So like I mentioned today, we’re going to talk about building and implementing better care plans. Recently we were talking about the top 10 complaints from caregivers over really the last eight months from the start of 2021 and care plans were in the top 10 complaints. And so that’s why I wanted to bring Lorraine on today to talk about care plans and give us some tips and best practices to better implement care plans. So the first tip learning that I want to cover is, is making care plans smart. We use that acronym S M A R T quite often when we’re talking about goals, but I love have you implemented it here with care plans as well. So why don’t you tell us about that, that first best practice?
Okay. So that first best practice, the idea of making your care plan goals and objectives, especially as smarter goals or objectives. So that’s smart acronym, you know, specific, measurable, achievable, relevant, and time oriented is really important to the goals that we put in place, because those are what we’re going to use to measure and to identify when we’re done. So, you know, it gives us a definition of done as well as allows the clients who were doing our care planning with, because it’s an interactive process to understand what we’re looking at for the goals of care. So, you know, when we’re looking for something specific that specific area improvement measurable, make it quantifiable in that quantifiable can be different depending on what type of care you’re providing to your clients. So if you’re working in a rehab or an area where you’re expecting to restore function, it’s easy to measure where you’re expecting them to go, because often it’s going back to what their prior state of function was prior to a surgical procedure or a whole health event.
But when you’re looking at palliative care, that idea of what you were looking to measure, what you’re looking for, that specific goal to be, can be very different. So, and then achievable because you don’t, you know, you don’t want to care plan for something that’s not going to be achieved. You want to look at what is achievable for that client based on where they are in their health status and where you’re expecting them to go relevant. You know, we, we for, I came from nursing schools. So I’ve written care plans that are huge and extensive, but what you want to do, especially when you’re looking at what services are being authorized is make sure that you’re putting those things into your care plan that are relevant to that care plan and to the service that you’re being authorized to provide it. And then time-oriented, we all need to know, you know, when we’re expecting things to happen. And so having that aspect of temp time into your care plans is really important.
Let’s, let’s segue right into the second tip because it goes right along with that time they oriented it’s, it’s assigning actions to your care plan. Sometimes a care plan is created, you know, from an initial assessment and then it goes nowhere, you know, it just kind of sits and there’s nothing done with it. So what, what’s this concept around assigning specific actions to your care plans?
So, you know, it’s, it’s kind of, there’s a, there’s an old adage about, you know, anybody can do it, but somebody needs to be assigned to do it otherwise nobody does it. So if you’re not assigning those actions out and making sure that they are either being handled by a role within a role, who’s going to be in the circle of care for that client or by the client themselves, because sometimes they’re being assigned to do activities as part of their health and wellness. If it’s not assigned, then often those are the things that will slip through cracks, or you don’t notice them until you come to do an evaluation or you start to plan for discharge. And you realize that in higher aspect has been missed as a result of not assigning someone to be responsible for that, or assigning a role to be responsible for that
Drawing on your clinical background. Maybe you could share kind of putting you on the spot, a story of a scenario gone wrong, you know, maybe where something wasn’t followed up with or an action wasn’t taken based off a care plan and what resulted.
Yeah. unfortunately, so I’ve done, I’ve done both quality reviews in my career. I’ve also been the nurse who’s been, you know, reviewing the care plan, getting ready for discharge. And all of a sudden I find this entire area that has not been addressed. And it, it happens no matter, you know, no matter what, but in some cases it can delay a discharge. If you, if you don’t have those mechanisms in place or you don’t have those plans in place. In other cases, you know, it’s, it’s really that understanding. So it, it results in something becoming much less smooth for the client. You know, they, they have an expectation of the care that’s being provided and when that entire gap happens there, it can be, it can be really challenging to recover from, and, and it can result in, you know, having to provide additional service just to make that.
Absolutely. I want to ask about streamlining the process, you’re streamlining those action items, every client’s needs vary. And so, you know, implementing or streamlining a care plan can be difficult because every assessment looks differently. So maybe just, what are your thoughts around streamlining the process and making sure you can be consistent even though the needs vary.
