CARE PLANNING FOUNDATIONS FOR SUCCESSFUL DOCUMENTATION

Transcription

1 CARE PLANNING FOUNDATIONS FOR SUCCESSFUL DOCUMENTATION 1 Presented by: Vanessa Emm BA, ACC/EDU, AC-BC, CDP TaggEmm Consulting MEPAP Instructor emm_vanessa@yahoo.com NAAP Vice President naap.vanessa@gmail.com

2 Care Plans A means of communication throughout the care center. The Lighthouse of documents. 2

3 QUALITY USE OF LEISURE TIME OR FREE TIME Community based recreation and leisure education resources. What s available in your community? What isn t available in your community? Independent, individual leisure options and choice based on stated preferences. Volunteer therapeutic work programs both within and outside the facility if applicable. Problem areas. 3

4 SOCIALIZATION AND MEANINGFUL INTERACTION Informal social interaction. How does this resident socialize with others to include staff, residents and volunteers. Structured group interaction. Passive, active, observer? One-to-one interaction. Body language, preferences. Community interaction opportunities. Again, what is and is not available in your community? 4

5 PARTICIPATION AND ENHANCED MOTIVATION Rekindling past interest and hobbies. Soliciting resident preferences and choices than integrating this information into the care center s structured programs. This would also include developing and implementing new programs to meet the needs. Special interest programs. Resident autonomy through decision making within various committees and resident council 5

6 FIRST LOOK Assessment The resident assessment should include but not be limited to: a.) Mood b.) Social History c.) Leisure routines and preferences d.) MDS 3.0 e.) Observations f.) Areas of Concern g.) Discharge Planning h.) Therapy i.) Diagnosis j.) Physical Conditions k.) Cognition Level l.) Medical Chart (physician s orders, nursing notes, H&P, Social Services) 6

7 MDS 3.0 ASSESSMENT SECTION F The intent of items in this section is to obtain information regarding the resident s preferences for his or her daily routine and activities and the importance level of these preferences. This is best accomplished when the information is obtained directly from the resident or through family or significant other, or staff interviews if the resident cannot report preferences. 7

8 BUILDING YOUR CARE PLAN After you have completed your full activity assessment and MDS 3.0 interview it s time to begin building the residents care plan to properly meet their individual needs and preferences. 8

9 STEP 1 Preference, Strength, Need, Concern, or Problem This area should include descriptions: any specific activity preferences or daily routines that were noted and/or observed during the assessment. Are there any factors that may affect their level of participation or engagement in activities either group or independent. What do they need for activity pursuits? Accommodations? Assistance? Adaptations? Therapy Schedule? MDS Codes Family Involvement? 9

10 STEP 1 EXAMPLE 1 Mrs. Smith was admitted for physical therapy following a left hip fracture. Mrs. Smith anticipates a short term stay, planning to return home to live with her daughter and son-in-law. During her initial assessment Mrs. Smith was relaxed, talkative, and pleasant with staff. Mrs. Smith stated that she isn t interested at this time in attending group programming that is offered by the care center and also declined 1:1 activity visits stating she is content with her independent daily routines. Mrs. Smith stated various independent activity routines including but not limited to: crossword puzzles, talking with friends and family on the phone, having company (daily), TV (news, All my Children, Dr. Phil, The Price is Right), and reading (mysteries, biographies, newspaper). During the MDS 3.0 interview Mrs. Smith identified the following as Very Important : to have reading materials available, to use the phone in private, to participate in religious services & practices, and to be outside when the weather is good. Mrs. Smith stated that she s never been overly social in group settings I ve never been much of a joiner. Mrs. Smith s family visit daily. Mrs. Smith is very focused on her therapy schedule and returning home as soon as possible. 10

