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This information was taken from the CMS training materials which
you can find on
the CMS site.
The updated Resident Assessment Instrument (RAI) consists of
three basic components:
1) the Minimum Data Set (MDS) Version 3.0,
2) the Care Area Assessment (CAA) process, and
3) the RAI Utilization Guidelines.
The RAI-related processes help staff identify key information
about residents as a basis for identifying resident-specific issues
and objectives. In accordance with 42 CFR 483.20(k) 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 services that are to be furnished
to attain or maintain the resident's highest practicable physical,
mental, and psychosocial well-being and any services that would
otherwise be required but are not provided due to the resident's
exercise of rights including the right to refuse treatment.
The MDS is a starting point. The Minimum Data Set (MDS) is a standardized
instrument used to assess nursing home residents. It is a collection
of basic physical (e.g., medical conditions, mood, and vision),
functional (e.g., activities of daily living, behavior), and psychosocial
(e.g., preferences, goals, and interests) information about residents.
When it is completed, the MDS provides a foundation for a more
thorough assessment and the development of an individualized care
plan.
The information in the MDS constitutes the core of the required
State-specified Resident Assessment Instrument (RAI). Based on
assessing the resident, the MDS identifies actual or potential
areas of concern. The remainder of the RAI process supports the
efforts of nursing home staff, health professionals, and practitioners
to further assess these triggered areas of concern in order to
identify, to the extent possible, whether the findings represent
a problem or risk requiring further intervention, as well as the
causes and risk factors related to the triggered care area under
assessment. These conclusions then provide the basis for developing
an individualized care plan for each resident.
The CAA process provides a framework for guiding the review of
triggered areas, and clarification of a resident's functional
status and related causes of impairments. It also provides a basis
for additional assessment of potential issues, including related
risk factors. The assessment of the causes and contributing factors
gives the interdisciplinary team (IDT) additional information
to help them develop a comprehensive plan of care.
When implemented properly, the CAA process should help staff:
*Consider each resident as a whole, with unique characteristics
and strengths that affect his or her capacity to function; *Identify
areas of concern that may warrant interventions;
*Develop, to the extent possible, interventions to help improve,
stabilize, or prevent decline in physical, functional, and psychosocial
well-being, in the context of the resident's condition, choices,
and preferences for interventions; and
*Address the need and desire for other important considerations,
such as advanced care planning and palliative care; e.g., symptom
relief and pain management.
What Are the Care Area Assessments (CAAs)?
The completed MDS must be analyzed and combined with other relevant
information to develop an individualized care plan. To help nursing
facilities apply assessment data collected on the MDS, previous
MDS versions provided Resident Assessment Protocols (RAPs) that
were triggered by MDS item responses specific to a resident that
alerted the assessor to the resident's possible problems, needs
or strengths. For the MDS 3.0, the RAPs have been replaced by
Care Area Assessments (CAAs). CAAs are identified by responses
to items coded on the MDS.
Specific "CAT logic". The CAAs reflect conditions, symptoms, and
other areas of concern that are common in nursing home residents
and are commonly identified or suggested by MDS findings. Interpreting
and addressing the care areas identified by the CATs is the basis
of the Care Area Assessment process, and can help provide additional
information for the development of an individualized care plan.
The CAA process does not mandate any specific tool for completing
the further assessment of the triggered areas, nor does it provide
any specific guidance on how to understand or interpret the triggered
areas. Instead, facilities are instructed to identify and use
tools that are current and grounded in current clinical standards
of practice, such as evidence-based or expert-endorsed research,
clinical practice guidelines, and resources. When applying these
evidence-based resources to practice, the use of sound clinical
problem solving and decision making (often called "critical thinking")
skills is imperative.
By statute, the RAI must be completed within 14 days of admission.
As an integral part of the RAI, CAAs must be completed and documented
within the same time frame. While a workup cannot always be completed
within 14 days, it is expected that nursing homes will make at
least some initial care planning decisions and not wait the entire
three weeks (i.e., until the required care plan completion date).
Documentation of interim care planning decisions must be made
along with the plan for further assessment and care planning,
as indicated, through the CAA process. For example, the initial
CAA review of urinary incontinence (CAA #6) may point out the
need for a more extensive evaluation, which cannot be completed
entirely within the required time period; however, some interventions
(e.g., recording and evaluating frequency and times of incontinence
and toileting and response to specific interventions) could be
initiated without waiting.
