Care planning moving from paper to person

Care Planning
Moving From Paper to Person
Presented by
Debbie Ohl RN, M.Msc., PhD.
Ohl and Associates
Committed to Quality Care & Professional Excellence
613 Compton Road
Cincinnati, Ohio 45231
MDSCarePlanBuilder.com

December 2011

Evolution of Care Planning
Look back to see ahead
Evolving regulations
Progression of care plans

Debbie Ohl & Associates LTC Consultants &
Educators MDSCarePlanBuilder.com
ThinkTheThoughts.com

1935 1965
 Poor houses  Federal funding for
Medicare/Medicaid
 SSA established public
 Standards put in place
assistance
 For profit homes proliferate
1970
1950  NH atrocities headline
newspapers
 States required to license
NH
1972
 Enforcement Standards not
 Welfare Reform Act funds
specify state survey and certification
to establish uniform
1956 standards and conditions.
Feds find NH substandard  Emphasis on institutional
framework: CAPACITY to
deliver care.

Mid 70’s-early 80’s
Outcome
 Patient Care & Services Survey born
Mechanical to correct emphasis on CAPACITY to
process with deliver to ACTUAL delivery of care.
conflicts,
omissions,  Controversy over legitimacy.
contradictions  Paper compliance in the form of
and animosity policies was nearing its end.
among team
members.
1975-76
 Use of paper in the form of care
plan takes center stage to insure
care delivery....or at least begins the
process.
Debbie Ohl & Associates LTC Consultants & Educators MDSCarePlanBuilder.com

Phase 1
Paper to Person 1976-1987

 EVERY resident must Result:
have a plan. • Multi-disciplinary conflict
 EACH discipline must • Plan fragmentation
have a plan. • Mass confusion
 Every diagnosis must • Mega citations
be on plan. • Care plan content
 All medications must expectations have
be on the plan. increasing demands.
 Total Confusion i.e. goal measurability.


Phase II
Interdisciplinary Team Building
Quality of Care
1987 1995 MDS 2.0
 OBRA creates • Assessment process
framework for formalized.
continuity of care. • Multi-disciplinary
 POC goals, conflict
interventions, target • Increased
dates used to site expectations for
deficiencies. documentation and
 Emphasis on Quality care delivery.
of Care. • RAPS about paper
not process.

1987 to September 30, 2010

 MDS 2.0 promoted inter-disciplinary care
planning.
 Quality Indicators and Measures created
benchmarks.
 RAPs provided insurance that at least the
obvious was care planned.
 Clinical assessment skills were maturing.
 Quality of care the expected norm.
 Care plans became more resident specific.


2010
Quality of Care Actualized

Quality of life comes to
forefront
Person Centered Care
emerging as Standard of
Practice.

Phase III
Intradisciplinary Team Building
Quality of Care Meets Quality of Life
October 1, 2010
MDS 3.0 promotes resident driven care planning.
CAA‟s demand looking beyond the obvious.
CAA‟s demand staying current with best
practices.
Quality of care is the norm.
Quality of Life comes to the forefront.
HUGE paradigm and culture change shifts
further advances the human condition.

1st Program Objective
Discuss expectations of person centered care
planning.

Discipline Specific Person and their
Professionals Significant Others

The Resident
A Unique Being

Administration
Regulators
and Staff


Discipline Specific
Professionals
1. Who will do what, when, how Person and their
and Significant Others
where regarding the MDS and
CAAs? Wishes: desire, hopes, wants
2. Have you considered the Preference :choice, preferred
setting for obtaining data action
collection? Maintain Individuality
3. How will the professional team
coordinate the information?

Administration and Staff
Regulators
Culture change… A shift in
emphasis: Change existing Face the same dilemma as the
mission and vision statement? facility. … Black and white may
now often be gray.
“Listen, Learn, Connect”.


Care Planning Teams
Team A group of people with a common
purpose
Discipline Relating to a particular field of study

• Multidisciplinary Many (Isolated, all mine)
• Interdisciplinary Between and among (mine, yours.
Sometimes ours)
• Transdisciplinary Strategy that crosses many
disciplinary boundaries to create a
holistic approach
Debbie Ohl & Associates LTC Consultants & Educators ours)
(Integrated, MDSCarePlanBuilder.com

“ Person-centered planning
begins when people decide
to listen carefully and in
ways that can strengthen the
voice of people who have
been or are at risk of being
silenced. ”
John O'Brien
A Little Book about Person Centered Planning

 Person-centered planning was
“invented” in an effort to offer people
who request and receive human
services the opportunity to describe and
define the characteristics and conditions
of life that represent for them a desirable
present and future.
 It was “invented” in an effort to offer
people who deliver those services an
opportunity to learn and to grow
alongside the person who is at the core
of the planning process.

