MDS Essentials MDS Essentials: Introduction to Care Area Assessments and Care Plans 4 Faculty Disclosures I have no financial relationships to disclose I have no conflicts of interests to disclose I will not promote any commercial products or services RAI User s Manual Chapter 4 Care Area Assessment Care Area Triggers Care plan Content All Planning Committee members, content reviewers, authors, and presenters have been evaluated for conflicts of interest and there are not any to disclose. 5 Educational Activity Completion and CE Disclosure Requirements for Successful Completion 1.25 contact hours will be awarded for this continuing nursing education activity. Criteria for successful completion includes attendance for at least 80% of the entire event. Partial credit may not be awarded. Approval of this continuing education activity does not imply endorsement by AANAC or ANCC (American Nurses Credential Center) of any commercial products or services. American Association of Post Acute Care Nursing (AAPACN)* is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. *AAPACN d/b/a American Association of Nurse Assessment Coordination (AANAC) Chapter 4: Care Area Assessment (CAA) Process and Care Planning 4.1 Background and Rationale The Omnibus Budget Reconciliation Act of 1987 (OBRA 1987) Mandated nursing facilities provide necessary care and services to help each resident attain or maintain the highest practicable well being. Regulations require facilities to complete a comprehensive, standardized assessment of each resident s functional capacity and needs The results of the assessment are to be used to develop, review, and revise each resident s comprehensive plan of care. This chapter provides information about the Care Area Assessments (CAAs), Care Area Triggers (CATs), and the process for care plan development for nursing home residents. 6 1
4.2 Overview of the RAI and CAAs 4.2 Overview of the RAI and CAAs The Resident Assessment Instrument (RAI) consists of three basic components 1. The Minimum Data Set (MDS) 2. The Care Area Assessment Process 3. The RAI Utilization Guidelines 7 The CAA process framework Guides the review of triggered areas Clarification of a resident s functional status and related causes of impairments Provides basis for additional assessment of potential issues, including risk factors Assessment of the causes and contributing factors gives the IDT additional information to help develop the comprehensive care plan 10 4.2 Overview of the RAI and CAAs The facility must develop a comprehensive care plan for each resident that includes measurable objectives timetables to meet a resident s: Medical Nursing mental psychosocial needs that are identified in the comprehensive assessment (42 CFR 483.20(k)) 8 4.2 Overview of the RAI and CAAs The CAA process should help staff Consider each resident as a whole, with unique characteristics and strengths that affect his or her capacity to function Identify areas of concern that may warrant intervention Develop, to the extent possible, interventions to help improve, stabilize, or prevent decline in physical, functional, and psychosocial well being, in the context of the resident s condition, choices, and preferences for interventions Address need and desire for other important considerations, such as advanced care planning and palliative care 11 4.2 Overview of the RAI and CAAs The MDS is a starting point Standardized instrument used to assess nursing home residents The MDS identifies actual or potential areas of concern Identifies areas of risk requiring further intervention 4.3 What are the Care Area Assessments (CAAs)? Care Area Assessments (CAAs) are triggered responses to items coded on the MDS Care Area Triggers (CATs) have a specified logic for each care area RAI Pages 4 16 4 41 provides CAT logic specifications The CAAs reflect conditions, symptoms, and other areas of concern that are common in nursing home residents Commonly identified or suggested by MDS findings 9 12 2
4.3 What are the Care Area Assessments (CAAs)? 20 Care Areas 4.4 What does the CAA Process involve? CAA process will help the IDT Identify causes and risk factors Identify and address associated causes and effects Determine how multiple triggered conditions are related Identify need to obtain additional medical, functional, psychosocial, financial, and other information about a resident s condition Identify affect on function and quality of life Identify if a particular risk of developing a condition Determine if a resident could benefit from rehab 13 16 4.3 What are the Care Area Assessments (CAAs)? The CAA process does not have any mandated, specific tool, nor does it provide any specific guidance on how to understand or interpret the triggered areas Facilities are to use tools that are current and grounded in current clinical standards of practices Evidence based, expert endorsed research, clinical practice guidelines, and resources Use sound clinical problem solving and decision making Critical thinking skills 14 4.5 Other Considerations Regarding Use of the CAAs Assigning responsibility for completing the MDS and CAAs The resident s assessment must be conducted or coordinated by a registered nurse (RN) with the appropriate participation