The RAI Process: CAAs, Care Planning and Beyond

The RAI Process: CAAs, Care Planning and Beyond

HARMONY UNIVERSITY

The Provider Unit of Harmony Healthcare International, Inc. (HHI)

Presented by:

Coleen Deschenes, RAC-CTRegional Consultant

and

Christine Twombly, RN, RAC-MT, LHRMRegional Consultant / Trainer

Speaker Bio (Coleen Deschenes)

Regional Consultant for Harmony Healthcare International, Inc.Over 20 years of experience in Long-Term CareCertified National Coordinator in NASPAC, specializing in Medicare Regulations, Reimbursement, MDS Accuracy, Mock Surveys, Quality Measures, and MDS MentoringFormer MDS Coordinator, Clinical Financial Operations Manager, and Reimbursement Manager

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Speaker Bio (Christine Twombly)

Clinical Consultant and Trainer with Harmony Healthcare International (HHI)Over 26 years of experience in Long-Term CareCertified Gerontological Nurse Certified AANAC Master Teacher and Certified Resident Assessment Coordinator (RAC-CT)Licensed Health Care Risk Manager (LHRM) Hands-on experience with MDS assessments and related care planning Extensive experience with SNFs to conduct Medicare documentation and billing compliance assessments and providing assistance with third-party medical review and the appeals process

Copyright © 2013 All Rights Reserved

RAI Process: CAAs, Care Planning and Beyond

Disclosures: The planners and presenters of this educational activity have no relationship with commercial entities or conflicts of interest to disclosePlanners:

Elisa Bovee, MS, OTR/LDiane Buckley, BSN, RN, RAC-CTBeckie Dow, RN, RAC-MTKeri Hart, MS CCC, SLP, RAC-CTKristen Mastrangelo, OTR/L, MBA, NHAChristine Twombly, RNC, RAC-MT, LHRM

Presenters:Christine Twombly, RAC-MT, LHRMColeen Deschenes, RAC-CT


Harmony Healthcare International, Inc.

Communication & Coaching: A Nurse’s Guide to Creating a Harmonious AtmosphereDisclosure Speakers:

Christine Twombly, RAC-MT, LHRMColeen Deschenes, RAC-CT

The speaker has no relevant financial relationships to disclose

The speaker has no relevant nonfinancial relationships to disclose

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Harmony Healthcare International, Inc.

The RAI Process: CAAs, Care Planning and Beyond

Criteria for Successful Completion

Complete Sign-in and Sign-Out on Attendance FormAttendance for entire sessionCompletion and submission of speaker evaluation form.

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The RAI Process CAAs, Care Planning and Beyond

ObjectivesThe learner will be able to define the purpose of the Care PlanThe learner will be able to define the purpose of the discharge Care Plan and summaryThe learner will be able to identify the correlation between the MDS, CAAs and the Care Plan, Discharge PlanningThe learner will be able to list three clinical areas a resident-centered Care Plan should address


OIG Report February 2013

In Fiscal Year (FY) 2012, Medicare paid $32.2 billion for SNF servicesTo participate in Medicare, SNFs must meet certain quality-of-care requirementsThese requirements are essential to ensuring that beneficiaries receive appropriate care and safe transitionsCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 8


SNFs must develop a Care Plan for each beneficiary and provide services in accordance with the Care PlanSNFs must plan for each beneficiary’s discharge to ensure a safe transition from one setting to anotherThe Office of Inspector General (OIG) has identified a number of problems with the quality of care provided



Used 2009 stay dataSample of 190 stays that projects to 1,104,692 stays in the populationEvaluated whether Care Plans contained measureable objectives with detailed time frames and whether services were provide in accordance to the Care Plan for the following categories of service:

(see next slide)Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 10


Scheduled toileting plans or bladder retraining programsParenteral IV or feeding tubesSkin treatmentsSpeech, occupational, and physical therapyRespiratory therapyRestorative nursing services


