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Putting the Care Back in Care Planning<p>​F-tag 656, failure to develop and implement a comprehensive care plan, has been on the top 10 deficiencies list for years. Although this is not a new regulatory requirement, facility staff still struggle to achieve compliance with care planning during annual and complaint surveys. <br></p><p>Negative and siloed views such as, “No one looks at the care plan anyway” or “Only the nurse assessment coordinator is allowed to update the care plan,” serve only to further distance the care plan from its actual intent. While some may mistakenly view it as useless paper compliance, care plans should be viewed as a valuable tool for all staff.<br></p><p>The overall intent of the care plan is to articulate an approach to meet the resident’s goals and preferences and address medical, physical, mental, and psychosocial needs. However, care plans often look instead like lists of general interventions for nonspecific problems, which cannot actually drive resident care.<br></p><p>Refocusing the development and use of the care plan as a valuable tool for the interdisciplinary team (IDT) may help to provide more resident-centered care, improve outcomes, and reduce the risk of receiving an F656 citation during survey.</p><h2>Redefine the Care Plan as an Invaluable IDT Tool </h2><p>The guidance provided in the “State Operations Manual (SOM)” for §483.21(b) requires that “facility staff must work with the resident and his/her representative, if applicable, to understand and meet the resident’s preferences, choices, and goals during their stay at the facility.” However, the regulation allows the facility to determine how this process will be completed and to delegate to appropriate staff members.<br></p><p>The guidance continues that, “the facility must establish, document, and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life.”<br></p><p>While this regulation is well-known to most facility staff and is used to develop the comprehensive care plan, the final product often falls short of becoming an ongoing IDT tool to drive the care and services that the resident receives daily. The focus must be on developing the care plan to meet the needs and preferences of the resident, which will meet the regulatory requirements. However, if the focus is on checking a box for regulation, the team will miss critical elements or interventions. <br></p><p>If a physician asks, “What are we doing for Mr. Jones’ chronic obstructive pulmonary disease [COPD]?” The answer, from medication to diet, should be articulated in the care plan, providing the full holistic approach from the IDT. If Mrs. Johnson’s daughter asks what the facility is doing to prevent her mother from falling, all current interventions, from activities to rehabilitation, should be present in the care plan. <br></p><p>Using the care plan as a collaborative tool among all departments helps align the care and services the resident receives to assist them toward their goals. However, to achieve this, facilities must establish clear expectations regarding the level of detail and enforce and monitor timely updating.<br></p><p>If the team shifts its focus from meeting the minimums of regulatory requirements to instead elevate the purpose of the care plan, they can accomplish both by more effectively driving the care and services for the resident.</p><h2>Self-Identify Problems with Care Planning </h2><p>Care plans can come in various shapes and sizes; they may be handwritten on paper, completed electronically and printed, or maintained in electronic medical records (EMRs). Although EMRs have many benefits, they can also leave some gaps. Often, EMR users add interventions by simply checking an electronic box, which can lead to generic care plans that are not resident-centered.<br></p><p>Ready-to-go interventions often require individualization once added to the care plan. Failing to individualize results in confusing and incomplete care plans. <br></p><p>While direct care staff should frequently be accessing and updating the care plans, clinical leaders should also monitor for compliance and the quality of these updates. If a resident’s care or interventions have changed, did the team member responsible for the change update the appropriate care plan? Have resolved interventions been appropriately archived? Are the care plans easy to read for non-medical individuals? <br></p><p>Each time clinical leaders identify an incomplete or generalized intervention, or failure to timely update, they also identify a potential survey tag. While the process of monitoring and identifying these problems may be labor-intensive initially, as the facility’s culture adopts the care plan as a tool, the task becomes easier. </p><h2>Remove the Siloes </h2><p>Often, staff develop multidisciplinary care plans and believe they are creating interdisciplinary care plans. The key difference is that multidisciplinary care plans focus on the discipline, not the resident. One way to move toward a successful interdisciplinary care