of health professionals It is common for facilities to assign specific MDS items or portion(s) of items and CAAs associated to various disciplines 17 4.4 What does the CAA Process involve? Care Area Triggers (CATs) Each CAT may require further evaluation Impact on specific issues/conditions or risk of issues Each triggered item must be assessed further through the CAA process May or may not represent a condition that should or will be addressed in the care plan Provides a flag indicating further assessment of the care area Some triggers may identify resident strengths 15 4.5 Other Considerations Regarding Use of the CAAs CAA Documentation Helps explain the basis for the care plan 1. Underlying causes 2. Contributing factors 3. Nature of the issue or condition What is the problem and why is it a problem 4. Complications affecting or caused by the care area 5. Risk factors related to the presence of the condition 6. Decision to care plan or not to care plan 7. Referrals or the need for additional evaluation by the attending physician and other health professionals, as appropriate 8. Resources or assessment tools used for decision making 18 3
4.5 Other Considerations Regarding Use of the CAAs Written documentation of the CAA findings and decisions making process may appear anywhere in the resident s record Use the Location and Date of CAA Documentation column (Section V) to note where the written documentation can be found Appendix C: CAA Resources Chapter 4 provides information on specific care areas triggered and the CAA process Appendix C contains both specific and general resources that nursing homes may choose to use to further asses care areas triggered from the MDS Resources provided solely as a courtesy CMS does not mandate, nor does it endorse, the use of any particular resource(s) 19 22 4.5 Other Considerations Regarding Use of the CAAs Key reminders The MDS may not trigger every relevant issue Not all triggers are clinically significant The MDS is not a diagnostic tool or treatment selection guide The MDS does not identify causation or history of problems 20 Example CAA Resource 23 Dx of PVD from hospital transfer documents, active monitoring Stage 3 pressure ulcer to coccyx, identified in hospital. Daily Alginate dressing applied. Surgical incision to left hip with daily dressing, incision is clean and dry. (wound sheets 4/1, TAR) Case Study Utilizing Appendix C Resource History of Arthritis to bilat knees and reports at treated with Aspercreme at home as needed, usually 4 5x s per week, currently is on NSAID treatment. Hospitalized for hip fracture, fall at home and was not found for 48 hours post fall. Resident has dx of Osteoporosis and takes Fosamax (H&P/ MAR) 21 24 4
Self reports pain to be constant to the coccyx and left hip, but intermittent to knee bilat, and lower back. Expresses relief from pain with rest, realigning left leg, pillow behind lower back while in a chair and schedule pain medication regimen. Expresses pain is worse with transfers and standing, and can only tolerate sitting in a chair or wheel chair for 30 minutes. Describes coccyx and left knee and hip pain as aching and describes lower back pain as throbbing. Self reports an acceptable pain rating of 5, has rated pain at a 6 7 daily, and reports this level of pain lasts for less than 30 minutes. Reports she does not like to take pain medication and would like to start reducing scheduled pain regimen after her coccyx wound heals. Reports lower back pain is chronic and has treated with Tylenol for many years and does not want anything stronger for the back pain. She would also like to switch from PO NSAID back to topical cream for her knees, if the pain improves once is up walking again. Self reports daily pain, constant, but better in the evening. Reports pain is at acceptable level of 5, for most of time last up to 30 minutes at higher level. 25 28 Self reports pain disturbs sleep at times, woke x2 during 4/12 and 4/14 to request PRN pain med during night. Limits time of activities due to not being able to tolerate sitting in a chair for more than 30 minutes, related to back and coccyx pain. Alternation in comfort related to left hip fracture, pressure ulcer on coccyx and chronic lower back pain, s/ p fall at home, neighbor found on floor 48 hours post fall. Surgical repair to left hip at St. Ann s Hospital, surgical wound to left hip with daily dressing changes. Pressure ulcer presented as a stage 3 on admission, daily treatment with alginate dressing and repositioning resident off of coccyx every 1 ½ hours while in bed and up in wheel chair or chair with cushion for max of 30 minutes. At risk for breakthrough pain due to complexity of condition and multiple sources of pain. At risk for infection to surgical wound and pressure ulcer. Resident has a strong desire to reduce scheduled pain medication management once pressure on coccyx is healed. Y Will proceed to care pain with goals to manage pain with scheduled pain medication and nonpharmacological interventions to maintain pain at the residents acceptable level of 5 or below. Will work with physician and resident to reduce scheduled pain medication as pressure ulcer heals and pain from hip fracture reduces. 26 29 No referrals at this time, currently working with OT, PT and physician Was ambulating independently prior to fall with hip fracture. She has started gait training with physical therapy, but does not ambulate with nurse or nurse aides. Uses a walker and wt bearing assist to transfer between surfaces. She also requires assist with body alignment and repositioning while in bed. Breakthrough pain medication requested on 4/11 and 4/12 after therapy treatments. Scheduled pain medication regime was adjusted on 4/12 to provide adequate pain relief during and following therapy. 27 30 5
