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9/22/2010
Debbie Ohl & Associates LTC Consultants &
Educators MDSCarePlanBuilder.com
ThinkTheThoughts.com 1
MDS 3.0 Care Planning
Presented by
Debbie Ohl RN, M.Msc., PhD.
Ohl and Associates
Committed to Quality Care & Professional Excellence
613 Compton Road
Cincinnati, Ohio 45231
MDSCarePlanBuilder.com
From Paper to Person
Debbie Ohl RN, M.Msc., PhD
Ohl and Associates
Long Term Care Consultants
Debbie@MDSCarePlanBuilder.com
Debbie’s 30 year consulting practice is an outcome of learning lessons the
hard way as a nursing director, sometime nurse’s aide and behind the
scenes administrator. She is a regulatory compliance and
interdisciplinary care planning specialist, authoring more than a dozen
manuals including HcPro’s, Big Book of Care Plans.
As a nationally recognized expert, Debbie has presented for many
prestigious organizations including the National Institute for Health , the
American College of Nursing HomeAdministrators, the National
Health Care Lawyer’sAssociation, and numerous Health Care
Organizations, and Nursing Facilities throughout the country.
Recently completing her Ph.D in Holistic Life Coaching, Debbie brings a
unique perspective on the impact that thoughts, feelings, and actions
have on ourselves and those we serve.
Debbie Ohl &Associates LTC Consultants & Educators
MDSCarePlanBuilder.com ThinkTheThoughts.com
Quality … Degree of excellence or worth
Life… A manner or way of existing
Autonomy… Self-governance, self-sufficiency
Quality of LifeQuality of LifeQuality of LifeQuality of Life
RAI…The path to improvement.

9/22/2010
Getting to the Care Plan
MDS 3.0 CATs CAAs
Program Objectives
Identify and discuss 3 to 5 new terms used in conjunction with
the MDS 3.0 and how they can be used in care planning.
Issue
Problem
CPS
CPGs
PHQ-9
BIMS
EBPs
PCP
Program Objectives
Discuss the expectations of person centered care planning.
Discipline Specific
Professionals
Person / S.O.
Wishes/Preferences
Administration
Staff
Regulators
Human Being
Resident

9/22/2010
Program Objectives
Identify the seven components of the care plan and at least one
key factor of each as it relates to RAI expectations.
Program Objectives
Discuss the three primary content areas to be considered in
care planning.
Active Disease
CAAs
Accommodation
of Need
• Impact on function
• Impact on life style
• 18
• 2
• Physical
• Cognitive
• Psychosocial
Evolution of Care Planning

9/22/2010
1935
Poor houses
SSA established public assistance
For profit homes proliferate
1950
SSA requires States to license
NH
SSA does not specify
enforcement standards
1956
Feds find NH substandard
1965
Medicare/Medicaid programs funded
by Feds
Standards put in place
1970
NH atrocities hit front page of news
papers
1972
ComprehensiveWelfare Reform Act
funds state survey and certification to
establish uniform standards and
conditions.
Emphasis is on institutional
framework: CAPACITY to deliver
care.
Mid 70’s-early 80’s
Patient Care & Services Survey born to correct emphasis on
capacity to deliver to ACTUAL delivery of care.
Controversy over legitimacy.
Paper compliance in the form of policies was nearing its end.
1975-76
Use of paper in the form of care plan takes
center stage to insure care delivery....
or at least begins the process.
Phase 1
Paper to Person 1976-1987
EVERY resident must have a plan.
EACH discipline must have a plan.
Every diagnosis must be on plan.
All medications must be on the plan.
Total Confusion
Result: Multi-disciplinary
conflict,
fragmentation, confusion,
many deficiencies.
• Care plan content expectations have
increasing demanding. i.e. goal
measurability.
Phase II 1987
InterdisciplinaryTeam Building
QUALITY of CARE
OBRA solidifies standards and creates a
framework for continuity of care.
Care plan goals, interventions and
target dates progressively used to site
deficiencies.
Emphasis is on Quality of Care.
Unified care planning efforts begin
with name change to IDT.
1995 MDS 2.0 Raises the Bar
• Assessment process formalized.
• Increased expectations in terms of
documentation and care delivery.
• RAPS about paper not process.

