10/12/16. What is a Care Area Assessment? CAA Decision Making. The RAI is a problem iden,fica,on process: MDS Data Gathering

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1 CAAs and Care Planning Chapter 4, RAI Manual The RAI is a problem iden,fica,on process: MDS Data Gathering CAA Decision Making Judy Wilhide Brandt, RN, BA, RAC-MT, CPC, DNS-CT judy@judywilhide.com MDS Basic Class Oct 2016 Develop Care Plan Implement Care Plan EvaluaRon ConRnue, Change, Stop Page Background and Ra,onale The Omnibus Budget ReconciliaRon Act of 1987 (OBRA 1987) mandated that nursing facilires provide necessary care and services to help each resident a1ain or maintain the highest prac4cable well-being. Facili4es must ensure that residents improve when possible and do not deteriorate unless the resident s clinical condi4on demonstrates that the decline was unavoidable. Fundamental promise made to all residents upon admission. RegulaRons require facilires to complete, at a minimum and at regular intervals, a comprehensive, standardized assessment of each resident s funcronal capacity and needs, in relaron to a number of specified areas (e.g., customary rourne, vision, and conrnence). The results of the assessment, which must accurately reflect the resident s status and needs, are to be used to develop, review, and revise each resident s comprehensive plan of care. CAAs and Care Planning are required for a cerrfied facility What is a Care Area Assessment? Change approaches Gather Data Decision making The review of one or more of the twenty condirons, symptoms, and other areas of concern that are commonly idenrfied or suggested by MDS findings. Care areas are triggered by responses on the MDS item set. Care Plan Process EvaluaRon ImplementaRon Appendix A-3 1

2 20 Care Area Assessments 1. Delirium 11. Falls 2. CogniRve Loss/DemenRa 3. Visual FuncRon 4. CommunicaRon 5. ADL FuncRonal / RehabilitaRon PotenRal 6. Urinary InconRnence and Indwelling Catheter 7. Psychosocial Well-Being 8. Mood State 9. Behavioral Symptoms 10. AcRviRes 12. NutriRonal Status 13. Feeding Tubes 14. DehydraRon/Fluid Maintenance 15. Dental Care 16. Pressure Ulcer 17. Psychotropic MedicaRon Use 18. Physical Restraints 19. Pain 20. Return to Community Referral 4-3 When implemented properly, the CAA process should help staff: Consider each resident as a whole, with unique characterisrcs and strengths that affect his or her capacity to funcron; IdenRfy areas of concern that may warrant intervenrons; Develop intervenrons to help improve, stabilize, or prevent decline in physical, funcronal, and psychosocial well-being, in the context of the resident s condiron, choices, and preferences for intervenrons; and 4-2 The process focuses on evaluarng these triggered care areas using the CAAs, but does not provide exact detail on how to select perrnent intervenrons for care planning. Address the need and desire for other important considerarons, such as advanced care planning and palliarve care; e.g., symptom relief and pain management. IntervenRons must be individualized and based on applying effecrve problem solving and decision making approaches to all of the informaron available for each resident. 4-3 CAAs are required with all comprehensive assessments: Admission Annual Significant Change Significant CorrecRon to Prior Comprehensive End Result of CAA Process: The care plan, the working acron plan developed from the findings that result from the CAAs Development of an individualized, interdisciplinary care plan designed to address the resident s specific problems, risk factors, and complicarons is the primary purpose of the RAI process 1-6 CATs Care Area Trigger (CAT) - MDS response indicarng that clinical factors exist that may or may not represent a condiron that should be care planned Triggers flag condirons that warrant further invesrgaron Examples: Any Weight Loss in SecRon K will trigger the NutriRon CAA Any Wandering in SecRon E will trigger the Falls CAA 4-4 2

3 How to Know if CAA Triggered: x See CAA Review of Indicators 8/7/16 See CAA Review of Indicators 8/7/16 x If box is checked, the area triggered, and Care Area Assessment (CAA) must be completed. If there is no SecRon V, no CAAs required. Once CAA is worked, put where required documentaron can be found and the date of that informaron. Most common CAA citation in Virginia is when the location and/or date are missing. See Dietary Assessment 8/7/16 See CAA Analysis 8/7/16 Once CAA is worked, put where required documentaron can be found and the date of that informaron. How to know what triggers each CAA SecRon 4.10 (begins on page 4-16) lists all logic tables for each CAA Logic table = what made it trigger CATs provide a flag for the IDT members, indicarng that the triggered care area needs to be assessed more completely prior to making care planning decisions. Further assessment of a triggered care area may idenrfy: Causes, Risk factors, and ComplicaRons associated with the care area condiron. The plan of care then addresses these factors with the goal of promorng the resident s highest pracrcable level of funcroning: (1) improvement where possible or (2) maintenance and prevenron of avoidable declines. [Includes support when decline is imminent] Page 4-4 Each triggered item must be assessed further to facilitate care plan decision making, but it may or may not represent a condiron that should or will be addressed in the care plan. The significance and causes of any given trigger may vary for different residents or in different situarons for the same resident. Different CATs may have common causes, or various items associated with several CATs may be connected. A risk factor increases the chances of having a negarve outcome or complicaron. Risk Factor: Impaired bed mobility Effect: Unrelieved pressure ComplicaRon: Pressure Ulcer 3