Bullet point summary Case Study Writing CAA Summary Notes Causes and contributing factors Treatments Surgical wounds care: Daily dressing changes. Pressure Ulcer care: Alginate dressing and repositioning resident off of coccyx every 1 ½ hours while in bed and up in wheel chair or chair with cushion for max of 30 minutes. Diagnosis Arthritis, chronic back pain, Osteoporosis, PVD 31 34 Case Study Two basic methods for writing a CAA Summary note Bullet Point Method Narrative Bullet point summary Risk Factors Breakthrough pain due to complexity of condition and multiple sources of pain. Infection to surgical wound and pressure ulcer. Strengths to consider in care planning Strong desire to reduce scheduled pain medication management once pressure on coccyx is healed. Desire to reduce/stop NSAID use and transition back to topical pain reliever Participating will with Occupational and Physical Therapy Motivated to return home, has social support and desires to utilize community resources: home health and life line Continued 32 35 Bullet point summary Nature of the problem Alternation in comfort related to Left hip fracture Pressure ulcer on coccyx Chronic lower back pain Arthritis to bilateral knees Causes and contributing factors S/P fall at home, neighbor found on floor 48 hours post fall. Surgical repair to left hip at St. Ann s Hospital Requires assist with bed mobility and transfers Wounds Surgical wound to left hip Pressure ulcer present as a stage 3 on admission Continued Bullet point summary Referrals to appropriate health professionals No referrals at this time Care Planning decision Will proceed to care plan Goals to manage pain with scheduled pain medication and non pharmacological interventions Goal to manage pain with in acceptable level of 5 Collaborate with physician to reduce pain medications per residents preference as she is able to tolerate 33 36 6
Case Study Two basic methods for writing a CAA Summary note Bullet Point Method Narrative 37 Summary Note Mrs. Jay has a strong desire to reduce scheduled pain medication management once pressure on coccyx is healed. She is also motivated to return home and has agreed to community resources post discharge including home health and life line. She has a strong community support and frequent visitors at the nursing home. No referrals are needed at this time as she is currently being treated by OT and PT and physician is aware of current pain management. Will proceed to care pain with goals to manage pain with scheduled pain medication and non pharmacological interventions to maintain pain at the residents acceptable level of 5 or below. 40 Summary Note Mrs. Jay was hospitalized for 4 days following a fall at home. Her neighbor found on floor 48 hours post fall. Surgical repair to left hip was completed at St. Ann s Hospital and resulted in a surgical wound to the left hip. Mrs. Jay developed a Stage 3 pressure ulcer from lying on the floor after her fall, this was identified in the hospital and continues alginate dressings in the facility. Mrs. Jay also suffers from chronic lower back pain, which has been addressed with her primary physician and treated with Tylenol. Continued 38 4.5 Other Considerations Regarding Use of the CAAs CAA Documentation Helps explain the basis for the care plan 1. Underlying causes 2. Contributing factors 3. Nature of the issue or condition What is the problem and why is it a problem 4. Complications affecting or caused by the care area 5. Risk factors related to the presence of the condition 6. Decision to care plan or not to care plan 7. Referrals or the need for additional evaluation by the attending physician and other health professionals, as appropriate 8. Resources or assessment tools used for decision making 41 Summary Note Mrs. Jay also has diagnosis of arthritis to knees bilat and was treating with topical cream prior to admission, currently taking PO NSAID and desires to return to topical treatment when pain is better managed. Mrs. Jay has daily moderate pain to her left hip, left knee, coccyx and lower back. She is at risk for and has experienced breakthrough pain due to complexity of condition and multiple sources of pain. She is also at risk for infection to surgical wound and pressure ulcer. Continued The RAI and Care Planning Person Centered Care Planning 39 42 7