Requirements Percentage of Stays in Which SNFs Did Not Meet Requirements

Medicare Payments for Stays in Which SNFs Did Not Meet Requirements

Care Plan Requirements

25.6% $3.1 billion

Service Requirements

15.4% $2.0 billion

Total 36.7% $4.5 billion

Percentage of Stays in Which SNFs Did Not Meet Care Plan or Service Requirements, 2009


Source: Office of Inspector General medical record review, 2012

Percentage of Stays in Which SNFs Did Not Meet Care Plan Requirements, 2009

Care Plan Requirements Percentage of Stays in Which SNFs Did Not Meet Care Plan Requirements

Care Plans address problem areas identified in the assessments

19.2%

Care Plans have measureable objectives and detailed timeframes

6.8%

Care Plans are developed by an interdisciplinary team

2.1%

Total 25.6%


Source: Office of Inspector General medical record review, 2012

OIG Report Findings

The OIG found that:74% of NHs surveyed in 2007 had at least one deficiency related to quality of careSNFs often did not develop appropriate psychosocial services Care Plans or provide all services identified in Care PlansSNFs failed to meet one or more Medicare requirements for beneficiary assessments or Care Plans about atypical antipsychotics


OIG Report Findings

The OIG found that:There were quality-of-care problems with beneficiaries discharged between SNFs and other facilitiesThere were quality-of-care problems within the SNFs, including development of pressure ulcers, malnutrition, dehydration, side effects from not receiving medications, and inadequate staffing levels leading to poor resident outcomes


OIG Report Recommendations to CMS

Strengthen the regulations on Care Planning and Discharge PlanningProvide guidance to SNFs about Care Planning and Discharge PlanningIncrease surveyor efforts to identify SNFs that do not meet Care Planning and Discharge Planning requirements and hold these SNFs accountable


OIG Report Recommendations to CMS

Link payments to meeting quality-of-care requirementsFollow up on SNFs who failed to meet Care Planning or Discharge Planning requirements or who provided poor quality care


Medicare RequirementsRelated to Quality of Care

Develop a Care Plan for each beneficiary and provide services in accordance with the Care Plan Provide services to attain or maintain the highest practicable physical, mental, and psychosocial well being of each beneficiary in accordance with the Care PlanPlan for each beneficiary’s discharge to ensure safe transition to next care settings



The Interdisciplinary Care Plan

The Interdisciplinary Care Plan

Serves as a road map that guides all staff involved in the resident’s careCommunicates vital resident care information to the entire interdisciplinary team (IDT)Contains specific detailed instructions for achieving resident goals


Overall Focus of Care Plan

Preventing avoidable declines in level of functioning or otherwise clarifying why another goal takes precedence (e.g., palliative approaches in end of life situation)Managing risk factors to the extent possible or indicating the limits of such interventions



Addressing ways to try to preserve and build upon resident strengths Applying current standards of practice in the care planning process Evaluating treatment objectives and outcomes of care



Respecting the resident’s right to decline treatment Offering alternative treatments, as applicable Using an interdisciplinary approach to Care Plan development to improve or maintain the resident’s functional abilities



Involving resident, resident’s family and other resident representatives as appropriate Assessing and planning for care to meet the resident’s medical, nursing, mental and psychosocial needs



Involving the direct care staff with the Care Planning process relating to the resident’s expected outcomesAddressing additional care planning areas that are relevant to meeting the resident’s needs in the long-term care setting


The Resident Assessment Instrument (RAI) Process

Similar to the nursing processGoal: Care delivery aimed at meeting resident’s needs based upon the completion of a comprehensive interdisciplinary assessment, Care Plan development and ongoing evaluation




Assessment The Minimum Data Set (MDS 3.0) assessment is an initial core set of screening, clinical, and functional status elements which forms the foundation of a comprehensive assessment process know as the Resident assessment Instrument (RAI) process


