do w e live for, if it is not to m ake life less difficult for each other? George EliotDebbie Ohl & Associates LTC Consultants &Educators MDSCarePlanBuilder.comThinkTheThoughts.com 21