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  1. The Introduction- Meeting Your Resident There is a skill in the art of introducing oneself and every healthcare professional must possess well practiced expertise in this area. The very essence of successful wellness care relies on this ability. This first meet and greet frequently establishes the baseline from which “trust” is built and that’s a seriously powerful tool for those wishing to care for others. You will find yourself doing this introduction repeatedly throughout your workday, and this one action will either hamper your relationship with those you serve or greatly lead to open and trusting exchange. Here are a few reminders about how to introduce yourself to your resident. Use your first and last name. You may wear a name badge to help participants remember your name until they become familiar with you. Even if your resident has short-term-memory issues, he/she will understand and appreciate this small formality. Call your resident by Mr./Mrs. and their last name as well. Those wishing you to use their first names or last name only will tell you so or may announce a preferred nickname. Endearing terms are NOT permissible. Avoid using terms like “sweetie” or “dear” remind yourself that these are very grown up adults; such terms are offensive and patronizing. Use a relaxed and friendly tone of voice. This will help establish a relaxed conversation. In addition, a relaxed tone will also serve to increase the residents’ confidence in your abilities. Keep the volume of your voice at a regular level unless it becomes evident that he/she is having difficulty hearing you. Remember that your “body language” will say more than words. Body language is the physical clue that we use often without thinking. Some examples of positive body language are smiling, a touch, nodding and making eye contact with the person who is talking. Examples of body language that express displeasure are frowning, raising an eyebrow and folding our arms over our chest. Body language should match what you are saying. Even people with severe memory problems who have difficulty understanding what you say, can still “read” your body language. Establish eye contact. This means looking at the person to whom you are talking. Eye contact tells the other person you are listening and that you mean what you are saying. Directly face the resident when you speak and get to his/her level (if they are sitting, sit down next to them). Keep in mind, however, and respect different cultural backgrounds and the possibility that they may interpret direct eye contact differently. It can be viewed as confrontational or authoritative posture – know this about your resident. Many older people have difficulty hearing and unconsciously rely on “lip-reading” to understand what others are saying. Never shout; it raises the pitch of your voice. Many older people lose the ability to hear high-pitched sounds. That is why many older people tell you they can understand a man’s voice better than a woman’s voice. Listening is extremely important. It is often more important to “zip your lip” and focus on what the other person is trying to tell you than it is to speak. It takes older people longer to react than the younger ones. Give older people plenty of time to respond to your questions/comments, never make them feel that time is of the essence. Communication is important in all interactions and it is the bridge to successfully learning the wants and needs of your resident. From introductions to day-to-day communication, you will establish a trusting relationship with each resident that forms mutual respect that dissipates the residents’ hesitation and opens the door for you to become his/her champion. Have a topic request or question for Celeste? Send them over to celestechase@activitydirector.org Enroll Now Activity Directors Network was founded in 1996 on the idea that we could help create elderly care that dramatically improved the lives of those we all serve. We envision facilities that feel like homes and that celebrate our resident’s individuality and allows them to live with dignity, purpose and joy. We believe the exchange of education and wisdom between the most talented teachers and passionate students is the way to make an impact. Each and every single one of you are the revolution that is changing everything. Thanks for being a part of The Network. Copyright © 2020 Activity Directors Network, LLC All rights reserved. Our mailing address is: 2010 US HWY 190 W Ste 120 Livingston, Texas 77351