The MDS is merely a starting point in the comprehensive RAI processMDS accuracy leads to identifying areas that impact resident care



Accurate completion

of the MDS assessment is critical to Care Plan development

Assessment (continued)



Decision –Making (CAA Process)Care Area Assessments (CAAs) are the link between the problem identification and the Care Plan developmentUse the CAA process as a guide to expand your assessment findings from the MDS, and then “chart your thinking”Care Areas triggered during the RAI process must be reviewed to determine Care Planning needs


Care Area Assessment

There are 4 parts to each CAA

Section I: The Problem

Section II: The Triggers

Section III: The Guidelines

Section IV: The CAA Key

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1. Delirium 2. Cognitive Loss/Dementia3. Visual Function4. Communication 5. Activity of Daily Living (ADL)

Functional/Rehabilitation Potential

6. Urinary Incontinence and Indwelling Catheter

7. Psychosocial Well-Being8. Mood State9. Behavioral Symptoms10. Activities

11. Falls12. Nutritional Status

13. Feeding Tubes

14. Dehydration/Fluid Maintenance

15. Dental Care16. Pressure Ulcer

17. Psychotropic Medication Use

18. Physical Restraints

19. Pain20. Return to

Community Referral



Care Area Trigger (CAT)Specific MDS response indicates that clinical factors are present that may or may not represent a condition that should be addressed in the Care PlanTriggers “flag” conditions for the interdisciplinary team to consider in making Care Plan decisions



The GuidelinesThe interdisciplinary team reviews the conditions under the CAA guidelines (and other assessment information as needed) to:

determine the nature of the problemunderstand the cause specific to the Resident

To get a better understanding of the relationship between the problem conditions and their effects on the ResidentKeep asking: how, when and why



Decision MakingDetermining the severity, functional impact and scope of a Resident’s problemsUnderstanding the causes and relationships between a Resident’s problemsDiscovering the “what’s” and “why’s” of Resident’s problems



CAA Documentation

While reviewing each CAA consider:

What MDS responses caused this to trigger?What issues or conditions contributed to those MDS responses?Were those issues or conditions addressed in the MDS?Is there a new onset of a problem that the resident did not previously have?


CAA Documentation

While reviewing each CAA consider:

Wht MDS responses caused this to trigger?What issues or conditions contributed to those MDS responses?Were those issues or conditions addressed in the MDS?Is there a new onset of a problem that the resident did not previously have?


CAA Documentation


CAA Documentation

CAA documentation helps to explain the basis of the Care Plan by showing how the IDT determined that the underlying causes, contributing factors, and risk factors were related to the care area condition for a specific resident


CAA Documentation

Documentation for each triggered CAA should describe:

The nature of the issue or condition (may include presence or lack of objective data and subjective complaints). In other words, what is the problem for this resident?Causes and contributing factors.Complications affecting or caused by the care area for this resident


CAA Documentation

Risk factors that arise because of the presence of the condition that affect the staff’s decision to proceed to care planningFactors that must be considered in developing individualized Care Plan interventions, including appropriate documentation to justify the decision to plan care or not to plan care for the individual residentNeed for referrals or further evaluation by appropriate health professionals

Care Plan Development

Care PlanningEstablishing a course of action that moves a Resident toward a specific goal, utilizing Resident strengths and interdisciplinary expertiseDefining the “how” of Resident care



Care Planning: Beyond The RAI

42 CFR 483.20(b): Facilities are responsible for assessing and addressing all care issues, regardless of whether or not they are covered by the RAIThis includes monitoring the resident’s condition and responding with appropriate interventions


The Care Plan should address the following special considerations/strengths, which may or may not be indentified through the CAAS:



Social historyCognitive status and communicationMental well being including mood and behavior issuesMobility issues

Vision Dental Improving continence Skin careNutrition/hydrationComfort ActivitiesDischarge planning



The facility must develop a Care Plan that meets these guidelines:

