- Email: [email protected]
Care based on need
CareBased On Need Decisions that are relevant to a person's status at a particular time do not remain relevant indefinitely; they must be reviewed periodically to correspond with the changing status of that person viewed in his or her entirety. The Long-Term Care Information System was developed in reANGELA FALCONE sponse to elders' problems in obThe Long-Term Care Information taining health services, problems System Assessment Process pre- caused by the fragmented nature of sented here describes the current long-term care in this country. Sestatus of older and chronically ill curing proper care obliges older persons in order that timely, rele- people to be expert judges of their vant decisions can be made about needs, knowledgeable about all sernursing care. vices available, and familiar with Living into older age carries with the eligibility requirements. Many it experiences and adjustments that health professionals are unaware of in myriad ways have directed suc- the range of long-term care proceeding events or caused some per- grams and their capacities, so it is manent alteration. All of us are unlikely that lay people would have changing constantly in response to th is information. physical, psychological, social, and The result is that most people environmental events. The types seek care from the service proand extent of change depend on the grams they know to be available. intensity of the precipitating event, Unfortunately, most health practiwhether it occurs solely, and on the tioners also adhere to a servicestrength and receptivity of the per- oriented rather than patientson it affects. The elderly, having oriented point of view. Consequentresponded to the greatest number ly, when people are not fitted to of events, are the most complex of services that best suit their needs, all human beings. outcomes are unsatisfactory, serThis complexity requires that vices are misused, and time and caregivers be knowledgeable about money are wasted. The individual the interrelationship of all dimen- must be the main focus of all decisions of each person when making sion making. care decisions. A decision made The LTCIS provides the comprewithout this understanding risks hensive assessment and projections being anything from incomplete to of service need that become the baharmful. Because events continue sis for long-term care decisions that to occur, people continue to change. are oriented to the individual. The framework for such decisions is called the care management cycle. A"Iela Falcone, RN, MPH, is executive d i- This cycle is initiated when an indirector of the Long-Term Care Assessment Training Center, Department of Public vidual seeks access to care. AssessHealth at Cornell University Medical Cen- ment, the next step, is simply a description of the person as he or she ter. New York. NY.
Matching services to the elder's needs is the secret of this practical and tested tool.
376 Ger iatric Nursing November/December 1984
is at the present time without judgments as to what the information might mean or decisions about what should be done about it. These judgments take place in subsequent steps of the care cycle. For an assessement to be as accurate and useful as possible, it must be comprehensive, objective, and in language common to all service practitioners. Basing decisions on anything less than comprehensive information leads to inappropriate or incomplete care. A printed diet sheet and instructions might be given to a woman who is described in the Assessment Process as overweight. Later in the care management cycle, it appears that the woman has not followed the diet. There are many possible reasons: her income is insufficient to buy foods listed in the diet, or she is illiterate and unable to read the instructions. Her visual impairment might be such that she cannot distinguish the printed page, or her living arrangement might not include kitchen appliances. If any of these constraints were known in advance, adjustments could have been made. The LTCIS Assessment Process describes an individual's sociodemographic status and identifying information; environmental, social support, and involved service provider information; medical status; functioning status; and services currently received(l). Sociodemographic and identifying information describes an individual's social and personal resources, providers from whom the individual is receiving services, usual living arrangements, and supportive services provided by family or friends. Medical status information includes a client's impairments, risk factors, medical conditions, and surgeries. Functioning status describes how an individual performs daily activities, communicates, moves about, and actually behaves, and his orientation. Services received describes therapies, other supportive services, nutritional status, nursing care, and the medications currently being taken. (See Assessment Process).