Okay. So when we’re care planning, there’s often, you know, what we to refer to as, as standards of practice. So there are standards, you know, for wound healing and for a variety of types of care. So we need to look at our standards, but we also need to balance that against the needs of the client and that individualized assessment. So it’s, it’s managing the standards, making sure that the standards are applicable for that client, making sure that you’re not applying in things that don’t make sense for that client or where that client is. But there’s a balance in there. Care plan libraries can help to support those standards of practice and then making sure that you’re still taking into account the client’s assessment and the client’s individual needs, and making sure that you’ve got that balance in place there
That was kind of hitting on, on the third tip here. No, no, no. That’s okay. Balancing kind of clinical best practices with you know, the needs of the individual client. Maybe you could speak to how that impacts the caregiver, you know, when there’s specific standards or kind of quality standards met, and you’ve identified those, you know, for this specific client that paints a clearer picture for the actual caregiver. So they understand what, what needs to take place in the home. So any thoughts about, you know, how striking that balance helps the caregivers deliver better care?
Well it helps the caregivers deliver better care because you, you know, you kind of go into that situation, understanding what’s needed what’s in place and having your care plan, align with those practices, as well as identifying where there needs to be a nuance in there because of the individual client’s requirements is, is incredibly helpful. And having that documented for them to support them is really important.
That one’s you know it may be a factor of how long I’ve worked in this situation, but I’ve worked in organizations where I’ve come into organizations sometimes as a consultant and, you know, they’ve got their care plans over here and they have the activities and the actions that they’re performing on the other side. And that can be a really challenging situation for a lot of reasons. One is that you end up having discrepancies between what’s documented in the plan of care and what’s actually being completed within the field or with the client themselves. And those discrepancies can result in again, gaps in care. So it’s, it’s really important to make sure that your care plan is involved in the workflow. So making sure that you’re not duplicating your documentation, you’re not resulting in discrepancies because you’ve got your care plan on one hand and you’ve got the actions that you’re completing on the other hand.
So bringing those in together and making sure that you’re not doing the double duplicate or duplication and documentation too many DS in that Fraser is really, really key. And I have one of the challenges is that very often you’ll get a new checklist or new ideas for documentation brought forth. And so in incorporating that you end up kind of ending up with more than one source of truth, and that can be really challenging. So it’s really important if can bring it back so that you’re not duplicating that documentation avoid building out redundant forms. You know, some cases you have to add more detail, but if you can go back and do your documentation based on what’s in your care plan, it will help you in a few ways. One, it makes sure that you’re following the care plan, you’re updating your care plan as interventions or activities change. And finally, it makes sure that you’re doing that evaluation of your care plan.
Hmm. I want to ask a rhetorical question, you know, what’s, what’s restricting you from doing this, is it, you know, schedule time priority. It’s a lot to maintain, especially if you’re a larger agency and you’re managing hundreds, if not thousands of care plans, you know, it’s a lot to do, but would just love to hear what what’s impeding you from, from making these changes or implementing this. Your fifth tip here is around, you know, evaluating your care plans on an ongoing basis. What, what do you want to share about just that ongoing evaluation of care plans? Yeah.
Yeah. And that actually ties a little bit to making sure that you’re aligning your care plan with the activities that you’re doing as part of your care. So when you have that ongoing evaluation and making sure that you’re evaluating throughout the care that you’re providing, it does a few things. One, it makes sure that, you know, you’re actually following that plan of care. You can figure out what’s been completed. What’s still outstanding. So you can see where you’re going with the progression with the client. It allows you to adjust your care plan. If you have interventions that are just not working. So it could be that you need to change your approach. It could be that, you know, this is not going to get you to that point. Maybe you need to bring in a different additional referrals at that point or additional information to the client.
So that interim evaluation point is incredibly helpful in terms of level setting, making sure that you’re making progress to your goals. It allows you to make changes and adjustments to that, to that plan of care. So that you’re actually going to get to that ultimate goal. It may be that you need to adjust what the goal is. You know, as you’re working with that client, you’ve discovered that, you know, they weren’t really at the functional point before or based on the recovery, it’s going to take them longer to get to that recovery points that you have that communication. It also helps the client to be aware because very often those really small, incremental changes that happen during the time that they’re receiving care, get missed. They don’t realize how many things that they’ve improved on because they’re focused on the part that’s still causing them struggle. So it allows you to celebrate those achievements with them as well. So I’m, I’m really in favor of making sure that you do that interim evaluation and that’s how come that care plan needs to be front and center, because it reminds both the caregivers and the clients of where they’ve come from and where they’re going to, and the fact that they’re actually moving forward in that.
