MDS Alert

See quiz on page 5 to evaluate your understanding of what care plans should address.

Make Your Care Plans About Language

One of the most important aspects of care plans is the orientation toward goals. Therefore, you need to make sure that the goals you and the interdisciplinary team (IDT) write into the care plan can be quantified and measured. Understanding the care plan as a living, written document that is followed and updated according to a resident’s condition is a useful way to frame its significance.

Since the care plan is a written document, focusing on language makes sense. The RAI Manual instructs whoever is writing the care plan to craft statements so they include the subject (first or third person), verb(s), modifiers, timeframe, and goal(s).

If the MDS is a way of collecting, recording, and categorizing data points, care plans should be narratives, telling the story of residents’ qualify of care and quality of life.

For example, the RAI Manual suggests writing something like “Mrs. Johnson will walk 50 feet with the assistance of one aide daily for the next 30 days in order to maintain muscle tone in her legs.”

What about CAAs?

Care area assessments (CAAs) or care area triggers (CATs) are areas of care that may be triggered upon the completion and submission of the MDS. They may reflect conditions, symptoms, or other causes for concern common among nursing home residents — or specifically warranted by an individual resident’s MDS. The RAI Manual describes CAAs as the bridge between the MDS and an individual resident’s specific care.

The CAAs reflect conditions, symptoms, and other areas of concern that are common in nursing home residents and are commonly identified or suggested by MDS findings. “Interpreting and addressing the care areas identified by the CATs are the basis of the Care Area Assessment process, and can help provide additional information for the development of an individualized care plan,” the RAI Manual says. on page 4-2.

The “CAA process provides a framework for guiding the review of triggered areas, and clarification of a resident’s functional status and related causes of impairments. It also provides a basis for additional assessment of potential issues, including related risk factors. The assessment of the causes and contributing factors gives the interdisciplinary team (IDT) additional information to help them develop a comprehensive plan of care,” the RAI Manual says.

Although several CAAs may be triggered by an individual resident’s MDS, they may not require separate care plans for each area of care triggered. “Since a single trigger can have multiple causes and contributing factors and multiple items can have a common cause or related risk factors, it is acceptable and may sometimes be more appropriate to address multiple issues within a single care plan segment or to cross reference related interventions from several care plan segments,” the RAI Manual explains.