IndividualizedComprehensiveMeasureable goalsInterventions aimed at meeting the desired outcomeTimetable to for completion



Linking Assessment and Care Plan



The Care Plan is driven by:Resident issues and/or conditions Resident unique needsResident strengthsEach resident’s unique characteristics



The MDS and CAAs re-evaluates the resident’s status at prescribed intervals (i.e., quarterly, annually, or if a significant change occurs( using the RAI manual as a guide)The Care Plan is then modified to provide individualized care the needs of the patient change



The Care Plan must be based on a thorough assessment, effective clinical decision making, and must be compatible with current standards of clinical practiceLooks at the resident as a whole with unique characteristics and strengths


Care Planning Process

The RAI process (MDS and CAAs) along with any other assessments used to accurately assess the resident’s condition are completed as the basis for Care Plan decision makingAll tasks can be done by the RN Coordinator, by regulation, but ideally is a cohesive effort of the entire IDT


Care Planning Process

Interdisciplinary Team includes:Resident and FamilyNursing PhysicianActivitiesDietarySocial ServicesTherapy




A new Care Plan does not always have to be developed after subsequent assessmentsThe IDT team may revise an existing Care Plan using the results of the latest comprehensive assessment.



The IDT team should evaluate the appropriateness of the Care Plan continuously and update when there is a clinical changeReview and update with Quarterly assessments, and modify as neededSign and date changes made on the hard copy


4 Parts of the Care Plan Process

Assessment – problem identification through RAI process and in-depth review of clinical data

Planning – Goal setting, development of individualized interventionsImplementation – Putting plan into placeEvaluation – Periodically review progress to goals and revision of established goals or interventions as indicated


Assessment

Collecting, organizing and analyzing data

Pre-admission informationHospital Discharge SummaryResident’s Medical recordStaff ObservationsShift to shift reportInterviews



Care Planning

Defining the Issue to be Care PlannedProblems: Condition, diagnosis, situation, or behavior that negatively impacts the person, requiring assistance, intervention, or correction by the staff Need (Psychosocial): An emotion, feeling, or social interaction that is important to the person and should be recognized. Strength: An ability, skill, characteristic, or trait a person possesses that should be recognized, encouraged, and/or promoted.


Issue Statement

Forming the Problem/Need Statement:

A statement of an actual or potential health problem identified through the RAI process Can use functional status or need (limitations or strength) or Nursing DiagnosisResident centered, not staff centeredShould be written in simple terms, not medical terminology.


Problem Statement

Sample Problem Statements:Requires assistance when ambulating due to gait disturbance resulting in frequent fallsPain related to recent hip fracture interferes with ADL participationPoor appetite due to mouth pain related to poorly fitting dentures


Problem Statement

Sample Problem Statements : (continued)

Strong identification with past occupation as a nurse resulting in desire to attempt to assist fellow residentsFinds strength in scientology faith and relies on faith to resolve health concernsSelf conscious about appearance due to new colostomy resulting in decreased activity participation


Goal Setting

Set goals that target either improvement, prevention, maintenance or palliative outcomesDevelop goals that are measurable and have a timeframe for completion or evaluation (the subject, the verb, the modifiers and timeframe)


Problem Statement

May be linked to related factors, etiology, and signs/symptoms

Problem statement related to (r/t) associated with (etiology related factors) as evidenced by (signs and symptoms

Ex: Left hip pain r/t L hip fracture/surgery as evidenced

Resident reports of pain which worsens with movementFacial grimace


Problem Statement

Ensure problem statements are written to identify problems for the resident not the staffFor example: “Resident strikes out at the staff during care”

The problem for the staff is that the resident is striking out at them, but what is the problem for the resident The resident’s problem can only be identified by doing a “root cause analysis”


Problem Statement

To identify and address the resident’s problem in this case the IDT must ask “why” until they are able to identify the reason the resident is striking out during care

Is the resident experiencing pain?Is the resident cold? Fearful?Modest?

