From Clinical Assessment Protocols and Outcome Scales to Care Planning Data Quality: From Clinical Assessment Protocols and Outcome Scales to Care Planning • Please put your speaker phone on mute (*6) • Do not put your phone on hold ! • Your screen should show a Participants panel and a Chat panel • If not, go into the panel menu by clicking the green tab • Then click on the Participants icon to open the Participant box and the Chat icon to open the Chat box • To ask a question during the WebEx, write it out in the Chat box and select “send to all participants …

Agenda The benefits of using the interRAI CHA CAPs and Outcome Scales to enhance the care planning process Review of selected resources in the interRAI CAPs manual and care planning binder Share some tips on how to create a care plan Discuss short care planning scenarios Share examples of how HSPs have incorporated the CAPs and Outcome Scales into their daily work flow

Objectives Understand the impact of using the CAPs and Outcome Scales when creating individualized care/service plans How to incorporate CAPs and Outcome Scales into the care planning process to enhance client outcomes Introduce strategies other HSPs have used to enhance their care planning process

Back to the Basics

What is the interRAI CHA? interRAI Community Health Assessment (CHA) helps identify adults needing supports to prevent or stabilize early functional or health decline An electronic standardized comprehensive assessment Modular format Not all inclusive – “minimum” data set Data elements designed to be used for: Care planning Quality improvement using quality indicators Outcome measures based on clinical scales

Assessment Process Flow Core CHA Care Plan Review Review: phone call or visit to review any aspect of the care/service plan CAPs &Outcome Scales Supplements Reassessment Reassessment: face to face comprehensive assessment 6 6

Outcome Scales/Measures & Clinical Assessment Protocols interRAI CHA Outputs Outcome Scales/Measures & Clinical Assessment Protocols

Outcome Scales / Measures Used to evaluate the clinical status of a client or group of clients and track their changes over time Software generated Derived from data collected by the completion of the interRAI CHA assessments Evidence based for decision making

Outcome Scales Outcome Scale Range Description Cognitive Performance Scale (CPS) 0-6 Indicator of Cognitive Status Based on sections C - Cognition & D - Communication & Vision Depression Rating Scale (DRS ) 0-14 Indicator of Depression Based on seven items from Section E1 - Indicators of Possible Depressed , Anxious or Sad Mood Pain Scale 0-4 Predictor of Pain Based on 2 pain questions - Pain Frequency & Intensity ADL Self-Performance Hierarchy Scale Is a measure of ADL performance Calculated from Core CHA & Functional Changes in Health, End-stage disease and Signs and Symptoms (CHESS) 0-5 Measures medical complexity & health instability Calculated from Core CHA & Functional Self-Reliance Index (SRI) 0 or 1 Categorizes clients as being either self-reliant or impaired Method of Assigning Priority Levels (MAPLe) 1-5 Is used to categorize clients into five levels of risk for adverse outcomes Instrumental Activities of Daily Living Involvement Scale ( IADL) 0-21 Is a measure of IADL involvement Based upon a sum of seven IADL Self-Performance

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

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

Clinical Assessment Protocols Functional Performance Cognition & Mental Health Social Life Clinical Issues

* CAP Triggered when Functional Supplement is completed Functional Performance Physical Activity Promotion CAP IADL CAP ADL CAP Home Environment Optimization CAP * Institutional Risk CAP * Cognition & Mental Health Cognitive Loss CAP Communication CAP Mood CAP Abusive Relationships CAP Delirium CAP* Behaviour CAP* Social Life Informal Support CAP Social Relationships CAP Clinical Issues Falls CAP Pain CAP Cardio-respiratory conditions CAP Dehydration CAP Prevention CAP Appropriate Medications CAP Tobacco and Alcohol Use CAP Urinary Incontinence CAP Pressure Ulcer CAP* Undernutrition CAP* Feeding Tube CAP* Bowel conditions CAP* * CAP Triggered when Functional Supplement is completed

How CAPs are Triggered 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 interRAI CHA Core Physical Activities Promotion CAP Triggers: 1st: G4a – Activity level less than 2 hrs 2nd: G2f- Locomotion-Independent 14

Summary of CAPs Triggers

Client CAPs Summary - Sample

Summary of CAP Trigger Levels * See the interRAI Clinical Assessment Protocol s Manual for description of levels

Using CAP Trigger Levels Clinical Assessment Protocols Trigger Level Urinary Incontinence 3 = Triggered to Facilitate Improvement in Bladder Function 2 = Triggered to Prevent Decline- Higher Rate of Decline Expected 1 = Not Triggered-Continent 0 = Not Triggered-Poor Decision-Making Prevention 2 = Triggered Because Preventive Strategy Not Pursued and No Recent Physician Visit 1 = Triggered Because Preventive Strategy Not Pursued, Despite a Recent Physician Visit 0 = Not Triggered Cognitive Loss 2 = Triggered To prevent Decline 1 = Triggered to Monitor for Risk of Cognitive Decline Institutional Risk 1 = Triggered

