Moriarty Consultation
Lee Moriarty, BS/CTRS
Living the Care Plan: Person-centered Care and the Revised CMS Regulations
Websites referenced during the Presentation:
Living the Care Plan: Person-centered Care and the Revised CMS Regulations
Websites referenced during the Presentation:
- CMS Memo Regarding Temporary Enforcement Delays for Certain Phase 2 F-Tags and Changes to Nursing Home Compare: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-18-04.pdf
- State Operations Manual: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
- Critical Elements Pathway: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html
- Legacy Project Questions: http://www.legacyproject.org/guides/lifeintquestions.pdf
- IMPACT (Improving Medicare Post-Acute Care Transformation) Act of 2014: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/SNF-QRP-Requirements-for-FY18-Reporting-Year-Fact-Sheet_updated.pdf
Person-Centered Care Plan Practices
Person-Centered Care Plan Practices
- Use Learning Circles to seek out input from those who will be affected by the change process
- Consistent Assignments being done across all shifts - REALLY doing it
- MDS and Care Plan Coordinator are the same person for each individual elder
- Move location of Care Plan Coordinator’s office to be closer to the residents
- Evaluate how the Baseline Care Plan is being used – who is using it? how is it being used? Is it accessible to those who need it?
- Use All About Me / Life Stories to find out who the elder is
- Use Huddle meetings to talk about newly admitted elders and to share information on all elders on an ongoing basis.
- Evaluate how section F of the MDS is completed and how the information is used
- Evaluate how all the interview sections of the MDS are completed
- Review CAA process to assess if this is being done properly and used to care plan appropriately.
- Evaluate all assessment forms being used for need, duplication, validity of info, etc.
- Evaluate the Discharge Planning process to assess if this is person centered (tool being used, services being arranged, etc.)
- Care Plan format: Resident writes care plan with you
- Care Plan format: I Care Plans
- Care Plan format: CNAs and other direct care staff write the approaches
- Explain care planning upon admission to the elder/ significant other
- Evaluate if the care plan invitation process lets the resident and the families understand the purpose of the meeting
- Evaluate if there is a more streamlined approach to the care plan invitation process (i.e. who sends out the letters, who are RSVPs tracked, etc.)
- Ask the resident who they want at the meeting and include that person/those people
- Evaluate if the right people are attending the care plan meeting
- Conduct the care plan meeting on the floor that the elder lives on
- Conduct the care plan meeting in the elder’s room
- Create a tool for the CNAs to provide care plan information for the care plan meeting
- Ask the staff if they know what is on their residents’ care plans
- Evaluate how the meeting is being conducted. (Does everyone feel included, is the process streamlined yet person centered?)
- Use QAPI tool for MDS Sec. F, Person-Centered Care Tracking Tool to gain an understanding of the elders needs and satisfaction with getting these met (https://www.nhqualitycampaign.org/goalDetail.aspx?g=PCC#tab2)
- Use stand up meetings to help convey what is going on with the elders
- Use focused walking rounds and other coaching moments to help mentor the team and make sure the care plan is being used
- Use the Clinical Pathway tools to evaluate how we are doing (Under downloads: LTC Survey Pathways https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/GuidanceforLawsAndRegulations/Nursing-Homes.html)