plan is to focus on the resident and their actual or potential needs. <br></p><p>For example, often the dietary department is responsible for completing section K of the Minimum Data Set, Swallowing and Nutritional Status. If a resident is coded as having a therapeutic diet, such as a diabetic diet, it will trigger the nutritional status care area assessment (CAA). This may result in the dietary manager or dietitian creating a care plan by focusing on the triggering reason. <br></p><p>The problem statement may read, “Mr. Jones receives a therapeutic diabetic diet due to having a diagnosis of diabetes.” This type of siloed care planning does not allow for an interdisciplinary approach because it does not focus on the resident’s needs. The resident’s need is not for a therapeutic diet, but rather, the management of his diabetes; the therapeutic diet is just one intervention the IDT provides the resident.<br></p><p>When the team shifts the focus to the resident’s needs and the resident’s goal is established with the team, the care plan becomes the IDT’s holistic approach to addressing these needs. As the road map to care, it is used to measure progress toward goals and ensure the resident’s preferences are being met.<br></p><p>The SOM, §483.21(b), states, “Care planning drives the type of care and services that a resident receives. If care planning is not complete, or is inadequate, the consequences may negatively impact the resident’s quality of life, as well as the quality of care and services received.” </p><h2>Include the Resident</h2><p>Among the tools available to surveyors are the Long-Term Care (LTC) Critical Element Pathways (CEPs). While there are over 40 tools, there is not one specifically for care planning. However, there are numerous pathways, from activities to behavior, and emotional status to nutrition.<br></p><p>All ask the same question&#58; Did the facility develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet the resident’s medical, nursing, mental, and psychosocial needs and includes the resident’s goals, desired outcomes, and preferences? <br>If this was not achieved, the facility will receive a F656 citation.<br></p><p>It is not enough to address what the IDT is doing for the resident’s needs—the resident must play an active part in developing the goals, expressing to staff what his or her desired outcome is, and the staff must understand his or her preferences for care. And just like updating the care plan when changes occur, the resident’s goals and preferences must be frequently reviewed with the resident to ensure it continues to reflect those goals and preferences. <br><br><em>Jessie McGill, RN, RAC-MT, RAC-MTA, is a curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN). She can be reached at <a href="mailto&#58;jmcgill@AAPACN.org" target="_blank">jmcgill@AAPACN.org</a>.</em></p>2021-09-01T04:00:00Z<img alt="" src="/Monthly-Issue/2021/September/PublishingImages/0921_cgiving.jpg" style="BORDER&#58;0px solid;" />CaregivingJessie McGill, RNThe overall intent of the care plan is to articulate an approach to meet the resident’s goals and preferences and address medical, physical, mental, and psychosocial needs.
Develop Nurses’ Clinical Skills to Enhance Care <p><img src="/Monthly-Issue/2021/August/PublishingImages/0821_cgvng.jpg" class="ms-rtePosition-1" alt="" style="margin&#58;5px;width&#58;100px;height&#58;100px;" />Perhaps now more than ever, nurses must utilize strong clinical assessment skills so that they can detect even the subtlest of changes and provide care that meets the needs of such a vulnerable population. <a href="https&#58;//pagepro.mydigitalpublication.com/publication/?m=63330&amp;i=716028&amp;p=24&amp;ver=html5">Read more.</a>​</p>2021-08-01T04:00:00Z<img alt="" src="/Monthly-Issue/2021/August/PublishingImages/0821_cgvng.jpg" style="BORDER&#58;0px solid;" />CaregivingAlexis Roam, RN-BC Over the past several years, the acuity and medical complexity of residents receiving care in skilled nursing facilities (SNFs) has increased significantly. For many SNFs, the medical complexity of the population has only intensified with the COVID-19 pandemic.
Managing Behavior Without Drugs: It’s a Team Effort<p>For myriad reasons, post-acute facilities are compelled to limit the use of antipsychotics and other sedating medications to the lowest possible levels. But this comes at a time when the population of residents with serious psychiatric illness in skilled nursing facilities continues to rise. <a href="https&#58;//pagepro.mydigitalpublication.com/publication/?m=63330&amp;i=716028&amp;p=28&amp;ver=html5" target="_blank">Read more.​</a></p>2021-08-01T04:00:00Z<img alt="" src="/Monthly-Issue/2021/August/PublishingImages/0821_mgmt.jpg" style="BORDER&#58;0px solid;" />ManagementRichard Juman, PsyDFor myriad reasons, post-acute facilities are compelled to limit the use of antipsychotics and other sedating medications to the lowest possible levels. But this comes at a time when the population of residents with serious psychiatric illness in skilled nursing facilities continues to rise.
