Taking Better C.A.R.E.

Transcription

1 Taking Better C.A.R.E. Of The Care Planning Process Care plans are on OIG and CMS radar! OIG study found in almost 40% of stays that SNFs do not develop care plans that meet requirements and do not provide services in accordance with care plan. Recommend: Strengthening regulations Increase surveyor scrutiny Link payments to compliance CMS agrees! Organizing is what you do before you do something, so that when you do it, it s not all mixed up! A.A. Milne The care plan creates an organized approach to meeting the resident s needs What are the healthcare concerns and what we should do about them. Be Honest. Does your care plan team act like Winnie the Pooh with a pot of honey or more like Eeyore when his house falls apart again! Are your care plans as alive and detailed as the 100 Acre Wood or as boring as IRS instructions? Can you tell who the resident is by reading the care plan? Does your care plan team actually talk to each other about the interventions during the care plan meeting, or do they do their section alone in their office? Is it a living, breathing, current representation of care provided? 1

2 Why/Why Not? Too many, too much work? For a 120 bed facility, 40 per month. Assuming 20 workdays, that would be 2 per day. Time consuming care plan sessions? 2 in an hour? Is the team aware of how the process should really work? I have my sections to do I don t know about anyone else. The other departments aren t always prepared Leadership of the care plan session? The Session: Breathing Life into it! Make the time! Baseline care plan within 48 hours! Make sure the ALL of the right people are present! Including RN responsible for the resident! Including CNA responsible for the resident! Mentor the process by: Requiring each department to review their sections (out loud). Encourage discussion of existing interventions and evaluation effectiveness. Ensure that interventions are resident specific. Ensure that interventions can actually be implemented; articulated in a way that direct care staff can implement. Opportunity to spot inconsistencies and/or contradictions. Take the credit for all staff is doing by ensuring documentation! The C.A.R.E. Plan: C C = Components to be included in ALL care plans (triggered or not) Transfer Ambulation/Locomotion ADLs Falls Skin Continence/Elimination Nutrition Activities 2

3 The C.A.R.E. Plan: A A = Degree of Risk based upon Assessment; and Related to/as evidenced by Degrees of Risk: At Risk For: address the risk factors to prevent actualization Alteration in: already a problem In some cases could have maintain Related to/as evidenced by: Diagnoses and observations of limitations/conditions The C.A.R.E. Plan: R R = interventions are Resident Specific; dated! Use risk factors or categories from assessments and how the risk factors are manifested by this resident. Example: if resident scores for risk in the friction/shear category on the Braden Scale, what does the resident do that creates the risk? Then care plan to that as evidenced by Example: if resident scores for risk in unsteady gait on the fall risk assessment, what is it about the resident s gait? Shuffling? Fast walking? Difficulty judging distance when turning corners? The C.A.R.E. Plan: E E: Evaluating Effectiveness of Interventions Find out from staff if interventions are still working, relevant, etc. This is different from whether the intervention is still being provided! Example: Resident is receiving Ensure at 10a and 2p. Resident is receiving the supplements but isn t drinking them! Resident continues to be provided with a built up spoon and a scoop plate but is now being fed by staff. Transfer: Be specific regarding type # of assists (effective date) If can use mechanical lift and/or manual, indicate circumstances Ambulation/locomotion: If assist is supervision, explain purpose of supervision, i.e. direction to destination? W/C = specify use of footrests, circumstances, adaptations to w/c, etc. ADLs: 3

4 Falls: BE SPECIFIC! Be resident specific PRIOR to any falls; not just generic. Use assessment! If alarms have been d/c ed, what are you doing instead? Consider temp use of alarms to identify patterns, which may lead to root cause identification. Enter fall date; enter intervention date. Post fall: Action Steps vs Interventions No change is No good! Skin: (don t combine with continence/elimination) Consider separating into two components: pressure ulcers vs others Skin tears, bruises, rashes: prevention vs treatment Pressure Ulcers: prevention; treatment Pressure Ulcer Prevention: Pressure Relieving surfaces (settings too!) Turning/positioning (specify): schedule, special instructions, devices Nutrition Moisture Heels When a pressure ulcer develops, MUST modify prevention interventions! Pressure Ulcer Treatment: Be specific regarding location/date Enter stage, size, pain management, treatment (could refer to POS) Strategies for healing promotion; infection prevention When a pressure ulcer develops, MUST modify prevention interventions! Resident non compliance: what alternatives have been developed to the optimal interventions. 4

5 More about Components Continence/Elimination: Assess type of continence to develop interventions Toileting schedule/programming Specifics regarding toileting: transfer, assist, privacy/fall risk Products Constipation/diarrhea More about components Nutrition: Diet Consistency tolerance Weight Consumption Gain/loss issues Nutritional status, i.e. labs, impact on health maintenance/wound healing More about components Activities: Resident specific If dependent upon staff for activities, does time provided make sense? Behaviors, fall risk, et al Behavior and Psychotropic Drug Use: The use of psychotropics is an intervention under Behavior problem. The use of psychotropics also creates another problem statement. Separate: Address/elaborate on behavior management strategies under Behavior. Address all aspects of medication administration, side effects, and triggers for dosage reduction under Psychotropic Drug Use. 5

6 Behavior: Identify target behavior. Interventions should be practical and doable by staff. If the interventions aren t effective, change them. Psychotropic Drug Use: Side effects to look for; how staff will recognize them. Reduction will be triggered when Reduction by resident, not justby calendar! Dementia: Preventing, relieving, and/or accommodating resident s distress (fear, confusion, sadness, agitation) or loss of abilities. Side Rails Other alternatives attempted PRIOR to placement of side rails. Indications for use. Interventions to minimize risk as applicable. Pain: Resident specific goal for pain control Specify medications used and indications for use (scale) Non pharmacological interventions keep it real! Infection Prevention, i.e. UTI, catheter use Medical Conditions and related medications Baseline Care Plan Within 48 hours of admission Minimum to properly care for the resident: goals based upon admission orders, MD orders, dietary orders, therapy, social service needs, immediate health and safety needs. Summary to resident/family: document that summary has been provided. If changes between baseline care plan and first version of comprehensive care plan, update the summary. 6

7 Additional Musings And If you have an electronic medical record and your nurses aren t sure how to access and modify the care plan there s a problem! If your nurses don t know what s in the care plan there s a problem! And a deficiency! Avoid may use enter the start date and date d/c Don t get lost in or rely on the canned clutter An I care plan can (and should) have specific interventions. Regulations do not create the right for a resident/family to demand that the facility use specific medical interventions or treatments that the facility deems not medically necessary or reasonable. Final Thoughts If we have something in the care plan, and we re not doing it, we ll get in trouble. TRUE BUT if you don t have something in the care plan that you should have, you ll also get in trouble! A comprehensive, fully articulated, resident specific care plan can ensure that the resident actually receives optimal and coordinated care and that will Always keep the facility safe! Presented By: Dorrie Seyfried Vice President IPMG Healthcare Risk Management Services 225 Smith Road, St. Charles ~ Illinois dorrie.seyfried@ipmg.com 7