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Nutrition Connection: Nutrition Care Plans for MDS 3.0

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(reprinted from Nutrition & Foodservice Edge, January 2012)

When did care planning begin? Did the original legislation for nursing homes require care plans?  The authors of the Social Security Act of 1935 initiated a public assistance program for the elderly, but no requirements or minimum standards of care were specified. It took more than 40 years for regulations to evolve to include care plans as the primary tool for provision of care. In the early 1980s the Patient Care and Services Survey process shifted the emphasis from written policies to the actual provision of care delivery using existing regulations.  Just having a policy was no longer enough; it had to be implemented, reviewed, and revised to get results.

Written care plans became the new yardstick for insuring resident care. Initially regulators required that each resident have a multidisciplinary care plan—meaning that every discipline was required to have a unique care plan for each resident. It took nearly a decade to move into the interdisciplinary care planning model.  The OBRA requirements of 1987 and MDS 2.0 solidified the survey standards and process. It formalized the assessment process and provided a framework for continuous improvement. More was expected in terms of care planning and care delivery.  MDS 3.0 is moving the nursing home industry towards improved quality of life and a person-centered approach to care planning by expanding the role of the resident in care decisions.

Regulations on Care Planning
Care planning is addressed in numerous sections of federal and state law, regulations, and in the Interpretive Guidelines.  The universal principle undergirding all of these regulations and guidelines is Resident Rights. One of the Resident Rights specified in §483.10(d):
…the resident has the right to choose a physician and treatment and participate in decisions and care planning.

Care planning is defined in §483.20(k) Resident Assessment Comprehensive Care Plans.
(1) The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident’s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

The care plan must describe the following:

(i) The services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being as required under §483.25;


(ii)  Any services that would otherwise be required under §483.25 but are not provided due to the resident’s exercise of rights under §483.10, including the right to refuse treatment under §483.10(b)(4).

The regulations require interdisciplinary teams to write a plan of care that addresses the problems identified through the MDS 3.0 process and that triggered CAA areas. The care plan must be specific and reflect intermediate steps for each outcome objective.  Care plans are reviewed quarterly and updated at least once a year or following a significant change. Residents are encouraged to voice personal preferences for care and participate in the care planning process.

What happens if the resident has different goals from the interdisciplinary team? A resident may refuse certain services or treatments that professional staff believes are necessary to assist the resident in reaching his or her highest practicable level of well-being. In order for a resident to exercise his or her right appropriately to make informed choices about care and treatment or to refuse treatment, the facility and the resident or the resident’s  legal representative (surrogate decision makers) must discuss the resident’s condition, treatment options, expected outcomes, and consequences of refusing treatment.  The facility is expected to address the resident’s concerns and offer relevant alternatives, if the resident has refused specific treatments and state these in the care plan. 

Does the resident have the right to refuse to follow a therapeutic or consistency modified diet? Therapeutic and consistency modified diets are part of the medical treatment to manage chronic and acute diseases. Residents can make an informed decision to refuse to follow therapeutic or consistency modified diets. It is vital to have clear documentation that the resident or resident’s legal representative understands the risks and likely consequences associated with these choices.

What if the resident is determined to be incompetent? Can this resident refuse treatment as well? Residents determined to be incompetent or incapacitated are excluded from the care planning process. However, it is desirable to allow these residents to assert their rights based on his or her degree of capability with input from the family or resident representative.  Family members or the resident representative may refuse medical interventions. The care plan must reflect the care being provided.

Care Planning Basics

The care plan outlines the goals/objectives for care and serves as a template for direct care services. The interdisciplinary team (IDT) uses the resident goals/objectives to monitor progress towards clinical goals.

The foundation of the nutrition components of the care plan is the comprehensive nutrition assessment. This is the starting point for good clinical problem solving and decision making and ultimately for the creation of a sound care plan. The RAI Manual does not specify a care plan structure or format.  The RD will identify nutrition diagnoses for incorporation into the care plan. Care plans may also state that the resident has made choices and self determination not to have facility staff provide recommended nutrition care. This should not be put in ‘non­compliant’ terms, but as the informed right of the resident. It is important to document and revise ongoing efforts to inform the resident or surrogate decision makers and monitor the resident’s nutritional status while making these choices.

Characteristics of a well-developed care plan include:

  • Looks at each resident as a whole human being with unique characteristics and strengths.
  • Gives the IDT a common understanding of the resident’s nutrition needs.
  • Provides additional clarity of potential issues and/or condi­tions by looking at possible causes and risks (CAA process).
  • Develops and implements an interdisciplinary care plan based on the assessment information gathered throughout the RAI process, with necessary monitoring and followup.
  • Identifies measurable goals of care.
  • States how the causes and risks associated with issues and/or conditions can be addressed to provide for a resident’s highest practicable level of well-being.
  • Re-evaluates the resident’s status at prescribed intervals (i.e., quarterly, annually, or if a significant change in status occurs) using the RAI and then modifies the individualized care plan as appropriate and necessary.

Does the CDM or RD have to address every triggered CAA in the care plan? Not all triggered conditions affect the resident’s functioning or well-being. These triggers should not be addressed in the care plan.

The care plan must address all the triggered conditions that affect the resident’s functioning and well-being. The IDT should review and revise the current care plan as needed and communicate with the resident or family regarding the proposed care plans.

