increase opportunities for person-centered care planning

3/24/2015

1

©Pathway Health 2013

Are We REALLY Offering the Resident Their

Choice? Increase Opportunities for

Person-Centered Care Planning and Decision Making

Susan LaGrange, RN, BSN, NHA Director of Education

Pathway Health

1 ©Pathway Health 2013

Upon completion of the presentation, attendees will be able to:

1. Describe the key strategies in developing a culture that leads to successful outcome of true resident choice

2. Verbalize a system to verify positive

outcomes related to resident choice

3. Identify resources available in the industry to assist facilities for further learning and system implementation

Objectives

2


Culture Change!

3


• It takes

– planning!

– It takes a bit of time!

– It takes a little digging!

– It takes patience!

– It takes creativity!

Collaboration WITH the Resident

4


• Also Takes:

– Planning

– Time

– Digging

– Patience

– Intuition

– Creativity

Collaboration WITH the Family


Where does a good amount of our information come from for the initial care

plan?

The Admission Process

Let’s Look at Our Processes

6

3/24/2015

2


• What are the nurses doing on that Friday pm when many of the residents are admitted?

– Passing medications – Treatments – Processing orders that came back after

the day shift left

– Calling practitioners for updates – Assessment follow up, documentation,

etc……

Admission Assessment


• Preadmission Assessment

– How is the information communicated?

– Are the nurses looking at the information from the hospitals?

• H&P

• IDT Notes

• Medication Review/Reconciliation

• Discharge Summary

From the Beginning…

8


• Who completes them?

– Friday pm or weekend admissions

– 24 Hour Care Plan?

• Where is the information derived?

• How is this communicated?

Admission Care Plans


Are WE MISSING a Piece of the Puzzle

10


Traditional

• Staff directed

• Medical/Diagnosis based

• Staff goals

• Therapy goals

• **Based on assessments when resident’s admitted to the facility

Person-Centered

• Resident directed

• Preferences (choice)

• Habits

• Routines

• History of Medical Management

• The resident’s understanding of medical management of conditions

• Resident’s goals

Traditional vs. Person-Centered


RAI PROCESS

12

MDS

CATs

CAAs

CARE PLAN

CAA SUMMARY

CARE ASSESSMENTS RESIDENT INTERVIEWS

3/24/2015

3


Preferences for Customary Routine and Activities:

INTENT:

• To obtain resident’s own preferences for both routines and activities

• Should be obtained directly from the resident or family/significant other

• To be used for Care Planning

• Is not all-inclusive

MDS Section F


• Clothing choice

• Personal belongings (caring for and securing)

• Bathing/showering

• Snacking

• Staying up at night

• Who should be involved in care discussions

• Privacy with phone calls

• Activity preferences

– Reading materials -Out of facility activities

– Music -Outdoor activities

– Group Activities -Religious activities

MDS Section F

14


CAA


• Based on the Comprehensive Assessment

• Based on Resident Choice and Preferences

• Individualized

• Goals that are realistic, measureable and make

sense to the resident!

• Approaches: Unique to the resident needs that

assist the resident in achieving the goal!

• Consistently Implemented

• Evaluation Process/Revisions as Necessary

Care Plan Essentials

16


• Begin even before admission if possible to set the tone and prepare for a successful transition.

• Upon admission, teach staff to take the time to identify resident choices and preferences for care, document them and communicate this to the care givers

• Take the time to include the resident in the RAI process with choices for care plan goals and intervention

• Educate all departments on resident choices and care planning decisions

Processes Necessary for Collaboration


• Where are the preferences/choices/habits of the resident documented:

– Nursing Notes

– Social Service Notes

– Activity/Recreational Therapy Notes

– Dietary Notes

***How do we put it all together??

Putting it all TOGETHER

18

3/24/2015

4


• I like to teach staff person centered care in a variety of ways:

– Making a pizza

– Planning a vacation

– Shopping trip

– Decorating a room

Key: We all have different preferences – and when we weave in the resident’s choices – we improve the odds of true person centered care!

Moving Staff Forward


• Education

• Shift to Shift

• Department to Department

• Documentation (C.N.A. Care Plans, Care Records, Care Cards, etc.)