9/22/2010
1987 to September 30, 2010
MDS 2.0 promoted inter-
disciplinary care planning.
Quality Indicators and
Measures created benchmarks
for outcomes.
RAPs provided insurance
that at least the obvious was
care planned.
Clinical assessment skills
were maturing.
Quality of care was the
expected norm.
Care plans became more
resident specific.
October 1, 2010
MDS 3.0 promotes resident
driven care planning.
CAA’s demand looking
beyond the obvious.
CAA’s demand staying
current with best practices.
Quality of care is the norm.
Quality of Life comes to the
forefront.
HUGE paradigm and culture
change shifts further
advances the human
condition.
2010201020102010
Quality of Care ActualizedQuality of Care ActualizedQuality of Care ActualizedQuality of Care Actualized
Quality of Life Comes to ForefrontQuality of Life Comes to ForefrontQuality of Life Comes to ForefrontQuality of Life Comes to Forefront
Terms for Care Planning
PCP
Critical thinking
Multidisciplinary
Interdisciplinary
Transdisciplinary
RAI
MDS
CATs
CAAs
CPGs
EBPs
SOP
DecisionTrees

9/22/2010
Terminology
RAI ResidentAssessment Instrument
MDS Minimum Data Set
CATs ClinicalAssessmentTriggers
CAAs ClinicalAssessment Areas
EBPs Evidenced Based Practices
CPGs Clinical Practice Guidelines
SOP Standards of Practice
PCP Person Centered Planning
Purpose of Clinical Assessment AreasPurpose of Clinical Assessment AreasPurpose of Clinical Assessment AreasPurpose of Clinical Assessment Areas
CAA’sCAA’sCAA’sCAA’s
Identify and clarify areas of concern from CATs.
Promote identification of underlying cause(s), risks,
complications.
Consider fixability factors.
Establish correlations among multiple triggered CATs.
Demands critical thinking skills.
RAP CAA
Possible problems in 18
care areas.
Triggers alert to possible
issues in care needs.
Triggered care area must
be thoroughly assessed.
Documentation must meet
criteria.
RAPS must be the tool
used for conducting
the assessment.
Possible problems in 20
care areas.
Triggers alert to possible
issues in the care needs.
Triggered care area must
be thoroughly assessed.
Documentation must meet
criteria.
There is no mandated
specific tool for
assessment.

9/22/2010
CAA ResourcesCAA ResourcesCAA ResourcesCAA Resources
RAI
• MDS 3.0 tools
BIMS
CPS
PHQ-9
• Chapter 4
Process steps 4-9
POC focus 4-12
20 CAAs 4-17
• Appendix C
CAA resources
Expert Resources
• CPGs
• EBPs
• SOP
• Decision trees
• Care paths
• Journals, etc.
• QIO’s
In-Facility
• Policy
A general plan to
guide decisions
•
• Procedure &
protocols
Fixed, step-by-
step sequence
activities or
course of action
Care plan
• Baseline
• Review and
revisions
• SMART goals
• Timelines
• Resident
preferences
CAA CompletionCAA CompletionCAA CompletionCAA Completion
PsychosocialWell Being
CAA DemandsCAA DemandsCAA DemandsCAA Demands
Coming off of auto pilot.
Problem solving in addition to problem management.
Assessment and Care Planning Policies and Procedures.
Staying up to date on changing practices.

