Individualized Service Plans: Meeting Resident/Participant Needs A Program for caregivers working in Virginia’s licensed assisted living facilities and adult day care centers.

What do I need to know to support this individual with their care needs?

At the end of this program, you will be able to…  Read and interpret the Uniform Assessment Instrument (UAI) or 

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Adult Day Care Center (ADCC) admission assessment Identify the Virginia licensing standards and regulations governing the completion and revision of the UAI and Individualized Service Plan (ISP) Understand/explain what is meant by the phrase “significant change” Discuss how ISPs/care plans can promote teamwork Identify resident needs from the UAI Understand the difference between a diagnosis and a need Discuss ways to individualize an ISP/care plan Develop and use goal oriented ISPs/care plans for your residents/participants

About the Regulations  Regulation  A legal rule

 Standards & regulations

are:  Generalized

 Standard  A measure of quality

 Not a book of instructions

 Often statements of intent  Enforced by the DSS

 Minimum requirements

The health, safety and welfare of the individual is always the bottom line.

Applicable Standards and Regulations  For ALFs:  “Definitions”: under Part I (22 VAC 40-72-10)  “Uniform Assessment Instrument” (22 VAC 40-72-430)  “Individualized Service Plans”: under part IV (22 VAC 40-72-440)

 For ADCCs:  “Definitions”: under Part 1 (22 VAC 40-60-10)  “Assessment Procedures”: (22 VAC 40-60-564)  “Plan of Care for Each Participant”: (22 VAC 40-60-570)

 To access these regulatory standards go to:

www.dss.virginia.gov

UAI: The Foundation of an ISP  An assessment tool

 Provides core of the ISP  Know how to read  Know how to interpret into needs

UAI: Purpose  To gather information to determine care needs  To determine if a person’s needs can be met by the facility  To determine eligibility for certain services  To plan and monitor care between agencies

 To keep a record of changes in resident status  To determine level of care

UAI: Functional Assessment  Activities of Daily Living (ADLs)

 Instrumental Activities of Daily Living (IADLs)  Psycho-social status

Best Practices Notes Psycho-Social Assessment:  Life history  Sources of comfort, fright, and joy  Privacy and environment preferences  Family dynamics and support issues  Grieving and loss  Transfer trauma Go the extra mile to know your residents

Know your resident!

UAI: Describing Function  I = independent  d = semi-dependent  D = dependent (human help only)  D = dependent (human & mechanical help)  D or TD = Totally dependent

http://www.dss.virginia.gov/files/division/dfs/as/as_intro_p age/manuals/uai/manual.pdf

More about Functional Status Important points:  Both impairment level and need for assistance  Ability, not preference  Past 2 weeks’ performance  All components of the task

Activity: Functional Assessment 1.

Mr. Roberts uses a cane only on days when he feels tired or out of breath.

2.

Mr. Heath sits down when he is out of breath.

3.

Mrs. Harper needs a mechanical lift or two-person transfer to get from her bed to her wheelchair. She can give no help.

4.

Mr. Conrad needs someone to put the sock and shoe on his weak side. He can take care of the other foot by himself.

UAI: Requirements Assisted Living Facilities:  Public pay  Private Pay Adult Day Care Centers:  Model form

UAI: What, Who, When Public Pay  What  Part A, Behavior Pattern,

Medication Administration (all)  Parts A & B (Dependant in 2+ ADLs or Behavior)  Who  Qualified Assessor, Case

Managers, Independent Physicians

 When  Prior to admission (no sooner

than 90 days)  Every 12 months  After a significant change

Private Pay  What  An abbreviated UAI – 2 pages

 Who  ALF employee who has

successfully completed UAI training, Independent Physicians, Case Managers, Qualified Assessor

 When  Prior to admission (no sooner

than 90 days)  Every 12 months  After a significant change

UAIs: Updating UAIs  Required at least every 12 months

AND  Required when a resident’s change in condition is expected to last more than 30 days OR Whenever a resident’s change in status appears to warrant a change in level of care

Check-up Point Which of the following might be a significant change? 1. A woman needing incontinence pads for the first time during a urinary tract infection 2. A man needing a walker following a stroke 3. A man with memory loss who starts becoming agitated during bathing 4. A woman who suddenly requests to eat in her room

ADCCs: Participant Assessment  Medical and functional condition  Mental status

 Social situation  Economic conditions

ADCCs: Assessment Details  Before admission  Required physical exam  Abilities and needs  Reviewed and updated at least every 6 months  Can needs still be met?

FAQs: Frequently Asked Questions  What happens to the UAI when a resident is transferred?  Can updates for a UAI be made on the existing form?

 What happens when a new resident acts differently than their

initial assessment?  Can an administrator designate more than one staff member to approve and sign completed UAIs?  Can you approve and sign a UAI you yourself completed?