11 STEP 1 EXAMPLE 2 Mr. Doe was admitted to the care center with no current plans for discharge. During the initial interview Mr. Doe displayed some difficultly when recalling some social history questions but was able to talk accurately about his life shortly before his admission, he was pleasant and interactive with staff.. Mr. Doe was living in his home alone prior to admission. Mr. Doe stated various activity interests including: poker, TV (basketball, baseball and football games, news), social events, fitness programs, and reading (newspaper, magazines). During the MDS 3.0 interview Mr. Doe identified the following as Very Important : to go outside when the weather is good, to participate in his favorite activities, to be around animals such as pets, and to have magazines and the newspaper available. Mr. Doe reviewed the activity calendar with staff. Mr. Doe stated he would like to be active daily and requested reminders and assistance to and from programs of his choosing. Mr. Doe has a dx of CHF and may display fatigue and require additional assistance. Mr. Doe s family don t live locally and won t be able to visit regularly. 11

12 STEP 2 Goal/Objective 1. What will the resident do? 2. How will the resident respond? 3. By When? (using a date) 4. What type of activities are targeted: large group, small group, oneon-one, independent. IS THE GOAL: Reasonable for resident Attainable for resident Observable by staff Individualized to residents specific needs and preferences 12

13 STEP 2 EXAMPLE 1 Mrs. Smith will participate and express satisfaction AEB verbalization to staff in chosen independent/self directed leisure pursuits such as: crossword puzzles, TV programs, and reading as desired by 1/1/2012. Resident s name is stated (Mrs. Smith) Will/Respond how (Stated satisfaction to staff) What type of activity (Independent/Self directed, crossword puzzles, TV, and reading) How often (as desired) By (1/1/2012) 13

14 STEP 2 EXAMPLE 2 Mr. Doe will choose and actively participate in programs of choice (i.e. men s club, fitness, outdoor activities, outings, parties and special events) minimum of once daily before his next review 1/1/2012. Resident s name is stated (Mr. Smith) Will/Respond how (Choose and actively participate in) What type of activity (Men s club, fitness, outdoor activities, outings, parties, special events) How often (daily) By (1/1/2012) 14

15 STEP 2 COMMON MISTAKES Resident goals can be written in error as staff goals. AVOID: Staff will assist Staff will provide Staff will provide verbal cues Anything that deals with staff and what staff will do and provide is an intervention/approach and should be documented accurately. 15

16 STEP 3 Approaches/Interventions 1. Use words such as: encourage, positive motivation, provide, remind. 2. This section needs to state everything staff will do and provide for the resident: Accommodations Modifications Limitations (i.e. wheelchair, HOH, vision impairment) Independent supplies/materials MDS 3.0 interventions Past interests Approaches must coordinate with the goal, problem/strength/need Staff are accountable for all stated approaches in the care plan 16

17 STEP 3 CONT. SPECIFIC, SPECIFIC, SPECIFIC All interventions/approaches should be individualized, specific and detailed to each resident: is the resident receiving 1:1 activities/interventions? If so there needs to be detailed approaches stating what are the preferred 1:1 s and what staff are doing during 1:1 s with the resident. does the resident like to read? If so there needs to be detailed approaches including preferred reading materials, genres, etc. all MDS Very Important & Somewhat Important codes needs to have coordinating approaches. All areas of the care plan need to have specific individualized interventions to ensure quality of life. 17

18 STEP 3 EXAMPLES 1. Staff will offer and provide reading materials of interest (westerns, mysteries, newspaper, engineering magazines) as needed. 2. During 1:1 visits activity staff provide the newspaper and read current events and the sports section to [name] as these are his preferred areas of the newspaper. 3. Staff will invite, encourage and assist [name] outside on the patio when the weather is good and upon request. 4. [name] currently doesn t have a TV in his room but his preferred activity is watching TV. Staff will invite and encourage him to use the activity room/day room TV for sporting events and the evening news daily until his TV arrives. 5. [name] is HOH but hears best in her left ear. During activities [name] needs to be seated near the facilitator with the facilitator seated on residents left side. For larger group programs [name] will be provided with a hearing amplifier. 18

