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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:

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Presentation Transcript

Your presenters are:

Barbara Bates, MSN, RAC-CT

Senior Consultant

Karen Choens, LMSW

Project Manager

learning objectives

After attending this conference, attendees will:

  • Be able to give 3 reasons why this approach to care planning is needed.
  • Be able to state 3 steps in the Exceptional Care Planning (ECP) process.
  • Be able to demonstrate the initial skills to begin to develop, implement, and sustain an Exceptional Care Planning program in their facility.
learning objectives cont d
  • Be able to describe 2 barriers and 2 benefits to implementing ECP.
  • Be able to state documentation requirements in developing Standards of Care (SOC) and how to utilize them effectively in an interdisciplinary team.
before going on to outcome objectives lets ask some questions
Before going on to outcome objectives, lets ask some questions…
  • Do you write the same thing again and again on care plans and sometimes wonder if they make a real difference for your residents?
  • If staff are absent, would relief staff know what special needs the residents have by looking at the care plans?
  • Are your care plans assuring that every CNA, nurse and members of the IDT are following current standards of care?
  • Does the care plans writing process take too long – taking time away from direct care?
based on your answers the outcome objectives for this training are
Based on your answers, the outcome objectives for this training are…

(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.

history of ecp
History of ECP

What is it?

  • A guideline for efficient and effective clinical record documentation and care planning.

Who developed this initiative?

  • The Bureau of Quality Assurance and The Wisconsin Board on Aging and Long Term Care. 

Why was it developed?

  • Out of concern that clinical records in nursing facilities were crowded with unnecessary, duplicative documentation that makes personal care information hard to find and takes too much time to complete.

The Outcome

  • Resident Centered Care Plans

Efficient and Cost-Effective Care Planning Demonstration Project

  • FLTC’s demonstration grant from the New York State Health Foundation (NYS) to implement ECP in nine diverse NYS nursing homes and evaluate it more rigorously.
ecp demonstration project results 2008 2010
ECP Demonstration Project Results (2008-2010)
  • ECP significantly reduced nurses’ time spent in documenting care plans as much as half- 50 percent!
  • Freed up time was spent with “people, not paper.”
  • Qualitative findings include improvement in communication between staff and family members, within the interdisciplinary team, and with aides.
  • Shorter, clearer care plans were less intimidating for families to provide input.
  • Interdisciplinary teams helped identify overlap in care and helped see all facets of a person.
ecp demonstration project results cont 2008 2010
ECP Demonstration Project Results cont.2008-2010
  • Analysis of monthly floor event reports showed that the intervention was associated with positive trends in reducing falls and hospitalizations.
  • All the participating facilities indicated that staff enjoyed participating in, creating and using the Standards of Care and are very positive about the ECP process.

Success in the original grant was the basis for new grant, Replicating Exceptional Care Planning in New York State Nursing Homes…

replicating ecp in nys nursing homes 2011 2013
Replicating ECP in NYS Nursing Homes2011-2013

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:

  • Nassau: Long Island State Veterans Home
  • Western NY: Catholic Health Continuing Care (Buffalo): Corporate implementation across six skilled nursing communities
  • North/Adirondack Region: CVPH (Plattsburgh)
working with surveyors advice given to ecp implementation sites
Working with Surveyors(Advice Given to ECP Implementation Sites)
  • The NYS Department of Health (DOH), responsible for CMS surveys, has supported this project from the beginning.
  • CMS does not mandate a specific care plan format; as SVH are evaluated using similar criteria, you do not need prior approval to implement ECP.
  • Your facility should notify surveyors of your care planning format when they arrive for survey.
  • Standards of Care should be on-hand for surveyors to review

and most importantly…


Staff must know the

Standards of Care,

know where they are found,

how to implement them correctly and

follow them.

focus of ecp
Focus of ECP

Documentation that serves a useful purpose

  • Eliminates duplicate documentation
  • Utilizes current research and resources
  • Focus on quality (not quantity) of content
  • Use of MDS language and definitions, improving consistency in the medical record
  • Documentation to support clinical care (not perceived surveyor needs)…that said, it will still help you with survey when properly implemented!
ecp s approach addresses top survey deficiencies
ECP’s Approach Addresses Top Survey Deficiencies