Check-up Point When does a UAI (for ALFs) or participant assessment (for ADCCs) need to be completed? 2. What 3 types of functioning abilities can be found on a UAI or participant assessment? 3. According to regulations, when must a UAI or participant assessment be updated? 4. Describe what ‘significant change’ means. Give one possible example. 1.

Activity: Your Dream House

Building Your House

Your Construction Team

ISP: A Blueprint for Care

ISP: Model Forms Needs/ Dates

Services

Who

When/Where

Expected Outcomes/ Time Frames

This table is for discussion only. It is not a model form.

Who can complete ISPs? ALFs –  The licensee/administrator or designee who has completed a DSS approved ISP training program.

+ input from:

 Resident and family  Case worker and/or case manager  Other healthcare workers and other persons, as appropriate

ADCCs –  Multidisciplinary personnel (not specified)  Participant and responsible family members

When are ISPs completed? ALFs –  Immediate needs – within 72 hours of admission  Comprehensive plan – within 30 days of admission  In writing ADCCs –  Prior to admission  Finalized within 30 days  In writing

When are ISPs revised? ALFs –  Reviewed and updated at least every 12 months  Reevaluated as resident’s condition changes-significant change

ADCCs –  Reviewed and updated at least every 6 months  Reevaluated and revised as significant changes occur.

Where are ISPs kept? Not under lock and key!  Accessibility is necessary.  Master plan-resident’s record  Copies in locations accessible to staff responsible for services  Privacy is a priority.  Plan for routine use.

A blueprint provides no guidance if it is filed away out of sight!

Application: Your Facility Consider these questions in terms of your own workplace: • Where are all the copies of ISPs located in your facility? • To your knowledge, how often do members of the nursing staff refer to ISPs?

•

Do you think it would be helpful to your colleagues to make any changes regarding the everyday use of ISPs?

• What might some of those changes be? •

How is the information in a resident’s ISP shard with new employees?

•

In general, what value does the staff in your facility place on ISPs?

ISPs: Important Points  Signing the ISP  IADLs  Preprinted ISPs

 Find the Technical Assistance at:  http://www.dss.virginia.gov  Adult & Child Care  ALF or ADCC  Applicable Regulations, Technical Assistance & Code References

Q: Who signs an ISP?  What the standards say

 Maintaining a record  DMAS and public pay

Q: Must IADLs be included?

YES!  Reflect assessed needs

 Services routinely provided  Availability of documentation

Q: Are preprinted or electronic ISPs acceptable?  Specific choices  Types of assistance  Extent of assistance

Could a float or family member understand?

ISPs: More Important Points  19 or fewer residents

 Independent status  Respite care  Reviewing and monitoring  Case manager  Do Not Resuscitate Order

ISP: The Role of the Reviewer  Review  Monitor  Implement  Modify  Inform

Reviewing ISPs

Review: To “see again”

Monitoring ISPs

Monitor: To watch, to keep track of

Implementing ISPs

Implement: To carry out; to accomplish

Modifying ISPs

Modify: To make changes to serve a new end

Informing about ISPs

Inform: To communicate knowledge of special interest or importance; to give information

Check-Up Point For your workplace (ALF or ADCC): 1. When must the ISP or Participant Care Plan be completed? 2. When must it be changed or updated? 3. List at least 3 of the duties of the staff member who reviews ISPs.

ISPs: Useful Concepts Habilitation vs. rehabilitation 2. Maintaining status 1.

#1: Habilitation vs. Rehabilitation Habilitation

Rehabilitation

 Adaptation & coping

 Restorative

 Secondary disability

 Therapist-initiated

 Following through, not

 Documented

initiating

#2: To Maintain, or Not? 4 3 2 1 0

An assisted living goal is never to “Maintain status.”

Know Your Goal!

When writing ISPs, consider what staff actually needs to do. What must happen for the job to be done well?

Habilitation or rehabilitation? Maintain or maximize function? What do staff need to know about the individual to provide care?

What makes an ISP work?  Based on assessed needs  Reasonable outcomes  Fluid  Accessible  Teamwork

 Individualized

ISP: A Plan for Teamwork  Different roles, one plan  Family involvement  Task breakdown  Responsibility

Activity: A Hospital Experience

ISP Requirements  Maximize the resident’s level of functional ability  Home-like environment  Services reflecting needs  Freedom of choice  Personal dignity

 Individuality

No Cookie Cutter ISPs!

Mrs. Simms: Example Resident  78-year-old, widowed 12 yrs  Married 46 yrs to a small town    

businessman, later mayor Catholic faith, regular attendee No children Homemaker and volunteer during married life and widowhood Enjoys knitting

Mrs. Simms: Example Resident • 78-year-old, widowed 12 yrs • Married 46 yrs to a small town •

• •

• •

businessman, later mayor Catholic faith, regular attendee No children Homemaker and volunteer during married life and widowhood Enjoys knitting, NASCAR races Has held a season’s ticket to the Redskins’ game for 10 yrs

Sources of Information • Interviews • UAI & other assessments

• History & Physical • Medical reports • Therapists & rehab • Mental health • Home health

• Observations • Family, friends, clergy, etc.

