Transcript Making Sense of the PA/POC Requirements
A Workshop Facilitated by Glenda M. Payne, RN, MS, CNN ESRD Technical Advisor, CMS Regions 4 & 6 Dallas, TX
First, let’s talk about:
The basic ESRD regulatory requirements for patient assessments and plan of care…
Every Patient Must Have
Individualized Patient Assessment Individualized Plan of Care By Interdisciplinary Team Done Timely Implemented Reviewed and Updated as Indicated
Who Is Needs to Be Involved?
IDT includes at a minimum: The patient or their designee (if the patient chooses) A registered nurse A physician treating the patient for ESRD A social worker A dietitian 4
Multidisciplinary Care vs. Interdisciplinary Care
Multidisciplinary Interdisciplinary
Work sequentially Work collaboratively Medical record is the chief means of communication Communication by regular discussions about patient status & the evolving plan of care 5
Timelines for Patient Assessments
New admits: Initially: Latter of 30 days/13 treatments Reassessment: 90 days after initial assessment Transfers/transients: If they come with: use that for 3 months, then reassess If they don’t come with: 30 days/13 treatments Stable patients: annually Unstable patients: monthly
Who Is “Unstable?”
Includes but is not limited to: Extended or frequent hospitalization (>15 days or >3 X a month) Marked deterioration in health status Significant change in psychosocial needs Concurrent poor nutritional status, unmanaged anemia & inadequate dialysis 7
When Must POC Be Implemented?
First assessment: within the same timeframe as the assessment (latter of 30 days/13 treatments) Any reassessment: 15 days after reassessment completed
What About Stable Patients?
If a “stable” patient’s outcomes do not meet the care plan goals in an area, the facility must recognize and address that aspect and revise the plan of care accordingly between annual comprehensive reassessments “Monitor, Recognize and Address” 9
Take It To the MAT
Measures Assessment Tool Current, professionally accepted clinical practice standards of care at your fingertips Common understanding of expected targets/goals Let’s take a look at the MAT…
What Do You Need to Document?
Process for patient assessment Patient plan of care development Goals Timelines Plan of care implementation Plan of care review/revision 11
Where Would This Work Be Documented?
Assessments Plan of Care Orders for treatment Interdisciplinary progress notes Lab results Dialysis treatment records PD flow sheets and clinic notes HD treatment records-pre/post assessments, monitoring during treatment 12
Dialysis treatment records?
Home patients: PD – look at 1-3 mo flowsheets ; HHD - 10-15 treatments: Is the patient following dialysis prescription? In-center Hemo - look at 10-15 treatments: Staff following dialysis prescription?
BFR,DFR, dialyzer, dialysate, heparin, Na/UF profile Medications administered as ordered?
Anemia management Mineral/bone disorder management Immunizations, ABT, other meds BP/ Fluid management 13
Documenting Implementation
Patient Plan of Care Interdisciplinary progress notes Nursing interventions Social services interventions Dietary counseling/education Referrals for rehab, vascular access, etc.
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Documenting Implementation
Patient education Modalities/self-care, home dialysis, transplantation Emergency procedures Infection prevention, immunizations, personal care, vascular access care Home training 15
CfC: PA and POC
Two interlocked Conditions: §494.80 Condition: Patient Assessment §494.90 Condition: Patient Plan of Care Corresponding requirements Patient Plan of Care “uses” Patient Assessment Doing either in isolation will not accomplish the intended goal: Individualized Care
Correlation of PA & POC
PA
Current health status (V502) Lab profile (V505) Medication/immunization history (V506)
POC
Incorporated into all POC tags Appropriateness of dialysis prescription (V503) Provide adequate clearance (V544) BP/fluid management needs (V504) Assess anemia (V507) Manage volume status (V543) Manage anemia (V547) Home pt ESA (V548) ESA response (V549) Assess renal bone disease (V508) Manage mineral metabolism (V546) 17
Correlation of PA & POC
PA
Nutritional status (V509)
POC
Effective nutritional status (V545) Psychosocial needs (V510) Evaluate family support (V514) Access type/maintenance (V511) Evaluate for self/home care (V512) Transplantation referral (V513) Evaluate current physical activity level & voc/physical rehab (V515) Psychosocial counseling/referrals/ assessment tool (V552) VA monitor/referral (V550) Monitor/prevent failure (V551) Home dialysis plan (V553) Transplantation status: plan or why not (V554) Rehab status addressed (V555) 18
[email protected]
Now to Let You Do Some Work!
In order for you to demonstrate knowledge of the link between the patient assessment and the plan of care for that specific patient, and
To identify critical components of the POC for specific patients,
We have created several case studies for your “IDT” to use in developing or updating POCs…
Pitfalls to Effective PA/POC
Doing great assessments; not doing a plan of care Not using the information gathered in the assessment to develop the POC Not implementing the plan Not reviewing the results to see if the plan is working Not updating the plan to change or refocus the goal(s) Not monitoring the individual’s progress after interventions are implemented