MDS Care Plans: A Person-Centered, Interdisciplinary Approach to Care, Second Edition

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MDS Care Plans: A Person-Centered, Interdisciplinary Approach to Care, Second Edition

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MDS Care Plans: A Person-Centered, Interdisciplinary Approach to Care, Second Edition

Improve your CAA process and develop a more comprehensive plan of care while improving MDS 3.0 accuracy!

MDS Care Plans: A Person-Centered, Interdisciplinary Approach to Care, Second Edition helps you navigate recent changes to the RAI and includes more than 100 customizable care plan templates, as well as the most up-to-date care area assessment (CAA) worksheets from CMS. With many updated regulations already in effect, this timely book covers Section GG, discharge planning, QAPI, person-centered care, and survey changes, as well as the changes resulting from the ICD-10 transition. 

The CAA worksheets available for download in this manual will help you improve resident outcomes by knowing what to look for in each assessment. Each care plan provides a framework for guiding the review of trigger areas and clarifying a resident’s functional status and related causes of impairments. By developing a template process to complete the CAA and modifying the care plans provided in this resource, you’ll fit the individual needs of your residents while satisfying the requirements of the new assessment process.

This product will help facilities:

  • Save time developing person-centered care plans using more than 100 customizable templates
  • Evaluate and create valuable CAAs and improve MDS 3.0 accuracy
  • Help customers navigate recent changes to the RAI
  • Integrate the voice of the resident, family, and staff in the development of the care plan
  • Make use of proven tools and expert guidance
  • Save time and effort by eliminating documentation redundancy when completing the CAA
  • Implement a strategic plan for the entire IDT that embraces person-centered care

What’s new in the second edition?

  • CMS’ most up-to-date CAA worksheets available for download
  • An expanded section on culture change for CAA process and outcome improvement
  • New care plans addressing discharge planning and Section GG functional abilities
  • Updated instructions for completing a baseline care plan within 48 hours of admission
  • Guidance on new MDS item sets and their implications for care planning according to the latest RAI changes, including Section GG and revisions to Sections O and P

Published: March 2019

Pages: 444
Format: 8.5x11 perfect bound
ISBN: 978-1-68308-909-4

Debbie Ohl, RN, NHA, M.Msc, PhD, is a successful consultant and author of more than 35 years. She is owner and senior consultant at Ohl and Associates, a consulting practice dedicated to promoting quality outcomes and professional excellence in nursing facilities. Ohl is a registered nurse, nursing home administrator, skilled geriatric clinician, nursing home consultant, educator, and author. She is an expert in nursing facility regulatory guidelines and clinical practice, specifically assessment and care planning.

Rosanna L. Benbow, RN, CCM, CIC, DNS-CT, RAC-CT, offers MDS consultation and a variety of other consulting for postacute care clients. Services for interim and PRN MDS nurses are also available through Leading Transitions. Benbow has over 22 years of experience in the long-term care industry, where she began as a certified nursing assistant. She has extensive clinical reimbursement experience in roles such as director of nursing, MDS coordinator, case-mix auditor, clinical IT specialist, and MDS/reimbursement consultant. While focusing on MDS and case management, Benbow has been highly involved in accountable care organization partnerships, policy development, Interact 3.0 implementation, and QAPI program development. Benbow is involved in several committees with AANAC and is a Certified InterACT Champion. She was a presenter at the 2014, 2015, and 2018 AANAC Conferences, where she spoke on managed care. She also does routine presentations for LeadingAge Indiana and Hoosier Owners and Providers for the Elderly.

Section 1: Care Area Assessments: Culture Change for Process and Outcome Improvement

Chapter 1: Transforming Our Mindset

Chapter 2: The Interdisciplinary Team’s Strategic Plan

Chapter 3: Making the CAAs Work

Section 2: MDS Care Plans

Chapter 4: TheEvolution of Care Planning
Chapter 5: Putting the Person in the Care Plan
Chapter 6: MDS Implications for Care Planning
Chapter 7: Correlations: QAPI, Resident Care, and Facility Practices 
Chapter 8: Adverse Events and Temporary Harm 
Chapter 9: Using the Care Plan

Appendix: Care Plan Index (more than 100 modifiable care plans in 21 categories)

1. Active Disease Diagnosis 
2. Activities 
3. Behavior, Mood, Well-Being 
4. Bladder Plans 
5. Bowel Plans 
6. Catheters 
7. Cognition, Dementia 
8. Communication 
9. Dehydration 
10. Dental 
11. Falls 
12. Health Conditions 
13. Infections 
14. Medication 
15. Nutrition 
16. Pain Management 
17. Restorative Nursing 
18. Sensory 
19. Skin Conditions 
20. Social Service 
21. Special Procedures

Bonus Downloadable Worksheets (CAA worksheets from CMS, updated October 2018 with the latest RAI updates, addressing 20 care areas)

1. Delirium
2. Cognitive Loss/Dementia
3. Visual Function
4. Communication
5. Activities of Daily Living
6. Urinary Incontinence and Indwelling Catheter
7. Psychosocial Well-Being
8. Mood State
9. Behavioral Symptoms
10. Activities
11. Fall(s)
12. Nutritional Status
13. Feeding Tube(s)
14. Dehydration/Fluid Maintenance
15. Dental Care
16. Pressure Injury
17. Psychotropic Medication Use
18. Physical Restraints
19. Pain
20. Return to Community Referral