MDS Alert

Shore up these key areas and watch your outcomes soar.

For starters: Develop an open system where the frontline staff feel comfortable participating in the care plan process -- and challenging the care plan content, suggests Cheryl Boldt, RN, NHA, a consultant with Maun Lemke in Omaha, Neb.

Otherwise, the care team can compile a "really good, complex care plan," but not one the resident really needs or wants, Boldt cautions. And the care plan may not provide a workable solution in the view of those who have to implement it on a daily basis.

Example: The care plan team may devise a toileting program for a resident that includes a specific toileting time related to when he suffered a fall. But the frontline staff knows based on their experience that the person really needs to go before that time, says Boldt.

Healthcare providers do a good job at identifying diseases and potential negative outcomes, but they don't always identify and play on a patient's strengths, notes Lynda Mathis, RN, lead consultant for LTC Systems in Conway, Ark. For  example, even if a patient is severely handicapped, the fact that he can make eye contact with you to get his attention is a positive, Mathis points out. And you can include that in the care plan as a strategy for communicating with the person and facilitating care.

Look for these two commonly overlooked strengths in care planning, suggests Cheryl Field, MSN, RN, CRRN, senior healthcare specialistwith PointRight Inc. in Lexington, Mass.

1. Motivation. The care team should find out what motivated the person in the past. For example, is the person someone who will do well with a walking goal that includes distance metrics? Or is he a social person who will do better walking from his room to a favorite event, such as Bingo? asks Field.

First things first: Rather than the care team prioritizing resident goals on its own, it should identify what the resident wants to work on first. Then when the resident experiences some success in reaching his prized goal, he'll be more motivated to work on other goals, Field says.

2. Past roles. A resident may not be interested in attending speech therapy sessions, Field notes. But before he suffered a stroke, he may have enjoyed reading to his granddaughter. And if the speech therapist knows this, she might engage him in working on reading to his granddaughter in preparation for the real deal -- or the resident might want to record a letter to his granddaughter,Field says.

In addition to CNAs providing direct care, the activities staff, housekeepers and dietary aides should know the care plan so they can do their part and let you know if the plan seems to be working, advises Boldt. For example, housekeepers may be the ones who notice that a resident seems to be in pain or is complaining about discomfort.

The dietary aide should know which residents are losing weight or not eating well, Boldt advises. They can then encourage the resident to eat when they deliver the meal trays or get alternative food selections if someone doesn't like what's offered.

Build some tools into the assessment process to catch problems with the care plan in order to make changes in real time, advises Jennifer Gross, BSN, RN, RACCT, a consultant with PointRight.

For example, if the resident has a continence care plan, a daily flow sheet completed by CNAs could alert everyone to the resident's lack of progress at a certain time of day, Gross notes. The team could use that information to change interventions at that time of day -- perhaps make a change to the toileting schedule, Gross suggests.