4 A care area issue/condiron may result from a single underlying cause: Care area issue may be due to a single cause: Or mulrple causes: Falls resulrng from new med that causes dizziness From a combinaron of mulrple factors: Falls resulrng from: New medicaron, New Med Dizziness New Med Forgot walker Fall Bed too high resident forgot walker, Fall bed too high or too low There can also be a single cause of mulrple triggers and impairments. Hypothyroidism can have diverse physical, funcronal, and psychosocial complicarons. May be very stable, may not. MDS for resident with Hypothyroidism may trigger: Delirium, CogniRve Loss/DemenRa, Visual FuncRon, CommunicaRon, ADL FuncRonal/RehabilitaRon, Urinary InconRnence, Psychosocial Well-Being, Mood State, Behavior Symptoms, AcRviRes, Falls, NutriRonal Status, DehydraRon, Psychotropic MedicaRon Use, and Pain Diagnosis hypothyroidism in SecRon I did not alone trigger all these CAAs, FuncRonal assessment revealed issues in each of the areas above. IDT is responsible for determining if the triggered events are due to Hypothyroidism, are related, or are unrelated and due to different things. Recognizing the connecron among various symptoms and trearng the underlying cause(s) to the extent possible, can help address complicarons and improve the resident s outcome. Sequence is important! Which came first, the delirium or the dehydraron? Conversely, failing to recognize the links and instead trying to address the triggers or MDS findings in isolaron may have liqle if any benefit for the resident with hypothyroidism or other complex or mixed causes of impaired behavior, cogniron, and mood. 4

5 Types of CATs PotenRal Problems: Suggest a problem that warrants addironal assessment Broad Screening Triggers: Assist in idenrfying hard-to-diagnose problems, e.g. delirium, dehydraron PrevenRon of Problems: Assist in idenrfying residents at risk of developing parrcular problems RehabilitaRon PotenRal: Aimed at idenrfying candidates with rehabilitaron potenral Step 1: IdenRfy the Trigger: Ex: Stage 3 Pressure Ulcer triggers: NutriRon and Pressure Ulcer CAA Step 2: Conduct thorough assessment of triggered CAAs using Review of Indicators or facility designated tool. Step 3: Determine whether issue should/should not be care planned. Step 4: Document findings. Working A CAA A separate care plan is not necessarily required for each area that triggers a CAA. If a single trigger has mulrple causes, contriburng factors and risk factors, it is acceptable and may somermes be more appropriate to address mulrple issues within a single care plan segment or to cross-reference related intervenrons from several care plan segments. Example: If impaired ADL funcron, mood state, falls and altered nutrironal status are all determined to be caused by an infecron and medicaron-related adverse consequences, it may be appropriate to have a single care plan that addresses these issues in relaron to the common causes Usually, illnesses and impairments happen in sequence. The symptom or trigger osen represents only the most recent or most apparent finding in a series of complicarons or related impairments. Detailed history is osen essenral to idenrfying causes and select the most beneficial intervenrons; e.g., the sequence over Rme of how the resident developed inconrnence, pain, or anorexia. While the MDS presents diverse informaron about residents, and the CAAs cover various implicarons and complicarons, neither one is designed to give a detailed or chronological medical, psychosocial, or personal history. CAA DocumentaRon: Page 4-6 For example, knowing that the Behavioral Symptoms CAA is triggered and that the resident also has a diagnosis of UTI is not enough informaron to know whether the diagnosis of UTI is old or new, whether there is any link between the behavioral issue and the UTI, and whether there are other condirons such as kidney stones or bladder obstrucron that might be causing or predisposing the resident to a UTI. DescripRon of causes and contriburng factors; Nature of the issue/condiron: what exactly the issue/problem for this resident and why is it a problem ComplicaRons affecrng or caused by the care area for this resident Risk factors related to the presence of the condiron that affects the staff s decision to proceed to care planning Factors that must be considered in developing individualized care plan intervenrons, including the decision to care plan or not to care plan various findings for the individual resident The need for addironal evaluaron by the aqending physician and other health professionals, as appropriate The resource(s), or assessment tool(s) used for decision-making, and conclusions that arose from performing the CAA; CompleRon of SecRon V (CAA Summary; see Chapter 3 for coding instrucrons) of the MDS. 5

