More About Care Area Assessments  

The first step in documenting CAA findings is to describe the nature of the issue or condition.  This may include presence or lack of objective data and or subjective complaints. In other words, what are the details of the problem for this resident?  Medical history is reviewed and the relevant history related to this specific care area is detailed.  This may include active and historical diagnoses and conditions as well as a brief summary of what led to admission to the SNF.  Potential or actual causes and contributing factors to consider when assessing for the care area triggered should be detailed.  This includes complications affecting or caused by the care area for this resident.

The next step is to identify risk factors that arise because of the presence of the condition that affects the staff's decision to proceed to care planning.  This may include a statement of how your findings may potentially impact the resident given.  What is the patient at risk for given your assessment of why these MDS items triggered (at risk for_____).  What do standards of clinical practice and relevant research findings indicate when a resident has this condition or issue?  This may include outcomes of other standardized assessments (Nursing Assessments). The specific assessment, date completed and score should be stated.

Next, identify factors that must be considered in developing individualized care plan interventions.  This information justifies the decision to proceed or not proceed to care plan for the individual resident.  Resident preferences, history of the condition, and the individualized impact of the issue on the resident should be considered.  For example, a patient may be edentulous for many years yet has had no nutritional or swallowing issues.  Although this triggered, these factors must be considering when determining if there is a need to proceed to care plan as a problem.  

The final step is to determine if there is a need for referrals or further evaluation by appropriate health professionals.  This may include medical professionals outside the facility (ophthalmologist, psychiatrist, dentist) or facility staff (rehabilitation therapies, social services).

The CAA facilitates the care plan decision making, but it may or may not represent a condition that should be addressed in the care plan.  The goal of completion of the CAA is to assess the resident to determine if there is a problem that must be addressed and therefore proceed to care plan.  The care plan then addresses these factors with the goal of promoting the resident's highest practical level of functioning.  This care plan may be developed with a goal of improvement where possible or maintenance with prevention of avoidable declines.  Pain and Return to Community are two new areas to be addresses since the introduction of MDS 3.0. Harmony will discuss the Pain CAA in detail during our upcoming Pain Webinar. See details below.

Contribution by Keri Hart, Harmony Healthcare Regional Director of Operations