A warm welcome to the

1
A warm welcome to the

• Exceptional Care Plan MeetingTrain-the-Trainer
  Session
• 9/23/08
• presented by
• The Foundation for Long Term Care
• and supported with grant funds from
• The New York State Health Care Foundation

2
Thanks to Teresian House

• For hosting us at this beautiful facility!

3
Introductions

• Your presenters are
• Carol Hegeman, Project Director
• Debi Buzanowski, Project Manager
• Sandra Biggi, Senior Consultant
• Jennifer Pettis, Trainer/Consultant
• Barbara Bates, Senior Training Consultant
• Dr. Diane Dewar, Evaluator
• Your regional trainers are
• Barbara Bates (west of Albany)
• Barbara Falkenberg (Albany area)
• Carol Wilson (New York City area)

4
Participants are staff from

• Amsterdam Memorial- Wilkinson Center
• Coler-Goldwater
• Eddy-Ford
• Fred Harriett Taylor Health Care Center
• Isabella Geriatric
• Maplewood Manor
• Menorah Home and Hospital
• Morningside Home
• Otsego Manor
• Our Lady of Mercy Life Center
• Robinson Terrace
• The Silvercrest Center
• Teresian House
• Unity Living Center
• Lets introduce ourselves by
• pairing off!

5
What is in your training packet

• Presentation Handouts
• Grant Summary
• Letter from the Department of Health
• Example Standards of Care
• Sample Policy and Procedures
• Evaluation Forms
• Time Allocation Form
• Facility Protocol Form
• Facility Events Form
• Staff Satisfaction Measure
• Reimbursement Form

6
Morning AgendaPlenary Session

• History of the project/ Care Planning Myths/ DOH
  relationships/
• Working with the DOH Surveyors (Sandy Biggi)
• DOH perspective (Jackie Pappalardi)
• Grant Design and Outcomes (Carol Hegeman)
• Grant Requirements/Work plan/Timeline
• (Debi Buzanowski)
• Evaluation Design and Nursing Home Requirements
• for the Evaluation (Dr. Diane Dewar)
• Working Lunch

7
Afternoon Agendaconcurrent workshops and
combined closing session

• Administrators Session Facility obligations,
  more details on evaluation, how to support and
  monitor the project, overview of planning,
  suggestions for a successful implementation and,
  if time permits, samples of the training content.
  (Carol Hegeman and Debi Buzanowski)
• For Trainers sample SOCs, how to revise them and
  teach the new process, small group work in
  adapting SOCs provided to the needs of each
  facility. (Barbara Bates, Barb Falkenberg and
  Carol Wilson)
• 230 PM Break
• 245 PM- 330 PM Closing Session (Trainers and
  Administrators)
• Summary of each workshop (Carol and Barb) 5
  minutes each
• Explanation of follow-up webinars (Barb and
  Debi)
• How to handle resistant staff and increase
  project buy-in (taken from existing FLTC
  training materials) (Carol and Debi, 20 minutes)
• 330 PM Adjournment

8
Project Rationale and Review

• Existing care plan processes in nursing homes
  are inefficient, lengthy and repetitive.
• It is the worst kind of inefficiency possible,
  being both wasteful and a deterrent to quality
  care.
• The goal of this project is to replace this
  existing wasteful care planning process with an
  efficient and cost-saving one.

9
Exceptional Care Planning

• Sandy Biggi
• Director of Nursing Facility Policy

10
Background to Exceptional Care Planning (ECP)

• History
• Wisconsin
• New York
• NYAHSA- Care Plan Renewal (CPR)
• Systems approach to ECP
• Understanding the protocol for implementation
• Care plan myths

11
History of ECP

• Wisconsin
• What is it?
• A guideline for efficient and effective clinical
  record documentation and care planning
• Who developed this initiative?
• Providers and provider associations in
  collaboration with The Bureau of Quality
  Assurance and The Wisconsin Board on Aging and
  Long Term Care    

12
History of ECP

• Why was it developed?
• Out of concern that clinical records in nursing
  facilities were crowded with unnecessary and
  duplicative documentation.
• Care plans were identified as a focus of these
  efforts.