The problem statement should be written to address the resident’s issue

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Goal Setting

Goal Setting

Elements of a GoalGoals should be Resident centeredGoals established should be a priority for the Resident not just the staffIt is important to ASK the Resident what their goals are Ask about their goals for quality of life and activity involvementIf Resident is unable to participate involve the family by asking them to identify what they believe the Resident goals would be



Goal Setting

Elements of a GoalWho

Resident, caregiver, staffWhat

The action the Resident/caregiver/staff will demonstrate or state

FrequencyHow often this action will occur

Qualifier – amount of times or number of occurrences

How far will the Resident ambulateHow many activities will the Resident participate in


Goal Setting

Functional GoalsShould clearly identify who will do what, with how much assistance, and why this is importantShould contain a qualifier to define when the goal has been metUnmet goals at the time of Care Plan review should be evaluated for their continued appropriateness and updated as needed



Goal Setting

Sample Goals:The Resident will be able to eat 50% of each meal without assistance within two weeksThe Resident will be able to ambulate 25 feet to the dining room for lunch with rolling walker and staff supervision within 30 daysMrs. Jones will report pain relief to level of no greater than “2”, 30 minutes after pain medication is given.


Goal Setting

Objective GoalsActivity related goals tend to be related to attending a specified number of activities per week

Resident will participate in activities of preference daily through next reviewResident will participate in 2 - 3 activities for mental stimulation and socialization through next review



Goal Setting

Objective Goals (Continued)These goals MAY be measurable but do not focus on the highest practicable level of well beingThe interpretive guidelines for F248 related to Activities indicates that goals such as those above that merely identify how many group activities a Resident will attend are “old and outdated”


Goal Setting

Examples of Poorly Written GoalsResident’s needs will be metResident will maintain current functional levelResident will maintain independenceResident will continue to ambulate dailyResident will participate in ADLs as able Resident will communicate wants/needsResident will consume diet served


The Care Planning Process

Examples of Poorly Written GoalsPsychosocial conditions tend to be more difficult to establish appropriate goals.

Resident will show decreased signs of depressionResident will not hit more than one staff member per weekResident will express satisfaction with social interaction Allow Resident to verbalize feelings



Care Plan Interventions

Specific, individualized approaches must then be developed. Serve as instructions for resident care and promote continuity of care by all staff. These instructions should be short and concise so they can be easily understood by all staff.



Developed in accordance with the MD ordersConsistent with current standards of practiceGoal directed



Precise approaches help the staff to understand and implement interventions successfullyGoals and approaches should be communicated to any staff members who may not have a direct role in developing the Care Plan

Sample Interventions

Pain medications per orders Scale (3-10)Tylenol 325mg 2 tabs po q4hrs PRN for mild pain (2 or less on pain scale)Medicate 1/2hr prior to therapy utilizing pain scaleAssess pain level utilizing pain scale every shift


Sample Interventions (continued)

Offer relaxation music of choice, resident prefers Yanni, or ClassicalOffer whirlpool bath for comfortEducate resident for potential side effects of Percocet, lightheadedness, upset stomach, vomiting, sedation, constipation


Implementation

Put your Care Plan into actionCommunicate Care Plan goals and interventions to resident and responsible staff on all shiftsUpdate C.N. A. assignment sheetsProvide feedback during Care Plan meeting


EvaluationCritically reviewing Care Plan goals, interventions in terms of achieved Resident outcomesAssessing the need to modify the Care PlanPeriodically review goals, approaches and staff/Resident adherence to the Care PlanMonitor the Resident’s response to care on a daily basisReassess quarterly, annually and when the Resident has a significant change



Evaluation

Evaluate your interventions.Determine whether goal has been met.If the goal has not been met:

Were approaches appropriate?Were the approaches carried out?Was the goal appropriate?Was the time frame realistic?Was this really a problem for this resident.


