Quality Care Area Assessments Lead to Better Outcomes through Care Planning

Members | June 04, 2018 | by Judy Wilhide

Chapter 4 of the RAI Manual is one of the least read and most important for quality outcomes.

Chapter 4 of the RAI Manual is one of the least read and most important for quality outcomes. It is an in-depth discussion of the CMS expectations for care planning in long-term care, and it contains excellent training and examples of how to conduct a thorough assessment to come to the correct care plan problem. If the problem is not correct, the interventions are destined to fail. A Care Area Assessment (CAA) triggers when an MDS response item is answered in a certain way. For example, coding J1800 as “1,” the elder has fallen since admission or the last assessment, triggers the Falls CAA. It is impossible to know how to care plan this area without conducting an investigation. The interventions are very different if the elder fell because she slipped on a puddle of water or because she had an exacerbation of Parkinson’s Disease and her legs gave way. Further, it would be crucial to know when she had her last meal, what medications she recently received, any co-morbidity issues (diabetes, schizophrenia, etc.), or how she was feeling emotionally that day. When A CAA triggers, it is an invitation to do an exhaustive investigation aimed at improving function when possible, maintaining function when improvement is not possible, or supporting as the elder wishes if decline is eminent. What follows are just some of the great recommendations from this portion of the RAI manual, beginning on page 4-14, having to do with identifying a problem statement after investigating a complaint.

Review a triggered CAA by doing an in-depth, resident-specific assessment of the triggered condition in terms of the potential need for care plan interventions. While reviewing the CAA, consider what MDS items caused the CAA to be triggered. This is also an opportunity to consider any issues and/or conditions that may contribute to the triggered condition, but are not necessarily captured in MDS data. Review of CAAs helps staff to decide if care plan intervention is necessary, and what types of intervention may be appropriate.

Using the results of the assessment can help the interdisciplinary team (IDT) and the resident and/or resident’s representative to identify areas of concern that:

  • Warrant intervention;
  • Affect the resident’s capacity to help identify and implement interventions to improve, stabilize, or maintain current level of function to the extent possible, based upon the resident’s condition and choices and preferences for interventions;
  • Can help to minimize the onset or progression of impairments and disabilities; and
  • Can help to address the need and desire for other specialized services (e.g. palliative care, including symptom relief and pain management).

Use the information gathered thus far to make a clear issue or problem statement. An issue or problem is different from a finding (e.g., a single piece of information from the MDS or a test result). The chief complaint (e.g., the resident has a headache, is vomiting, or is not participating in activities) is not the same thing as an issue or problem statement that clearly identifies the situation. Trying to care plan a chief complaint may lead to inappropriate, irrelevant, or problematic interventions.

Example:

Chief Complaint: New onset of falls

Problem Statement: Resident currently falling 2-3 times per week. Falls are preceded by lightheadedness. Most falls occurred after she stood up and started walking; a few falls occurred while attempting to stand up from a sitting or lying position.

It is clear that the problem statement reflects assessment findings from which the investigation may continue and relevant conclusions drawn.

While the CAAs can help the IDT identify conditions or findings that could potentially be a problem or risk for the resident, additional thought is needed to define these issues and determine whether and to what extent the care area issue and/or condition is a problem or issue needing an intervention (assessment, testing, treatment, etc.) or simply a minor or inconsequential finding that does not need additional care planning. For example, a resident may exhibit sadness without being depressed or may appear to be underweight despite having a stable nutritional status consistent with their past history. The IDT should identify and document the functional and behavioral implications of identified problematic issues/conditions, limitations, improvement possibilities, and so forth (e.g., how the condition is a problem for the resident; how the condition limits or impairs the residents ability to complete activities of daily living; or how the condition affects the residents well-being in some way).