CAAs are not required for Medicare PPS assessments. They are required
only for OBRA comprehensive assessments (Admission, Annual, Significant
Change in Status, or Significant Correction of a Prior Full).
However, when a Medicare PPS assessment is combined with an OBRA
comprehensive assessment, the CAAs must be completed in order
to meet the requirements of the OBRA comprehensive assessment.
What Does the CAA Process Involve?
Facilities use the findings from the comprehensive assessment
to develop an individualized care plan to meet each resident's
needs. The CAA process refers to identifying and clarifying areas
of concern that are triggered based on how specific MDS items
are coded on the MDS. The process focuses on evaluating these
triggered care areas using the CAAs, but does not provide exact
detail on how to select pertinent interventions for care planning.
Interventions must be individualized and based on applying effective
problem solving and decision making approaches to all of the information
available for each resident.
Care Area Triggers (CATs) identify conditions that may require
further evaluation because they may have an impact on specific
issues and/or conditions, or the risk of issues and/or conditions
for the resident. Each triggered item must be assessed further
through the use of the CAA process to facilitate care plan decision
making, but it may or may not represent a condition that should
or will be addressed in the care plan. The significance and causes
of any given trigger may vary for different residents or in different
situations for the same resident. Different CATs may have common
causes, or various items associated with several CATs may be connected.
CATs provide a "flag" for the IDT members, indicating that the
triggered care area needs to be assessed more completely prior
to making care planning decisions. Further assessment of a triggered
care area may identify causes, risk factors, and complications
associated with the care area condition. The plan of care then
addresses these factors with the goal of promoting the resident's
highest practicable level of functioning: (1) improvement where
possible or (2) maintenance and prevention of avoidable declines.
A risk factor increases the chances of having a negative outcome
or complication. For example, impaired bed mobility may increase
the risk of getting a pressure ulcer. In this example, impaired
bed mobility is the risk factor, unrelieved pressure is the effect
of the compromised bed mobility, and the potential pressure ulcer
is the complication.
Even if the MDS does not trigger a particular care area, the facility
can use the CAA process and resources at any time to further assess
the resident. Recognizing the connection among these symptoms
and treating the underlying cause(s) to the extent possible, can
help address complications and improve the resident's outcome.
Conversely, failing to recognize the links and instead trying
to address the triggers or MDS findings in isolation may have
little if any benefit for the resident with hypothyroidism or
other complex or mixed causes of impaired behavior, cognition,
and mood.
The RAI is not intended to provide diagnostic advice, nor is it
intended to specify which triggered areas may be related to one
another or and how those problems relate to underlying causes.
It is up to the IDT, including the resident's physician, to determine
these connections and underlying causes as they assess the triggered
care areas and any other areas pertinent to the individual resident.
Not all triggers identify deficits or problems. Some triggers
indicate areas of resident strengths, and can suggest possible
approaches to improve a resident's functioning or minimize decline.
For example, MDS item responses indicate the "resident believes
he or she is capable of increased independence in at least some
ADLs" (item G0900A) may focus the assessment and care plan on
functional areas most important to the resident or on the area
with the greatest potential for improvement.
In addition to identifying causes and risk factors that contribute
to the resident's care area issues or conditions, the CAA process
may help the IDT Identify and address associated causes and effects;
*Determine whether and how multiple triggered conditions are related;
*Identify a need to obtain additional medical, functional, psychosocial,
financial, or other information about a resident's condition that
may be obtained from sources such as the resident, the resident's
family or other responsible party, the attending physician, direct
care staff, rehabilitative staff, or that requires laboratory
and diagnostic tests;
*Identify whether and how a triggered condition actually affects
the resident's function and quality of life, or whether the resident
is at particular risk of developing the conditions;
*Review the resident's situation with a health care practitioner
(e.g., attending physician, medical director, or nurse practitioner),
to try to identify links among causes and between causes and consequences,
and to identify pertinent tests, consultations, and interventions;
*Review the resident's situation with a health care practitioner
(e.g., attending physician, medical director, or nurse practitioner),
to try to identify links among causes and between causes and consequences,
and to identify pertinent tests, consultations, and interventions;
*Determine whether a resident could potentially benefit from rehabilitative
interventions;
*Begin to develop an individualized care plan with measurable
objectives and timetables to meet a resident's medical, functional,
mental and psychosocial needs as identified through the comprehensive
assessment.
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