  2. As you review the care plan history, take note on how care plan documentation lends itself towards an integrated team care approach. While history shows that fundamental care plans were initially used as care guidelines for volunteers without medical experience or training; you will see that it later develops into one of today’s most valuable instruments for quality measures, nursing home payment, and state inspections. Let’s take a look at the historical care plan development over the centuries and its relevance in supporting continuity of care. 31st BC (3100 BC to 3001 BC) -15th Century Historically speaking, medical oversight was primarily focused in reactive care mode; treatment was rendered based on symptoms without much thought to taking preventative measures for the individual’s future health. The middle ages brought about explanations that the medical phenomenon was connected to spirituality and religious belief systems. Preceding modern medicine, most of the care regimens provided to patients were focused on either external symptoms, or a spiritual or magical basis. 16th-19th Century The 16th through the 19th century brought about a period of heavy scientific discovery, leading to the transition of supernatural explanations to natural explanations for disease and illness. People began to see illness as something that could eventually be eradicated, and saw health as a natural state of the body that should be maintained and protected, further stepping away from traditional notions of supernatural explanations or divine punishment. 1930s The 1930s marked the entry of clinically driven” care plans” into focus for nursing professionals. When the length of hospital stays increased, there was time due to the length of stays to implement written plans. (Nursing team leads would often use care plans as a guide for the less-educated members of the team). 1970s The emergence of “life care planning” involved many industry professionals during this time. The converging principles of the fields of “Experimental Analysis of Behavior” (EAB), development psychology, and case management established “life care planning” factors: a summartive statement, communication tool, preventative planning, basic components, individualized plans, and needs come first ideology. 1980s In the 1980s and the following decades; “life care planners” were involved in consultations with insurance carriers and also with attorneys involved in litigation. “Life care planning” played a large initial role in the field of litigation. It has since expanded into elder care, chronic illness and discharge planning. It has also expanded the number and types of professions who can each be involved in a part of care planning. 2000s The extent of professionals and care providers expanded with individual cases coming from rehabilitation counseling, rehabilitation nursing, physciatrist, and case management professions. Both paper based and digital technology based “care plans” were regularly being used by patients and their care providers. A proliferation of digital technology based care plans also began to take hold in later years. Current Day Today, nursing home care plan data is used for quality measures, nursing home payment, and state inspections. Centers for Medicare & Medicaid Services (CMS) transitioned Medicare to the more quality-based practice of reimbursing for care management of eligible patients. Other private insurance companies are beginning to follow suit to prioritize consistent, preventative care facilitated by patient-accessible care plans. Excerpt from The Care Plan- A Road Map CE Course by M. Celeste Chase This course takes you through the Activity Departments required documentation process from the Baseline Care Plan through the final creation of the Comprehensive Care Plan. Particularly focus is tailored to the individuality of the resident and that care plans are in no way intended to be “cookie cutter” care plans. An appropriate and useful care plan begins with an effective and complete individualized assessment. When designing a care plan for each resident the professional must ensure that multiple sources within the Interdisciplinary Team assessments are considered to address the resident’s specific needs. The care plan you write must address these issues. The care plan is a representation of the accumulation of the facility’s assessment process. It is the final compilation of the individual resident’s problems, needs, and strengths. The care plan definitively scopes the resident’s care treatment process, describing conditions to be treated, expected outcomes, and the specific customized care services to be rendered. This course is intended to help you to become more proficient and savvy when it comes to realistic and relevant care plan development. Workshop Objectives: Understand care plan relevance relating to resident treatment Learn how care plans have evolved historically Understand the development process leading to the care plan creation Understand how to implement SMART care plan goals Utilizing IDT assessment tools data for care planning Understanding resident rights in care planning participation Recognize the progress notes and care plan relationship Recognize the initial assessment and monthly calendar relationship Revising the care plan – why or why not Merging care plans – consolidate IDT members contributions When to use short term care plans Understand Rehabilitation care plans Workshop Content: Care Plan Overview – What is this document? The History of Care Plan Development Understanding SMART Goals The Process – Baseline Care Plan to Comprehensive Care Planning Reporting Timeliness Common Care Plan Mistakes Care Plan Examples General Documentation Principles Documentation Corrections About Your Instructor Celeste was involved in the startup of a medical adult day center in the role of Activity Director and worked closely with the Alzheimer’s Association, Massachusetts Chapter during