Top 5 Immediate Jeopardy Determinations

(FY 2011 Surveys, VA Geriatrics and Extended Care Operations presentation NSVH Conference 2012)

  • Resident Assessments: Comprehensive plans need to be individualized (Tag 92, CFR #51.110(e)
ecp s approach addresses top survey deficiencies1
ECP’s Approach Addresses Top Survey Deficiencies

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)

  • Develop Comprehensive Care Plans: 9,070
  • Services Provided Meet Professional Standards: 8,986
  • Clinical Records Meet Professional Standards: 7,962
step 1 how to get buy in for making a change
Step 1-- how to get “buy-in” for making a change

Access your facility’s current care plan system.

Yes No

Are the care plans lengthy?

Are Care plans repetitive

from one resident’s plan

to another?



step two of buy in
Step Twoof Buy-In

Determine ways to demonstrate support for buy in: EXAMPLES

  • Audit time spent by each discipline in completing care plans or length of care plan meetings.
  • Audit number of incidents of care plans not being followed related to missing or unseen information.
  • Audit the amount of repetitive or duplicative documentation related to care plans.
  • Audit staff use of care plans.
step three
Step Three
  • Establish an Interdisciplinary Team to develop facility Standards of Care based on current, accepted clinical guidelines.
  • Design an implementation plan.
  • Develop a care model that establishes the standards as the building blocks to the resident centered care planning process.
  • Review all of your facility’s current policies within the context of new facility SOC.
step four
Step Four
  • Review regulations, both federal and state, with respect to care plan requirements.
  • Ensure the interdisciplinary team understands what must be included in the care plan process.
  • Establish how compliance will be achieved.
care plan regulatory requirements
Care Plan Regulatory Requirements

F279: Comprehensive Care Plan

  • Based on comprehensive assessment
  • Measurable outcomes with time frames for completion which reflect resident’s wishes
  • Attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being
  • Manage risk factors in the care plan
  • Build on resident’s strengths
  • Reflect standards of current professional practice
  • Offer alternatives if resident refuses treatment
  • Evaluate treatment objectives and outcomes of care
care plan regulatory requirements1
Care Plan Regulatory Requirements

F280: Allow the resident the right to participate in the planning or revision of the resident's care plan

  • Respect resident’s right to refuse treatment
  • Utilize an interdisciplinary approach
  • Family and resident representative involvement in care planning
  • Consider: functional status,

rehab/restorative nursing,

health maintenance, discharge potential,

medications, and daily care needs

care plan regulatory requirements2
Care Plan Regulatory Requirements

F281: Utilize current standards of practice

F282: Provide care by qualified persons according to each resident's written plan of care

  • Determine if care was provided by qualified staff and whether staff implemented the care plan correctly and adequately
  • Involve direct care staff with the care planning process relating to resident’s expected outcomes
  • Show that the care plan is sufficient to meet the needs of a new admission prior to comprehensive assessment
step five
Step Five
  • Establish policies and procedures followed by development of facility Standards of Care.
  • Utilize published guidelines (i.e., AMDA, AANAC, ANA, GNA, Hartford Foundation for Geriatric Nursing, RAI manual, etc.) as references for the standards.
  • Review/revise all corresponding policies/procedures related to each standard.
  • Interdisciplinary Team may consider linking the Standards of Care to the Care Area Assessments (CAAs).
Before and After

Exceptional Care Planning Examples

hearing standard of care
Hearing Standard of Care
  • Upon admission, resident’s hearing needs will be identified, devices will be labeled and logged on property sheet. Note battery size.

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.

  • Adaptive equipment will be provided as needed.
  • Maintain extra hearing aid batteries and assist with changing 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.

hearing standard of care1
Hearing Standard of Care

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.

  • Flush ears as per procedure.


skin integrity pressure ulcer prevention standard of care
Skin Integrity /Pressure Ulcer PreventionStandard of Care

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.