Yeah, I’m thinking of drawing on the benchmarking study, the average client length of service 13 months, chances are pretty slim that a client’s needs day one versus 13 months later look the same. So consistently evaluating that care plan and making changes, like you said, there’s incremental changes that even need to be documented that could easily be overlooked, but it’s so important to just consistently be reviewing those plans to make sure everything’s being kept up with,
I think that’s useful from doing those interim evaluations is that you’re seeing goals, their goals or objectives that aren’t being met is to be able to look for patterns within those objectives, because you may find out that you’re just being roadblocked on a variety of objectives based on one issue. And if you resolve that issue, you help to move that issue forward. You’ll suddenly unblock the entire plan of care that you’re doing for your client and you allow it to move forward. So sometimes it’s not just focused on what you are accomplishing, but when you’re not meeting those objectives or you’re not meeting those goals, what, what is the factor there? If there’s multiple factor two factors, or if it’s coming down to one thing, perhaps you can move things forward.
I I’m thinking about readmission rates. It’s something that surprisingly, not too many agencies in private duty are tracking and I’m thinking, you know, what better way to utilize our care plans in showing the outcomes that we’re driving. I know I’m putting you on the spot, you know, bringing up this concept of readmission rates, but what are your thoughts around using care plans to measure outcomes and to prove outcomes?
I think that’s, you know, the, the use of the data that we’re putting into our clinical charts for analysis and looking at meeting outcomes is really, really key. Which is one of the reasons why it’s, you know, sometimes a little bit challenging. So you don’t want to say, you know, I’m 10% men, 20% men. Sometimes it’s hard to ascribe a number to a specific outcome, but that information is very, very helpful in terms of where you’re going in terms of meeting that goals and can also help you if you’re evaluating regularly is looking at whether or not it is a risk-free admission. If you’ve got outcomes or goals or interventions, looking at the patient’s status, it may help you to identify those people who are at risk of going back into a readmission cycle.
Absolutely. And yeah, it’s not just a readmissions that we’re talking about here. I’m just thinking of all the, the outcomes that we can drive and how important it is for us to be able to measure those and then be able to prove them when we’re approaching a referral source or when we’re prospecting with potential clients, you know, being able to show them the value that we’ve driven for other similar clients is really powerful.
Yeah. Especially in, in some products that I’ve worked with we can evaluate, you know, the percentage of bulls that we’ve per client, but we can also drive that information up to a higher level of achievement. So we can look at going across our population where we’re going, and that can help to identify, you know, practices that we’re doing that are really helping. It could be things that we need to introduce within programs. And we can also look at things that are potentially not as helpful, and then look at adjusting our programs to meet those. So the outcome and the evaluation of that information is, is really, really important. So doing the analysis behind that and looking at patterns
Definitely. Oh, but you on the spot again just drawing on your, your provider experience any other stories or examples of times when you’ve seen the implementation of a care plan used really effectively and how it benefited the client or the caregiver, or, you know, incited a new process within your organization, something along those lines.
I’ll give you a couple of, I’ll give you at least one example. We’ll try right now. So I’ve worked with an organization and part of driving their care plans when the, so they did extended care in the home, they were pediatric complex pediatric care. But part of their evaluation process started with each visit. They would basically look at that, see that child’s status that day and identify whether or not that child is doing well stable or whether or not they thought that child might be tipping, tipping the precipice there. And so they would include that evaluation as part of every shift of care that they were doing. And that was, that was just part of their standard of practice. Basically looking at respiratory circulatory, you know, they’re looking at those key factors to identify if that child is stable.