Walking the Tightrope Between Risk and Autonomy<p>In the morning stand-up meeting, the charge nurse reports that Mrs. Jones (pseudonym) was upset that she was not offered cake when most of the other residents had been given some. Mrs. Jones has diabetes, her blood sugar is not well controlled, and her physician has ordered a diabetic diet. The staff offer her alternatives, but they note she is getting more upset and has started to decline going to meals and activities. She has told her nurse assistant that “it’s not worth living this way.”<br></p><p>It is the quintessential challenge for health care providers in long term care&#58; balancing the rights of each resident to make decisions and the multiple risks that may co-exist in supporting those choices. Balancing these sometimes conflicting responsibilities often feels like walking a tightrope without a net, but just as with performers, it gets better with practice. </p><h2>Resident Rights and Duty of Care</h2><p><a href="http&#58;//cms.gov/" target="_blank">The Centers for Medicare and Medicaid Services</a> website contains a document for residents titled, “Your Rights and Protections as a Nursing Home Resident,” and within the first paragraph it talks about residents’ rights to be informed and to make their own decisions. The bottom line is that people do not give away their civil rights on taking up residence in a long term care community.<br></p><p>All health care professionals have the duty of care, to avoid behaviors that could reasonably and foreseeably cause harm. So, on this surface is where the conflict occurs, between the resident right to self-determination and the professional and organizational responsibility to minimize potential for harm.</p><h2>Informed Decision</h2><p>Several important caveats to consider are capacity and risk. Does the resident have the capacity to understand the risks and make an informed choice? The key factor here is that capacity is a legal term and not something that is determined solely by the staff. Only when an advanced directive or power of attorney has been triggered would the staff look to another individual for decision making.<br></p><p>The second important issue is that the resident has been made aware of the risks and benefits of different options. Additionally, the options cannot be putting other residents at risk.</p><h2>Defining Risk</h2><p>Geriatrician G. Allen Power, MD, has described risk as “the chance that something occurs that is different than is expected.” Health care professionals tend to focus on the negative risk, concentrating on the bad things that could happen. However, there are positive risks as well, that something better than expected may happen.<br></p><p>It is also important to keep in mind that risks are not only physical, but they can also be psychological and social. Health care professionals have been taught to focus primarily on the physical risk. This is what gave rise to the era of “physical restraints” since they were thought to increase physical safety (they were wrong), and there was little to no attention to the psychological and social implications of their use.<br></p><p>In their own lives, health care professionals take physical risks every day; they eat, walk, take a shower. Yet rarely do they think of these things as risky because they do not expect to choke, trip on the stairs, or slip in the shower. People value doing those activities, so the tradeoff of a small potential negative event is outweighed by the positive effect gained in doing it. No one has led a risk-free life.<br></p><p>Like everyone else, older adults must balance freedom of choice against safety/risk&#58; It is the balance between what is important to them and what is important for them. <br></p><p>Health care has historically been paternalistic by making decisions for people, presuming to be acting “in their best interest” of safety over autonomy, deciding what is important for the resident or the organization providing the care. What health care has often failed to recognize is that there is dignity in risk; making choices is integral to experiencing life.<br></p><p>With advancing resident rights, health care practitioners are realizing that learning what is important to the resident, and having open communication to make informed decisions, can support a solution that is both important to the resident and more likely to be the best for them as an individual. It means being flexible in addressing individual resident challenges and recognizing that one-size-fits-all rules and regulations are what depersonalize care delivery. Just like risk is not the same to each person, the response of an organization and staff must have nuance as well.