13
History of ECP

• The Process
• Establish standards of care in your facility (RAP
  based, Nursing diagnosis based, and Sign/Symptom
  based) these are what you do for all residents
  related to a specific concern these are
  supported by facility policies and procedures
• Teach established standards frequently
• Care Plan interventions are variations to the
  standard
• Use clear concise documentation

14
History of ECP

• The Outcome
• Resident Centered Care Plans
• AAHSA based quality of life standards
• Embodied genuine beliefs in quality care among
  all facility staff
• Focused on resident individuality (e.g., routine,
  relationships, preferences, strengths, home like
  environment, dignity, power of human touch, and
  FUN)

15
History of ECP

• Documentation that serves a useful purpose
• Eliminates duplicate documentation
• Utilizes current research and resources
• Focus on quality (not quantity) of content
• Documentation to support clinical care (not
  perceived surveyor needs)
• Use of MDS language and definitions, improving
  consistency in the medical record

16
History of ECP

• New York/NYAHSA
• National Conference-2001
• State Associations meeting-2001
• New York state DOH-2001
• NYAHSA DNS conference Nov. 2001
• NYAHSA pilot-2002
• NYAHSA pilot at DNS conference Nov. 2002
• NYAHSA pilot at Spring Institute May 2003
• NYAHSA study-2003 to present
• NYSHF grant- 5/1/08 - 4/30/10

17
Care Plan Myths

• We must use a specific care plan format.
• No specific care plan format or structure is
  mandated
• Format should be efficient and user-friendly

18
Care Plan Myths

• Everything triggered on the MDS needs to be on
  the care plan.
• Staff may decide that a triggered condition does
  not affect the residents functioning or
  well-being and therefore should not be addressed
  on the care plan. The RAP documentation will
  support the decision-making.
• Conversely, staff may decide that items not
  triggered do affect the residents functioning or
  well-being and therefore should be addressed on
  the care plan

19
Care Plan Myths

• Every problem on the care plan requires
  resolution.
• Resident problems cannot always be solved
• Consider overall focus for the resident
  IMPROVEMENT PREVENTION MAINTENANCE
  PALLIATION
• Some residents may have more than one, but a
  primary focus makes the care plan more precise
  and streamlined

20
Care Plan Myths

• All goals need to be reached in three months.
• Time frames will vary
• Range from few days to weeks to months to ongoing
• The more and specific and measurable to goal, the
  more likely success is
• Be realistic!

21
Care Plan Myths

• Every detail of care given to the resident must
  be written on the care plan.
• Standards of practice are acceptable
• Standard interventions (routine care approaches)
  on the care plan create unnecessary length and
  defeat the purpose of an individualized care plan

22
Care Plan Myths

• Medications must be included as care plan
  problems.
• Medication use is an intervention, not a care
  plan problem
• There should be standards of care for medication
  administration and monitoring
• The Medication Administration Record (MAR) can be
  considered part of the care plan
• (continued on next slide)

23
Care Plan Myths

• Consideration may need to be given to recent
  changes in medication, use of multiple
  medications with potential interactions, or
  medications that put the resident at risk for a
  functional decline
• Medications as prescribed should be in the
  Standard of Care, not written on the care plan

24
Care Plan Myths

• All potential problems must be on the care plan.
• There is no requirement for all potential
  problems to be addressed on the care plan
• Ask yourself, If we do nothing additional, and
  the resident continues on their current path, is
  there likely to be a problem?

25
Care Plan Myths

• All documentation that supports the care plan
  must be in one location.
• The care plan details can consist of multiple
  documents in several different locations or
  formats that is workable for all staff who need
  to use the care plan
• The outcome of care is the most important factor,
  not the format
• Explain the care plan format to all users,
  including surveyors

26
Care Plan Myths

• Therapy notes must be on the care plan.
• There is no need for duplication of therapy
  information
• Therapy plans of care can and should be
  considered part of the care plan

27
DOH Approval

• The DOH has agreed to this project. There is a
  hard copy of the letter in your handouts and a
  truncated version in your next slide. You will
  hear a DOH representative shortly.
• Please note the requirement that you notify your
  regional surveyor when you start implementing the
  project.

