CareNotes

Article 13 “Individualized Care Approaches Reflected in Care Planning”

AHCA has published the report “Building Prevention into Every Day Practice: A Framework for Successful Clinical Outcomes.” The framework was built by the AHCA Clinical Practice Committee with the goal of developing solutions for reducing rehospitalizations and adverse events. Quality of care drives business success or failure in long term and post-acute care. This framework acknowledges that clinical results need both an organizational and a clinical foundation. This framework report consists of 13 articles. Below is the 13th article in the series. You can view previous articles in previous CareNotes blog posts. 

Clinical Foundation: Individualized Care Approaches Reflected in Care Planning

What does this mean?

The interdisciplinary team (IDT) process is responsible for the overall daily care of the people we serve. Every resident/patient must be assessed systematically and risk areas and causes of symptoms and conditions must be identified for each individual. The IDT then creates the individual patient care plan that reflects relevant risks, underlying causes, and likes, dislikes and what is important to the individual.

• Experience shows that “knowing” the person enriches their care and supports positive outcomes.
• Interventions are more effective because they are relevant to their underlying risks and causes, because they have meaning to the person, and because staff understand “who” the person is and“how”the person may think.

The common approach to creating a blueprint or road map for each individual’s care is via a care plan. While there are many care plan models (e.g.“I” Care Plans; Nursing diagnosis care plans…), what matters most is that the plan is individualized based on understanding the person is and what is important for their quality of life and quality of care.

• Every team member must know their responsibilities on the care plan and follow the process.
• All goals and interventions in a care plan must be in the proper context—not in silos—and must reflect an understanding of the “big picture” including the individual’s physical, functional, and psychosocial dimensions. For example, weight issues do not just involve the dietitian or food preferences, but may involve medical issues and medication-related side effects of dry mouth or anorexia.
• The care plan becomes our principal guidance for structure and process related to this individual’s outcomes.

Some approaches are the same for all individuals,for example, with pressure ulcers. All individuals will have skin assessments, weekly wound measurements and reassessments, and interventions to try to reduce risk factors. Individualization would involve such items as management of specific risk factors, what support surfaces to use, and what might motivate the individual to comply if they do not keep their heels floated.

Why is this important?

Individualized care plan approaches that are based upon a systematic process including thorough assessment and accurate cause identification will help the person reach their highest practicable level of function and well-being.This plan comes from the interdisciplinary team (IDT)process driven by the individual resident/patient as well as adequate and timely documentation of why decisions were made, whether and to what extent the decisions made a difference, and monitoring that leads us to reassess and refine the plan effectively, as needed.

The MDS was originally designed as a tool to assess and document key information on each LTC patient as the foundation for a care plan that identifies risks and identifies interventions to minimize the risk to the patient in various care areas. However, the MDS alone does not provide enough information to individualize most aspects of care.

What are some examples?

• An individual with dementia was “bothering” other patients with dementia by frequently trying to direct their actions. This was leading to altercations and raising the distress levels on the unit. The IDT had tried many interventions with no improvement. The exasperated IDT was about to give up when a nursing assistant who cared for this individual and often spoke with the visiting family members said, “Why don’t you get him a big calculator? He was an accountant for 40 years in charge of a department.” The IDT realized that they had omitted the step of identifying “who” this person was and “what” he was like before the memory loss. After giving the resident charts with dollar amounts and a calculator and asking him to total up the columns for the businessoffice, the altercations decreased.
• A care plan said that the resident would maintain a pulse oximetry above 93. Staff kept worrying when it fell even slightly below 93, even though the resident was not noticeably dyspneic, so they tried to make him wear oxygen that he did not want. But once it was recognized that the resident had COPD and that the pulse oximetry result was less important than the respiratory rate and other vital signs, they changed the care plan and he did fine without nasal oxygen.

What is my part (as an individual employee, manager, or practitioner)?

• As a manager, help develop and implement systematic approaches to assessment and interpretation in the proper context of information based on the assessment,to yield an individualized care plan.
• Continually remind everyone to avoid jumping to premature conclusions about what is going on and what to do about it, to think about whether they have enough information to draw conclusions,and to seek additional information if they do not.
• Promote a culture that promotes asking questions, challenging assumptions, and identifying and rethinking situations where the results may not be optimal.
• Managers can also review care plans with the staff for accuracy and pertinence, and point out ways that they can be consolidated and individualized.
• As practitioners, verify and validate diagnoses; incorporate input from the resident, staff, and families into our treatment decision making, review the medication regimen and look for connections between current symptoms and adverse consequences related to existing medications, explain to staff what symptoms or consequences they might expect and the medical foundation for those resident’s symptoms, explain and document the rationale for treatments to staff, residents, and families; coordinate a periodic review of the care plan with the staff, and adjust treatments based on staff monitoring and reporting of resident responses.
• As staff members, avoid “canned” care plans, think carefully about whether current care plans are accurate and relevant, point out when care plans may not make sense or are not working, follow the care plan once it is finalized or updated, and identify and offer suggestions to overcome barriers to implementing desired interventions.
• Focus on improving efforts to identify links between causes and consequences before going to care planning. Look for multiple causes of individual symptoms (behavior, falling, weight loss, etc.) and common causes of multiple symptoms. Engaging in this thinking is important to identifying relevant interventions and to avoid fruitless “symptom chasing.”

What can my organization do?

• Support resources and processes that help familiarize staff more readily with each person’s care plan; for example, through daily rounding; weekly IDT rounds at report time; point-of-care devices,and other means.
• Promote a culture of sound clinical reasoning, good problem solving, enhanced diagnostic quality, knowledge of potential treatment complications, and improved coordination and communication with practitioners.

Resources/Tools

HATCh Change Package

Shared Decision Making

Shared Decision Making HealthIT

Resident Assessment Instrument/Minimum Data Set Manual

Teaching Clinical Reasoning(American College of Physicians, 2015)

Key Takeaways: Individualized Care Approaches Reflected in Care Planning

• The care plan is the principal guidance for structures and processes related to each individual’s outcomes.
• Individualized care plan approaches based upon a systematic process help the person reach their highest practicable level of function and well-being.
• Resources and processes that help familiarize staff more readily with each person’s care plan is essential.
• The care plan must be done in the proper context, without discipline-specific or topic-specific “silos.”

Probing Questions for Team Reflection and Discussion

1. How do we breathe life into care plans?
2. What do we do well to know each person? What can we do better?
3. Do our care plans reflect an understanding of the “big picture” and are all goals pertinent and in the proper context?
4. Are we helping each person reach their highest practicable level of function and well-being? How do we know?