  • Skin will be observed daily during care routines. Any changes will be reported to the charge nurse.
  • Pressure reduction will be achieved by using pressure reduction mattress, cushions, and pressure point protectors as needed.
  • Protective creams/lotions will be applied as needed for dry skin. Apply barrier cream after each incontinent episode.
  • Lifting sheets will be used to reposition residents to reduce shearing.
  • Use only one large incontinent pad under resident.
nutrition hydration standard of care
Nutrition/Hydration Standard of Care

Every resident shall receive suitable and sufficient hydration, nutrients, and calories to maintain health.

  • Residents shall be offered balanced meals three times a day with supplements offered as need arises
  • Obtain resident preferences for food likes/dislikes, customary times for meals, food preparation, etc.
  • Fresh water is provided each shift, as appropriate
  • Food and fluids provided at meals will be encouraged and monitored via consumption records.
  • Residents will be offered 120 cc of fluids with each medication administration.
  • Residents shall be offered snacks and fluids three times per day between meals as appropriate
  • Residents will be weighed monthly, with closer monitoring as needed.
  • Monitor labs as available
  • Meal tray will be served promptly upon arrival to the unit
  • Monitor and report S/Sx of dehydration (dry/cracked lips, dry oral mucosa, rapid unplanned weight loss, weakness/lethargy, sudden onset of confusion, elevated temperature and the absence of infection, hard stools/increased constipation, concentrated urine/UTI).
soc documentation format
SOC Documentation Format
  • Definition of Standard
  • Risk Factors
  • Standard of Care (Interdisciplinary)
  • CNA Considerations
  • Reference(s) used to develop standard
step six
Step Six
  • Educate all staff on the standards.
  • Ensure ongoing education is provided for all current staff, on orientation for newly hired or returning staff, when revisions occur to the standards or policies, and PRN.
  • Attendance records need to be maintained, systems developed to ensure training is ongoing, and decisions as to where records will be stored.
step seven
Step Seven
  • Audit and Evaluate Outcomes.
  • Audit compliance of staff with the standards – Are they following?, Using?
  • Evaluate the effectiveness of the standards in meeting regulatory requirements and are up-to-date.
  • Evaluate the effectiveness of the standards in delivery of quality of care and life for the residents.

American Association of Nursing Assessment Coordinators –

American Medical Directors Association –

Long Term Care Nursing Desk Reference

Foundation of Long Term Care –

ECP Replication Project webpage:


Hartford Institute for Geriatric Nursing –

National Gerontological Nursing Association –

National Guideline Clearinghouse –

Long Term Care State Operations Manual

RAI Users Manual (2012)

where do we go from here
Where do we go from here?
  • Talk with Administrative staff – get support.
  • Develop an implementation plan – timeline.
  • Establish steering committee – market the program – determine which unit will start.
  • Develop facility SOC policy.
  • Determine what SOC will be developed.
  • Begin developing SOC.
  • Implement ECP utilizing steps to success.
ecp procare training consulting service menu options
ECP ProCareTraining & ConsultingService Menu Options

ECP Foundational Course

  • Format: In-person, interactive training led by Senior ECP Trainer(s) with administrative and clinical staff representing all disciplines
  • Homes have the option to schedule a regional training for several Veteran Homes in a common location
  • 6-hour, 2 session course: Generally, 9am – 12pm, 1-4pm

To receive more information about scheduling ECP training/consulting, please contact Karen Choens (née Revitt) at 518-867-8385 extension 165 or email

ecp procare training consulting service menu options1
ECP ProCareTraining & ConsultingService Menu Options

Follow-up Consulting Options:

A. Format: Individual site visit by Senior ECP Trainer(s) to provide:

  • Follow-up training and/or
  • Review of SOC and ECP care plans developed

B. Format: Individual conference call (option for live webinar included) with Senior ECP Trainer(s) to offer feedback on:

  • SOC digitally submitted by Vet Home’s ECP Implementation Team to Consultant
  • Challenges/Concerns encountered thus far in implementation

To receive more information about scheduling ECP training/consulting, please contact Karen Choens(née Revitt) at 518-867-8385 extension 165 or email