28
Letter from the NYS DOH to the NYSHF
29
Lets welcome Jackie PappalardiDirectorDivision
of Residential ServicesOffice of Long Term Care

30
Overview of Grant Design Part 1

• The trained staff train staff on two or four
  intervention units only (depending on your size)
  to use the new care planning process. Important
  Assure that the other units are not trained in
  or using the intervention until the program has
  been running at least six-nine months.
• Intervention going in all intervention units
• After a six-nine month period. the trained staff
  conducts training for the remaining units. (These
  units are the wait-control units.) The research
  design involves comparing differences between the
  units that have been trained and the units that
  have not been trained.

31
Overview of Grant Design Part 2

• An FLTC trainer will conduct three or more site
  visits to all 14 nursing homes to monitor
  problems, assist implementation and assess
  success of implementation to date. These trainers
  are resources to you. Use them!
• FLTC staff will conduct qualitative case studies
  at each nursing home and summarizes individual
  and aggregate findings.

32
Grant Requirements Overview

• Send an administrative team member and a team of
  at least three staff to the September 23rd.
• Implement the care planning program according to
  the concepts taught in the training as close to
  the original design as possible.
• Notify your regional DOH office and their DOH
  surveyors that they are participating in the care
  planning program.
• Participate fully in data collection
  requirements- this may include MDS data
  information, staff retention numbers and staff
  satisfaction surveys.
• Allow a project trainer and/or FLTC staff member
  to visit your facility at mutually agreeable
  times three or four times during the life of the
  project to assist with project implementation and
  to assess progress.
• Prepare progress reports to the FLTC
• Prepare financial reports and documentation to
  the FLTC in a timely manner.
• There will be additional information on this in
  the administrators section

33
Grant Timeline

• 9/08-Trainer Training- Todays Session!
• 9/08-10/08- Base line data collection
• 10/08-12/09- Facility Trainers train staff on
  intervention units
• 11/08-10/09- FLTC Trainer conducts site visits
• 11/08-2/10- FLTC Trainer conducts 4 webinars
• 1/09-1/10- FLTC Project Director conducts case
  studies
• 4/09- Data collected and summarized
• 6/09- Trainer Training
• 6/09- 12/09- Facility Trainers train staff on
  wait comparison units
• 12/09- Data collected and summarized

34
Evaluation Module

• Diane M. Dewar, PhD
• University at Albany

35
Evaluation Goals

• Goal to determine the impact on the investment
  per dollar spent on the intervention vs. the
  standard care plan protocols
• Hypothesis the intervention yields more
  improvements per dollar spent on training and
  education of nursing staff
• Objectives how does the investment in either
  regime
• Improve quality of care
• Increase staff efficiency in caring for residents
• Reduce medical costs
• Improved staff retention

36
Methods

• Compare costs and outcomes in the intervention
  vs. wait comparison nursing home units on key
  outcome variables
• Overhead costs sunk cost since the value is the
  same across units
• Costs for wait comparison nursing home units
• Time value of basic staff training
• The value of staff time in documentation vs.
  resident care
• Costs for intervention
• Train the trainer costs
• Time value of basic staff training
• The value of staff time in documentation vs.
  resident care

37
Types of Evaluation

• Hypothesis 1 the intervention will yield less
  time for documentation and more time for resident
  care, implying greater efficiency in caregiving
• Data elements compare costs of intervention and
  standard units with total societal savings per
  unit of the intervention.
• Data needs staff time for administration vs.
  resident care costs associated with
  documentation vs. resident care costs associated
  with instituting the intervention vs. standard
  protocols
• Decision rule the intervention is more efficient
  than standard protocols as more value is placed
  in resident care vs. administrative services