<br></p><p>Thus, the challenge arises not when the resident makes a choice, it is when he or she makes a choice that the health care professionals or the community do not agree with. This is not to say the health care professional should not make recommendations based on training and expertise, but the resident’s values and life experiences must be elicited and understood first, since all decisions must be viewed through their lens. <br></p><p>Risk should be reviewed for potential physical, psychological, and social impact. Beyond these it must address both the potential benefits and negative implications of taking one action versus another, including taking no action at all.</p><p style="text-align&#58;center;"><img src="/Monthly-Issue/2021/July/PublishingImages/mgmt_RiskTaking.jpg" alt="Risk Taking" class="ms-rtePosition-4 ms-rteImage-1" style="margin&#58;5px;width&#58;375px;height&#58;369px;" /><br></p><p>A realistic view of both the likelihood and potential severity of any consequences needs to be mutually established and understood to the best of the team’s ability. Additionally, decisions should be evaluated through a lens of proportionality; that is, are the suggested interventions or even the need for interventions at a level commensurate with the issue at hand? Like the physical restraint example listed earlier, restricting all mobility because some mobility is unsafe was not a proportional response. </p><h2>Documenting Risk Discussions</h2><p>Like most areas of long term care, documenting the decision-making process and resident involvement is critical. A written record of the assessment of options, potential positive and negative implications, and recommendations from professionals involved is required to show informed decision making.<br></p><p>Clear documenting should reflect that the resident is aware of the potential positive and negative outcomes as could reasonably be known to the group. Keep in mind, this could be a negotiation where each side may need to readjust their options to find a decision that can support the resident and be accommodated by the home. Managed risk contracts may be an option to show this process as an addendum to a care plan.</p><h2>Ongoing Review and Learning</h2><p>The plan of care should be reviewed on a regular basis to see if the decision still meets the resident’s needs, values, and preferences. These ongoing reviews will also help the resident to see if their decisions are having the desired outcome or if additional interventions may be needed to support or alter their decision. <br></p><p>Staff should also use reflection on the process, the decisions, and a review of what is working and not working as they adapt to a more person-centered approach. It may be uncomfortable to accept when their professional judgment was considered but the resident chose a different direction. However, seeing the person, their values and preferences, and how those contributed to the resident making a different choice can reframe the care delivery process, so the resident is truly at the center of the health care team.<br></p><p>It is also important for everyone to recognize that these decisions are not written in stone, just on the care plan. They can and should be edited as more information is revealed via resident and staff experience.<br></p><p>A trial “failure” should be a learning experience, where in this situation with these variables something did not have the outcome expected. Proper implementation, documentation, and ongoing review and support to minimize potential risk within the resident’s life choices are the keys to balancing risk and autonomy while providing person-centered care.<br></p><p>For Mrs. Jones, a restrictive diet is more likely to help her physically by keeping her blood sugar more tightly regulated, but her lack of engagement and socialization with meals and activities is impacting her psychologically and socially. Further dialogue is clearly needed to determine reasonable options for monitoring food selection and the risks to her health, while staff need to better understand her life and health care priorities.<span></span></p><p><span><em><img src="/PublishingImages/Headshots/CathyHainesCiolek.png" class="ms-rtePosition-1" alt="" style="margin&#58;5px;" /></em></span>Based on this real-life example, it was mutually agreed that Mrs. Jones’ care plan was updated to keep the diabetic diet for meals, but have it relaxed for a “regular” snack in activities with her friends. With this she completed a larger portion of her meals, and there was not a significant change in her blood sugar regulation with the new plan. <em><br></em></p><p><em>Cathy Haines Ciolek, PT, DPT, FAPTA, is president of Living Well With Dementia®, providing education and consulting to improve well-being and create positive expectations for aging adults. She can be reached at <a href="mailto&#58;cciolek@livingwellwithdementiallc.com" target="_blank">cciolek@livingwellwithdementiallc.com</a> or 302-753-9725.​</em></p>2021-07-01T04:00:00Z<img alt="" src="/Monthly-Issue/2021/July/PublishingImages/0721_mgmt.jpg" style="BORDER&#58;0px solid;" />ManagementCathy Haines CiolekIt is the quintessential challenge for health care providers in long term care: balancing the rights of each resident to make decisions and the multiple risks that may co-exist in supporting those choices.