6 Wriqen documentaron of the CAA findings and decision making process may appear anywhere in a resident s record. For example: discipline-specific flow sheets, progress notes, care plan summary notes, a CAA summary narrarve, etc. Nursing homes should use a format that provides the informaron as outlined in this manual and the State OperaRons Manual (SOM). If it is not clear that a facility s documentaron provides this informaron, surveyors may ask facility staff to provide such evidence. Use the LocaRon and Date of CAA DocumentaRon column on the CAA Summary (SecRon V of the MDS 3.0) to note where the CAA informaron and decision making documentaron can be found in the resident s record. Also indicate in the column Care Planning Decision whether the triggered care area is addressed in the care plan. 4-7 Sample Narra>ve Note: Urinary Incon>nence CAA CAA triggered because Mrs. Jones is frequently inconrnent and requires assistance with toilerng secondary to her mulr-infarct demenra (see CAA 2 for details). At Rmes she is aware of her need to void but cannot communicate that need for assistance and has an inconrnent void. She is aware that she has voided in her brief, and will somermes communicate her desire for toilerng or being changed with verbal or physical behaviors. She is at risk for declining ability to be aware of need to void, and risk of skin breakdown and infecron related to inconrnence. Will refer to restorarve nursing for scheduled toilerng plan. Will proceed to care plan for restorarve toilerng, inconrnence care, and mirgaron of risks of inconrnence. Sample Narra>ve Note: Urinary Incon>nence CAA that Virginia Surveyors will like: CAA triggered because Mrs. Jones is frequently inconrnent (see conrnence tracking 4/7 4/13/18) and requires assistance with toilerng (CNA ADL tracking 4/7 4/13/18) secondary to her mulr-infarct demenra (see CAA 2 for details). At Rmes she is aware of her need to void but cannot communicate that need for assistance and has an inconrnent void (See nursing notes 4/7, 4/10/18). She is aware that she has voided in her brief, and will somermes communicate her desire for toilerng or being changed with verbal or physical behaviors (See nursing note 4/9/18). She is at risk for declining ability to be aware of need to void, and risk of skin breakdown and infecron related to inconrnence. Will refer to restorarve nursing for scheduled toilerng plan. Will proceed to care plan for restorarve toilerng, inconrnence care, and mirgaron of risks of inconrnence. Thoughts Developing care plan intervenrons was never intended to be the job of the MDS nurse or any other ONE person. It s not the dietary care plan it s the resident s care plan. The person who works the CAA is the project manager to ensure all necessary disciplines are consulted for appropriate intervenrons, based on evidence and current standards of pracrce. 4.5 Other Considera>ons Regarding Use of the CAAs Assigning responsibility for comple,ng the MDS and CAAs. FaciliRes may assign specific MDS items and CAAs to various disciplines e.g., the dierran completes the NutriRonal Status and Feeding Tube CAAs, Proper decision making through the CAA process may involve consulrng other disciplines to come to the right conclusion. Ex: idenrfying specific medical condirons or medicaron side effects that cause anorexia leading to a resident s weight loss It is the facility s responsibility to obtain the input that is needed for clinical decision making (e.g., idenrfying causes and selecrng intervenrons) that is consistent with relevant clinical standards of pracrce. For example, a physician may need to get a more detailed history or perform a physical examinaron in order to establish or confirm a diagnosis and/or related complicarons. 6

7 Iden,fying policies and prac,ces related to the assessment and care planning processes. The medical director is responsible for overseeing the implementaron of resident care policies in each facility, and the coordinaron of medical care in the facility. It is recommended that the facility s IDT members collaborate with the medical director to idenrfy current evidence-based or expert- endorsed resources and standards of pracrce that they will use for the expanded assessments and analyses that may be needed to adequately address triggered areas. CAAs to Care Plans Requirements As required at 42 CFR , the comprehensive care plan is an interdisciplinary communicaron tool. It must include measurable objecrves and Rme frames and must describe the services that are to be furnished to aqain or maintain the resident s highest pracrcable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident s wriqen plan of care. Good assessment is the starrng point for good clinical problem solving and decision making and ulrmately for the crearon of a sound care plan. MDS is just a starrng point No CMS mandated format or structure for the care plan Care Planning goes beyond the MDS Neither the MDS nor the remainder of the RAI includes all of the steps, relevant factors, analyses, or conclusions needed for clinical problem solving and decision making for the care of nursing home residents. MDS/CAA process does not provide sufficient informaron to determine if the findings from the MDS are problemarc or merely incidental, or if there are mulrple causes of a single trigger or mulrple triggers related to one or several causes. RAI was not designed to capture a history of a resident s symptoms and impairments. Thus, it can potenrally be misleading or problema4c to care plan individual MDS findings or CAAs without any addi4onal thought or inves4ga4on. The overall care plan should be oriented towards: 1. PrevenRng avoidable clarifying why another goal takes precedence (e.g., palliarve approaches in end of life situaron). 2. Managing risk factors to the extent possible or indicarng the limits of such intervenrons. 3. Addressing ways to try to preserve and build upon resident strengths. 4. Applying current standards of pracrce 5. EvaluaRng treatment of measurable objecrves, Rmetables and outcomes of care. 6. RespecRng the resident s right to decline treatment. 7. Offering alternarve treatments, as applicable