And by looking at those few key measures with each shift, they were able to trend first of all, make sure. So they could quickly see that tip in the precipice when there was a small change in, in status, which allowed them to intervene much more quickly. And what would happen is they would kind of have three statuses. One was basically a green child was with the normal range for them expected. Then they would put them into a status of watcher. If there were just a little bit of changes on the, on the measurable outcomes that they were using. And then finally, you know, there was the, we need to refer, we need to transfer to a hospital. So they, they kind of had those three levels. And by doing that and doing it consistently across each visit that evaluation was very, very helpful for them. And that was documentation incorporated within their plan of care for that child.
I was going to say the data geek inside of me loves, loves trends and trending things because yeah, it gives you such a clear picture of what’s happening and where, you know, you need to step in or make a change. And so I can just visualize kind of like the trending over time and how beneficial that is.
And it can also be really helpful depending, you know, we have, we have clinicians who are super experienced and who have that intuitive knowledge and can recognize that change. Whereas we have people who are earlier in their practice careers, who they may have the inkling that there’s something going on, but unless they’ve got something that’s kind of black and white for them to help lead them down that path, they sometimes miss those really subtle cues. So that’s where I really like having something objective for them to measure, because it allows them as they’re going along that practice. So you always have that, that range of practitioners and having that ability to support those people who are newer in their practice so that they don’t have to learn via skin or, or, you know, those, those horrible nursing stories that some of us have in our history.
I’m good. Hey, one of the things that I get asked a lot is when should we bring certain people on board, at what point do we need to be hiring for this position or that position? And, and I think one thing we’re also seeing in the industry is it’s kind of like Jeanette saying, she’s saying, Hey, we’re, non-medical home care, but we’re also seeing a lot of people start to cross that line a little bit as the governments come in and provide a different funding and things like that. So at what point, Lorraine, if you’re in nonmedical and you’re trying to, to move over or you’re, you’re a new agency, at what point do you hire somebody specifically for care planning?
That’s that’s a great question actually. And it depends a little bit on your, on your client population. So when you’re working on medical home and they’re, your clients are relatively stable, but if you’re finding that they’re needing more and more assistance, or if you’re starting to give them more referral information. So they’re, you know, the services that they’re having, you need to start to refer out or start to give them information about other options that are available for care. That may be a situation where you need to start looking at who, who would make sense to bring in from a care planning perspective or whether or not it’s just information that needs to be provided to them. In which case you could put an information library in place for them. That would be a possibility. Does that sound like something that would work?
Yeah. Good question, Kara. Thanks for chiming in maybe just in closing Lorraine, you can highlight, you know, really just key advice for agencies looking to improve or, you know, re-establish some of their care planning processes. What would be, you know, your, your takeaway here, your advice for these providers?
So for the providers and advice related to care planning is to take a look at where you’re, where you’re currently at. So, you know, my, my recommendation, anytime I’m looking at a process improvement is still look at where I’m currently at and where the needs, where the needs are. So what am I doing currently? What’s working well, what is challenging to the, to the other providers, the organization, or what’s been challenging, or what’s been the feedback from the clients because the clients have, have perspectives on the care that they’re receiving and whether or not it’s meeting their needs as well. And then using that as your stepping stone to go forward.
Yeah, that was drawing on kind of from this last, last tip and closing here. I want to just recap these five tips that we’ve covered today, which is making your care plans smart, S M A R T assigning actions to every step of your care plan balancing. The third one is balancing clinical best practices with the specific needs of your clients. The fourth one is incorporating the care plan into the care workflow, into the whole spectrum of the care that takes place. And then the fifth one that you kind of just drew on is, is ongoing evaluation. That’s really our takeaway for providers today is to figure out where you are, figure out what you’re doing. Well find maybe your gaps or weaknesses within care planning and take steps, or establish a meeting with your team to reconvene and talk about what’s going well, and what’s not going well and where you can, you know, make those refinements or those tweaks to a district care planning. So Lorraine with that, you know, I think we’ll close out the conversation today and say, thanks for being here. Thanks for sharing some of your insights. Thanks for representing Elia care. Some of our listeners today may maybe using liar care or maybe using other EMR, but it’s a great platform and you all work closely with home care pulse, and we’re, we’re glad to do that. And so thank you so much for joining us today.