The comprehensive care plan is an interdisciplinary communication tool (42 CFR 483.25) Must include measurable objectives and times frames Describe the services that are to be furnished to attain or maintain the resident s highest practicable physical, mental and psychosocial wellbeing Must be reviewed and revised periodically Services provided must be consistent with the residents written plan of care Care plan structure or format is not specified 43 46 Must maintain all residents assessments completed within the previous 15 months in the active record Can be maintained electronically or paper If electronic signatures are not used or not allowed by state law, must maintain at a minimum hard copies of signed and dated CAAs (V200B C), correction completion (X1100A E) and assessment completion (Z0400 Z0500) in active clinical record (RAI page 2 7) 44 47 45 48 8
49 Overall care plan should be oriented towards: 1. Preventing avoidable declines in functioning or functional levels or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end of life situation) 2. Managing risk factors to the extent possible of indicating the limits of such interventions 3. Addressing ways to try to preserve and build upon resident strengths 4. Applying current standards of practice in care planning 5. Evaluating treatment of measurable objectives, timetables and outcomes of care 6. Respecting the resident s right to decline treatment 52 Continued Overall care plan should be oriented towards: 7. Offering alternative treatments, as applicable 8. Using an appropriate interdisciplinary approach to care plan development to improve the resident's functional abilities 9. Involving resident, family and other resident representatives as appropriate 10. Assessing and planning for care to meet medical, nursing, mental and psychosocial needs 11. Involving direct care staff with care planning process relating to expected outcomes 12. Addressing additional care planning areas that are relevant to meet the resident s needs 50 53 The care plan is driven not only by resident issues/conditions Also includes Resident s unique characteristics Strengths Resident s goals Needs Life history Preferences 4.8 CAA Tips and Clarifications Care plan goal statements should include: Subject (first or third person) Verb Modifiers Time frame Goal(s) 51 54 9
4.8 CAA Tips and Clarifications A separate care plan is not necessarily required for each area that triggers a CAA A single trigger can have multiple causes and contributing factors Multiple items can have a common cause or related risk factor It is acceptable to address multiple issues within a single care plan segment or to cross reference related interventions from several care plan segments Example: If impaired ADL function, mood state, falls and altered nutrition status are all determined to be caused by an infection and medication related adverse consequences, it may be appropriate to have a single care plan that addresses these issues in relation to the common cause 55 Associated Regulations 483.20 Resident assessment (b) Resident assessment instrument. A facility must make a comprehensive assessment of a resident s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. 58 4.8 CAA Tips and Clarifications Completion or modification of the care plan applies only to comprehensive assessments Admission Significant Change in Status Assessment (SCSA) Significant Correction to Prior Comprehensive (SCPA) Annual A new care plan does not need to be developed after each SCSA, SCPA, or annual. May need to revise existing care plan using the results of the latest comprehensive assessment Also need to evaluate the appropriateness of the care plan at all times including after Quarterly assessments and modify as needed 56 Associated Regulations 483.20 (e) Coordination Coordination includes: Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident s assessment, care planning, and transitions of care Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment 59 Associated Regulations Associated Regulations 483.21(b) Comprehensive Care Plans (1) The facility must develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights set forth at 483.10(c)(2) and 483.10(c)(3), that includes measurable objectives and timeframes to meet a resident s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following: The services that are to be furnished to attain or maintain the resident s highest practicable physical, mental, and psychosocial well being 57 60 10
Associated regulations 483.21(b) Comprehensive Care Plans (2) A comprehensive care plan must be (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident s representative(s). An explanation must be included in a resident s medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident s care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident s needs or as requested by the resident. (iii) Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments. Please continue with New to MDS OBRA Scheduling Essentials 61 64 Key Points The MDS and CAAs are not the only resource for care planning Involve the resident, it is his/her plan of care Understand and include the resident s goals in the care plan Entire team needs to fully understands the federal regulations surrounding care planning MDS Essentials RAC CT Education Advancement Education Advancement Professional Development Expert within your Organization Successfully Completed RAC CT Completed QCP CT Completion of Medicare University RAC MT, QCP MT 62 65 MDS Essentials Questions Please submit questions to: The New to MDS Community 63 66 11