8 Care Plan Tips and ClarificaRons 8. Using an appropriate interdisciplinary approach to care plan development to improve the resident s funcronal abilires. 9. Involving resident, resident s family and other resident representarves as appropriate. 10. Assessing and planning for care to meet the resident s medical, nursing, mental and psychosocial needs. 11. Involving the direct care staff with the care planning process relarng to the resident s expected outcomes. 12. Addressing addironal care planning areas that are relevant to meerng the resident s needs in the long-term care sewng. Care Plan goals should be measurable. The IDT may agree on intermediate goal(s) that will lead to outcome objecrves. Intermediate goal(s) and objecrves must be perrnent to the resident s condiron and situaron, measurable, and have a Rme frame for compleron or evaluaron. Care plan goal statements should include: The subject (first or third person), the verb, the modifiers, the,me frame, and the goal(s). Interventions: Specific and responsive to assessment & identified issue or problem Explains what staff are to do when caring for resident Consistent with current standards of practice Categories: improve, stabilize, or maintain current level of funcron to the extent possible, based upon the resident s condiron and choices and preferences for intervenrons Care Plan Tips A separate care plan is not necessarily required for each area that triggers a CAA. Since a single trigger can have mulrple causes and contriburng factors and mulrple items can have a common cause or related risk factors, it is acceptable and may somermes be more appropriate to address mulrple issues within a single care plan segment or to cross reference related intervenrons from several care plan segments. The 7-day requirement for compleron or modificaron of the care plan applies to the Admission, SCSA, SCPA, and Annual RAI assessments. A new care plan does not need to be developed aser each SCSA, SCPA, or Annual reassessment. Instead, the nursing home may revise an exisrng care plan using the results of the latest comprehensive assessment. FaciliRes should also evaluate the appropriateness of the care plan at all Rmes including aser Quarterly assessments, modifying as needed. 8

9 Key components of the care plan may include, but are not limited to the following: Specific intervenrons, including those that address common causes of mulrple issues AddiRonal follow-up and clarificaron Items needing addironal assessment, tesrng, and review with the pracrroner Items that may require addironal monitoring but do not require other intervenrons Opportunities for Successful Use of Care Plan Integrate into daily facility activities Team huddles : CNA, nurses, therapists, etc. Morning standup meeting Change of shift report QA audits Risk meetings Medicare meetings Others Systems to Keep Care Plan Current Link care plan actions to other parts of the clinical record Physician orders Medication/treatment administration records Systems to Keep Care Plan Current When modifying care plan because of new incident develop both treatment and preventive components Systems to Keep Care Plan Current Use appropriate target dates within goals to facilitate resolution Systems to Keep Care Plan Current Incorporate identification of need for care plan review into: Review of 24 hour report Risk meetings Include revisions as part of the transcription process for new orders 9

10 Systems to Keep Care Plan Current Share responsibility Create ownership by the team, not by department Evaluate efficiencies Systems to Keep Care Plan Current Link related care plans [issues & concerns with interventions] to each other to reduce number of care plan pages Remove old care plan pages that are no longer current to the thinned files (archived/history files) Systems to Keep Care Plan Current Develop timely audit process Develop system for immediate correction & re-education Analyze data for trends/patters Example: Decide Assess Do Evaluate From American Medical Director s AssociaRon for LTC Webinar www Chileshealthcare com 10

11 www Chileshealthcare com www Chileshealthcare com Inadequate Indications for Antipsychotic Use Antipsychotics should not be used if the only indication is one or more of the following: Wandering Poor self-care Restlessness Impaired memory Mild anxiety Insomnia Unsociability InaqenRon or indifference to surroundings FidgeRng Nervousness UncooperaRveness Verbal expressions Behaviors that do not represent a danger to the resident or others Guidance to Surveyors F-329: Unnecessary Drugs 11

12 BPSD: Behavioral and Psychological Symptoms of Demen,a 12

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16 QuesRons? 16