Traditional Care Plans:Diagnosis focused using nursing diagnosis formatWritten by the staff based on what they believe is best for the ResidentInterventions focus on standards of practice for diagnosisCare plan written in third person – “Resident will…”Care plan focuses on adapting the Resident to facility routine



Resident Directed Care Plans:Resident focusedResident, family, and staff develop a Care Plan that focuses on the Residents wishesIndividualized interventions to meet the Resident’s needs and desiresCare plan written in the first personCare plan focuses on continuing the Resident’s lifelong routines during the nursing home stay


Traditional Care PlanProblem/Need

Goal Intervention

Alteration in thought process r/t history of CVA and short-term memory loss

Resident will be oriented to person, place, time, and surroundings at all times

Introduce self during careProvide orientation to day and surroundings with all daily care Place facility calendar in roomInvite Resident to attend activities daily provide reminders to attend prior to scheduled activityEncourage attendance at the current events activity


Resident Focused Care Plan

Problem/Need

Goal Intervention

Short-term memory problem due to recent CVA

Paul will use the activity calendar to select activities of choice daily

Place the monthly activity calendar in Paul’s room on the wall near his bedDuring am care please show him the calendar of events for the day and assist in selecting some that will interest himThroughout the day remind Paul of the activities that he plans to attend for the day and assist with finding eventPaul enjoys most activities that offer refreshments but he does not enjoying attending activities that involve music of any kindReligion is very important to Paul –be sure to invite him to the Sunday service



Goal Intervention

Resident wanders due to dementia

Resident will not wander into other Residents rooms

Redirect to appropriate area within facilityEncourage Resident to remain in common areasTeach Resident not to enter other Residents roomsPraise for appropriate behaviors



Problem/Need

Goal Intervention

I like to walk throughout the home and sometimes wander into other Resident’s rooms

I will continue to ambulate freely throughout the home daily through the next review

I like to walk with the staff. I will walk with you anywhere. If the weather is nice please take me outside for walks after lunch.I do not like to take naps and I will not sit even when I am tired unless you sit with me for a while. I like to play cribbage and checkers – help me find someone who will sit and play with me after dinner



Goal Intervention

Potential for Impaired social interaction r/t adjustment to unit

Resident will participate in 2 - 3 activities weekly for mental stimulation and socialization through next review

Introduce to roommate and fellow Residents Provide access to a monthly activity calendarEncourage and assist Resident to 2 – 3 activities for mental stimulation and socializationProvide 1:1 visits as neededPraise for appropriate behaviors and offer opportunities for successEncourage rest periods


Resident Focused Care PlanProblem/Need/Interests

Goal Intervention

Maureen enjoys knitting and needle crafts

Maureen will continue to knit daily

Encourage family to bring in items from home that Maureen has been working on Provide craft box for storageInvite Maureen to attend activities that involve craftsIntroduce to Residents with similar interests and encourage them to meet daily with small group knitting clutchCopyright © 2013 All Rights Reserved 88Harmony Healthcare International, Inc.


Problem/Need/Interests

Goal Intervention

Potential for alteration in nutrition and hydration

Resident will maintain adequate nutrition and hydration as evidenced by stable weight (+/-4%) and no s/s of dehydration

Diet and consistency as orderedSet up assist PRNMonitor weights PRNSupplements and fortified food as orderedLabs and meds as orderedMonitor for signs and symptoms of dehydrationOffer HS snackEncourage fluids dailyReport any significant wt changes to RD



Problem/Need/Interests

Goal Intervention

Since my recent CVA I have being experiencing a decreased appetite resulting in 10 lb weight loss this month

To maintain my current weight and regain 5 lbs

It helps to have my special adaptive silverware provided by OT at the table during mealsI eat better when I sit with my friends Sally and SueI do not like to brush my teeth prior to eating since the toothpaste alters the taste of my meal; instead just assist me to rinse my mouth prior to meals and brush them afterWeigh me once weekly in the am prior to my bath