In the interRAI Clinical Assessment Protocol Manual How CAPs are Organized In the interRAI Clinical Assessment Protocol Manual

CAP Information is Organized by 4 Parts Manual Tips Problem (Client Need) Provides information to help the assessor identify and / or understand how an issue can affect the client or the client population as a whole Overall Goals Of Care (Grey Box) Vary but include the possibility of: (1) Resolving Problem; (2) Reducing Risk; (3) Increasing Potential for improvement Triggers Link the information gathered in the assessment to the problem referenced by the CAP Assessor should validate each CAP against specified criteria in manual to confirm if it makes sense for the client Guidelines (Service Provision) Help to think through relevant underlying issues and move toward a plan of care Utilize best practices to promote optimal client care planning outcomes, in conjunction with your agency protocols.

From CAPs to Care Planning 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 21

Sharing their Journey HSPs share how they have incorporated CAPs and Outcome Scales into the care planning process Tips for success Resources used or developed

Enhancing the Care/Service Planning Process Overview

Putting It All Together

What is a Care/Service Plan Roadmap to provide direction and guidance to all those involved in the clients care Essential communication tool A collaborative plan of service created with input from client and assessor

Characteristics of a Care/Service Plan Client Centered Current Accurate Clear Relevant Collaborative

Components of a Care/Service Plan Care/service plans are generally organized by four categories: Problem statement/client needs Client goals Service provision/interventions Review date

CLIENT NEED* (Problem Statement) Components of a Care/Service Plan DATE TRIGGERED CAP CLIENT NEED* (Problem Statement) CLIENT GOAL SERVICE PROVISION** (Guidelines) RESPONSIBLE PROVIDER REVIEW DATE *Client Needs = Problems in interRAI CAPs Manual **Service Provision = Guidelines in interRAI CAPs Manual 28 28 28

Care/Service Planning

Sample Scenario #1 Mr. K Mr. K is an 81 year old who lives alone. He attends Cedar Village Adult Day Program twice a week and is independent with ADLs but requires assistance with meal preparation and shopping. His daughter visits him twice per week, prepares some meals and does the grocery shopping. He no longer drives. Staff noticed that Mr. K could only see large print when reading the newspaper and was asking for the volume of the TV to be raised. Reason for assessment: Routine reassessment - completed after 1 year.

Using the interRAI CAPs Manual Prevention CAP Triggered Level: Preventative Strategy not Pursued AND no Recent Physician Visit Problem “alerts the health care professional to the need to determine if the person has unmet preventive health requirements” “Immunizations are designed to prevent illness, screening is designed to detect unrecognized illness at an early and treatable stage” “Early detection and treatment of problems that interfere with functioning may result in functional deficits being postponed or even prevented altogether”. Overall Goals of Care “To ensure that persons who have not received preventative measures are identified and appropriate action taken” Triggers “No recent physician visit & one or more prevention strategies not followed: “ no eye exam (1 year), hearing exam (2 years), influenza vaccine (1 year) Guidelines / Interventions “Sensory Impairments” “recommend annual ophthalmologic evaluation in older persons” “provision of hearing aides and other assistive devices may produce dramatic improvement in function” “Vaccinations “ “influenza…5th leading cause of death in this age group” “Older persons should be vaccinated each year before the flu season except…” “..have shown to be on average 70% effective in preventing influenza..30% often having milder illness than unvaccinated ..”

Sample Care Plan -scenario #1 Mr. K Triggered CAP Client Need* Client Goal Service Provision** Responsible Provider Review Date Prevention CAP Preventative Strategy not Pursued AND no Recent Physician Visit Triggers: Eye exam, Hearing exam, Influ shot Mr. K did not have an eye exam in the last year, a hearing exam in past 2 years or influenza vaccine in past year Mr. K will complete eye and hearing exams. Mr. K will have his annual influenza vaccine in October 2015 Daughter to make an apt for Mr. K with family Physician to have an eye and hearing test completed. Daughter to take Mr. K for annual Influenza vaccine in Oct 2015 Daughter Oct 31 2015 *Client Needs = Problems in interRAI CAPs Manual **Service Provision = Guidelines in interRAI CAPs Manual 32

