Community Care Information Management Community Support Services Common Assessment Project (CSS CAP) interRAI CAPs (Clinical Assessment Protocols) & Care Planning Version 3.0 December 2011

2 Welcome and Introductions Objectives interRAI Outcome Measures and Scales Introduction to CAPs and Benefits How are CAPs Triggered? Practice Using CAPs Manual Care Planning Break Practice Creating a Care Plan Wrap-up, Evaluations and Q & A Agenda: CAPs and Care Planning

3 Please introduce yourself –Your name –Your HSP –Your role What is your personal goal in attending this training session? Participant Introductions

4 Ice Breaker

5 Education Material Let’s review: –The Assessor Workbook –The interRAI Clinical Assessment Protocols Manual

6 Upon completion of the CAPs and Care Planning training session you will have increased your understanding about: How CAPs focus on the client’s function and quality of life, assessing their needs, strengths and preferences The link between information gathered in the interRAI CHA assessment and the triggered CAPs and Outcome Measures and Scales How to use CAPs to create a care plan that meets the needs of the client How CAPs and Outcome Measures and Scales provide the basis for outcome-based assessments and facilitate referrals where appropriate Learning Objectives

7 Functions of embedded scales: Evaluate current status of client Track outcomes of care Aggregate comparisons for quality benchmarking Available outcome measures: Cognitive Performance Scale (CPS) Depression Rating Scale (DRS) IADL Involvement Scale Changes in Health, End stage Signs and Symptoms (CHESS) Pain Scale Self-Reliance Index (SRI) ADL Self-Performance Hierarchy Scale MAPLe Adapted with expressed permission from ideas for health, University of Waterloo, June The following outcome measures and scales are generated by your software automatically once the assessment has been completed: interRAI CHA Outcome Measures and Scales

interRAI CHA Outcome Measures and Scales: Mr. Patterson Let’s review for Mr. Patterson: CPS Pain MAPLe

interRAI CHA Outcome Measures and Scales: Mr. Patterson Let’s review for Mr. Patterson: CHESS & MAPLe

10 Clinical Assessment Protocols Structured, problem oriented frameworks to organize information and support care planning Specific clinical characteristics are used to identify clients who could benefit from further evaluation of specific problems either because they are: –at risk for decline or –show potential for improvement Trigger links to a series of problem oriented assessment protocols Clinical expertise and choice is important Not care path/care maps Adapted with expressed permission from ideas for health, University of Waterloo, June 2010

11 Key Points About CAPs report: Generated by software only Using the information from the Core CHA and Functional Supplement, it identifies key areas that need to be addressed in the following four sections: –Functional performance –Cognition and mental health –Social life –Clinical issues Each section contains CAPs triggered for a client Guidelines in the manual help the assessor create the plan of care, provide appropriate service, and/or make timely referrals The CAP report is generated by your software automatically once the assessment has been completed. Clinical Assessment Protocols cont’d

12 CAPs: Enable client’s strengths, needs and preferences to be taken into consideration when developing the care plan Guide the plan of care to potentially resolve problems, reduce the risk of decline or increase the potential for improvement Help the assessor to visualize a complete picture of the problem: internal and external factors Will work with all of the interRAI assessment tools Benefits of CAPs

13 CAPs Throughout interRAI Tools [ i ] interRAI LTCF, not RAI-MDS 2.0

14 CAPs Throughout interRAI Tools (cont’d) [ ii ] interRAI HC, not RAI-HC 2.0

15 Adapted with expressed permission from ideas for Health, University of Waterloo, July Functional Performance: Physical activity promotion IADL ADL Cognition and Mental Health: Cognitive loss Communication Mood Abusive relationships Social Life: Informal support Social relationships Clinical Issues: Falls Pain Cardio-respiratory conditions Dehydration Prevention Appropriate medications Tobacco and alcohol use Urinary incontinence CAPs Triggered from Core Assessment

16 Functional Performance: Home environment optimization Institutional risk Cognition and Mental Health: Delirium Behaviour Clinical Issues: Pressure ulcer Undernutrition Feeding tube Bowel conditions Adapted with expressed permission from ideas for Health, University of Waterloo, July Additional CAPs Triggered When Functional Supplement is Completed

17 CHA Core Assessment Triggers: 1st: G4a – Activity level less than 2 hrs 2nd: G2f- Locomotion-Independent Physical Activities Promotion CAP CAPS link the information gathered in the assessment with the goal of problem resolution, reducing the risk of decline or increasing the potential for improvement How CAPs are triggered

18 Problem (Client Need) Overall Goals of Care Triggers Guidelines (Service Provision) How to use the CAPs Manual

19 Break

20 All triggered CAPs must be addressed in a care/service plan Validate triggered CAPs with client to ensure that they are relevant and important Prioritize triggered CAPs with client for the development of the care plan Adapted with expressed permission from ideas for health, University of Waterloo From CAPs to Care Planning

21 Putting It All Together

22 A Care/Service Plan is: A communication tool, based on assessment of the client’s care/service needs, is to be used by the care team members Intended to put measures in to place to prevent decline and manage risk A collaborative plan of service created with input from client and assessor Care/Service Planning

23 Characteristics of a Care Plan Individualized Current Accurate Clear Relevant Collaborative

24 *Client Needs = Problems in CAPs Manual **Service Provision = Guidelines in CAPs Manual Components of a Care Plan DATE TRIGGERED CAP CLIENT NEED (Problem Statement) CLIENT GOAL SERVICE PROVISION (Guidelines) RESPONSIBLE PROVIDER REVIEW DATE

25 Divide into small groups Assign a recorder and presenter Using case study, CAPs Report and CAPs Manual create a care/service plan for the assigned CAP Share results in the large group Let’s practice!

26 Assessment Process Flow Core CHASupplements CAPs & Outcome Scales Care PlanReviewReassessment Review: phone call or visit to review any aspect of the care/service plan Reassessment: face to face comprehensive assessment

27 Education Material Powerpoint presentations Case studies Reference sheets Evaluations interRAI CHA CAPs Manual for project-led sessions Facilitator binder Assessor workbook Certificate of completion Project Supports Website – –Electronic copy of all education material Support Centre – option 9 Supportive calls from project Training Resources

Next Steps Electronic Care/Service Planning

29 Certificate of completion signed by facilitator Let’s sign up for Supported Training - CAPs and Care Planning Evaluation Next Steps

Wrap-up and Questions

Thank you! Project Support Centre Contact Information Toll Free: , option 9 Website: