Using CMS Care Planning Guidance to Develop Best Practices

1. Using CMS Care Planning Guidance to Develop Best Practices

2. Presenters: Suzanne Ribero-Balassone BSN VP of Clinical Services Cheryl Dexter RN, MS VP of Quality & Compliance PACE Organization of Rhode Island

3. Learning Objectives: At the end of the presentation, the learner will be able to: Explain ways to incorporate participant needs and preferences into the Care Planning Process, Formulate a participant-centered Care Plan utilizing the CMS-defined five (5) essential components, and Describe two (2) methods of measuring compliance with Care Plan guidance

4. Where we were: Has everyone been here? IDT members ill-prepared for Care Planning Meetings Morning meeting chaos Hours spent in meetings Care Plans focused on what �IDT� wants, not what the participant wants/needs So many Care Plans, so little tracking! Unfocused agenda�or no agenda at all Lack of compliance with Requests for Service Every timeline was 6 months

5. Rationale for Change: Needed an organized approach to the Care Planning process Thank you CMS for the Care Planning Guidance Opportunity to shed the old and bring on the new!

6. Fixing Our Problems: Create Order Out of Chaos Rules for Team Behavior Morning Meeting and Care Planning Meetings Scribe Tool Agenda

7. Fixing Our Problems: Whose Care Plan is it Anyway? Intake and Assessments � what do YOU want? SMART Objectives Change of Status Tool (COST) � objective Review with Participant and Family/Caregiver

8. S-M-A-R-T Elements

9. Fixing Our Problems: What Do They Really Want? �I want a CNA for 2 more hours every Friday.� Versus �I need more CNA time for meal preparation.� Request and Decision (RAD) Tool Home Care Assessment Tool

10. Essential Elements of the Care Plan:

11. Creating the Care Plan: Problem: keep asking why Objective: well-defined, participant focused, SMART Interventions: realistic, practical Timelines: specific, agreed upon; not 6 months Responsible Staff: who will act and document outcome

12. Audit � So, how did we do? Anecdotal Information Care Plans were IDT Centered Interventions were not discipline-specific Nearly every timeline was �Within 6 months�

13. Measuring Compliance � 2 Methods Quantitative S-M-A-R-T Presence of all 5 elements in the Care Plan Qualitative Problem ? Objectives ? Interventions ? Outcome

14. Measuring Compliance - Quantitative S-M-A-R-T Best to have a baseline! Retrospective audit pre-changes Current audit Same participants Same problems Pre-changes and post-changes

15. Measuring Compliance - Audit Tool SMART Audit Example 0 = no compliance 1 = partial compliance 2 = full compliance

16. Results: SMART Audit N=20 CP Items

17. Measuring Compliance - Qualitative Documenting Outcomes Real-time during Morning Meeting Did we implement the interventions? Did we document the outcomes of the interventions? EMR � can document none/partial/full goals met

18. Best Practices: Organize Remove the chaos Team Behavior Agenda Documentation during Morning Meeting

19. Best Practices: Focus on the Participant Remove the goals of the IDT Intake & Assessment Achievable, agreeable, realistic and reachable What is the participant really asking for?

20. Best Practices: Tools Remove the subjectivity Assessment COST RAD

21. Conclusion: Result The participant, the caregiver and the IDT are working with a realistic, participant-focused care plan

22. Questions or Comments:

23. Thank you! Suzanne Ribero-Balassone (401) 490-6566 ext. 151 sbalassone@pace-ri.org Cheryl Dexter (401) 490-6566 ext. 165 cdexter@pace-ri.org