When you or your loved one is admitted to long-term care or for skilled care the interdisciplinary team of the nursing home must complete a comprehensive assessment. The interdisciplinary team with the resident, resident’s family, surrogate or representative should develop a care plan that meets the resident’s needs to attain or maintain the highest practicable physical, mental and psychosocial well-being.
The comprehensive assessment is called the Resident Assessment Instrument (RAI), which is specified by each individual state the resident resides. The RAI is most commonly referred to the MDS (Minimum Data Set) assessment. The MDS is what drives reimbursement from Medicare and Medicaid.
The MDS includes the Resident Assessment Instrument and the RAPs (Resident Assessment Protocols). The RAI and the RAPs are what drives the plan of care that you or your resident is to receive while in the nursing home. A registered nurse must coordinate the assessment with the participation of the interdisciplinary team members (nurses, nursing assistants, rehabilitation therapists, activity professionals, medical social workers, dieticians, dietary managers, or other professionals).
The Resident Assessment Instrument is the comprehensive assessment that is used to identify the functional capacity and health status of the resident. The assessment includes the following sections: Identification and demographic information, customary routines, cognitive patterns, communication, vision, mood and behavior patterns, psychosocial well-being, physical functioning and structural problems, continence, disease diagnosis and health conditions, dental and nutritional status, skin conditions, activity pursuits, medications, special treatments and procedures, and the residents discharge potential. The RAI must accurate reflect the resident’s status in all areas as the nursing home must use the results of the assessment to develop the plan of care.
Once the RAI is completed, it triggers Resident Assessment Protocols (RAPs). There is a RAP for each section of the RAI. When a RAP is triggered it most often indicates that there is a potential problematic care/need for the resident that must be addressed. The RAP requires additional assessment and documentation to identify all contributing factors to the area of concern/need and how the interdisciplinary team will proceed to address the care/need.
When all of the RAPS are completed the interdisciplinary team with the resident, resident’s family, surrogate or representative develops the Care Plan. The care plan is used to drive the care and support that the resident requires from the nursing home staff with measurable objectives and timetables. The care plan should list each need/concern/problem with a corresponding goal/objective, the interventions/approaches that will be used to achieve the goal/objective and which disciplinary team will be providing the interventions/approaches.
The MDS assessment is to be completed by the 14th day from admission then reviewed quarterly there after (about every 92 days). The full MDS assessment must be completed again annually and when there has been a significant change in condition.
The care plan must be completed by the 21st day from admission and up dated as goals/objectives and interventions/approaches are met or revised. New care plans are developed annually or when there is a significant change of condition.
Nursing homes are to provide you with a care plan meeting on about the 21st day and every 90 days or so respectively. They should be notifying you by a letter giving you the day and the time. Nursing homes schedule a block of time 1 or 2 days out of the week when the interdisciplinary team will be available to meet with you for about 15 to 20 minutes to discuss the care of your loved one. They conduct the meetings for several residents and the meetings are usually back-to-back. If you are unable to make the meeting they usually allow you to reschedule the meeting, however don’t be surprised if only one team member is available for the meeting.
At your first care plan meeting you will want them to review the complete plan of care with you and the resident so you can have input and help accommodate revisions you feel are necessary for your residents well-being. Some nursing homes like to skip reviewing the care plan with you because it is so timely. Don’t let them get away with it. This is your opportunity find out how they are going to care for your resident and to ask questions about the care they will provide, the condition and the status of your resident. Make the most of this opportunity!
As the resident’s family, surrogate or representative you are the strongest advocate for the resident and it is very important to keep your eyes, ears alert and your mind and heart wide open. The nursing home staff know that you love and care for your resident. They truly want to provide the best care. Your presence, believe or not provides the encouragement for them to provide that care!
I am a new MDS Coordinator and would like information on how to conduct a care-plan meeting.
Posted by: Jacqueline Stinnette | May 28, 2006 at 09:53 PM