Resident Assessment

Each resident is assessed on admission by the physician, nurse, social services director, activity director, and other disciplines as appropriate. This team of professionals uses a collaborative approach to planning the care of the resident or patient.

Persons usually enter a nursing facility with functional status problems caused by physical deterioration, cognitive decline, the onset or exacerbation of an acute illness, or other related factors. All necessary resources and disciplines must be used to ensure residents achieve the highest level of functioning possible (quality of care) and maintain their sense of individuality (quality of life). A Resident Assessment Instrument (RAI) provides a structured, standardized approach for applying a problem identification process in long-term care facilities.

The RAI helps facility staff to gather definitive information on a resident's strengths and needs, which must be addressed in an individualized care plan. It also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the facility to track changes in the resident's status. The implementation steps include:

• Assessment
• Decision-making
• Care Planning
• Implementation
• Evaluation

As the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident's unique path toward achieving or maintaining the highest practicable level of well-being.

Assessment 

Assessment includes taking stock of all observations and information about the resident. This is accomplished by utilizing the Minimum Data Set (MDS). The MDS is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of the comprehensive assessment for all residents of long-term care facilities certified to participate in Medicare or Medicaid. The items in the MDS standardize communication about resident problems and conditions within facilities and to outside agencies. The MDS is also used for the Medicare and Medicaid reimbursement system and to monitor the quality of care provided to nursing facility residents. The MDS contains items that reflect the acuity level of the resident, including diagnoses, treatments, and an evaluation of the resident’s functional status. The MDS is used as a data collection tool to classify residents in Resource Utilization Groups (RUG) and is used in the prospective payment system (PPS) for nursing facilities. The MDS data is also used to monitor quality of care by monitoring a set of 24 quality indicators that were developed by researchers to assist the state in identifying potential care problems in a nursing facility. The MDS assessment is required by day five after admission and a full admission assessment is required by day 14. Medicare then requires assessment at 30, 60, and 90 days. The MDS must be transmitted to the state by these required intervals.

Decision Making  

The next step of decision making involves the use of the Resident Assessment Protocols (RAPs). RAPs are structured, problem-oriented frameworks for organizing MDS information and examining additional, clinically relevant information about an individual. RAPs help identify social, medical, and psychological problems and form the basis for individualized care planning. There are 18 RAPs and four components in the RAPs protocol. Triggers are specific resident responses for a MDS element, identifying residents who have or are at risk for developing problems and requiring further evaluation. The trigger legend is a form that summarized all of the triggers for the 18 RAPs and is a worksheet that is used by the interdisciplinary team members to determine which RAPs are triggers. The RAPs analysis is performed by the staff to draw a conclusion about whether to proceed or not to the plan of care. The RAPs summary sheet documents the decisions made during the evaluation process.

Care Planning

Care planning establishes a course of action that moves a resident toward a specific goal utilizing individual resident strengths and interdisciplinary expertise. The plan of care is used as a template to deliver care to a resident. Developing the plan of care also involves the interdisciplinary team. This team consists of the physician, the nurse, the MDS coordinator, the social worker, activities, the chaplain, nutrition services (dietician), and other team members as needed. The plan of care is updated as required care changes and at predetermined intervals as defined by CMS. A plan of care is required upon admission to the facility and this is completed using physician orders and nursing assessment. The full plan of care formed by the MDS and RAPs process is due by day 21 of admission. The plan of care must be updated as the condition of the resident changes and as noted above at required assessment periods.

Implementation & Evaluation

The next two steps, care plan implementation and evaluation, refer to the use of the plan of care and its continuing re-assessment and evolution. The interdisciplinary team is charged to continually assess and change the plan of care as needed. Care plan meetings are held for each resident at the end of required assessment periods and include the interdisciplinary team, physician, resident and family members.  A discussion of progress, issues, and resident needs are covered. These meetings aid in the evaluation of the progress of the plan of care while highlighting needed changes to the  plan of care as necessary for continued progress.