9/22/2010
CPGsCPGsCPGsCPGs Clinical Practice GuidelinesClinical Practice GuidelinesClinical Practice GuidelinesClinical Practice Guidelines
Guidelines developed to help health
care professionals and patients make
decisions about screening, prevention,
or treatment of a specific health
condition.
EBPsEBPsEBPsEBPs Evidence Based PracticesEvidence Based PracticesEvidence Based PracticesEvidence Based Practices
1. Conscientious decision-making based not only on the
available evidence but also on patient characteristics,
situations, and preferences.
2. Recognizes that care is individualized and ever changing
and involves uncertainties and probabilities.
3. A philosophical approach that is in opposition to rules of
thumb, folklore, and tradition.
SOPSOPSOPSOP Standard of PracticeStandard of PracticeStandard of PracticeStandard of Practice
A diagnostic and treatment process that a
clinician should follow for a certain type of
patient, illness, or clinical circumstance.
That standard will follow guidelines and
protocols that experts would agree with as
most appropriate, also called "best practice."

9/22/2010
Decision TreeDecision TreeDecision TreeDecision Tree
Used in determining the
optimum course of
action, in situations
having several possible
alternatives with
uncertain outcomes
Don’t get bogged down!Don’t get bogged down!Don’t get bogged down!Don’t get bogged down!
EBP, CPG, Care paths, etc.
Give me a break!
15 minutes

9/22/2010
Terminology Countdown
RAI ResidentAssessment Instrument
MDS Minimum Data Set
CATs ClinicalAssessmentTriggers
CAAs ClinicalAssessmentAreas
EBPs Evidenced Based Practices
CPGs Clinical Practice Guidelines
SOPs Standards of practice
PCP Person Centered Planning
CT CriticalThinking
How does person
centered care differ from
resident centered care?
The identification and evaluation of evidence to guide decision making.

9/22/2010
Critical ThinkingCritical ThinkingCritical ThinkingCritical Thinking
1. Gathers and assesses relevant information.
Raises questions and problems
States them clearly and precisely
Comes to well-reasoned conclusions and solutions
testing them against relevant criteria and standards;
2. Thinks open-mindedly within alternative systems of thought,
recognizing and assessing: if,then
3. Communicates effectively with others in figuring out
solutions to complex problems without being unduly
influenced by others' thinking on the topic.
Your Job
To interpret and address the CareTo interpret and address the Care
Areas identified by the CATs andAreas identified by the CATs and
develop an individualized caredevelop an individualized care
plan that keeps the person at theplan that keeps the person at the
center of all activities.center of all activities.
Summarize your learning
☺

9/22/2010
Lunch Time ☺
Care Planning Teams
Team A group of people with a common purpose
Discipline Relating to a particular field of study
• Multidisciplinary Many
• Interdisciplinary Between and among
• Transdisciplinary Strategy that crosses many disciplinary
boundaries to create a holistic approach

9/22/2010
Care Area Assessments
Promotes identification of cause and effect relationships,
contributing and complicating factors and risk identification
Correlates triggering relationships and implications
among multiple triggered CATs.
Advances recognition of resident strengths,preferences, wishes.
Considers correctability.
Requires Logical Care Plan Linkage
CAA Review
1. Identify relevant triggers.
2. Identify type of trigger.
3. Identify the possible causes, contributing factors, and risk
factors .
4. Analyzing and draw conclusions.
5. Develop a personalized, resident-specific care plan based
directly on conclusions including insight of IDT members,
resident, significant others.
38
Tools, Tips & Clarifications
for Care Planning
BIMS
CPS
MMSE
PHQ-9
Issue
Problem

9/22/2010
BIMSBIMSBIMSBIMS
Brief Interview for Mental
Status
Interview process used to test
the resident’s memory
o Repetition of 3 words
o Orientation
o Recall
Residents must be capable of
responding.
If resident rarely/never
understands staff assesses
resident based on their
observations.
CPS
Cognitive Performance Scale
used in RUGs III to
evaluate the level of cognitive
impairment
MMSE
Mini Mental Status Exam
questionnaire used to screen
for cognitive impairment.
PHQ9PHQ9PHQ9PHQ9
Resident Mood Interview
Patient Health
Questionnaire with
9 questions
Looking for signs of
depression
Residents must be
capable of responding.
Staff PHQ if 3 or more
items not completed by
resident.
ISSUE
About
yesterday and tomorrow.
Grey area,
intangible.
Typically not solvable.
PROBLEM
About
here and now.
Black and white,
tangible.
Something can be done.

