MDS and CAAs: The Journey to Great Care

1. MDS and CAAs: The Journey to Great Care Amy Ruedinger, RN RAC-CTPinnacle Innovative Healthcare Solutions

2. Objectives • Analyze recent updates to the RAI manual and the Medicare benefits manual • Updates • Potential financial impact of the recent updates to the RAI process • Tips for implementation of RAI changes and updates • Other Updates and concerns • Evaluate the components of root cause analysis as it pertains to overall documentation and the CAAs process • Gain tips to promote effective documentation • Examine the connection between MDS, CAAs/root cause analysis and the plan of care • Discuss the benefits and potential challenges of providing person-directed cares.

3. RAI UPDATES & OTHER CONCERNS

4. RAI Updates • FY 2014 changes- effective 10/1/13 • Distinct calendar days for therapy ( may effect Med A eligibility) • Discussion of “presumptive coverage” • RAI Manual updates • Modification/Inactivation policies • Challenges and concerns- Review • Need to open assessments timely • Regulatory guidelines • Financial concerns • Who is responsible for this task?

5. RAI Updates Impact and Tips • Increased awareness of “presumptive coverage” qualifiers • Medicare A coverage decisions • Scheduling /workload • Financial

6. Miscellaneous Concerns • Quality Measures • How are they determined? • What do they mean? • Discharge Planning • New CMS focus and guidelines

7. ROOT CAUSE ANALYSIS & DOCUMENTATION

8. Root Cause Analysis • Defining root cause analysis • “WHY? WHY? WHY?” • “SO WHAT?? • WHY IS THIS IMPORTANT?” • Examples • Root cause analysis and the QA Process • Determine the reason for the concern • Develop a plan to manage the concern • Example: QM triggers for “Behaviors affecting others” • Which resident/s are triggering? • Which behaviors? • Why are the residents having these behaviors? • What can we do to manage the behaviors? • Using root cause analysis in documentation • Writing CAAs/Care plans

9. Documentation Standards Standards of Practice related to documentation • Proves that facility was providing care it was paid to provide (think Med A charting) • Required part of the resident’s care and validates that care was given • Proves that standards of care were met • Essential element of communication

10. Documentation Standards Standards of Practice related to documentation • Reflective of resident response to cares and actions taken to rectify unsatisfactory response • Timely and completed only during or after giving cares • Chronological • Internally consistent

11. Documentation Standards Charting consistency and objectivity • Documentation should reveal consistent interventions among disciplines • Consistency within the resident record • Quality of content, not quantity of words • Allegations about cares or comments about staff members should not be in charting • Avoid charting about staffing shortages (tx not done due to lack of staff)

12. Documentation Standards Tips for improving documentation • Ensure consistency across all disciplines, as well as billing department • Strong documentation requires communication between disciplines to ensure that all are “on the same page” • Encourage each discipline to document only on their relevant areas

13. Documentation Standards Documentation tips: what to document • Assessments, observations, concerns, interventions-cares and treatments • Incorporating critical thinking and root case analysis of what happened and why • Note action taken, resident response and evaluation • Critical thinking/root cause analysis—did it work? If not, what next?

14. Documentation Standards Documentation tips: How to document • Be specific when describing behavior( not: “unruly” or “agitated” or “uncooperative”) • This does not really paint an accurate picture of what is happening with the resident • Document precipitating factors, what makes it better and what makes it worse • Incorporating root cause analysis • Document any specific resident statements • Document cares and interventions • Document resident response to cares and interventions

15. Documentation Standards Documentation tips: Cares/treatment/intervention • Charting regarding cares/interventions and responses should be consistent with resident status • Describe resident response to any teaching, including understanding. List specific information given • Document all safety precautions taken to protect resident