,,An assessment that is useful to more than one caregiver requires that the information be stated in objective terms that describe observable and/or measurable qualities rather than in subjective or interpretive terms. An objective description of how a man walks would be "he walks with a mechanical aid, a walker." A subjective description would be that "he can walk" with no mention of whether he actually walks. "He could walk alone" is an interpretive description that still does not mention whether he actually walks. All information in the LTCIS Assessment Process is stated in objective terms so that different assessors record the same information about the same individual in the same way. The information is presented in mutually exclusive, exhaustive categories for computerization if data processing and analysis are desired. Whenever more than one service practitioner is or will be involved in an individual's care, it is essential that there be mutual understanding and a means to communicate about that individual. A comprehensive, organized, treatment program and continuity of care are seriously jeopardized if a common "language" is not used by all service practitioners. Each item in the LTCIS Assessment Process is defined in easily understood and remembered terms. The use of this assessment language when describing an individual reduces disagreements about care decisions among practitioners with different educational backgrounds or employment settings. Clear communication among shifts and between providers at the time of referral helps assure that care will continue without interruption. After the assessment information is obtained, it is reviewed in its entirety in the second step of the care management cycle to determine whether the individual has service needs. On the form Translation to Service Needs, 20 items of the assessment information are used to project whether any of 11 different services is required. The services
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are audiology, dental services, emotionaI and social assessment or treatment, homefinding, housekeeping, meal preparation, nursing, ophthalmology/optometry, physi'cal therapy, shopping, and speech therapy (see Translation to Service Needs). To project, or predict, the service needs requires that the specific Assessment Process terms be used so that experienced professionals can make accurate decisions about service need. If an individual is noted to have a hearing impairment for which no compensation is used or has been attempted, audiology testing is recommended. Dental service is recommended when the assessment shows less than a majority of adult
j -
-
-t
-
teeth present and no compensation used. The individual's combined behavior pattern and orientation status indicates whether he needs supervision by others, an emotional and social assessment, or immediate treatment. The needs for housekeeping, meal preparation, and nursing care are predictable by the levels at which the individual performs activities of daily living: bathing, dressing, toileting, transferring, bowel function, bladder function, and eatingjfeedingtz). A person who is dependent in two or more of these activities needs the assistance of a nurse's aide or lay person and housekeeping services. Someone dependent in five or more
Geriatric Nursing November/December 1984377
activities needs the additional services of a nurse and help with meal preparation. These projections do not suggest that the skills of a nurse are necessary to assist the individual directly with activities of daily living, but that a nurse is needed, at a minimum, to plan, direct, and supervise service provision. Individuals fed intravenously or by clysis are in need of a professional nurse. .Gauging the need for a practical or registered nurse to administer medications, monitor drug effects, or both is also done to determine requirements for nursing care. Uncorrected visual impairment calls for evaluation by an ophthalmologist or optometrist. The assessment ofjoint motion, paralysis/ paresis, missing limbs, and frac-
378 Geriatric Nursing . November/December 1984
tured hips projects the need for physical therapy. A speech impairment occurring within the previous six months indicates a need for speech therapy. If living arrangements are a problem, home-finding services to locate noninstitutional living space are specified. The LTCIS Assessment Process is comprised of the assessment and Translation to Service Needs just described. Using this information and service-needs projections for decision making leads to the next step in the care management cycle-the planning and specific decision-making steps. Referral or discharge planning is a systematic process. Determining the array of services needed is the first step in this process . How fre-
quently the ' required services are needed is addressed. Those services that an individual's own social support system will provide are recorded. Service programs in an individual's community that can provide for each of his remaining needs are taken into account. The individual's methods of payment-from private insurance, government programs, and self-pay to no charge for service or no known method of payment-are matched with available providers. It is futile to refer an individual for a service when there is no method of payment. It is important to explore all possible payment sources on the individual's behalf. The possible combinations of service providers actually available are then presented as referral options for patient, family, physician, and referral planner. Referral decisions are validated in this way. Level of care decisions based on the criteria in use are made by comparing . the criteria with applicable assessmentand service need data. A specific care plan is developed next by reviewing the assessment in its entirety to identify all risk fac tors or functions that are not within normal ranges. Impaired functions are dealt with in the care plan. Related problems are combined and addressed as a whole. Two schools of thought about care plans exist. One maintains that all problems should be listed even if the plan of treatment is to do nothing at the time. The other holds that only priority problems be listed and addressed. Both approaches are ' possible within the care management cycle as are combinations and variations of each. A frequent difficulty with care plans is the choice of terms. One of the most useful features of the LTCIS is its objective, common language. The words used in the Assessment Process are sci precise they can be used on the care plan. If it has been judged that "walks with mechanical help , a walker," as stated on the assessment, is a problem for the client, then the care plan will note in the problem list, "walks with mechanical help, a