Problem/Need

Goal Intervention

Since my recent CVA I have being experiencing a decreased appetite resulting in 10 lb weight loss this month(continued)

To maintain my current weight and regain 5 lbs

Keep my physician informed of any significant changes in my weightI prefer not to get up too early for breakfast – I like to eat hot cereal and eggs with coffee around 9:30 amIf you notice I am not eating offer me snacks- chocolate is my favorite and I always have M&M’s from my family in my room. I also like chocolate protein shakesMy daughter often brings in my favorite foods from home please remind me they are available and assist with prep



Quality Probes:Does the Care Plan address the needs, strengths, and preferences identified in the comprehensive Resident assessment?Is the Care Plan oriented toward preventing avoidable declines in functioning or functional status?How does the Care Plan attempt to manage risk factors?Does the Care Plan build on the Resident strengths?Does the Care Plan reflect standards of current professional practice?



Quality Probes:Do the treatment objectives have measureable outcomes?Corroborate information regarding the Residents goals and wishes for treatment in the plan of care by interviewing Residents especially those identified as refusing treatment.



Quality Probes (continued):Determine whether the facility has provided adequate information to the Resident to enable the Resident to make informed choices regard their treatment.If the Resident has refused treatment, does the Care Plan reflect the facility’s efforts to find alternative means to address the problem?


Care Plan Should Always:




Be a working tool with highlighted areas of discontinued goals with signatures and dates changes as they occur.Address ways to try to preserve and build on the resident’s strengthsApply current standards of practice in the care planning processEvaluate treatment of measureable objectives, timetables, and outcomes of care



Respect the resident’s right to refuse or decline treatmentOffer alternative treatments, as applicableUse an appropriate interdisciplinary approach to Care Plan development to improve the resident’s functional abilitiesInvolve the resident as appropriate

Surveyors will Probe…Can the staff describe the care, services, and expected outcomes of the care they are to provide?Do the staff have a general knowledge of the care and services being provided by other team members?Does staff understand the relationship of these expected outcomes to the care they provide?Is the staff actually doing what the Care Plan says?



Care Plan

The Federal requirements for care planning in nursing homes are located at 42 CFR 483.20(k)(1) and (2) and are described in the interpretive guidelines in Appendix PP of the SOM

The SOM can be found at: http://www.cms.hhs.gov/Manuals/IOM/list.asp

http://www.cms.hhs.gov/Manuals/IOM/list.asp

http://www.cms.hhs.gov/Manuals/IOM/list.asp

Discharge Planning

When the SNF anticipates the discharge of a beneficiary to another care setting or home it must plan for the dischargeAs part of this planning the SNF must develop a discharge summary to help ensure coordination of care and safe transition to the new setting


Discharge Planning

The discharge summary should include:

A summary of the beneficiary’s stayA summary of the beneficiary’s status at the time of dischargeA post-discharge Plan of Care, including:

Beneficiary’s and family’s preferencesHow the beneficiary will access servicesHow care will be coordinated among caregiversDischarge education and instructions


Discharge Planning

The discharge summary should provide an adequate clinical picture of the beneficiary and detailed individualized care instructions to ensure that care is coordinated and that the beneficiary transitions safely from one care setting to anotherThe interdisciplinary team, including the physician, should participate


Final Thoughts

Care Plans ensure that the residents needs are met throughout their stay and after dischargeIncreased scrutiny on the quality and content of Care Plans, as well as resident outcomes, can be anticipatedThe SNF is required to develop a Plan of Care in accordance with the resident’s individualized needsCopyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 103

Questions/Answers

Harmony Healthcare International1 (800) 530 – 4413www.Harmony-Healthcare.comctwombly@[email protected]


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The RAI Process: CAAs, Care Planning and Beyond

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Transcript of The RAI Process: CAAs, Care Planning and Beyond