Think about individualization like the almost endless variations of coffee drinks available these days. With an extra pump of this or a drizzle of that, we enjoy endless ways to individualize our order. Beyond coffee, we all have our own routines and ways to complete different tasks, from what we eat, the order in which we eat it, and how and when we drink a beverage during the meal.
Despite acknowledging the various ways we go about accomplishing our daily routines, many facility teams still struggle to develop a truly person-centered individualized care plan. This article offers step-by-step instructions to help create care plans as individualized as an iced white chocolate mocha with caramel drizzle and vanilla sweet cream cold foam.
Step 1: Assess for clinical problems, conditions, and risks
The resident may be unable to articulate to staff his or her needs or understand the concept of a care plan. That’s one reason the comprehensive care plan is developed after the MDS assessment and the care area assessments. The process identifies key areas that may be problems or an increased risk for the resident and guides the team through an evidence-based analysis of the different care areas.
For example, a resident may trigger for the nutritional care area because he is on a therapeutic diet and has a diagnosis of diabetes mellitus. This by itself starts the process of the individualized care plan: a problem specific to the resident has been identified.
But the care plan cannot be developed entirely from the MDS assessment alone, which is only a starting point. Additional areas require care plans to address the needs of residents. Think of the 20 care areas as “menu specials,” items that are commonly ordered, but there is still a full menu of other choices to select. Once the 20 care areas are reviewed and analyzed, the team must consider all aspects of the resident to identify any other needs that should be addressed in the care plan.
Consider a resident who wants to smoke throughout the day. A comprehensive care plan would address the risks of this choice, even though it was not identified during the care area assessment process. Using a tool like the AAPACN New Admission Sample Questionnaire tool can help identify items that may not have been revealed during the RAI process.
Step 2: Involve the resident and representative (if indicated)
The participation of the resident and/or his or her representative is essential to develop an individualized care plan and it’s also a federal requirement. F-Tag 656 details the obligations under §483.21(b) Comprehensive Care Plans, stating,
In consultation with the resident and the resident’s representative(s)—
(A) The resident’s goals for admission and desired outcomes.
(B) The resident’s preference and potential for future discharge. Facilities must document whether the resident’s desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose.
(C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.
As the guidance details, the resident or representative must be involved in establishing the care planned goals, the next step in developing an individualized care plan.
Step 3: Identify the resident’s goal for each care planned problem, condition, or risk
To develop an individualized care plan, the resident’s own goals for the concern, problem, or area of risk must be understood. One way to identify if your team has individualized goals is to review all residents’ goals for a similar problem. If the goals nearly match, it strongly suggests the plan is not individualized. Consider a care plan library that has a generic goal for a resident with diabetes to maintain blood glucose levels within the target range to prevent both short-term complications (such as hypoglycemia and hyperglycemia) and long-term complications (such as neuropathy, retinopathy, and cardiovascular disease).
Although this generic goal likely aligns with the clinical team’s objective for managing the condition and also with the resident’s overarching goals to manage diabetes, it is key to learn if the resident has a more specific goal. For example, one resident wants to manage her diabetes with diet to reduce and eventually eliminate the need for daily insulin. Another resident wants to balance blood sugar enough to enjoy a daily serving of ice cream. The team may need to work with the resident to align the clinical goals for safely managing a condition with the resident’s preferences.
Step 4: Understand the resident’s personal preferences and cultural values
Step 4 requires the facility team to talk with the resident and/or representative to understand preferences and any cultural values that need to be respected. This may involve learning about the resident’s former lifestyle, routines, and beliefs, and identifying important traditions. The resident’s personal preferences can be as straightforward as dietary choices, preferred activities, and daily routines. But it could also include essential wishes to ensure quality of life, such as a bathroom routine, time of day for a shower, or a choice about getting up early or sleeping in.
Cultural values may be reflected in a resident’s ethnic and religious background. The entire team needs to be involved because these values may dictate dietary restrictions based on religious beliefs or other customs that involve all staff at the facility. These values need to be incorporated into activities, routines, and care planned as appropriate.
Step 5: Develop resident-specific interventions
The care plan is further individualized by developing interventions specific to the resident and not just applied generically to everyone. For example, residents with diabetes may be at higher risk for developing a diabetic foot ulcer and therefore require periodic foot checks. Although this intervention is appropriate for all residents with diabetes, it can be further individualized based on the resident’s clinical needs, risk factors, and preferences. One resident may have no history of skin problems and well-controlled diabetes, so the podiatrist recommends only monthly foot exams by the nurse. Another resident has a history of diabetic foot ulcers and wears offloading shoes. Due to this resident’s increased risk, the nurses must conduct a weekly foot exam. Moving the focus of the problem to the resident’s needs transforms a generic intervention into an individualized one.
Step 6: Review the care plan regularly with the resident
The care plan must be reviewed with the completion of any MDS assessment but should also be checked and/or updated with any changes in the resident’s care between assessments. The resident should be told about any changes to the care plan. It is also important to use the scheduled care plan reviews to ensure the established goals and interventions continue to align with the resident’s preferences.
Just like our coffee orders, preferences can change. The resident may grow tired of a certain activity or want to start a new hobby. Or because of a change in medication, the resident is more fatigued now and needs to sleep later rather than getting up early. The resident must be given the opportunity to change goals and preferences over time.
Conclusion
Often the barrier to achieving individualized care plans is using generic goals and interventions based on a problem area. This is like ordering a coffee without the barista asking if you would prefer cream, sugar, or other flavors. The facility team must ask residents how they would like care to be provided while in the facility. When the team focuses on the resident and ensures the resident and family are engaged in both goal setting and sharing personal preferences and cultural values, an effective individualized care plan will naturally follow.
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