• Ongoing rapport with the resident/family

Communication

20


• Formal Interviews

• Informal Visits

• Resident Council

• Family Input

• Care Plan Conferences

Resident Interviews


• To sort through the information and identify the individualized needs and wishes of each resident

• What is THEIR perception?

• Asking, “What would YOU like to see differently?

Taking the TIME…

22


GROUP EXERCISE


Resident: Identify 3 Unique things about you that you would want in your care plan Care Giver: Describe how you would Care Plan this and ensure that these 3 areas are incorporated in care

24

3/24/2015

5


How Do WE Verify Choice Inclusion?

25


1. Audit charts (See Handout)

2. Interview the Resident

3. Interview the Staff

4. Observe

5. Check the 24 hour report

a) Are new problems/concerns added to CP?

b) Are the goals and interventions consistent with resident choice?

c) What does the resident say?

How Do We Verify

26


Area for Correction Plan Date Due Responsible Party

Care plan does not contain specific individualized information from the CAA

1. Education will be provided for all IDT members involved in CAA and care planning process.

2. All care plans will be reviewed and updated with individualized goals and interventions with next MDS cycle

3. Audits will be completed weekly to monitor compliance

4. Results of audits will be addressed in the Quarterly QA Committee Meeting

5/15/15 Starting 5/15/15 for 3 months Starting 6/1/15 7/1/15

DON or Designee DON or Designee IDT Team DON or Designee

C.N.A. Care Record not updated with current care plan information

1. Education will be provided for all IDT members involved in care planning to update C.N.A. Care Record

2. All C.N.A. Care Records will be cross-referenced/updated with Care Plans

3. Audits will be completed weekly to monitor compliance

4. Results of audits will be addressed in the Quarterly QA Committee Meeting

5/15/15 Starting 5/15/15 for 3 months Starting 6/1/15 7/1/15

DON or Designee DON or Designee IDT Team DON or Designee

Action Plan

27


Examples of Tools

28

©Pathway Health 2013 29

©Pathway Health 2013 30

3/24/2015

6

31


Resources

32


• https://www.nhqualitycampaign.org/goalDetail.aspx?g=PCC

• https://www.pioneernetwork.net/CultureChange/

• http://thegreenhouseproject.org/

• http://www.edenalt.com/

• http://www.polisherresearchinstitute.org/#!assessment-instruments/c16rg

• http://www.amda.com/consumers/CultureChangeMar10.pdf

• http://www.commonwealthfund.org/publications/in-the-literature/2010/jan/person-centered-care-for-nursing-home-residents

Informational Websites


Thank You!!!

34


Sue LaGrange, RN, BSN, NHA, CDONA

Director of Education

Pathway Health 35

https://www.nhqualitycampaign.org/goalDetail.aspx?g=PCC

https://www.nhqualitycampaign.org/goalDetail.aspx?g=PCC

https://www.pioneernetwork.net/CultureChange/

https://www.pioneernetwork.net/CultureChange/

http://thegreenhouseproject.org/

http://thegreenhouseproject.org/

http://www.edenalt.com/

http://www.edenalt.com/

http://www.polisherresearchinstitute.org/#!assessment-instruments/c16rg




http://www.amda.com/consumers/CultureChangeMar10.pdf

http://www.amda.com/consumers/CultureChangeMar10.pdf

http://www.commonwealthfund.org/publications/in-the-literature/2010/jan/person-centered-care-for-nursing-home-residents


















ACTION PLAN

Area of Action Findings Recommendations Goal Date Responsible Person(s)

Date:__________ Individual Resident Care Plan (Initiate within 24 hours of admission) Initals________

© Micron Electronics, Inc, - All Rights Reserved - Copy With Permission Only

DNR/DNI Full Code Discharge Plan/Comments:

***Fall Risk Yes No If Yes, implement safety measures) Bed Alarm Chair Alarm Sensor Grab Bar R / L Floor Mat Other _______________