to develop program modules to serve the Alzheimer’s diagnosed participants. She was exclusively instrumental in the successfully implementation of the center’s Child and Adult Care Food Program (CACFP); working with the state to create the centers reporting structure and standards for compliance to state specified regulations. Celeste was recognized for her business development contributions and was became the Centers’ Program Director. Celeste has served as consultant and “Guest Instructor” for Activity Directors Network since 2011- supporting the student educational experience in pursuit of Activity Director Certification. She is currently lead instructor for Activity Directors Network and author of the National Activity Professional Training Course (NAPT). Celeste continues to support educational opportunities as the author of The Activity Consultant’s Help Desk since its inception in 2018. This Activity Directors Network newsletter reaches a readership with interest in further developing of their professional knowledge base as senior care industry professionals. She has also written Continuing Education (CEU) courses and has authored the “Behavioral Health Programming Guide for Skilled Nursing Facilities”. Have a topic request or question for Celeste? Send them over to celestechase@activitydirector.org Activity Directors Network was founded in 1996 on the idea that we could help create elderly care that dramatically improved the lives of those we all serve. We envision facilities that feel like homes and that celebrate our resident’s individuality and allows them to live with dignity, purpose and joy. We believe the exchange of education and wisdom between the most talented teachers and passionate students is the way to make an impact. Each and every single one of you are the revolution that is changing everything. Thanks for being a part of The Network. Copyright © 2020 Activity Directors Network, LLC All rights reserved. Our mailing address is: 2010 US HWY 190 W Ste 120 Livingston, Texas 77351
  3. New Mandated Patient Driven Payment Model (PDPM) PDPM is one of the initiatives resulting from the Improving Medicare Post-Acute Care Transformation Act of 2014 (the IMPACT Act). In July 2018, CMS finalized a new case-mix classification model, the Patient Driven Payment Model (PDPM) which is the proposed new Medicare payment rule for skilled nursing facilities. This model is intended to replace the current Resource Utilization Group (RUG-IV) system with a completely new way of calculating reimbursement and is slated to go into effect beginning October 1, 2019. Under PDPM, therapy minutes are removed as the basis for payment in favor of resident classifications and anticipated resource needs during the course of a resident’s stay. PDPM assigns every resident a case-mix classification that drives the daily reimbursement rate for that individual. The currently utilized Resource Utilization Group, Version IV (RUG-IV) billing will end on September 30, 2019. PDPM will be a significant shift in how SNFs are paid, and facilities need to start preparing for the change. PDPM: Removes therapy minutes as a determinant of payment and creates a new model where payment is linked to differences in clinical characteristics. Creates a separate payment component for Non-Therapy Ancillaries (NTA), using resident characteristics to predict utilization of these services Focuses on clinically relevant factors and ICD-10 diagnosis codes to determine payment The implementation of PDPM will be one more step towards moving reimbursement for care from volume to value. As payment shifts from therapy focus to clinical characteristics focus, there will need to be more detailed documentation to support the medical condition. Under currently utilized RUGs, there are approximately 20 items on the MDS which impact reimbursement. Under PDPM, there will be approximately 160 items which impact reimbursement. MDS Implications - Patients over Paperwork PDPM emphasizes patients over paperwork, as it eliminates the current (MDS) schedule. MDS assessments will be more streamlined under the PDPM model. Only two required assessments: the five-day assessment and the discharge assessment. The five-day assessment must be completed between: Days one and eight and will be effective for the entire length of stay unless an optional assessment is performed. Each facility may need to revise the systems currently in place to make sure that the information critical to reimbursement is recorded accurately on the five-day assessment. Missing an item on the five-day MDS will impact reimbursement for the entire resident stay. Note: Current 14-day, 30-day, 60-day and 90-day assessments will be discontinued. Discharge assessments will not impact reimbursement―however; this is where therapy notes will be reported. If a resident leaves the facility and is away from the facility for less than three days, then the stay is considered the same admission. If the resident is away for more than three days, the admission is considered a new admission, and the Non-Therapy Ancillaries (NTAs) and therapy payments are returned to day one payment. HINT: NTA’s are a long list of diagnostic categories and clinical support services needed to care for those patients that may