Care Planning

1. Care Planning Version 02

2. Agenda Introduction Overview - What is new? Organizational Components of the Library Care Area Assessment (CAA) Process and Care Planning “I” Care Approach to Care Planning – Integration into ADL System Questions and Answers CAA Process and Planning Agenda “I” Care Approach Q & A

3. Care Plan Among Top Ten Deficiencies

4. Documentation and Nurse Care Planning Process - • “A primary purpose of documentation and recordkeeping systems is to facilitate information flow that supports the continuity, quality, and safety of care”… Importance of Care Planning Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Hughes RG, editor. Rockville (MD): Agency for Healthcare Research and Quality (US); 2008 Apr

5. “Karkkainen and coworkers identified three themes in the literature reflecting the tensions in the record: demands of the organization, nurses’ attitudes and duties, and the patient’s involvement in care.” Karkkainen, Bondas, and Eriksson conducted a metasynthesis of 14 qualitative research reports to determine how well individualized patient care was represented in nursing documentation. Documentation and the Nurse Care Planning http://www.ncbi.nlm.nih.gov/books/NBK2674/

6. Researchers argued that “individualized patient care is not visible in nursing documentation, and that current methods used to standardize communication in the records (forms with check-off lists) contribute to this gap.” Documentation and Nurse Care Planning “Nahm and Poston found a statistically significant increase in the quality of nursing documentation after system implementation and a reduction in the variability of charting.” http://www.ncbi.nlm.nih.gov/books/NBK2674/

7. “The challenge is to design systems that are patient focused but also reap the benefits of standardization in terms of more accurate, precise, and up-to-date information transfer among all members of the interdisciplinary team.” Documentation and Nurse Care Planning http://www.ncbi.nlm.nih.gov/books/NBK2674/

8. Care Planning Module allows you to build high quality care plans in minutes • The system contains libraries of care plans that can be used immediately • We encourage that you further personalize your library to suit the facility needs Care Plans Version 02

9. It is recommended that your Facility Library is edited by your Multidisciplinary Care Planning Team. • To be effective and comprehensive, Care Planning process must involve All disciplines Care Planning Team

10. Care Planning Team can greatly enhance the Facility Library by customization that incorporates your facility policy and procedures. Care Planning Process in ADL

11. “Knowing yourself is the beginning of all wisdom” • Aristotle Knowing Your Facility

12. ADL Data Care Plans have been noted on the “Ultimate Resource for Sample Care Plans” List • March 14th, 2011 • Digital Doorway, a popular nursing blog Ultimate Resource

13. Facility Library

14. Once the Facility Library reflects vocabulary, process, and procedures of your facility the MDS Rules are edited. This process will ensure that module builds high quality Care Plans. Care Planning Process in ADL

15. Care planning IN ADL

16. My name is Svetlana. I was discharged from the hospital just a couple of hours ago… Svetlana

17. ADL Library Admission Care Plan

18. ADL Library Admission Care Plan IDT Member responsible for Admission checks off the required care from the template

19. The Admission Care Plan includes: 1. Any risks the resident may pose to himself or herself, including any risk of falling, and interventions to mitigate those risks. 2. Any risks the resident may pose to others, including any potential behavioral triggers, and safety measures. 3. The type and level of assistance 4. Customary routines and Comfort requirements. 5. Drugs and treatments required (OE Module) 6. Known health conditions, including allergies and other conditions upon admission, including interventions. 7. Skin condition, including interventions. 8. Diet orders, including food texture, fluid consistencies and food, restrictions (OE) ADL Library Admission Care Plan

20. Care Plan can Reordered according to priority Set Up Priorities This Care Plan provides clear directions to staff and others who provide direct care to the resident.

21. My name is Barry. I have macular degeneration. I am very concerned about the rapid vision loss I am experiencing. I am unable to read my favorite Sunday paper and afraid that I might fall when I walk. I feel unbalanced… Barry

22. CMS Guidelines Example

23. CMS Guidelines

24. “The focus of the care plan should be to prevent decline when possible and to enhance vision to the extent possible when reversal of visual impairment is not possible, as well as to address any underlying clinical issues and/or conditions identified through the CAA or subsequent assessment process.” CMS Guidelines Example “This might include treating infections and glaucoma or providing appropriate glasses or other visual appliances to improve visual acuity, quality of life, and safety.” CMS’s RAI Version 3.0 Manual CH 4: CAA Process and Care Planning

25. I speak Russian. My English is not so well. I am worried that I am not understood. If I need something, how do I tell my care giver what I need? Is there anyone here that can speak my language??... Svetlana

26. A field in MDS can be used to build a Care Plan. Great Though

27. A1100 Does the resident need an Interpreter? • Yes Value 1 MDS Rules Step 1: create a problem set

28. Step 2 Create MDS Rule Insert Logic

29. MDS Rules Insert problem

30. Svetlana

31. I used to communicate well and liked conversations with family and friends. My health has been getting worse. It is very straining to speak for long periods of time for me. Often I have periods of confusion. I find myself in unfamiliar places. At times I do not recognize people that take care of me. I may become frightened… Barry

32. “I” Care Plan Great Idea

33. “I” Problem Enter Problem

34. Enter Goal “I” Goal

35. Enter Approaches “I” Approach Help me recognize that I am loved, cared about, and important in the lives of others regardless of failing Health. Unless safety is involved, do not argue with me

36. Barry has his good and bad days, but you won’t hear about Barry striking at his care givers. They know just what to do to make him aware of his surroundings. He found new love for music… he still stumbles “I” Care

37. Svetlana is happy in her new environment. She is confident she is going home soon . She has made friends and is very content with her care takers…she is very talkative… “I” Care

38. “Regarding care plans, the real issue is making the care plan resident centered. First person care plans can be poorly written and not resident centered. At the same time, third person/traditional care plans can be well written and resident centered… • The driving force behind all change should be improving the care we deliver to our residents. Changes that are effected just for the sake of change, or to jump on the popular bandwagon are unlikely to produce the change where it really matters.” Changes What’s Wrong with Care Plans—and How to Get it Right Holly F. Sox, RN, BSN, RAC-CT - Clinical Editor, www.Careplans.com

39. ADL Data Systems, INC • Olga@adldata.com • 9 Skyline Drive • Hawthorne, NY 10532 • (914) 591 1800 Questions?More Information? All images of persons are published with permission from http://www.freedigitalphotos.net