News, Skilled Nursing Facility

Understanding the evolution of care planning sets the stage for improvement

Editor’s note: This post is an excerpt taken from HCPro’s popular title, MDS Care Plans: A Person-Centered Interdisciplinary Approach to Care by Debbie Ohl, RN, M.Msc, PhD.

Looking back in time can help us understand the significance of care planning. Federal involvement in nursing homes began with the passage of the Social Security Act in 1935. At the time, there were only public poor houses, which were dire at best; the majority of people in these poor houses were aged. The legislators did not want these places used to care for the elderly.

The Social Security Act established a public assistance program for the elderly, which proliferated the growth of voluntary and proprietary nursing homes. Consequently, in 1950, the Social Security Administration required states participating in the program to establish licensing programs, although the requirement did not specify what the standards or enforcement should be; consequently, little changed.

Bureaucracy moves slowly and is fraught with roadblocks for change. In 1956, a study of nursing homes called attention to problems with the quality of care. Most facilities were found to be substandard; staff members were poorly trained or untrained, and few services were provided. In 1965, the Medicare and Medicaid federally funded programs for nursing homes were significantly expanded; standards were uniformly put in place for nursing homes participating in the federal program. Few nursing homes were capable of meeting the health or safety standards or providing the level of service expected under the program.

In 1970 and 1971, nursing home problems came to the forefront with front-page news stories, such as a fire killing more than 30 residents in Ohio, food poisoning in a Maryland home killing 36 residents, and numerous horror stories about care atrocities. As a result, in 1972, Congress passed a comprehensive welfare reform bill that funded state survey and certification activities in an effort to establish and enforce uniform standards and conditions for operating nursing facilities. The federal law required a single set of standards to be developed. The emphasis was on the institutional framework rather than on the resident’s care. Later in the 1970s and early 1980s, the Patient Care and Services Survey was created to rectify this problem. However, there was controversy over the legitimacy of this process, which had shifted the emphasis to the actual provision of care delivery using existing regulations. Very simply stated, having a policy was no longer enough, it had to be implemented, reviewed, and revised to get results; paper compliance in the form of policy and procedure was nearing its end.

The use of paper for care plans was the new gauge for ensuring resident care, although it would take another 20-plus years to achieve its intent. The move from paper to person in determining compliance has been a long road of transitions and lessons learned.

During the first phase of the care planning evolution, regulators demanded that each resident have a care plan that was multidisciplinary in nature. In other words, each discipline was required to have its own care plan. An unintended consequence of this approach was that each discipline became fearful of being cited if something was missing on its plans. Consequently, plans often contradicted one another and certainly missed the mark of being resident oriented (but the contradictions and omissions fueled survey deficiencies). This was particularly the case between nursing and dietary. The social services and activities departments generally looked at the nursing care plans and picked out some aspect to use on their plans. It took nearly a decade to move into the interdisciplinary care planning model. As with many changes in nursing homes, the transition to a unified care planning team began with the name change. We just started saying the care plan was interdisciplinary, but for the most part, things remained business as usual with care plans.

Intermixed during this period were other expectations (all designed to get us to pay attention and focus). Each diagnosis required a care plan, whether it was primary or secondary to the presenting problems or had no impact on current status. Surveyors told facilities that every medication was supposed to have a care plan (their interpretation). Once the industry got the hang of writing something on paper and calling it a care plan, regulators shifted the emphasis to phase two, which involved getting the writers to create measurable goals. It didn’t matter that the goals did not measure anything meaningful in terms of functional status; they were measuring something (e.g., resident will be able to walk four feet, unassisted). The resident may have been able to walk four feet, but what did this actually mean for the resident? In retrospect, it was a way of teaching us the basics: What are you trying to accomplish and how will you know if you do?

Historically, care plans were rarely if ever used as a working tool for resident care. There were major growing pains, a lot of misinformation, and misguided understanding of what should and should not be care planned that resulted from rumors (the he-said/she-said phenomena). Confusion reigned, and care plans were a burden facilities dealt with. The plans were used as a tool for surveyors more than for resident care. Our care plans were driven by what we thought surveyors wanted to see. The process was mechanically driven; nonetheless, certain expectations were in place, and care delivery and its quality improved.

It took the Omnibus Budget Reconciliation Act of 1987 (OBRA) requirements to solidify the survey standards and process and to provide a framework for continuous improvement. The Minimum Data Set (MDS) 2.0 process was a big help in the unification of the care team and including the resident as the primary player in the process and not just on paper. Formalizing the assessment process, expecting more in terms of care planning and care delivery, and outcome measurements, such as the quality measures, are now essential tools to meet regulator, consumer, and professional expectations. In retrospect, job one was to improve the quality of care, which has absolutely occurred. Job two is improving the residents’ quality of life by treating them as unique individuals with a lifetime of history. This transition started in 2000.

The MDS 3.0 has expanded the assessment process. The MDS and their sister the Care Area Assessments have created a more focused and in depth tool to structure resident focused, quality of life oriented care plans. Computer companies have responded with lengthy computerized plans that are pages and pages of data triggered from completed RAI’s. While it may help surveys confirm information from the assessment, these plans are not effectively utilized by day to day caregivers for resident care. These plans are simply too lengthy to be a functional tool. We are finding ourselves at the next crossroad: Meeting regulatory care planning requirements while having a functional plan that captures the essence of the person for day to day use.