be more medically complex or demonstrate a higher acuity. NTA’s are calculated, upon admission, by assessing a patient’s clinical profile. Facilities will have the option to perform an Interim Payment Assessment (IPA) should the resident’s clinical characteristics change. This assessment must be completed within 14 days of the change in characteristics and can affect reimbursement. This assessment is similar to a significant change and will only be used as such. Under PDPM, cognitive testing will become more important. Specifically, the Brief Instrument for Mental Status, or (BIMs) which is completed in order to satisfy Section C: Cognitive Patterns on the Minimum Data Set (MDS) to effectively guide care planning for residents with confusion or a cognitive impairment. Knowing whether a resident has a mild-to-severe cognitive impairment will truly impact: Care planning and the interdisciplinary team’s approach, and SNF revenue – by increasing the Case Mix Index related to the SLP component under PDPM. NOTE: A cognitive impairment requires more resources; thus it will pay more in the new system. The MDS has been an important tool in driving resident care over that last 30 years, and continues to be relied upon for quality data but it has primarily been utilized as an assessment tool to drive the plan of care with little impact to reimbursement. However, with the implementation of PDPM and the shift from therapy-driven reimbursement to clinical characteristics as the basis for reimbursement; the MDS will become vital data to obtaining proper reimbursement. The Activity Department The elimination of 14-day, 30-day, 60-day and 90-day assessments will alleviate some documentation stress and allow all interdisciplinary departments to spend more quality time in resident interactions. However, with this change, the Activity Department will need to spend more time on the daily documentation process. The daily progress notes need to more clearly detail how the resident pursues activity interests and their level of engagement. Surveyors will be looking for more details in this new process, especially with one-to-one documentation. The new PDPM revised reporting is said to fit into a broader push by CMS toward “patient-centered” reimbursement models that more accurately measures and matches payment rates to the residents’ needs. Remember, it is critical for services to be driven by patient need, not administrative or payer mandates. The Nursing Department Under the soon-to-be retired Resource Utilization Group (RUG) system, therapists often dictated a resident’s overall care plan, as their services formed the backbone of Medicare reimbursements. But with therapy no longer driving the reimbursement narrative, nurses will once again return to clinical characteristics of the resident’s individual needs. Nurses may also become individual facilities’ point people for handling the new reimbursement paperwork burdens. Accurately recording residents’ diagnoses and specific medical issues will be vital to receiving the proper compensation for the services — and while experts are split over the exact coding expertise needed to get the job done — front-line nurses and Minimum Data Set (MDS) coordinators will need to be perfect when performing initial assessments. Summary In short, therapy hours will no longer drive reimbursements. Providers will receive Medicare payments based on their patients’ care needs, bringing the focus back on individual residents and away from meeting volume benchmarks. The same story is playing out across the industry to realign incentives around patient characteristics rather than running up the tab on the volume and intensity of services. Resources: https://skillednursingnews.com/2019/03/pdpm-101-what-skilled-nursing-providers-need-to-know-now/ https://avalere.com/insights/strategic-imperatives-for-skilled-nursing-facilities-preparing-for-new-payment-system https://www.ahcancal.org/facility_operations/medicare/Pages/PDPM-Resource-Center.aspx https://electronichealthreporter.com/what-is-the-patient-driven-payment-model-how-skilled-nursing-providers-can-get-ahead-of-pdpm/ https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/MLN_CalL_PDPM_Presentation_508.pdf https://www.berrydunn.com/blog/is-your-revenue-cycle-team-ready-for-medicares-patient-driven-payment-model-pdpm https://www.berrydunn.com/blog/new-patient-driven-payment-model-from-cmswhat-to-expect-and-what-to-do Have a topic request or question for Celeste? ---------------------------------------------------- ENROLL Now --------------------------------------------- Activity Directors Network was founded in 1996 on the idea that we could help create elderly care that dramatically improved the lives of those we all serve. We envision facilities that feel like homes and that celebrate our resident’s individuality and allows them to live with dignity, purpose and joy. We believe the exchange of education and wisdom between the most talented teachers and passionate students is the way to make an impact. Each and every single one of you are the revolution that is changing everything. Thanks for being a part of The Network. --------------------------------------------------------------
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