9/22/2010
10 Care Plan Must Have’s10 Care Plan Must Have’s10 Care Plan Must Have’s10 Care Plan Must Have’s
MDSCare PlanBuilder.com ThinkTheThoughts.com
Six general care planning areas
1. Functional Status
2. Rehabilitation/Restorative Nursing
3. Health Maintenance
4. Medications
5. Daily Care Needs
6. Discharge Potential
Priority PlansPriority PlansPriority PlansPriority Plans
1. Unstable health conditions.
2. Pain management.
3. New areas of risk: falls, skin,
dehydration, etc.
4. New problems requiring use of
psychoactive medication to
correct or control.
5. Medications with high risk for
side effects, or adverse drug
reactions.
6. Wounds, pressure ulcers.
7. Medicare RUGs (reason for
coverage) skilling services.
8. Acute problems
* Falls
* New pressure sores
* Unplanned weight loss
* Unplanned weight gain
* Elopement
* Resident to resident abuse,
* UTI’s
* URI’s
* Other

9/22/2010
Components of the Care Plan
1
2
7
3
6
4
5
Care Plan
Statement
Care Plan Guidance
Problem / Need
Strength
Scope, Severity,
Stability
CAA
Interventions
Approaches
Clear
Concise
Do-able
Done
Review Dates
& Places
Nurse’s Notes
Progress notes
IDT notes
Goal (s)
Related
Linked
Measurable
Reasonable
Do-able
Responsibilities
Oversight
Delivery
Content
Contains
Issue
Reason
Impact 4 Quadrants
Risk
Strengths
Resident Input
Fix ability
Fix it
Improve it
Maintain it
Control it
Slow the decline
Minimize/prevent
complications
Use the 4
Quadrant
What physically
mentally socially
emotionally?
Ask each
discipline: what
can you offer
What does the
resident want??
Delivery means
insuring
consistent
implementation
Oversight
means
monitoring for
effectiveness
Review Date
based on SSS
Interim
Or
Expected to be
met
Resident Input
3.3.3.3. Developing GoalsDeveloping GoalsDeveloping GoalsDeveloping Goals

9/22/2010
2.2.2.2. Resident VoiceResident VoiceResident VoiceResident Voice
4.4.4.4. Target DatesTarget DatesTarget DatesTarget Dates
Meet Goal or Check ProgressMeet Goal or Check ProgressMeet Goal or Check ProgressMeet Goal or Check Progress
Consider the Scope, Severity, and StabilityConsider the Scope, Severity, and StabilityConsider the Scope, Severity, and StabilityConsider the Scope, Severity, and Stability
Scope Severity Stability
Pervasiveness of the
problem.
Seriousness of the problem. Current status of the
problem.
Present continuously (3)
Intermittent, patterned (2)
Sporadic (1)
Immediate jeopardy to health
& safety of self or others (4)
Harm present or eminent (3)
Potential for harm (2)
Minor (1)
To what degree is the
problem solved
and or what is the
likelihood of
reoccurrence if
interventions are
withdrawn?

9/22/2010
5.5.5.5. ApproachesApproachesApproachesApproaches
Determining Interventions & ActionsDetermining Interventions & ActionsDetermining Interventions & ActionsDetermining Interventions & Actions
.
6.6.6.6. MonitoringMonitoringMonitoringMonitoring
a.a.a.a. Deciding on AccountabilityDeciding on AccountabilityDeciding on AccountabilityDeciding on Accountability
6.6.6.6. MonitoringMonitoringMonitoringMonitoring
b.b.b.b. Implementation