19 GETTING THE WORD OUT How are you certain that your staff know what interventions you have planned: 1. Copies of each residents care plan kept in the activity office. 2. Copies of each residents care plan kept with the daily participation logs for quick and easy reference. 3. Care plan notice form filled out each time a new care plan is developed or revised/updated. 19

20 MDS CAT S & CARE PLANNING MOOD SECTION Four of the seven triggers in the Psychosocial Well- Being CAT s are directly linked to activity preferences. Here are two from the Mood Section: 1. The resident indicated they have little interest or pleasure in doing things as indicated by D0200A1 2. The staff assessment indicated that the resident has little interest or pleasure in doing things as indicated by: D0500A1 The activity staff are responsible for obtaining this information from Social Services to address any concerns in the resident care plan and IDT meetings. 20

21 MDS CAT S & CARE PLANNING ACTIVITY PREFERENCE SECTION Here are two from the Activity Preference Section: 1. Residents responding that it is Not important at all or Not very important to participate in favorite activities. Indicated in F0500F 2. During the staff assessment there wasn t an indication that the resident prefers participating in favorite activities. Indicated in F0800Q The activity staff are responsible for correctly coding Participating in favorite activities for the resident. 21

22 COMMON MISTAKE RE: FAVORITE ACTIVITIES Many times Favorite Activities are considered to be planned scheduled group or 1:1 programs. Keep in mind that Favorite Activities are whatever the resident deems as preferred programming: 1. TV 2. Reading 3. Self-directed/independent activities 4. Outings/Activities with family/friends It s important that these are care planned specifically and appropriately. 22

23 THE MDS IS YOUR TOOL FOR A SUCCESSFUL RESIDENT CENTERED CARE PLAN 23

24 MRS. SMITH STEP 1/EXAMPLE 1 CARE PLAN WALK THROUGH Problem, Strength, Need, Concern or Problem Mrs. Smith was admitted for physical therapy following a left hip fracture. Mrs. Smith anticipates a short term stay, planning to return home to live with her daughter and son-in-law. During her initial assessment Mrs. Smith was relaxed, talkative, and pleasant with staff. Mrs. Smith stated that she isn t interested at this time in attending group programming that is offered by the care center and also declined 1:1 activity visits stating she is content with her independent daily routines. Mrs. Smith stated various independent activity routines including but not limited to: crossword puzzles, talking with friends and family on the phone, having company (daily), TV (news, All my Children, Dr. Phil, The Price is Right), and reading (mysteries, biographies, newspaper). During the MDS 3.0 interview Mrs. Smith identified the following as Very Important : to have reading materials available, to use the phone in private, to participate in religious services & practices, and to be outside when the weather is good. Mrs. Smith stated that she s never been overly social in group settings I ve never been much of a joiner. Mrs. Smith s family visit daily. Mrs. Smith is very focused on her therapy schedule and returning home as soon as possible. 24

25 Goal/Objective Mrs. Smith will remain satisfied with her daily chosen activity/leisure routines as evidence by verbalization to staff and will request supplies for self-directed activities as needed by 1/12/

26 Approaches/Interventions 1. Staff will respect Mrs. Smith s right to refuse activity participation and chosen activity routines. 2. Activity staff will briefly visit with Mrs. Smith during rounds and assess for any in room activity supplies such as: crossword puzzles, mystery and biography books, the newspaper and religious reading materials (Bible, devotions). 3. Activity staff will invite and provide assistance as needed to the outdoor sitting areas. 4. Mrs. Smith requested and was provided the care center s cable channel listing. Mrs. Smith doesn t want to miss her favorite programs. 5. Mrs. Smith has stated that she have never been much of a joiner and doesn t want to feel pressured from staff to participate in programming or be incessantly invited and reminded of activity programs. 26