walker." This straightforward method of listing problems has several advantages: it documents that the problem exists, calls the problem to everyone's attention, and saves time for the authorts) of the care plan. Once problems have been listed, the anticipated goals are recorded and a time specified for their accomplishment. The goals are stated in measurable terms so that there is a way to determine whether they have been met. The most direct way to set goals is to decide first whether improvement, maintenance, or deterioration is the expected outcome within the time set. The amount of change to expect must be reasonable or the individual and caregivers will be frustrated by failure or by the impracticality of the plan. The terms used to describe the goals are derived from the assessment. If improvement is expected in walking, the goal would be listed as "walks without help." If maintenance is expected, "walks with mechanical help, a walker," would be the goal. If deterioration is likely, "walks with mechanical and human help" or "does not walk" would be listed. Treatment or care approaches to accomplish the goals set for each problem are recorded next. These approaches are stated simply and include the kind of treatment, frequency, any pertinent details of its performance, and the expected caregivers. Once that is finished, the discharge plan is developed and recorded as part of the care plan. If it is decided that the individual should continue to receive service at the setting where he is located, this is recorded as the discharge plan. But if the individual might benefit from referral elsewhere, then a referral or discharge plan would be made. The individual's agreement with the care, discharge, or referral plans is essential if they are to be useful. Assessment Process completion, referral, and care planning can be accomplished by one practitioner working alone or by a caregiving
team. II! either case, there is only one care plan, the individual's, not separate plans for different practitioners. The fourth step in the care management cycle is to provide the services and treatment approaches specified in the care plan. The provision or non provision of those services is documented in the person's record. Immediate effects from those treatments and unusual occurrences are recorded also. At the time specified in the care plan for achieving goals, the individual is assessed again to learn his current status and determine whether the treatment approaches were successful, the goals realistic
Hundreds of health care providers across the U.S. are finding LTCIS tools helpful.
or too ambitious, the individual not motivated to participate, and so on. Documentation on whether the treatment approaches were followed and other effects are useful in the progress evaluation. Reassessment is the initial step of the next care management cycle. After the information has been reviewed to evaluate progress, the reassessment data are available to use in the steps of service need identification, referral and care planning, service provision, and back again to assessment. When the assessment information indicates that no services are needed, the individual goes off the cyclehe has become independent in all ways, has died, or has moved out of the service provision area. The Assessment Process form becomes a summary of the individual's progress during the time service was provided. At referral, the Assessment Process becomes the transfer or referral form. The LTCIS Assessment Process is also valuable for utilization re-
view decisions, pharmacy review, health .planning, staffing needs, and orientation of new staff. Equally important, it can be the framework for gerontological nursing education. The Assessment Process has been successfully tested for statistical significance(3). It has been in use by every type of service provider concerned with long-term care for more than five years. An LTCIS Assessment Process manual and abstract forms are designed for teaching and everyday use. At present about 700 health care providers across the United States are using the LTCIS Assessment Process for many purposes. It is the official assessment tool in the statewide preadmission screening program in Virginia and is being considered for use in two other states. Nurses, social workers, physicians, therapists, nurses' aides. outreach workers, and administrators use the LTCIS for various purposes. A more recently developed Patient Care Management Record System is now available. It incorporates the Assessment Process and all other information needed to manage and to satisfy Medicare and licensure regulations. This new record provides practitioners and administrators with a streamlined, cost-efficient, and useful management tool. Education, training, and consultation about how to use the LTCIS Assessment Process and Patient Care Management Record System, and about their incorporation with existing or new programs is available from the Long-Term Care Assessment Training Center, Cornell University Medical College, 421 East 70th Street, New York, New York 10021. References I. Jones, E. W. Patient Classification for LongTerm Care: users manual. (DHEW Pub!. No. (HRA) 74·3107) Washinaton. DC. U.S. Gov· ernrnent Printing Office, 1974. 2. Katz, S .• and Akpom, C. A. A measure of primary sociobiological functions. Tn(J.Health Servo 6(3):493-508, 1976. 3. Falcone. A. R. Development 0/ a Long-Term Care Information System Final Report. (W. K. Ke1loa Foundation Grant No. 5(0) Lansing, Michigan Office of Services to the Allin •• 1979.