38
Types of Evaluation, continued.

• Hypothesis 2 the intervention will yield a
  greater percent prevented in health outcomes
  (i.e., pressure sores and falls), implying
  greater efficiency in caregiving and improved
  quality of care
• Data elements MDS data on pressure sores and
  falls, EQUIP generated likelihood of incidence of
  adverse outcomes
• Data needs percent of falls and pressure sores
  in each unit costs associated with documentation
  vs. resident care costs of instituting the
  intervention vs. standard protocols
• Decision rule the intervention will be more
  efficient if it has the lower percentage of
  adverse outcomes per dollar invested in the
  intervention relative to the standard protocol

39
Types of Evaluation, continued.

• Hypothesis 3 the intervention will yield lower
  rates of hospitalization and associated
  post-hospital costs , implying greater efficiency
  in caregiving and improved efficiency in care
  delivered
• Data elements MDS data on hospital admissions,
  and discharges
• Data needs costs associated with hospital
  discharges in each unit costs associated with
  documentation vs. resident care costs of
  instituting the intervention vs. standard
  protocols
• Decision rule the intervention will be more
  efficient if it has the lower incidence of
  hospital admissions, and lower costs per
  discharge per dollar invested in the intervention
  relative to the standard protocol

40
Types of Evaluation, continued.

• Hypothesis 4 the intervention will yield higher
  rates of staff retentionimplying a greater level
  of staff satisfaction due to less documentation
  requirements, as well as greater efficiency in
  the intervention in achieving staff retention
  targets
• Data elements retention rates pre and
  post-intervention from the HR staff
• Data needs retention rates in each unit pre-and
  post-intervention costs associated with
  documentation vs. resident care costs of
  instituting the intervention vs. standard
  protocols
• Decision rule the intervention will be more
  efficient if it has the higher retention rate
  relative to the standard protocol

41
Timeframe of Study

• Pre- and post-design
• Pre-intervention period yields baseline data
• Post-intervention period will yield an initial
  increase in utilization of services and decrease
  of adverse events due to increased focus on
  caregiving
• Final period of evaluation will yield more robust
  measures of efficiency and effectiveness due to
  the reduction of the Hawthorne effect on staff

42
Final Analysis

• Success will be determined by the rate of
  implementation across the state by other
  facilities
• If 70 of respondents are willing to try the
  intervention, then the argument for dissemination
  of the intervention will be validated.

43
The Evaluation

• The evaluation is intended to answer these
  questions
• Does the project
• improve quality of care for resident?
• 2. increase staff efficiency in caring for
  residents?
• 3. reduce medical costs.
• 4. improve staff retention.

44
Evaluation tools to be used

• Cost-effectiveness analysis (CEA) will be used to
  test the increased efficiency of the LTC staff,
  the improved quality of care, the decreased rates
  of hospitalization, and the increased staff
  retention over the life of the intervention
  period.
• Cost benefit analysis (CBA) is a systematic
  enumeration of all dollar benefits and costs.
  The decision rule is to select the alternative
  (the intervention or the existing care plan
  process) that produces the greatest net benefit

45
More evaluation overview

• Oral presentation by Dr. Diane Dewar

46
End of morning session

• Would you please pick up your lunch and then
  move to your break-out group?

47
Concluding Joint Session

• Workshop Summary
• Webinars
• Project Management Tools

48
Workshop Summary

• Three main ideas from
• -the train-the-trainer session
• -the administrator session

49
Webinars

• Why? Because good adult education calls for
  reinforcement and refinement of educational
  content. On-line education is the most efficient
  way to do this. Will also help address any
  knowledge gap caused by turnover.
• When? Mutually agreeable times decided among all
  three trainers and all nursing homes. Next one
  anticipated in December-January.
• There will be a total of four.
• How to make them meaningful? Send Barb Bates
• your suggestions for
  content at any time.
• FYI Slides from todays content will be posted
  to the FLTC website
• shortly. We will send you an email letting
  you know when,

50
Managing people challenges

• 1) Conflict management skill reviewed in the
  administrator session..
• acknowledgement the complaint and
• recognize what the person is feeling.
• 2) Increasing project buy-in.
• make the idea their own!
• how do you think this could work?
• and

51

• Be excited and confident!
• Confidence is catchy!

52
The EndThanks for coming!