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Care Plan Conferences Play an Important Role in Risk Management

Care plan conferences are not only a time to discuss the current plan of care for a resident, but also a time to disclose other pertinent information that is needed to make informed decisions regarding a resident's care needs. The facility should encourage the resident, family representatives and/or surrogates to participate in these conferences routinely. Care plan conferences typically last between two to three hours, depending upon the acuity of the resident. The more informed of the care and services being offered, the more educated the resident, family representatives and/or surrogate will be.

If the family representative and/or surrogate are unable to attend the care plan meeting in person, determine if a conference call with the team is possible. Should they decline the conference call, the care plan team should provide the family with a written summary of the information discussed via mail or email. With families that may be more challenging, the care plan team may choose to mail the care plan summary as certified mail, so there is documentation that the resident representative received the summary.

During the conference, it is very important to discuss the resident's medical diagnoses, what his or her current symptoms are, as well as potential or actual negative expected outcomes. The Internet has several family-oriented disease education pamphlets available to download. The care plan coordinator should print two of these – one for the resident, family representative and/or surrogate and one to put in the care plan section of the resident's chart. Though the resident, family representative and/or surrogate may feel informed about the disease, providing written information and discussing the disease process with them shows them the critical thinking and expertise used in developing the resident's individualized care plan.

Providing information and education also should be done when the resident is non-compliant or chooses not to follow the recommendations or physician's orders for the disease process. By educating the resident, family representatives and/or surrogates of the potential negative outcomes related to non-compliance, and the alternatives that have been offered to the resident, the facility has met the regulatory intent of educating the family on the potential negative outcomes. As non-compliant issues arise, the care plan team may need to have another care plan conference with the resident, resident representative and/or surrogate. Care plan conferences must be held quarterly, per federal guidelines; however, they can be held more often as the facility and care plan team deem necessary.

The care plan conference is not only a time for the care plan team to talk about the resident's disease processes and the services being provided, but it also is a time to ensure the team is gathering information from the resident, family representative and/or surrogate. The resident, family representative and/or surrogate may come with other issues or concerns they would like to have addressed. The care plan team should be prepared to address potential issues, concerns or questions such as:

  • What a care plan conference is, how often is it held and what will be discussed at each conference.

  • Who the resident, resident representative and/or surrogate should contact if they have a specific question they need answered before the next care plan conference.

  • Has there been any change in the health or behavioral status of the resident since admission or last conference? If so, explain why in simple terms.

  • Have there been any adverse events or occurrences that have taken place (falls, pressure ulcer or behavioral outbursts)? What was the root cause?

    • Disclose if these events can be prevented, reduced or if they will continue to occur due to the resident's disease process and cognitive status.

  • Has the resident been seen by any physicians? If so, what was the outcome from the visit?

  • Has the resident had issues with their vision or teeth?

  • Have there been any recent labs drawn? If so, what were the results?

  • Have there been any medication changes since admission or the date of the last conference?

  • What is the status of any special therapies that are or have been provided?

  • How is the resident eating, including percentage of meal intake? Have they lost or gained weight?

  • How are the resident, family representative and/or surrogate adjusting to the nursing home placement?

  • How often does the resident participate in activities or social events?

  • Any changes in the resident's living will or DNR status?

  • Are there any items the resident may need or want with them (special photos, reading materials, electric razors, clothing or foot wear)?

  • Are there any changes in facility administration, nursing administration or other department leadership? What is their new contact information?

  • Are there any changes in the resident representative and/or surrogate contact information? Do they have a preference for being contacted? Is there a time of day they do not desire to be contacted? If so, what time do they prefer?

By using the care plan conferences to disclose the resident's high risk concerns, the facility is completing an essential step in its risk management program.

Sources:

  1. Centers for Medicare and Medicaid: RAI MDS 3.0 Manual, Chapter 4 & Appendix C

  2. Center for Medicare & Medicaid: Appendix PP – Guidance to Surveyors for Long Term Care-Facilities: F279 Comprehensive Care Plans.

  3. www.Medicare.gov: "What's a care plan in a nursing home?"

  4. www.consumervoice.org: The National Consumer Voice for Quality Long-Term Care: "Assessment and Care Planning: The Key to Quality Care."

 

 
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