The Facts

Person-centered care is an idealistic approach
to resident care that became common around
1985.
It was designed to allow people with
developmental disabilities to have a voice in
their lives and to facilitate self determination.
By the late 1990‟s the concept had filtered into
other areas of health care.

 Person-centeredness is about intentionally being
with people.
 It demands a personal commitment to engaging
conscious awareness and self-reflection about the
relationship between what we are thinking, feeling
and actually doing ……
 Not everyone needs or benefits from a person-
centered planning process…
 Essential lifestyles plans are developed through a
process of asking and listening. The best
essential lifestyle plans reflect the balance
between competing desires, needs, choice and
safety ………
 It is critically important to remember that a plan is
not an outcome.

How does person
centered care differ
from resident
centered care?

Person Centered v. Resident
Centered
Person Centered Resident Centered
Standard of Practice Obsolete
 Resident driven  Professionally driven
 Addresses resident  Addresses what the
preferences related to resident needs.
their needs.  Individualized, but not
 Individualized and personalized
personalized.  Facility routine
 Resident routine  About doing things for
 About being with or to resident
resident

Quality of Life

Quality … Degree of excellence or worth
Life… A manner or way of existing
Autonomy… Self-governance, self-
sufficiency

RAI… The path to improvement.

Our New Mission is
PERSON FIRST care planning
Keeping this in mind may lessen the
frustrations, anxieties, and regulatory
fears we will surely face as we transition
into the next generation of care planning.


Care Plan Formats
1. Common Plan: Problem Goal Intervention
The format most of us our familiar with

2. I Plan
Typically reads like a book or changes language content of
PGI plan
Often written in 1st person even when person cannot speak
for self.

3. Suggested format: PNS R/T R/I R/C PCP …which
means?

Which means?
PNS : Problem Need
Strengths
R/T : Related to
R/I : Resulting In
R/C: Risk / Complications


2nd Program Objective
Identify the seven components of the care plan and one
key factor of each as it relates to RAI expectations.
7

5

3
4

1st Components of the Care Plan
Incorporate PNS R/T R/I R/C PCP

PNS Problem, Need, Strengths (&
preferences)
R/T Related to
R/I Resulting in
R/C Risk, Complications
PCP Physical, Cognitive, Psychosocial


Care Plan with Pain as the Root Problem
Components of Pain Care Plan: Analgesia, Quality of Life, Ability to Function
PROBLEM/NEED GOAL(S) Target APPROACHES/ Res
What does the Date INTERVENTIONS Disc
/STRENGTH
resident want?
Problem: Description of 1. Resolve and Medication plan
pain: type, source, eliminate the
location, intensity issue if possible Who can do
What
2. Pain Relief / When
Related to: why pain
Control Where
How often.
Resulting in/ creating 3. Quality of Life -
/impacting: affect on What can you
functional status PCP make better?
- What is the best
you can expect?
Risks / complication
(from pain and med used)

Strengths/Wishes:

Care Plan Content
Specific General
 Person centered  Functional status
maintaining and  Rehab and restorative
improving quality  Health maintenance
of life.
 Medication
 Daily care needs
 Discharge potential


Priority Plans
1. Unstable health 6. Wounds, pressure
conditions. ulcers.
2. Pain management. 7. Medicare RUGs
3. New areas of risk: falls, (reason for coverage)
skin, dehydration, etc. skilling services.
4. New problems requiring
8. Acute problems
use of psychoactive * Falls
medication to correct or * New pressure sores
control. * Unplanned weight
loss
5. Medications with high * Unplanned weight
risk for side effects, or gain
adverse Associates LTC Consultants &
drug reactions. * Elopement
Debbie Ohl &
Educators MDSCarePlanBuilder.com * Resident to resident
ThinkTheThoughts.com abuse,

2nd Component of the Care Plan
Resident Voice

 Preferences
 Wants
 Wishes
 Accommodations


3rd Component of the Care Plan
Goals

 What influences selection of goal dates ?


