Pearls of Wisdom for Care Planning: Ideas to help residents and staff get exceptional results. Introductions. Your presenters are : Barbara Bates, MSN, RAC-CT Senior Consultant Karen Choens , LMSW Project Manager. LEARNING OBJECTIVES. After attending this conference, attendees will:
Pearls of Wisdom for Care Planning:Ideas to help residents and staff get exceptional results
Your presenters are:
Barbara Bates, MSN, RAC-CT
Karen Choens, LMSW
After attending this conference, attendees will:
(1) to achieve resident centered care planning based on current standards of care.
(2) to educate the heath care team in research-based clinical practice.
(3) to reduce time spent on ineffective paperwork.
The ECP Grant staff are providing resources and support to facilitate achievement of these outcome objectives in the Replication Project.
What is it?
Who developed this initiative?
Why was it developed?
Efficient and Cost-Effective Care Planning Demonstration Project
Success in the original grant was the basis for new grant, Replicating Exceptional Care Planning in New York State Nursing Homes…
280 professionals from 104 nursing homes have attended dissemination trainings
(Spring 2012) Albany, Rochester, Queens & Westchester
(Winter 2012) North Creek, Syracuse & Long Island
30 Sites have submitted LOAs to participate in the grant and receive implementation support, including:
and most importantly…
Staff must know the
Standards of Care,
know where they are found,
how to implement them correctly and
Documentation that serves a useful purpose
Top 5 Immediate Jeopardy Determinations
(FY 2011 Surveys, VA Geriatrics and Extended Care Operations presentation NSVH Conference 2012)
Top Ten Most Common Nursing Home Deficiencies (ProPublica’s Nursing Home Inspect Tool, database includes
262,500 deficiencies from CMS reports over last three years)
Exceptional Care Planning
Steps to Success
Access your facility’s current care plan system.
Are the care plans lengthy?
Are Care plans repetitive
from one resident’s plan
Determine ways to demonstrate support for buy in: EXAMPLES
F279: Comprehensive Care Plan
F280: Allow the resident the right to participate in the planning or revision of the resident's care plan
health maintenance, discharge potential,
medications, and daily care needs
F281: Utilize current standards of practice
F282: Provide care by qualified persons according to each resident's written plan of care
Before and After
Exceptional Care Planning Examples
2.Specific use of hearing aids (preferences and wearing schedule) will be individualized on care plan.
3.Resident room and personal items will be organized to allow for maximum independence.
4.Resident will be oriented to surroundings as needed.
7.Encourage resident to provide self care for hearing devices when capable.
8.Report any change in hearing to the nurse. Any changes will result in referral to appropriate health care professionals.
9.Refer to audiology clinic as needed.
10.If necessary, resident will be reminded to wear hearing aids and assisted with placement.
11.Hearing aids will be clean, checked for good repair and work order prior to insertion.
12.Caregiver will speak clearly, slowly, and stand within field of vision.
13.Obtain feedback from resident to assure understanding of the communication.
14.Allow time for resident to respond.
15.In the event of resident refusal to wear/use communication devices, attempt to determine reason why and network with resident, family, and IDT to determine reason for refusal and attempt to remedy reason.
16.Residents will have periodic ear exam completed by Medical and/or RN and wax removal as needed.
17.Medications as ordered.
Every Resident’s skin will be assessed for potential problems, appropriate treatments provided, and pressure-relieving equipment utilized to promote healing and to prevent skin breakdown.
Every resident shall receive suitable and sufficient hydration, nutrients, and calories to maintain health.
American Association of Nursing Assessment Coordinators – www.aanac.org
American Medical Directors Association – www.amda.edu
Long Term Care Nursing Desk Reference
Foundation of Long Term Care – www.fltc.org
ECP Replication Project webpage:
Hartford Institute for Geriatric Nursing – www.hartfordign.org
National Gerontological Nursing Association – www.ngna.org
National Guideline Clearinghouse – www.guidelines.gov
Long Term Care State Operations Manual
RAI Users Manual (2012)
ECP Foundational Course
To receive more information about scheduling ECP training/consulting, please contact Karen Choens (née Revitt) at 518-867-8385 extension 165 or email [email protected]
Follow-up Consulting Options:
A. Format: Individual site visit by Senior ECP Trainer(s) to provide:
B. Format: Individual conference call (option for live webinar included) with Senior ECP Trainer(s) to offer feedback on:
To receive more information about scheduling ECP training/consulting, please contact Karen Choens(née Revitt) at 518-867-8385 extension 165 or email [email protected]