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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 email@example.com 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
Greetings! I am looking for insight on how to develop meaningful goals for resident Care plans. I am having difficulty striking a balance between having a valuable long term goal, and having a measurable goal. A generic measurable goal such as: "A resident will participate in ____ activities ____ times per week through the review date" is easy to measure, but really feels more like an intervention than a goal. And picking a number of times to participate in a particular activity feels arbitrary to me. Out of all the ways of spending time, why is this one more valuable than others? The more honest-feeling goals of "so and so will experience satisfaction with daily activity involvement" are difficult to document and measure. One formula I have seen which might strike a happy middle ground is "so and so will demonstrate (quality of life, satisfaction, engagement, etc.) by participating in _______ activities _____ times per week through the review date." However, it still doesn't seem quite true to real life. Any suggestions on improving resident goals for care plans? Thanks! -D