Geriatric Nursina November/December 1984379
Matching services to the elder's needs is the secret of this practical and tested tool.
376 Ger iatric Nursing November/December 1984
is at the present time without judgments as to what the information might mean or decisions about what should be done about it. These judgments take place in subsequent steps of the care cycle. For an assessement to be as accurate and useful as possible, it must be comprehensive, objective, and in language common to all service practitioners. Basing decisions on anything less than comprehensive information leads to inappropriate or incomplete care. A printed diet sheet and instructions might be given to a woman who is described in the Assessment Process as overweight. Later in the care management cycle, it appears that the woman has not followed the diet. There are many possible reasons: her income is insufficient to buy foods listed in the diet, or she is illiterate and unable to read the instructions. Her visual impairment might be such that she cannot distinguish the printed page, or her living arrangement might not include kitchen appliances. If any of these constraints were known in advance, adjustments could have been made. The LTCIS Assessment Process describes an individual's sociodemographic status and identifying information; environmental, social support, and involved service provider information; medical status; functioning status; and services currently received(l). Sociodemographic and identifying information describes an individual's social and personal resources, providers from whom the individual is receiving services, usual living arrangements, and supportive services provided by family or friends. Medical status information includes a client's impairments, risk factors, medical conditions, and surgeries. Functioning status describes how an individual performs daily activities, communicates, moves about, and actually behaves, and his orientation. Services received describes therapies, other supportive services, nutritional status, nursing care, and the medications currently being taken. (See Assessment Process).
,,An assessment that is useful to more than one caregiver requires that the information be stated in objective terms that describe observable and/or measurable qualities rather than in subjective or interpretive terms. An objective description of how a man walks would be "he walks with a mechanical aid, a walker." A subjective description would be that "he can walk" with no mention of whether he actually walks. "He could walk alone" is an interpretive description that still does not mention whether he actually walks. All information in the LTCIS Assessment Process is stated in objective terms so that different assessors record the same information about the same individual in the same way. The information is presented in mutually exclusive, exhaustive categories for computerization if data processing and analysis are desired. Whenever more than one service practitioner is or will be involved in an individual's care, it is essential that there be mutual understanding and a means to communicate about that individual. A comprehensive, organized, treatment program and continuity of care are seriously jeopardized if a common "language" is not used by all service practitioners. Each item in the LTCIS Assessment Process is defined in easily understood and remembered terms. The use of this assessment language when describing an individual reduces disagreements about care decisions among practitioners with different educational backgrounds or employment settings. Clear communication among shifts and between providers at the time of referral helps assure that care will continue without interruption. After the assessment information is obtained, it is reviewed in its entirety in the second step of the care management cycle to determine whether the individual has service needs. On the form Translation to Service Needs, 20 items of the assessment information are used to project whether any of 11 different services is required. The services
I TUI:PMQC SU....ARy OF PROVIDERS
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I~ -"
-!L
DATE
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~
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are audiology, dental services, emotionaI and social assessment or treatment, homefinding, housekeeping, meal preparation, nursing, ophthalmology/optometry, physi'cal therapy, shopping, and speech therapy (see Translation to Service Needs). To project, or predict, the service needs requires that the specific Assessment Process terms be used so that experienced professionals can make accurate decisions about service need. If an individual is noted to have a hearing impairment for which no compensation is used or has been attempted, audiology testing is recommended. Dental service is recommended when the assessment shows less than a majority of adult