9/22/2010
Care Plan Formats
Common PlanCommon PlanCommon PlanCommon Plan “I” Plan“I” Plan“I” Plan“I” Plan
PGI Reads like a book
Or
Changes language content
of common plan
“I” care plan samples
I-Format Care Plans http://paculturechangecoalition.org
SKIN:I am at risk for skin breakdown because of my decreased
mobility.I had an open area on my coccyx,which I obtained while
in the hospital. It has improved to just a reddened area. I want to
keep healing.Assist me to reposition every two hours if I have not
done so on my own. Remind me to keep off my back as much as
possible when I am in bed. I have a special pressure-reducing cushion
on my chair, which needs to be straightened, before I sit in it every
morning. My bed has a pressure-reducing mattress. I take a
multivitamin to help with skin healing. I concentrate on making sure I
eat proteins at every meal. Remind me that protein will help in
healing.
GOAL:I wish to remain free of skin breakdown.
COMMUNICATION/MEMORY:I used to communicate well
and enjoy a hearty conversation.Humor has always been a part
of my communication style. I have become much weaker as my
health has declined. Sometimes I find it hard to even to answer I
am tired. Occasionally I have episodes of confusion. Sometimes I
do not know where I am and I become frightened. Please provide
orientation during these times and when you are providing my
care. Let me know who you are and what you are going to be
doing. I usually recognize my children and my spouse. Holding
m y wife’s hand comforts me.When I am confused and frightened, I
may strike out at you. Use calm gentle touch and hand massage
while providing me reassurance.
*GOAL: I don’t want my memory loss and confusion to
interfere with my ability to accept the care I need. I do not
want to hurt my caregivers

9/22/2010
Comfort (Rhode Island Quality Partners)
I take regular medication for pain. Sometimes I need extra boost of
medication. I also benefit from stretching so I like to attend the
morning exercise group. The massage therapist seems me every
Friday for an hour. Massage makes all the difference.
Goal: To be free from breakthrough pain in my back
Sleep medication prn.
Discourage napping during the day.
Side rails up.
IF unable to sleep place in Geri-chair.
IF I am walking at night please offer to walk
with me.
Place sashes in doorways of resident rooms
who are disturbed by my presence at nite.
Offer me snacks.
I like to read the sports section of the paper
and play solitaire.
I‘softer’ Plan
I like to walk
during the night.
Taken from web site on I care plans
Care Plan with Pain as the Root Problem
Components of Pain Care Plan: Analgesia, Quality of Life, Ability to Function
PROBLEM/NEED
/STRENGTH
GOAL(S)
What does the
resident want?
REVIEW
Date
APPROACHES/
INTERVENTIO
NS
Resp.
Discip
IssueIssue:: why painwhy pain
DescriptionDescription of pain:of pain:
type, source, location,type, source, location,
intensityintensity
ResultingResulting in/in/
creating/impacting:creating/impacting: affectaffect
on functional statuson functional status
PMS/E:PMS/E:
Risks / complicationRisks / complication
(think about from pain(think about from pain
and med used)and med used)
ResidentResident
Strengths/Wishes:Strengths/Wishes:
1. Resolve and
eliminate the
issue if possible
2. Pain Relief /
Control
3. Quality of
Life, - What
can you make
better?
- What is the
best you can
expect?
Medication plan
Who can do
What
When
Where
How often.

9/22/2010
7. Review and Revision
Target dates outside of facility established reviews.
Who does it? Where will it be documented?
What if the plan is off track?
Care conference scheduled reviews.
Overview
Status of goals
Met
Unmet
Rationale
New areas of concern
Assessment of Care Plan ActivitiesAssessment of Care Plan ActivitiesAssessment of Care Plan ActivitiesAssessment of Care Plan Activities
1. Acute problems are addressed
timely.
2. Care plans geared to preventing
avoidable declines?
3. Care plans consistently manage
resident risk factors in a timely
manner?
4. Care plans recognize and build
on resident strengths?
5. Goals measurable?
6. Goals achievable?
7. Goals met ?
9. The IDT work together?
10. Some team members write their own
care plans for fear they will
otherwise be cited?
11. Documentation reflects status
and/or rationale on each care plan
goal?
12. Direct care staff on all shifts and
units are informed about the care
plan goals and interventions?
13. The direct care staff can explain
what the goals are and why they are
doing what they are do?
Person Centered Care Planning
What do we live for, if it
is not to make life less
difficult for each other?
George Eliot

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