Delivering care in a nursing home is complex and critical; it therefore requires guidance by regulatory requirements and professional standards of practice. Delivering care to meet a resident’s need is based on the completion of a comprehensive assessment as well as the development of a care plan based upon the assessment. It is necessary that this assessment process is documented in order to assure continuity of care and to identify improvements, declines, or maintenance of a resident’s condition.
The function of Care Area Assessment (CAA) process is that of a decision facilitator. Care Areas are triggered by Minimum Data Set (MDS) item responses indicating the need for additional assessment based on care area triggers (CATs) or problem identification, which links the care planning decisions and the MDS.
Care Area Assessment
Professionals should take the following steps to conduct Care Area Assessments (CAAs) in long-term care facilities:
- Complete an MDS assessment
It involves screening, clinical assessment, and functional status elements, including coding categories and common definitions, which are the foundation of a comprehensive assessment for residents of long-term care facilities, who are certified to participate in Medicare and Medicaid.
- Evaluate CATs
CATs are a set of MDS items and responses, which indicate particular conditions affecting nursing facility residents. Triggers are considered to be specific resident responses for one or a combination of MDS elements.
- Perform CAAs
This involves reviewing one or more of the 20 conditions, symptoms, and areas of concern, commonly identified by MDS findings. Care areas are triggered by responses on the MDS item set.
- Develop a Care Plan
It involves establishing a course of action after obtaining input from the resident, his physician, and an interdisciplinary team that moves him toward resident-specific goals.
The resources, research, or assessment tools, used in completing the CAA, should be documented. It will help to develop and revise the plan of care to improve the residents’ status, maintain function, and prevent decline.
CAA Care Plan
Majority care areas, covered under the CAAs, are problematic for nursing home residents. The CAA process guides on to focus on key issues identified during a comprehensive MDS assessment and directs health professionals and facility staff to evaluate triggered care areas. The Interdisciplinary Team (IDT) identifies relevant assessment information about the resident’s status. After input is obtained from the resident, his family or legally authorized representative, the IDT decides whether to develop a care plan for triggered care areas.
The CAA documentation must include the unique or casual risk factors for lack or decline of improvement. The care plan addresses these factors, with an aim to promote the resident’s highest practicable level of functioning, that is: improvement where possible; or maintenance and prevention of avoidable declines. Documentation might appear anywhere in the clinical record. It should support the decision making about whether you should proceed with a care plan for the triggered CAA, and the care plan interventions type(s) that are appropriate for a particular resident.
A care plan is driven by identified resident issues and/or conditions. A care plan, based on an effective clinical decision making, a thorough assessment, and is compatible with current clinical practice standards, provides a strong basis for optimal approaches to quality of care and life needs of residents. A care plan should:
- Look at each resident as a human being with unique strengths and characteristics
- View the resident in distinct functional areas to gain knowledge about the resident’s functional status (MDS)
- Give the IDT a common understanding of the resident
- Re-group the gathered information to identify possible issues/conditions the resident might have (triggers)
- Provide clarity of potential issues/conditions by looking at possible risks and causes (CAA process)
- Develop and implement an interdisciplinary care plan that is based on the assessment information gathered throughout the Resident Assessment Instrument (RAI) process, with required monitoring and follow-up
- Provide information about how the risks and causes associated with issues/conditions should be addressed to provide for a resident’s well-being (care planning)
- Re-evaluate the resident’s status at prescribed intervals using the RAI; and modify the individualized care plan as appropriate.
For more insights on how to complete a Care Area Assessment (CAA), attend this Webinar by expert speaker Marilyn Mines RN, BC, RAC-CT, who brings over 40 years of experience as a practicing Registered Nurse to her role as Director of Clinical Services for FR&R. You will also learn about the development of a viable care plan that is made as per the patient’s specific need.