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Is Your Care Plan Alive and Breathing?
Home » News » Is Your Care Plan Alive and Breathing? |
Say the words "care plan" and every nursing facility employee nods. “Yes, of course we have a care plan for each patient—it’s required by regulation and state surveys.” In practice, nearly every facility has its own care-plan template. But is your care plan a living document about the care of the resident or is it a sketchy plan that’s hidebound until pulled out for those 7-, 14-, 30-, 60-, and 90-day Medicare-required reviews?
“The care plan is a concept that is broken across the industry,” says Linda Riccio, former Aegis Therapies regional vice-president. “Because of survey requirements, the care plan becomes a paper compliance task. But it really should be an ongoing, coordinated team effort to provide the resident with the best care possible.”
A good care plan is an interdepartmental team entity, born when the resident’s preadmission information is reviewed and alive through discharge follow-up. Nursing, therapy, dietary, social services, and even activities all have information to share. “Team care meetings are often thought of as an extra step,” says Mark Richards, national director of clinical services at Aegis Therapies. “The mentality becomes ‘Let’s get it done.’ But to provide the best care, there has to be a point where all departments talk to each other about what is going on with the resident. The easiest way to do that is to work off a care plan.”
Because so much of resident care centers on increasing physical abilities, therapy is a pivotal point in any care plan. The team relies on therapy to help the patient get to the next level of ability—transfers, ADLs, voice, and eating. Then nursing takes over to follow through on care requirements. “Most facilities feel that communication between nursing and therapy needs to be stronger, but somehow the care-planning meeting never becomes part of that discussion,” says Riccio. “If that flow of communication doesn’t happen—for example, if therapy does the treatment minutes but is not included in the care-plan meetings—the facility will lack the body of information that really addresses the total needs of the patient.”
One of the hallmarks of a good care plan is a call for interdisciplinary action. “For a balance problem, for example, the care plan wouldn’t just call for therapy five times a week for six weeks,” notes Riccio. “It would also say that nursing will observe the patient during independent toilet transfers or activities and will watch for sit-to-stand progress. The plan needs to address what all disciplines are doing.” That kind of communication also provides for accountability. “We know something’s gone wrong in the care-planning discussion if we learn that Mr. Wist transfers in therapy with a moderate assist of 1, yet when the CNA gets him up in the morning, he transfers with a max assist of 2.”
The communication works in both directions. For example, if therapy learns in the care-plan meeting that Mrs. Biddle has been having problems eating in the dining room, the therapist can pass by at mealtime and talk with the caregivers about a different approach to help her eat. “Quality therapy, integrated into the care-plan meeting, can help drive patient care,” notes Richards.
According to Robert Campion, executive director of Heritage Square Healthcare Center in Greendale, Wisconsin, fluidity is an indispensable aspect of the care plan. “We can’t just set goals and say we’ll revisit them in six weeks,” he warns. “We have to meet the patient’s changing needs.” Heritage Square has three care-planning teams, one for each of its units, comprising the case manager nurse, nurse supervisor, therapy leader, and social worker. “Therapy and the social worker establish a baseline of what the person’s function was before the deficit and what environment the patient wants to return to,” explains Campion. “Then therapy sets goals. Basically we have a road map of where we want to go in an estimated period of time.” The care plan allows everyone to read the same map and discuss progress as viewed by the various departments at the meeting. Heritage holds care-plan meetings every Monday and Thursday. “If we’re not on course,” says Campion, “we can change easily.”
Caregiver education ensures carryover from therapy sessions to the patient’s daily life. “In the beginning, therapy directs caregiver education to nurses and aides that work with the patient on the floor,” says Campion. He cites the example of a recently admitted patient who may need to transfer from a wheelchair to the toilet. After several therapy sessions, the therapist may want him to walk from bed to bathroom. “The therapist may determine he is safe enough to be walked with a gait belt and hands-on assistance from an aide, but the resident may not necessarily want to do that. If the aide is educated about that goal, she will be able to care for the patient differently and ultimately help him progress faster.”
Family education, too, is essential so that they understand what mom or dad can do or can’t do. At Beverly Healthcare Columbus, in Columbus, Nebraska, families and residents are invited to come to care-plan meetings. “Often the family thinks the resident might be better off at home,” says Lynn Teply, PT at Columbus. “It’s important for them to hear our professional opinions, whether they want to or not.”
For staff members pressed for time, attending care-plan meetings often can seem like a burden. For therapy, the issue is even more complicated because time away from the patient is unbillable. Keeping meetings short and on topic is crucial. “If necessary, we might bring the therapist in first to talk about a situation and then she can leave,” says Teply. The problem is also solved when the resident and family are included in meetings. “It’s billable time because you are doing education for the patient and family,” she notes.
The culture of putting the patient first can’t happen in a vacuum; it requires the attention of everyone involved, including the resident and the family. If your care plan is a living, breathing document, based on interdepartmental communication, it will be nimble enough to monitor the patient’s progress, anticipate his or her needs, and create the best possible outcome. “You can’t be so structured that you can’t meet the needs of what the resident and the family want,” says Staci Cardenas, executive director of Beverly Healthcare Columbus. “We set up a meeting when we notice any change in the resident. Sometimes we might have two or three care meetings a week.”
That’s a focus on the patient, not on the regulations.
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