Does the resident have the right to change his or her mind once a plan of care is started? Remember that the resident or family may have a different perspective on the delivery of care and may decline particular services and treatments (e.g. thickened liquids). It is vital to honor the resident’s wishes and document the alternatives offered before the care plan is finalized. Be sure the family and resident are told the possible consequences of declining recommended interventions.

Steps in the Care Planning Process
Care planning is a process that has several steps that may occur at the same time or in sequence.

  1.  The RAI process (MDS and CAAs) and any other additional assessments as required by the resident ‘s condition are completed as the basis for care plan decision making.  By regulation, this process may be completed solely by the RN Coordinator, but ideally the CDM and RD will work collaboratively with the IDT to write the care plan.
  2. The CDM or RD uses clinical problem-solving and decision-making steps to make decisions.  Goals and approaches for each problematic issue and/or condition may overlap.  The IDT may decide to address the problematic issues and/or conditions collectively in the care plan.
  3. After assessing the resident, the CDM or RD may decide that a triggered condition does not affect the resident’s functioning or well-being and should not be addressed on the care plan.
  4. Documentation of all nutrition-related care planning issues should be included as part of the CAA review documentation.
  5. The CDM or RD should include input from the resident, family, or resident’s representative in creating the individualized care plan.
  6. In some cases, a resident may decline particular services or treatments that the CDM or RD believes may assist him or her to attain the highest practicable level of well-being.  In such cases, the resident’s wishes should be honored and documented in the clinical record and alternatives should be offered before the care plan is finalized.
  7. The CDM or RD collaborates with the IDT on the intermediate goal(s) that will lead to outcome objectives.  The intermediate goal(s) and objectives must be pertinent to the resident’s nutritional status, measurable, and have a time frame for completion or evaluation.
  8. The CDM or RD, with input from the resident, family and/or resident representative, identified specific, individualized steps or approaches that will be taken to help the resident achieve his or her goal(s).  These approaches serve as instructions for resident care and provide for continuity of care by all staff.  Precise and consise instructions help staff understand and implement interventions consistently.
  9. The final care plan should be agreed to and discussed with the resident or the resident’s legal representative.
  10. The goals and approaches should be communicated to other direct care staff who were not directly involved in developing the care plan.
  11. Review the care plan quarterly, annually, and following a significant change.
  12. Changes to the care plan should occur as needed in accordance with professional standards of practice and documentation.  CDMs or RDs should communicate changes to the care plan to the IDT members as needed.

Types of Care Plans
There are three basic categories of care plans:

  • Traditional
  • Interdisciplinary resident centered
  • Resident or Person directed

Traditional care plans are usually written from the staff’s perspective, meaning they are staff driven. Each department has specific tasks that are done independently of other departments. Residents have some input, but the systems in place drive staffing decisions and resource utilization. Traditional care plans incorporate all aspects of care (e.g. medical, nursing, physical, nutrition, and psychological issues). These care plans may include medical terminology that is unfamiliar to residents or their families. Traditional care plans identify problems with related goals, interventions, and disciplines responsible for implementation. Interventions may be customized for individual residents or selected from a pre-set list.

While the template for the care plan is similar to traditional, interdisciplinary resident-centered care plans give the resident more input in care decisions and customary routines. Interdisciplinary resident-centered care plans incorporate the resident’s preferences, interests, lifestyle choices, spiritual needs, and cultural practices. The goal is to maximize independence in daily life based on unique choices made by the resident. Interdisciplinary resident-centered care plans are written in easy-to­understand language and involve multiple disciplines. Implementing interdisciplinary resident-centered care plans requires teamwork, cooperation, and communication among staff.

The ‘I Care’ resident or person-directed care plans are totally focused on the wants, needs, and desires of the resident. The resident sets goals for care and defines ‘quality of life’ from the resident’s perspective. It is providing care the resident wants in a manner in which the resident wants rather than what works best for the staff. Person-centered care components are determined by asking and listening to the residents. These care plans are intended to honor and respect the voice of the resident. The resident’s wishes are delineated into a format that communicates the message to all members of the team providing care and support. These plans should reflect a balance between competing desires, needs, choices, and safety.

Portions of the care plan may be written from the resident’s perspective. These are called ‘I Care” care plans. Statements in the care plan are written in the first person, I want…, I like…, I prefer…’ The idea of “I” plans is to improve communication with staff about who the person is, to have staff become more familiar with the resident, and to remind them that the resident is more than a room number or a diagnosis, thereby improving the quality of care they receive.

Person-centered care isn’t about generating new forms or increasing workload. It is intended to shift the emphasis away from a paper-oriented process of care delivery. Simply saying your facility has ‘person-centered care’ or embraced ‘culture change’ does not automatically make the changes a reality. Change takes time and effort to evaluate the current systems in place to provide care. These systems are typically reflected in the care plan.

Implications for Practice
Care planning is not about format! Care planning is a process rather than a physical item; it is a means to an end, rather than an end in itself. Person-centered care is more than delivering care or giving care plans a new name. It is shifting emphasis from the mechanics of care plans and delivery of care to actually honoring the uniqueness of that human being who needs our assistance.

By Mary D. Litchford, PhD, RD, LDN

Mary Litchford, PhD, RD, LDN is a nationally-recognized speaker and the author of various articles and books, including Common Denominators of Declining Nutritional Status.