Sample Scenario #2 –Rosa Rosa is a senior who lives alone with her cat Fluffy. She receives help from her neighbor to brush her hair and put on her shoes as well as support from a Homemaker for shopping once every two weeks. Rosa recently fell at home and bruised her right arm. The Homemaker contacted the Case Manager to report that Rosa was not feeling well. Rosa had a flare-up of Rheumatoid Arthritis in her (Rt) Hip and (Rt) Hand. Rosa said the pain was severe and was present on a daily basis. Rosa now requires physical assistance with getting in and out of the tub. Reason for assessment: Significant Change in Status (ex. Fall ) completed after 4 months

Sample Care Plan - Scenario #2 Rosa Triggered CAP Client Need* Client Goal Service Provision** Responsible Provider Review Date Activities of Daily Living CAP Triggered to Facilitate Improvement Triggers: some help with ADLS Flare up of chronic condition Fall Rosa requires extensive assistance with bathing and supervision for dressing lower body and combing hair. Prevent further functional loss resulting from flare up of arthritis and treat associated pain Rosa will be able to put on her shoes and complete personal hygiene tasks. Arrange for PSW to visit once per week (1 hour) to assist Rosa with Bathing. Neighbour agrees to assist with personal hygiene and dressing lower body until pain is controlled. - See Pain CAP details See Falls CAP details Assessor PSW Neighbour 2 weeks July 14 2015 *Client Needs = Problems in interRAI CAPs Manual **Service Provision = Guidelines in interRAI CAPs Manual 34

Sample Care Plan - Scenario #2 Rosa Triggered CAP Client Need* Client Goal Service Provision** Responsible Provider Review Date Pain CAP High Priority Triggers: Severe pain Rosa has daily severe pain in (Rt) hand and (Rt) Hip due to a flare up of arthritis. To keep Rosa comfortable and relieve suffering To lower Pain scale score from 4 to 2 or 1 Schedule appointment for the family doctor for medication review & pain assessment. Apply ice pack as needed Arrange transportation for appointment - see Social Relationship CAP Assessor Physician Rosa 1 week July 7 2015 *Client Needs = Problems in interRAI CAPs Manual **Service Provision = Guidelines in interRAI CAPs Manual 35

Sample Care Plan - Scenario #2 Rosa Triggered CAP Client Need* Client Goal Service Provision** Responsible Provider Review Date Falls CAP Medium Risk of Future Falls Triggers: Single fall Recent fall at home related to inappropriate footwear To ensure safety - identify underlying risk factor for falls - To wear safe shoes Rosa will have no further falls or falls with injury. Rosa will wear safe footwear Rosa will be assisted to put on her walking shoes daily Rosa Neighbour 2 weeks July 14 2015 *Client Needs = Problems in CAPs Manual **Service Provision = Guidelines in CAPs Manual 36

Sample Care Plan - Scenario #2 Rosa Triggered CAP Client Need* Client Goal Service Provision** Responsible Provider Review Date Informal Support CAP Triggered Triggers: Not independent with some IADLs lives alone alone for long periods during the day Rosa requires assistance with shopping, transportation and housework Rosa is alone for long periods during the day Rosa will receive assistance with housekeeping and transportation due to recent decline in these IADL’s See Social Relationship CAP Homemaking support will increase to two hours every 2 weeks to provide housekeeping and continue with shopping support. Homemaker 2 weeks July 14 *Client Needs = Problems in CAPs Manual **Service Provision = Guidelines in CAPs Manual 37

Sample Care Plan -scenario #2 Rosa Triggered CAP Client Need* Client Goal Service Provision** Responsible Provider Review Date Social Relationship CAP Triggered Triggers: Feels lonely Reasonable level of cognitive assets - CPS – 0 Ability to understand others – 0 (Understands) Rosa often feels lonely. To reduce loneliness and isolation Increase Rosa’s engagement in social activities. Rosa wants to attend ADP 3 days per week Referral will be made to assist Rosa to attend an Adult Day Program in line with Rosa’s preferred level of involvement Referral will be made for transportation re: medical appointments, ADP Assessor 4 weeks July 28 2015 *Client Needs = Problems in interRAI CAPs Manual **Service Provision = Guidelines in interRAI CAPs Manual 38

Summary: Value and impact of using the CAPs and Outcomes Scale reports Benefits of using interRAI CAPs Manual Tips and examples of how use the outputs to inform care planning and improve client outcomes Begin to include the outputs at your regular team meetings, client and family discussions

Resources interRAI CHA CAPs and Care Planning Binder Reassessment Best Practices Trigger Level Categories interRAI Clinical Assessment Protocols - For Use with interRAI’s Community and Long Term Care Assessment Instruments Manual Website www.ccim.on.ca Service Desk csscap@ccim.on.ca 1-866-909-5600 option 9

Wrap- up

Thank you! Service Desk Contact Information Email: csscap@ccim.on.ca Toll Free: 1-866-909-5600, Option 9 Website: www.ccim.on.ca