27 Problem, Strength, Need, Concern or Problem Mr. Doe Mr. Doe was admitted to this care center with no current plans for discharge. Mr. Doe has a diagnosis of dementia with behavior disturbances and a history of wandering with some exit seeking. Mr. Doe has displayed some confusion/ frustration when asked several direct questions in a row. Mr. Doe has also displayed some difficultly with adjusting to his new settings in the care center, prior to his admission he was living in his home with family (daughter Julie). Mr. Doe stated various activity interests including but not limited to: gardening, watching sports on TV, reading the newspaper, looking through farming magazines, activities that provide snacks and refreshments. During the MDS 3.0 Mr. Doe identified the following as important: being around animals such as pets (Mr. Doe s daughter had a dog at home named Scooby that he loves dearly), participating in his favorite activities, participating in religious services and practices, and doing things with groups of people. Mr. Does daughter visits regularly (2-3x a week). Mr. Doe was a garlic/onion farmer for most of his life and can relate and enjoy talking about farming. Due to Mr. Doe s diagnosis and displayed confusion/frustration he will benefit verbal cues and reminders regarding programs and additional staff assistance during activities. 27

28 Goal/Objectives Mr. Doe will choose and attend a program of interest minimum of once daily and remain in the program for the duration of the activity without showing signs of frustration By 1/1/

29 Approaches/Interventions 1. Respect Mr. Does right to refuse activity participation. 2. Mr. Doe will receive pet visits weekly and family will be encouraged to bring in Scooby for regular visits. 3. Activity staff will provide a newspaper daily and farming magazines. 4. Activity staff will remind, invite and assist Mr. Doe to programs of choice and preference (gardening, sports on TV, and programs that offer snacks & refreshments (happy hour, birthday parties, special events, cooking club). 5. During activities staff will provide one-on-one directions and supervision along with positive praise for all Mr. Does attempts during activities. 6. Activity staff will monitor Mr. Doe during programs for exit seeking and/or wandering and will report any incidents to nursing staff. 7. Activity staff will provide positive redirection when signs of frustration occur. Beneficial interventions include talking about Scooby, farming, asking for assistance with the care center s garden, tips on gardening, family and sporting events. If interventions aren t successful assist Mr. Doe to a calmer environment and attempt interventions again in a one-on-one setting. 8. Allow Mr. Doe time to respond. Do not ask numerous questions in a row as this has shown to frustrate Mr. Doe. 9. Mr. Doe is Catholic and would like to receive weekly communion. Activity staff have contacted the Catholic Church and made the appropriate arrangements. 10. The activity department will provide garlic & onion sacks to use for positive reminiscing with Mr. Doe. 29

30 I CARE PLANS I care plans are a different format for writing a care plan. I care plans can be just as specific, individualized and appropriate for a resident. Example My name is Ann. I really enjoy being social and active. While I ve been in LTC I have had the opportunity to meet a lot of new people and try some new things. I need some reminders and assistance to and from the activities that I enjoy such as: parties, special programs and bingo. I would like to attend these programs each time they are offered. 30

31 KEY TO SUCCESSFUL CARE PLANS Quality assessments, intakes, and documentation. Samples provided include: 1. Annual Assessment 2. Initial/Re-Admission Assessment 3. Significant Change Assessment 4. Quarterly Review Assessment 5. Initial/Reassessment Intake Form 6. Blank Care Plan Form 7. Individual Resident Activities Form 8. Activity Evaluation Form 9. Overall Activity Plan 31

32 A Care Plan is your CANVAS It is up to YOU to paint the accurate picture for your residents 32

33 Assessment/ History Approaches/ Interventions Resident Centered Activity Care Plan MDS 3.0 Goal/Objectives Preference, Strength, Need, Concern, or Problem 33

34 HELPFUL FOR REVIEWING CARE PLANS Review activity participation logs/mds Review 1:1 documentation Review previous progress notes Resident interview/review of current care plan Staff interviews 34

35 WHEN WRITING A CARE PLAN KEEP THIS IN MIND What s important to me? What would I want people to know about me? What would my expectations be? What should I expect? What if my voice isn t heard? Will people understand me? Will I be HAPPY? 35

36 36 QUESTIONS?