PLAN OF CARE: WHAT IS IT AND WHY IS IT IMPORTANT?

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Gerald Carr
6 years ago
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1 PLAN OF CARE: WHAT IS IT AND WHY IS IT IMPORTANT? A presentation at the Champlain Family Councils Regional Network s Conference Presenter: Zsófia Orosz November 5, 2016

Association of Non-Profit Homes and Services for

2 Collaborators 2 Bruyère Centre for Learning, Research and Innovation in Long-Term Care Ontario Association of Non-Profit Homes and Services for Seniors (OANHSS) Ontario Long-Term Care Association (OLTCA)

3 Care Plans in Ontario s LTC Homes 3 A Plan of Care is a written document or set of documents that provide directions to staff on how a resident s care should be delivered. 1 It covers: planned care for the resident; the goals the care is intended to achieve; clear directions to staff and others who provide direct care to the resident. Over 40 provisions related to Plan of Care and care planning in the Ontario Long Term Care Homes Act. 1 Source: Office of the Auditor General of Ontario, 2015)

4 Why Focus on Plan of Care? 4 Better documenting goals of care, outlining planned care for residents and providing clear direction to care providers can help ensure that residents receive the highest quality of care. #1 compliance issue.

5 Project on Plan of Care 5 Review of compliance reports Literature review on care planning Understand what Homes are doing Develop tools Homes can use Learning from compliant Homes

6 6 REVIEW OF INSPECTION REPORTS

7 Inspection Reports 7 Reviewed publically available information: We found 63 Homes compliant in the sense that they only received Written Notifications in for 4 years. We looked at 11 Homes with the highest number of Compliance Orders and Voluntary Plan of Corrections.

8 Key Themes from the Review 8 Inconsistent documentation Inconsistent documentation & practice Incomplete documentation Lack of communication Care Plan not assessed/re-assessed/updated Involvement of resident/family/sdm

9 Top Three Issues Homes are Struggling with 9 Theme: Inconsistent documentation and practice LTCHA 6.7- Ensure that the care set out in the Plan of Care is provided to the resident as specified in the plan Resident left unattended while on the toilet, even though the Plan of Care indicates that the resident is at high risk of falls. Theme: Care plan not assessed/ re-assessed/ updated LTCHA 6.1- Ensure that the care set out in the Plan of Care is provided to the resident as specified The resident s snack service report only listed that the resident is to receive 125 ml of assorted juices at snacks and a half of a sandwich at afternoon snack, not listing the resident s preferred juice, yogurt, or the nutritional supplement Theme: Incomplete documentation LTCHA 6.2- Care set out in the Plan of Care is based on an assessment of the resident and the needs and preferences of that resident Plan of Care indicates patient has no teeth (in reality, has real teeth - not reported how many) - Interview with staff indicate otherwise

10 10 WHAT THE LITERATURE SAYS ABOUT CARE PLANNING

11 Literature Review 11 There are different types of care plans, for example: care plans for specific long-term conditions (e.g. diabetes); palliative care plans involving advanced care and end of life care; discharge or transition care plans for patients moving between different settings and health care providers. We could not find studies or publications that cover the complexity and comprehensive nature of care plans and care planning processes in Ontario s LTC Homes.

12 12 LEARNING FROM BRIGHT SPOT HOMES

enablers aiding them to meet all Plan of Care-related regulations.

13 Learning from the Bright Spots 13 What are they doing well? Interview and survey compliant Homes to understand the factors and enablers aiding them to meet all Plan of Care-related regulations. Bright Spot LTC Homes Are there processes that others can use? What is necessary for success in this area?

14 To Sum Up 14 Plan of Care is very important Plan of Care is a complex issue Ontario s LTC Homes are struggling to be compliant with Plan of Care This project aims to help Homes become compliant with Plan of Care requirements How can Family Councils contribute to the project?

LTC Task Force on Resident Care and Safety

LTC Task Force on Resident Care and Safety LTC Task Force on Resident Taking Safe Care Beyond the Poster on the Wall Nancy Cooper, Director of Policy and Professional Development, OLTCA Debbie Humphreys, Senior Director, Corporate and Public Affairs,