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:
• 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…
1) Do you write the same thing again and again on care plans
and sometimes wonder if they make a real difference for your
residents?
2) If staff are absent, would relief staff know what special
needs the residents have by looking at the care plans?
3) Are your care plans assuring that every CNA, nurse and
members of the IDT are following current standards of care?
4)
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…
(1) to achieve resident centered care planning
based on current standards of care.
(2) to educate the heath care team in researchbased 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
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.
7
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.
8
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…
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Replicating ECP in NYS Nursing Homes
2011-2013
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)
 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…
11
Staff must know the
Standards of Care,
know where they are found,
how to implement them correctly
and
follow them.
12
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
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 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
Exceptional Care Planning
Steps to Success
16
Step 1-- how to get “buy-in” for making a
change
Access your facility’s current care plan system.
Yes
Are the care plans lengthy?
Are Care plans repetitive
from one resident’s plan
to another?
No
x
x
17
Step Two of 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.
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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.
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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.
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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 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 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
 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).
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Before and After
Exceptional Care Planning
Examples
Communication - Before
Problem
Resident has bilateral hearing loss,
wears hearing aids both ears, and due
due to loss of short term memory
frequently removes hearing aids and
misplaces.
At risk for loss of hearing devices.
Strength:
Resident enjoys social activities, TV,
listening to music, and is cooperative
with care
Goal
Approaches
Resident’s hearing
devices will be available
for use daily to enhance
communication and will
not be misplaced
through the next review
period.
Hearing will remain
adequate for resident to
communicate with
others and actively
participate in social
activities as evidenced
by singing at music
program, answering
questions appropriately
through next review.
1. Encourage resident to wear hearing aids.
2. Keep hearing aids working and in good
repair.
4. Keep hearing aids clean and free of ear
wax.
5. Notify audiology clinic when hearing aid is
in need of repair.
6.Maintain extra hearing aid batteries and
change as needed.
7.PRN audiology clinic
8. Assist resident with hearing aide
placement as needed
9.Monitor environment for hearing aides to
present loss
10. Speak clearly and slowly to resident
while standing in resident’s field of
vision.
11. Monitor for signs of increased hearing
loss
12. PRN ear examination and wax removal
as needed per MD orders
13. Medications as ordered
14. Flush ears as per procedure
15. Ensure resident is wearing hearing aids
at all meals and activities.
Hearing Standard of Care
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Upon admission, resident’s hearing needs will be identified, devices
will be labeled and logged on property sheet. Note battery size.
Specific use of hearing aids (preferences and wearing schedule) will
be individualized on care plan.
Resident room and personal items will be organized to allow for
maximum independence.
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.
Encourage resident to provide self care for hearing devices when
capable.
Report any change in hearing to the nurse. Any changes will result in
referral to appropriate health care professionals.
Refer to audiology clinic as needed.
If necessary, resident will be reminded to wear hearing aids and
assisted with placement.
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.
18.
Flush ears as per procedure.
Reference: Consultgerirn.com
After Care Plan -Communication
Problem
Goal
Approaches
I, James Right have hearing
loss in both my ears requiring
use of hearing aids. I become
more confused, especially in
the late afternoon and
evening and will take out my
hearing aids forgetting where
I have placed them.
I need to have my room
checked, as well as my meal
tray and trash as I may throw
them out by mistake.
My hearing devices
will be available for
use daily to enhance
my communication
and will not be
misplaced through
the next review
period.
1. Follow communication/hearing
Standard of Care (All
disciplines)
2. Monitor resident’s
environment, particularly
meal trays and trash to
prevent hearing aid loss.
(Dietary, Nursing,
Housekeeping)
My hearing will
remain adequate for
to communicate with
others and so I can
actively participate in
Strength:
social activities by
3. Encourage resident to wear
singing
at
music
I enjoy socializing, listening to
hearing aids at all meals,
program,
answering
TV and music in my room,
when attending activities
questions
asked
of
and attending activities. I am
and listening to TV or music.
me, and conversing
cooperative with my care and
(Nursing, Recreation,
at socials through
enjoy talking with my
Dietary)
next review period.
caregivers.
Before Care Plan– Skin Integrity
Problem
Goal
Approaches
Resident is at risk for
Resident’s skin 1. Monitor skin each shift
2.
Report changes in skin
skin break down due to integrity will
immediately to charge nurse
history of pressure ulcer remain intact
3.
Use pressure relieving devices
on coccyx, recent
as evidenced
4.