j -
-
-t
-
teeth present and no compensation used. The individual's combined behavior pattern and orientation status indicates whether he needs supervision by others, an emotional and social assessment, or immediate treatment. The needs for housekeeping, meal preparation, and nursing care are predictable by the levels at which the individual performs activities of daily living: bathing, dressing, toileting, transferring, bowel function, bladder function, and eatingjfeedingtz). A person who is dependent in two or more of these activities needs the assistance of a nurse's aide or lay person and housekeeping services. Someone dependent in five or more
Geriatric Nursing November/December 1984377
activities needs the additional services of a nurse and help with meal preparation. These projections do not suggest that the skills of a nurse are necessary to assist the individual directly with activities of daily living, but that a nurse is needed, at a minimum, to plan, direct, and supervise service provision. Individuals fed intravenously or by clysis are in need of a professional nurse. .Gauging the need for a practical or registered nurse to administer medications, monitor drug effects, or both is also done to determine requirements for nursing care. Uncorrected visual impairment calls for evaluation by an ophthalmologist or optometrist. The assessment ofjoint motion, paralysis/ paresis, missing limbs, and frac-
378 Geriatric Nursing . November/December 1984
tured hips projects the need for physical therapy. A speech impairment occurring within the previous six months indicates a need for speech therapy. If living arrangements are a problem, home-finding services to locate noninstitutional living space are specified. The LTCIS Assessment Process is comprised of the assessment and Translation to Service Needs just described. Using this information and service-needs projections for decision making leads to the next step in the care management cycle-the planning and specific decision-making steps. Referral or discharge planning is a systematic process. Determining the array of services needed is the first step in this process . How fre-
quently the ' required services are needed is addressed. Those services that an individual's own social support system will provide are recorded. Service programs in an individual's community that can provide for each of his remaining needs are taken into account. The individual's methods of payment-from private insurance, government programs, and self-pay to no charge for service or no known method of payment-are matched with available providers. It is futile to refer an individual for a service when there is no method of payment. It is important to explore all possible payment sources on the individual's behalf. The possible combinations of service providers actually available are then presented as referral options for patient, family, physician, and referral planner. Referral decisions are validated in this way. Level of care decisions based on the criteria in use are made by comparing . the criteria with applicable assessmentand service need data. A specific care plan is developed next by reviewing the assessment in its entirety to identify all risk fac tors or functions that are not within normal ranges. Impaired functions are dealt with in the care plan. Related problems are combined and addressed as a whole. Two schools of thought about care plans exist. One maintains that all problems should be listed even if the plan of treatment is to do nothing at the time. The other holds that only priority problems be listed and addressed. Both approaches are ' possible within the care management cycle as are combinations and variations of each. A frequent difficulty with care plans is the choice of terms. One of the most useful features of the LTCIS is its objective, common language. The words used in the Assessment Process are sci precise they can be used on the care plan. If it has been judged that "walks with mechanical help , a walker," as stated on the assessment, is a problem for the client, then the care plan will note in the problem list, "walks with mechanical help, a