***Skin Risk (Braden on admit) High Risk-Initiate CP- tissue tolerance Special Mattress Heel Protectors/Elevate heels Barrier cream W/C cushion Repositioning Q_____hrs Incision _________________ Wound Location:_________________ Prior to admit: Yes No ***Behavior/Mood/ Safety History of abusive behaviors Behaviors ↑ res. to res. altercation Mood Issues:_________________ ________________________________________________________________ Behaviors _____________________ ________________________________ Interventions:_____________________ ________________________________ Environmental Risks:___________ ________________________________ Elopement Risk_______________ Wanderguard _________________ Pain Control (Observe for pain) Has pain or discomfort or potential Location:_____________________ Use pain scale as applicable Pain management plan Interventions:__________________

Isolation Precautions____________

Bathing Tub Schedule_____________ Shower Schedule _______________ Bed bath Independent Assist with bathing 1 2 Dressing Obtains own clothing Assist with dressing 1 2 Ind. Set-up Cues Partial Total Other__________________ Grooming Independent Set-up/cues Partial Assist Total Assist Special Instructions: _____________ Oral Hygiene Ind. Set-up Assist Total Dental Status Own Teeth Dentures Upper Lower Partial Upper Lower Bowel Continent Incontinent Assist 1 2 Self Last BM________________ Bowel Program Bladder Continent Incontinent Assist 1 2 Self Foley Straight cath Leg bag Ostomy:___________________

Toileting Plan: Toilet Urinal Bedpan Commode Check and Change Prompt Habit Training Product:______________________ Schedule:____________________ ___________________________________

Ambulation Independent with ambulation Assist with ambulation 1 2 Aids for mobility_______________ Transfer Independent transfer Assist transfer 1 2 Special transfer aids or mechanical lift____________________________ Mobility Assist repositioning 1 2 Assist with bed mobility 1 2 Wheelchair mobility Self 1 Side Rails Type ___________ Splints Type _______________

Vision Adequate Impaired Glasses Reading glasses only Contacts

Cognitive Comatose Alert and Oriented:_____________ Forgetfulness Confusion: ___________________

Communication Adequate Hearing Hearing Aid R L Deaf Other________________

Activity Pursuits Awake during day, sleeps all night Naps in a.m. Naps in p.m.

Independent in activities Assist to activities In-room ***Dehydration Risk Yes No Comments:

Fluid Restriction:___________ cc Nutritional Status Oral problem(s) Chewing Swallowing problems Mouth pain Choking/aspiration

Diet Order ______________________ Allergies ______________________ Special Likes:___________________ Dislikes:_______________________ Special Needs __________________ Thickened Liquids Type:_________ Meal Assistance Independent Set-up Partial assist with feeding Total assist with feeding Adaptive equipment – i.e. built-up

spoons, plate guard, nosey cup, etc.

Dining Room Breakfast Noon Evening Room Tray:___________________ Snacks Nourishments Enteral Tube Feeding: _________ IV Fluids: Type:________________ ___Nacl lock __PICC __Central line Dialysis Shunt Oxygen____liters/min per____

Problem: Adjustment to SNF placement Fall Risk R/T ________________ Potential for alteration in comfort R/T_____________________________

Goals: Resident will adjust to environment by __________. Resident will not fall x 30 days_______________. Resident will remain comfortable daily through_____________.

Interventions: Orient to environment and routine Monitor for safety Observe for signs of discomfort ______________________________

Resident Name: _________________________________________________________________________________ MR# _______________ Room:_____________

Date:__________ Individual Resident Care Plan (Initiate within 24 hours of admission) Initals________

© Micron Electronics, Inc, - All Rights Reserved - Copy With Permission Only

Date Problem Related to Goal Goal Date

Intervention Discipline Responsible

Date: Nurse Signature: Resident Name: _________________________________________________________________________________ MR# _______________ Room:_____________

© HP - All Rights Reserved - Copy With Permission Only

PERSON-CENTERED CARE PLAN AUDIT

Care Plan Problem Goal is measureable,

realistic and individualized based on documentation, assessments and CAA’s

Interventions are individualized and meaningful toward goal

New problems identified are added timely to the care plan

Information is located on the C.N.A. care plan or care record

Staff interviewed and aware of goal and interventions

Evidence of review and revisions are noted

Resident #: ________________________________ Date of Audit: _________________

Signature: _________________________________

increase opportunities for person-centered care planning

Documents