4th Component of the Care Plan
Target Dates

 MEET GOALS  CHECK PROGRESS

Target Dates Outside of Scheduled Reviews.
Who does it?
Where will it be documented?
What if the plan is off track?


Approaches

.


Monitoring

a. Accountability b. Implementation


Review and Revision

 Care conference scheduled reviews.
 Overview
 Status of goals
 Met
 Unmet
 Rationale
 New areas of concern


3rd Program Objectives
List the 10 Care Plan Must Haves‟ to Meet Standards of
Practice

A standard of practice is a diagnostic
and/or treatment process that a clinician
should follow for a certain type of
patient, illness, or clinical circumstance.
That standard will follow guidelines and
protocols that experts would agree with
as most appropriate, also called "best
practice."

1. Prevent avoidable declines 10 Care Plan Must
Haves‟ to Meet
2. Manage risk
Standards of Practice
3. Address resident strengths
4. Utilize standards of practice in care planning
process
5. Evaluate treatment objectives and outcomes
6. Respect right to refuse treatment, offer
alternatives, adapt.
7. Use an inter/trans disciplinary approach
8. Involve family and resident representatives
9. Assess and plan to meet needs of new
admissions
10.ThinkTheThoughts.com direct care staff in planning
Involve the

Which of the following
Care Plan Format Examples
Do You Think Best Serve the Resident
and Comply with Regulatory
Requirements?


Taken from web site on I care
plans

Sleep medication prn.
Discourage napping during the day.
Side rails up.
IF unable to sleep place in Geri-
chair.
I „softer‟ Plan

I like to walk IF I am walking at night please offer
during the night. to walk with me.
Place sashes in doorways of
resident rooms who are disturbed by
my presence at nite.
Offer me snacks.
I like to read the sports section of the
paper and play solitaire.


I-Format Care Plans from http://
“I” care plan sample SKIN
paculturechangecoalition.org

 I am at risk for skin breakdown because of my
decreased mobility. I had an open area on my
coccyx, which I obtained while in the hospital. It
has improved to just a reddened area. I want to
keep healing. Assist me to reposition every two
hours if I have not done so on my own. Remind me
to keep off my back as much as possible when I am
in bed. I have a special pressure-reducing cushion
on my chair, which needs to be straightened, before
I sit in it every morning. My bed has a pressure-
reducing mattress. I take a multivitamin to help with
skin healing. I concentrate on making sure I eat
proteins at every meal. Remind me that protein will
help Ohl &healing. Consultants &
Debbie in Associates LTC
 GOAL: I wish to remain free of skin breakdown.

Care Plan with Pain as the Root Problem
Components of Pain Care Plan: Analgesia, Quality of Life, Ability to Function
PROBLEM/NEED GOAL(S) Target APPROACHES/ Res
What does the resident Date INTERVENTIONS Disc
/STRENGTH
want?
Problem: Description of 1. Resolve and Medication plan
pain: type, source, eliminate the
location, intensity issue if possible Who can do
What
2. Pain Relief / When
Related to: why pain
Control Where
How often.
Resulting in/ creating 3. Quality of Life -
/impacting: affect on What can you
functional status PCP make better?
- What is the best
you can expect?
Risks / complication
(from pain and med used)

Strengths/Wishes:

Person Centered Care
Planning

What do we live for, if it
is not to make life less
difficult for each other?
George Eliot

Debbie Ohl RN, M.Msc., PhD
Ohl and Associates
Long Term Care Consultants
Debbie@MDSCarePlanBuilder.com

Debbie‟s 30 year consulting practice is an outcome of
learning lessons the hard way as a nursing director,
sometime nurse‟s aide and behind the scenes
administrator. She is a regulatory compliance and
interdisciplinary care planning specialist, authoring more
than a dozen manuals including HcPro‟s, MDS 3.0 Care
Plans Made Easy and Care Area Assessments.
As a nationally recognized expert, Debbie has presented for
many prestigious organizations including the National
Institute for Health , the American College of Nursing
Home Administrators, the National Health Care Lawyer‟s
Association, and numerous Health Care Organizations,
and Nursing Facilities throughout the country.
Recently completing her Ph.D in Holistic Life Coaching,
Debbie brings a unique perspective on the impact that
Educators MDSCarePlanBuilder.com actions have on ourselves and
thoughts, feelings, and
those we serve.

Care planning moving from paper to person

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