Apply A & D ointment after
weight loss , recent
by no pressure
each episode of incontinence
5.
Reposition resident with lift
decline in mobility, and ulcer
sheet
incontinence of bladder. development
6.
Encourage resident to turn self
through next
as able
review period. 7. Monitor resident for
Strengths: Resident is
cooperative with care
and is cognitively intact.
Family very supportive.
8.
9.
10.
11.
incontinence and change at
least every 2 hours
Encourage meal completion
Encourage fluids
Encourage between meal
nourishments
Monitor weight monthly 30
Skin Integrity /Pressure Ulcer Prevention
Standard 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.
1.
Skin will be observed daily during care routines. Any changes
will be reported to the charge nurse.
2.
Pressure reduction will be achieved by using pressure reduction
mattress, cushions, and pressure point protectors as needed.
3.
Protective creams/lotions will be applied as needed for dry skin.
Apply barrier cream after each incontinent episode.
4.
Lifting sheets will be used to reposition residents to reduce
shearing.
5.
Use only one large incontinent pad under resident.
31
Problem
After – Skin Care Plan
Goal
Approaches
I, James Right am at risk
for skin break down due to
a past pressure ulcer on
my coccyx, a recent
weight loss of 20 lbs, a
decline in my mobility,
and an increase in urinary
incontinence.
Strength: I like to
participate with my care
and am very clear in my
decision making and
surroundings.
My skin integrity
will remain intact
as evidenced by
no pressure
ulcer
development
through next
review period
1.
Follow Skin Care
Standard of Care
2.
Roho cushion in
wheelchair
3.
Low air loss mattress on
bed
4.
Apply Aloe Vesta lotion
to elbows and heels with
am and pm care
5.
Follow nutrition/hydration
standards of care
6.
Follow toileting
standards
Follow mobility
standards
7.
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Problem
“Before “ Nutrition Care Plan
Goal
Approaches
Resident has poor nutritional
status. Is not completing meals,
has had recent weight loss, and
general decline in overall health
condition – labs show elevated
BUN, low albumin, and total
protein.
Strength: Resident has a good
family support system
Resident will
increase weight by
3-5 pounds in the
next 30 days.
1. Assess for physical assistance with
eating
2. Serve meal tray promptly
3. Encourage meal completion
4. Encourage between meal
nourishments
5. Encourage fluid consumption
6. Monitor weight weekly
7. Obtain food preferences and
provide foods of choice
8. Monitor labs
9. Monitor for s/sx of dehydration
10. Provide water at bedside
11. Investigate with MD for appetite
stimulant
12. Meals in dining room
13. Encourage family to bring home
made foods
14. OT/SLP evaluation
33
Nutrition/Hydration Standard of Care
Every resident shall receive suitable and sufficient hydration, nutrients, and
calories to maintain health.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
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).
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“ After” Nutrition Care Plan
Problem
Goal
Approaches
I, James Right have difficulty
with my nutrition due to not
wanting to finish my meals, a
recent weight loss of 20 lbs, and
a decline in my overall health.
I want to increase
my weight by 3-5
pounds in the next
30 days.
1.See Nutrition /Hydration SOC
2.Obtain weekly weights
My lab work shows an elevated
BUN, low albumin, and total
protein which places me at high
risk for dehydration, skin
breakdown and falls
Strength: I have a very caring
and supportive family
My BUN, albumin,
and total protein lab
values will be within
acceptable range
per my physician in
60 days.
3. Encourage my family to eat dinner
with me in small dining room and to
bring in homemade foods I like.
(Nursing, SW, Dietary)
4. I prefer to sit at table 7 in the main
dining room for breakfast and lunch
meals to socialize with my tablemates
(Nursing, Dietary)
5. OT/SLP evaluations to r/o feeding,
ADL, swallowing problems.
6. Consider appetite stimulant after
discussing with the me and
investigating with the MD.
35
SOC Documentation Format
• Definition of Standard
• Risk Factors
• Standard of Care (Interdisciplinary)
• CNA Considerations
• Reference(s) used to develop standard
36
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.
37
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.
38
Best Practices
References
American Association of Nursing Assessment
Coordinators – www.aanac.org
American Medical Directors Association –
www.amda.edu
ConsultGeriRn.org
Careplans.com
Long Term Care Nursing Desk Reference
Foundation of Long Term Care – www.fltc.org
ECP Replication Project webpage:
References
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)
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 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 krevitt@leadingageny.org.
ECP ProCare Training & Consulting
Service 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 krevitt@leadingageny.org.