Needs & Dates  Need vs. diagnosis  ADLs and IADLs  Date identified

Why did this person come to assisted living (or ADCC)?

Hello, Mrs. Simms History and Physical –  CVA in 2003  Right-sided weakness  Attended rehab

Mrs. Simms’ Needs Functional Status: UAI, Section 2  Dressing  Ambulation  Home maintenance  Meal preparation

Mrs. Simms’ Needs Functional Status: UAI, Section 2  Dressing – MH & HH  Ambulation – MH Only  Home Maintenance – 1 (Independent)  Meal preparation – Needs help

A Word of Caution …

Each item that rates a ‘d’ or ‘D’ or ‘Needs help’ on the UAI MUST appear on the ISP as a need for assistance.

Services  What the staff will do…  What the facility will do…

Specifically.

It’s all about verbs. The direct care staff will … • Assist

• Arrange for

• Organize

• Set up

• Facilitate

• Reorient/validate

• Supervise

• Listen

• Provide

• Praise/encourage

• Carry out

• Reinforce

• Accompany

• Monitor

….by….

Services: One Final Word  Individuality  Independence  Freedom of choice

Mrs. Simms and her ISP

Description of Needs and Date Identified

Dressing 06/25/06

Services to be Provided

Mrs. Simms and her ISP

Description of Needs and Date Identified

Dressing 06/25/06

Services to be Provided

• Verbal cues for maximum use of assistive devices • Assist with opening/closing of fasteners • Stand-by assist. For undergarments – by resident request only. • Stand-by assist. For balance.

Persons who will provide services           

Direct care staff Nurse aid/CNA Licensed nursing staff Activity department Dietary/dining department Maintenance/housekeeping Administration Hospice personnel Family Physical/occupational therapy Transportation

When & Where  # Times per day

 In resident’s apartment

 # Days per week

 Throughout the facility

 Throughout the day

 Common areas

 AM & PM

 Per doctor’s orders

 Upon rising and before

 During scheduled

retiring

mealtimes  Dining room and resident’s apartment

Expected Outcomes/Goals    

“The resident will…” Reasonable Appropriate Measureable or observable Maximum function Never… ‘Maintain status.’

Setting Goals  What is the need?  Why does the need exist?  What improvements can be expected?  What will facilitate improvement?  How long will progress be measured?

 How long will it take?  What to do when the goal is met?

Same Need – Different Goals & Services

Mrs. Simms returns

Needs & Date

Dressing 06/25/06

Services

• Verbal cues… • Assist…fasteners • Stand-by… request • Stand-by… balance

Who

When/Where

Expected Outcomes/ Goals

Mrs. Simms returns Needs & Date

Dressing 06/25/06

Services

Who

When/Where

Expected Outcomes/ Goals

• Verbal cues… • Assist…fasteners • Stand-by… request • Stand-by… balance

Direct Care Daily AM care Resident will be Staff; Nursing & PM care, dressed in clean, Staff and as needed neat clothes of her choice on a In resident’s daily basis. apartment She will participate in dressing herself to the maximum extent of her ability.

Time Frames  Designate on ISP

 Not required by standards

Hints & Tips  What is the need?  Why does the need exist?  What can reasonably be expected?  What will facilitate maximum functioning?  How will goal achievement be measured?

 How long will it take?  Who is going to do it?  What does staff need to know to provide care for the

resident?

The 5-Step Method 1. 2. 3. 4. 5.

Gather information. Identify needs. Develop the plan. Implement the plan. Evaluate.

(Then repeat from the top.)

1. Gather Information  Different sources  UAI  Multidisciplinary  Report sand interviews

2. Identify Needs  From assessments  Include all identified needs  No diagnoses  “….has a need for assistance with…”

3. Develop the Plan  Appropriate form  Clear, legible writing in ink  One need per row of blocks  Services to meet needs  Who, when, and where

 Expected outcome of services  Time frame  How to measure

4. Implement the plan  Inform staff  Copies where needed

 Teamwork  Designated reviewer  Review and revise per DSS regulations

5. Evaluate Different levels, different focus:  As a document  As a blueprint for care  As an overall program review

Common ISP Problems Don’t fall into these traps!  Substituting diagnosis for a need  Listing multiple needs in a block  Using generalities  Using technical language  Using too many abbreviations  Using ‘maintain status’ as a goal

 Illegible and messy  Assuming reader

   

comprehension ISP developer not properly trained ISP not used as daily care guide Working copies not available Failure to cover all UAI needs

Partnering with your Inspector  Different interpretations  Culture of trust  A member of the team  Asking questions  Moving forward

 Keep the big picture

Bottom line = resident well-being

Thank You! Phone: (804) 828-1565 Website: http://www.sahp.vcu.edu/gerontology/ Email: [email protected] Be sure to “like” us on Facebook https://www.facebook.com/vcugerontology