Community Care Information Management
Community Support Services
Common Assessment Project
(CSS CAP)
interRAI CAPs (Clinical Assessment Protocols)
& Care Planning
Version 3.0
December 2011
Agenda: CAPs and Care Planning
Welcome and Introductions
Objectives
interRAI Outcome Measures and Scales
Introduction to CAPs and Benefits
How are CAPs Triggered?
Practice Using CAPs Manual
Care Planning
Break
Practice Creating a Care Plan
Wrap-up, Evaluations and Q & A
2
Participant Introductions
Please introduce yourself
– Your name
– Your HSP
– Your role
What is your personal
goal in attending this
training session?
3
Ice
Breaker
4
Education Material
Let’s review:
– The Assessor Workbook
– The interRAI Clinical
Assessment Protocols
Manual
5
Learning Objectives
Upon completion of the CAPs and Care Planning training
session you will have increased your understanding about:
• How CAPs focus on the client’s function and quality of life,
assessing their needs, strengths and preferences
• The link between information gathered in the interRAI CHA
assessment and the triggered CAPs and Outcome Measures
and Scales
• How to use CAPs to create a care plan that meets the needs
of the client
• How CAPs and Outcome Measures and Scales provide the
basis for outcome-based assessments and facilitate referrals
where appropriate
6
interRAI CHA Outcome Measures and Scales
The following outcome measures and scales are generated by your
software automatically once the assessment has been completed:
Functions of embedded
scales:
• Evaluate current status of
client
• Track outcomes of care
• Aggregate comparisons for
quality benchmarking
Adapted with expressed permission from
ideas for health, University of Waterloo,
June 2010.
7
Available outcome measures:
• Cognitive Performance Scale
(CPS)
• Depression Rating Scale (DRS)
• IADL Involvement Scale
• Changes in Health, End stage Signs
and Symptoms (CHESS)
• Pain Scale
• Self-Reliance Index (SRI)
• ADL Self-Performance Hierarchy
Scale
• MAPLe
interRAI CHA Outcome Measures and
Scales: Mr. Patterson
Let’s review for Mr.
Patterson:
• CPS
• Pain
• MAPLe
interRAI CHA Outcome Measures and
Scales: Mr. Patterson
Let’s review for Mr.
Patterson:
• CHESS &
• MAPLe
Clinical Assessment Protocols
Structured, problem
oriented frameworks to
organize information
and support care
planning
Adapted with expressed permission from
ideas for health, University of Waterloo,
June 2010
10
• Specific clinical characteristics are
used to identify clients who could
benefit from further evaluation of
specific problems either because
they are:
– at risk for decline
or
– show potential for improvement
• Trigger links to a series of problem
oriented assessment protocols
• Clinical expertise and choice is
important
• Not care path/care maps
Clinical Assessment Protocols cont’d
The CAP report is generated by your software automatically once the
assessment has been completed.
Key Points About CAPs report:
• Generated by software only
• Using the information from the Core CHA and Functional
Supplement, it identifies key areas that need to be addressed in the
following four sections:
– Functional performance
– Cognition and mental health
– Social life
– Clinical issues
• Each section contains CAPs triggered for a client
• Guidelines in the manual help the assessor create the plan of care,
provide appropriate service, and/or make timely referrals
11
Benefits of CAPs
CAPs:
• Enable client’s strengths, needs and preferences to be
taken into consideration when developing the care plan
• Guide the plan of care to potentially resolve problems,
reduce the risk of decline or increase the potential for
improvement
• Help the assessor to visualize a complete picture of the
problem: internal and external factors
• Will work with all of the interRAI assessment tools
12
CAPs Throughout interRAI Tools
[ i ] interRAI LTCF, not RAI-MDS 2.0
13
CAPs Throughout interRAI Tools
(cont’d)
[ ii ] interRAI HC, not RAI-HC 2.0
14
CAPs Triggered from Core
Assessment
Functional Performance:
Social Life:
• Physical activity promotion
• IADL
• ADL
• Informal support
• Social relationships
Clinical Issues:
Cognition and Mental Health: • Falls
•
•
•
•
Cognitive loss
Communication
Mood
Abusive relationships
Adapted with expressed permission from
ideas for Health, University of Waterloo, July
2010.
15
•
•
•
•
•
•
•
Pain
Cardio-respiratory conditions
Dehydration
Prevention
Appropriate medications
Tobacco and alcohol use
Urinary incontinence
Additional CAPs Triggered When
Functional Supplement is Completed
Functional Performance:
• Home environment optimization
• Institutional risk
Cognition and Mental Health:
• Delirium
• Behaviour
Adapted with expressed permission from
ideas for Health, University of Waterloo, July
2010.
16
Clinical Issues:
•
•
•
•
Pressure ulcer
Undernutrition
Feeding tube
Bowel conditions
How CAPs are triggered
CHA Core Assessment
Triggers:
1st: G4a – Activity level less
than 2 hrs
2nd: G2f- Locomotion-Independent
17
CAPS link the information
gathered in the assessment with
the goal of problem resolution,
reducing the risk of decline or
increasing the potential for
improvement
Physical Activities
Promotion
CAP
How to use the CAPs Manual
• Problem (Client Need)
• Overall Goals of Care
• Triggers
• Guidelines (Service Provision)
18
Break
19
From CAPs to Care Planning
• All triggered CAPs must be addressed in a
care/service plan
• Validate triggered CAPs with client to ensure
that they are relevant and important
• Prioritize triggered CAPs with client for the
development of the care plan
Adapted with expressed permission
from ideas for health, University of
Waterloo
20
Putting It All Together
21
Care/Service Planning
A Care/Service Plan is:
• A communication tool, based on assessment of the
client’s care/service needs, is to be used by the care
team members
• Intended to put measures in to place to prevent decline
and manage risk
• A collaborative plan of service created with input from
client and assessor
22
Characteristics of a Care Plan
• Individualized
• Current
• Accurate
• Clear
• Relevant
• Collaborative
23
Components of a Care Plan
DATE
TRIGGERED
CAP
CLIENT
NEED
(Problem
Statement)
CLIENT
GOAL
*Client Needs = Problems in CAPs Manual
**Service Provision = Guidelines in CAPs Manual
24
SERVICE
PROVISION
(Guidelines)
RESPONSIBLE
PROVIDER
REVIEW
DATE
Let’s practice!
• Divide into small groups
• Assign a recorder and
presenter
• Using case study, CAPs
Report and CAPs
Manual create a
care/service plan for the
assigned CAP
• Share results in the
large group
25
Assessment Process Flow
Review: phone call or visit to review any
aspect of the care/service plan
Core CHA
Supplements
CAPs &
Outcome
Scales
Care Plan
Reassessment: face to face comprehensive
assessment
26
Review
Reassessment
Training Resources
Education Material
•
•
•
•
•
Project Supports
Powerpoint presentations • Website
– www.ccim.on.ca
Case studies
– Electronic copy of all
Reference sheets
education material
Evaluations
interRAI CHA CAPs
• Support Centre
Manual for project-led
– csscap@ccim.on.ca
sessions
– 1-866-909-5600 option 9
• Facilitator binder
• Assessor workbook
• Supportive calls from project
• Certificate of completion
27
Next Steps
Electronic Care/Service Planning
Next Steps
• Certificate of completion signed by facilitator
• Let’s sign up for Supported Training - CAPs and
Care Planning
• Evaluation
29
Wrap-up and Questions
Thank you!
Project Support Centre
Contact Information
Email:
csscap@ccim.on.ca
Toll Free: 1-866-909-5600, option 9
Website: www.ccim.on.ca