Community Care Information Management

Community Support Services Common Assessment Project

(CSS CAP)

interRAI CAPs (Clinical Assessment Protocols)

& Care Planning

Version 3.0December 2011

2

Welcome and Introductions

Objectives

interRAI Outcome Measures and Scales

Introduction to CAPs and Benefits

How are CAPs Triggered?

Practice Using CAPs Manual

Care Planning

Break

Practice Creating a Care Plan

Wrap-up, Evaluations and Q & A

Agenda: CAPs and Care Planning

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Please introduce yourself– Your name– Your HSP– Your role

What is your personal

goal in attending this

training session?

Participant Introductions

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Ice Breaker

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Education Material

Let’s review:– The Assessor Workbook

– The interRAI Clinical Assessment Protocols Manual

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Upon completion of the CAPs and Care Planning training session you will have increased your understanding about:

• How CAPs focus on the client’s function and quality of life, assessing their needs, strengths and preferences

• The link between information gathered in the interRAI CHA assessment and the triggered CAPs and Outcome Measures and Scales

• How to use CAPs to create a care plan that meets the needs of the client

• How CAPs and Outcome Measures and Scales provide the basis for outcome-based assessments and facilitate referrals where appropriate

Learning Objectives

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Functions of embedded

scales:• Evaluate current status of

client• Track outcomes of care• Aggregate comparisons for

quality benchmarking

Available outcome measures:• Cognitive Performance Scale

(CPS)• Depression Rating Scale (DRS)• IADL Involvement Scale• Changes in Health, End stage

Signs and Symptoms (CHESS)• Pain Scale• Self-Reliance Index (SRI)• ADL Self-Performance Hierarchy

Scale• MAPLe

Adapted with expressed permission from ideas for health, University of Waterloo, June 2010.

The following outcome measures and scales are generated by your

software automatically once the assessment has been completed:

interRAI CHA Outcome Measures and Scales

interRAI CHA Outcome Measures and Scales: Mr. Patterson

Let’s review for Mr. Patterson:

• CPS• Pain• MAPLe

interRAI CHA Outcome Measures and Scales: Mr. Patterson

Let’s review for Mr. Patterson:

• CHESS &• MAPLe

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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

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Key Points About CAPs report:• Generated by software only• Using the information from the Core CHA and Functional

Supplement, it identifies key areas that need to be addressed in the following four sections:– Functional performance– Cognition and mental health– Social life– Clinical issues

• Each section contains CAPs triggered for a client • Guidelines in the manual help the assessor create the plan of care,

provide appropriate service, and/or make timely referrals

The CAP report is generated by your software automatically once the assessment has been completed.

Clinical Assessment Protocols cont’d

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CAPs:• Enable client’s strengths, needs and preferences to be

taken into consideration when developing the care plan

• Guide the plan of care to potentially resolve problems, reduce the risk of decline or increase the potential for improvement

• Help the assessor to visualize a complete picture of the problem: internal and external factors

• Will work with all of the interRAI assessment tools

Benefits of CAPs

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CAPs Throughout interRAI Tools

[ i ] interRAI LTCF, not RAI-MDS 2.0

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CAPs Throughout interRAI Tools (cont’d)

[ ii ] interRAI HC, not RAI-HC 2.0

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Adapted with expressed permission from ideas for Health, University of Waterloo, July 2010.

Functional Performance:• Physical activity promotion• IADL• ADL

Cognition and Mental Health:• Cognitive loss• Communication• Mood• Abusive relationships

Social Life:• Informal support• Social relationships

Clinical Issues:• Falls• Pain• Cardio-respiratory conditions• Dehydration• Prevention• Appropriate medications• Tobacco and alcohol use• Urinary incontinence

CAPs Triggered from Core Assessment

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Functional Performance:• Home environment optimization• Institutional risk

Cognition and Mental Health:• Delirium• Behaviour

Clinical Issues:• Pressure ulcer• Undernutrition• Feeding tube• Bowel conditions

Adapted with expressed permission from ideas for Health, University of Waterloo, July 2010.

Additional CAPs Triggered When Functional Supplement is Completed

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CHA Core Assessment

Triggers:1st: G4a – Activity level less than 2 hrs2nd: G2f- Locomotion-Independent

Physical Activities Promotion

CAP

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

How CAPs are triggered

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• Problem (Client Need)

• Overall Goals of Care

• Triggers

• Guidelines (Service Provision)

How to use the CAPs Manual

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Break

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• 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

From CAPs to Care Planning

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Putting It All Together

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A Care/Service Plan is:

• A communication tool, based on assessment of the client’s care/service needs, is to be used by the care team members

• Intended to put measures in to place to prevent decline and manage risk

• A collaborative plan of service created with input from client and assessor

Care/Service Planning

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Characteristics of a Care Plan

• Individualized

• Current

• Accurate

• Clear

• Relevant

• Collaborative

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*Client Needs = Problems in CAPs Manual

**Service Provision = Guidelines in CAPs Manual

Components of a Care Plan

DATEDATE TRIGGERED TRIGGERED CAPCAP

CLIENT CLIENT NEED NEED

(Problem (Problem Statement)Statement)

CLIENT CLIENT GOALGOAL

SERVICE SERVICE PROVISION PROVISION ((Guidelines)Guidelines)

RESPONSIBLE RESPONSIBLE PROVIDERPROVIDER

REVIEW REVIEW DATEDATE

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• Divide into small groups • Assign a recorder and

presenter• Using case study, CAPs

Report and CAPs Manual create a care/service plan for the assigned CAP

• Share results in the large group

Let’s practice!

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Assessment Process Flow

Review: phone call or visit to review any aspect of the care/service plan

Reassessment: face to face comprehensive assessment

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Education Material

• Powerpoint presentations• Case studies• Reference sheets• Evaluations• interRAI CHA CAPs

Manual for project-led sessions

• Facilitator binder• Assessor workbook• Certificate of completion

Project Supports• Website

– www.ccim.on.ca– Electronic copy of all

education material

• Support Centre– csscap@ccim.on.ca– 1-866-909-5600 option 9

• Supportive calls from project

Training Resources

Next Steps

Electronic Care/Service Planning

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• Certificate of completion signed by facilitator • Let’s sign up for Supported Training - CAPs and

Care Planning• Evaluation

Next Steps

Wrap-up and Questions

Thank you!

Project Support CentreContact InformationEmail: csscap@ccim.on.ca

Toll Free: 1-866-909-5600, option 9

Website: www.ccim.on.ca