walker." This straightforward method of listing problems has several advantages: it documents that the problem exists, calls the problem to everyone's attention, and saves time for the authorts) of the care plan. Once problems have been listed, the anticipated goals are recorded and a time specified for their accomplishment. The goals are stated in measurable terms so that there is a way to determine whether they have been met. The most direct way to set goals is to decide first whether improvement, maintenance, or deterioration is the expected outcome within the time set. The amount of change to expect must be reasonable or the individual and caregivers will be frustrated by failure or by the impracticality of the plan. The terms used to describe the goals are derived from the assessment. If improvement is expected in walking, the goal would be listed as "walks without help." If maintenance is expected, "walks with mechanical help, a walker," would be the goal. If deterioration is likely, "walks with mechanical and human help" or "does not walk" would be listed. Treatment or care approaches to accomplish the goals set for each problem are recorded next. These approaches are stated simply and include the kind of treatment, frequency, any pertinent details of its performance, and the expected caregivers. Once that is finished, the discharge plan is developed and recorded as part of the care plan. If it is decided that the individual should continue to receive service at the setting where he is located, this is recorded as the discharge plan. But if the individual might benefit from referral elsewhere, then a referral or discharge plan would be made. The individual's agreement with the care, discharge, or referral plans is essential if they are to be useful. Assessment Process completion, referral, and care planning can be accomplished by one practitioner working alone or by a caregiving
team. II! either case, there is only one care plan, the individual's, not separate plans for different practitioners. The fourth step in the care management cycle is to provide the services and treatment approaches specified in the care plan. The provision or non provision of those services is documented in the person's record. Immediate effects from those treatments and unusual occurrences are recorded also. At the time specified in the care plan for achieving goals, the individual is assessed again to learn his current status and determine whether the treatment approaches were successful, the goals realistic
Hundreds of health care providers across the U.S. are finding LTCIS tools helpful.
or too ambitious, the individual not motivated to participate, and so on. Documentation on whether the treatment approaches were followed and other effects are useful in the progress evaluation. Reassessment is the initial step of the next care management cycle. After the information has been reviewed to evaluate progress, the reassessment data are available to use in the steps of service need identification, referral and care planning, service provision, and back again to assessment. When the assessment information indicates that no services are needed, the individual goes off the cyclehe has become independent in all ways, has died, or has moved out of the service provision area. The Assessment Process form becomes a summary of the individual's progress during the time service was provided. At referral, the Assessment Process becomes the transfer or referral form. The LTCIS Assessment Process is also valuable for utilization re-
view decisions, pharmacy review, health .planning, staffing needs, and orientation of new staff. Equally important, it can be the framework for gerontological nursing education. The Assessment Process has been successfully tested for statistical significance(3). It has been in use by every type of service provider concerned with long-term care for more than five years. An LTCIS Assessment Process manual and abstract forms are designed for teaching and everyday use. At present about 700 health care providers across the United States are using the LTCIS Assessment Process for many purposes. It is the official assessment tool in the statewide preadmission screening program in Virginia and is being considered for use in two other states. Nurses, social workers, physicians, therapists, nurses' aides. outreach workers, and administrators use the LTCIS for various purposes. A more recently developed Patient Care Management Record System is now available. It incorporates the Assessment Process and all other information needed to manage and to satisfy Medicare and licensure regulations. This new record provides practitioners and administrators with a streamlined, cost-efficient, and useful management tool. Education, training, and consultation about how to use the LTCIS Assessment Process and Patient Care Management Record System, and about their incorporation with existing or new programs is available from the Long-Term Care Assessment Training Center, Cornell University Medical College, 421 East 70th Street, New York, New York 10021. References I. Jones, E. W. Patient Classification for LongTerm Care: users manual. (DHEW Pub!. No. (HRA) 74·3107) Washinaton. DC. U.S. Gov· ernrnent Printing Office, 1974. 2. Katz, S .• and Akpom, C. A. A measure of primary sociobiological functions. Tn(J.Health Servo 6(3):493-508, 1976. 3. Falcone. A. R. Development 0/ a Long-Term Care Information System Final Report. (W. K. Ke1loa Foundation Grant No. 5(0) Lansing, Michigan Office of Services to the Allin •• 1979.
Geriatric Nursina November/December 1984379