16. Documentation Standards Care Plan Documentation • Care plan should be updated when there is a change in resident status or resident orders • New interventions when there are new mood/behavioral concerns • If new med, is there an intervention needed to monitor effectiveness or side effects? • If interventions have been ineffective in past, probably should not be repeated (especially in case of falls/behaviors ) • Incorporate root cause analysis to help determine why the interventions used previously were not effective and plan for other interventions that may be more appropriate • Care plan should match MDS and the resident’s current status • Ex: If MDS reflects short term memory deficit, reminder to use call light or call for assistance with tasks or activities may not be appropriate

17. CAAS & Care Planning

18. CAAs • CAA process guides the ID team through a comprehensive assessment of the resident’s functional status • Each CAA must be addressed, but may not need to be care planned • CAA documentation should address the reason that the CAA triggered • Identify: • Areas that warrant intervention • Areas that impact resident function • How to minimize decline and avoid functional complications • Address palliative care, including symptom relief and pain management

19. CAAs ROOT CAUSE ANALYSIS • “Chart your thinking” • Documentation should include: • Nature of the condition • Underlying causes-diagnoses, conditions, meds, labs • Contributing factors-complications • Unique risk factors-complications, justification for care planning or not care planning • Need for referrals • Decision to proceed with care planning

20. CAAs CAAs: • Cognitive CAA • Communication CAA • Mood CAA • Behavior CAA • Psychosocial CAA

21. CAAs Areas of concern for each CAA: • Current status or level of function • Reason for the CAA to be triggering • Recent changes- improvements or declines • Precipitating factors /What makes the situation better or worse • Comparison to most recent prior MDS-BIMS and Mood scores, etc • Diagnoses and conditions • Meds, labs, treatments • Need for referrals • Other areas • Care Plan-develop, continue, revise

22. CAAs and Care Planning Care Planning • Address areas as triggered in the CAA ( unless you decided not to proceed with care plan) • Combine care plan areas when it makes sense • Goals for improvement, prevention of complication or decline, palliative goals, maintenance goals • Care plan can address resident strengths and preferences • Involve resident and family or legal representative

23. CAAs and Care Planning Develop a plan of care which promotes: • Highest level of function, • Improvement when possible, • Maintenance and prevention of declines

24. CAAs and Care Planning Care Planning • Use the information you learned in the CAAs and root cause analysis to develop a plan of care that is specific and effective for that resident • Incorporate the resident’s goals and preferences as much as possible • PERSON-DIRECTED CARE • Care plans can contain individualized approaches • Care plans are a working document and should be accessible to all staff

25. Care Planning • Examples • What kind of help does the resident need and/or want? • When would s/he like the help? • What would s/he prefer to do for themselves? • What has worked or not worked in the past and why? • How will this affect care planning now?

26. Care Planning Culture Change, Care planning and Person-directed Care: • Linda Bump is one the pioneers of the culture change movement • “Bump’s Law” can be the basis and driving force behind every decision- big or small. • What does the resident want? • How did the resident do it at his/her previous home? • How do you do it at home? • How should we do it here?

27. Envision….Person-directed cares • Dining • Medications • Cares • Activities • Decorations and Furnishings • Policies • Staffing • Expanded Social History • Communication with families regarding the philosophy of culture change

28. Envision….Person-directed cares • Residents choosing and planning activities • Natural waking times • Easier medication administration • Staff self scheduling • Staff eating with residents • Residents decorating their living and common spaces • Meaningful engagement every day

29. Envision….Person-directed cares “Person-directed care means we get out of the way when they express their preferences” • Put the resident at the center • Include the family • Educate • Know Best Practices • Write and implement clear policies regarding choice

30. Person-Directed Cares • Tips for incorporating Person-Directed Care into the resident’s plan of care and daily life • Suggestions and sharing from the participants

31. Thank You Amy Ruedinger, RN, RAC-CT Pinnacle Innovative Healthcare Solutions, LLC (920) 609-7997 E-mail: pinnaclemds@yahoo.com E-mail: amy@pinnacleinnovativesolutions.com ~Facilitating Peak Performance in Senior Health and Housing ~