It’s Not Just a Desk Job: Improving Person-Centered Care Through the RAI Process

Posted By: Emily Royalty-Bachelor, Staff Writer
Post Date: 11/14/2017

There is no one right or wrong way to be a nurse assessment coordinator. The role often varies by state, by facility, and by the individual filling the role.


But, suffice it to say, there are certain elements of the job that are applicable across the board—like, say, completing the MDS, or scheduling assessments.


Tasks like these usually require the quiet solitude of an office with a closed door, or at least a computer to access software. So it’s understandable why many people might associate the role of a NAC with a desk job.


But the truth is, the RAI process is not something that can be completed from your work chair. And if you’re spending the majority of your workday sitting at a desk, you’re missing out on key elements of your roles and responsibilities. The role of the NAC involves a lot of face-to-face interaction, both with the interdisciplinary team and—especially—with the residents.


NACs, like every other member of the facility staff, are in the business of providing person-centered care. The operative word here is “person.” If you’re not interacting with the people, how can you ensure they’re at the center of the care you’re delivering?


The RAI process, just like every component of care provided at the facility, needs to incorporate the resident’s voice and resident’s choice. Here’s how to make sure you’re doing just that:


Interviews and Care Planning


It starts with the interview process.


In many facilities, it’s the job of social services to conduct the interviews on cognition, mood, and behavior. But in small facilities, these interviews fall to the NAC, as does the pain interview.


“You obviously have to be in front of the resident to get that information, because you’re looking for their voice. You’re giving them the option of choosing among treatment alternatives,” says Maureen McCarthy, BS, RN, RAC-MT, QCP-MT, and president and CEO of Celtic Consulting.


This has always been important, but it has become even more so with the requirements of participation laid out in the Mega Rule, she says.


“It's clear that CMS wants us to utilize more of the resident's voice and choice, not just in care planning but in the direction of their treatment plan. If you're not in front of the resident, telling them the treatment alternatives and asking them what their preferences would be, it's going to be difficult to get that information relayed all the way to the care plan, so that the folks who are taking care of this resident know how this resident prefers to be taken care of,” she says.


As an example, says McCarthy, she once knew of a resident with mid-level dementia who was averse to showers.


“Prior to The Brady Bunch, there really weren't showers in people's bathrooms. You had a bathtub, you had a sink, you had a toilet. So he was of the age that didn't take showers, and he was convinced that if you took a shower, you were going to get pneumonia,” she said.


Upon his admission, it was indicated in section F of the MDS that he would prefer not to take showers but would prefer baths or sponge baths. But those preferences weren’t incorporated into the plan of care, so the resident was put into the shower, and he became highly distressed as a result.


“They could have saved the patient so much distress if they had gone with his choices and provided an alternative in order to perform the care within the resident's wishes,” she says.


Section GG and Resident Goals


Another way resident voice can be heard through the RAI process is with section GG, which was added last year.


“One of the pieces that we're supposed to be doing is collaborating with the clinical staff and the rehab staff as to determining this resident’s usual performance. So we should also be talking to the resident and/or their representatives and asking to find out, ‘What was your prior performance? What level were you at? What are you normally able to do at home?’” says McCarthy.


McCarthy estimates that in two-thirds of facilities, section GG completion is left up to rehab, with very little nursing involvement.


“So we're really not looking at the usual performance within the unit. We're really asking rehab to guide that decision-making component, and they're not always talking to the resident first,” she says.


As an example, McCarthy recalls a particular rehab company she consulted with that decided it would list only one goal in section GG, because CMS didn’t require more than one goal to be noted.


“The resident had other goals that would have also been appropriate to document, but they only put the one,” she says.


The biggest problem? The goal that was listed didn’t accurately reflect a goal of the resident’s.


“They never talked to the resident before they established the goal, and when it came to reviewing the goal and initiating the rehab plan, the resident said, ‘I'm not going to do that, that's not my goal.’ They set up these goals in a vacuum without asking the resident,” says McCarthy.


That’s not what CMS is looking for. That’s why it’s important when establishing resident goals to ask person-centered questions: What are your goals for admission? What do you plan to get out of your stay here? What would you like to be able to do by the time you're discharged?


“So if we think the resident needs to get up 17 stairs to the second floor to get into their master bedroom, and the resident comes back and says, ‘No, I'm getting a hospital bed in my dining room and I only need to go up three stairs to get into my home,’ that's a different goal. And we should be asking that of the resident to develop that care plan,” says McCarthy.

And communication shouldn’t stop at the resident; all members of the IDT should be communicating with each other regarding the resident’s particular goals as they relate to that discipline.


“Let them know what you learned about the resident. Say, ‘Hey, listen. When I was speaking to the resident, they told me that they'd like to do this, this, and this. How can we overcome or mitigate this problem and come together for the benefit of the resident?” says McCarthy. “The care plan should become the resident's tool on how to take care of them, rather than the interdisciplinary team's assessment of what those problems are.”


And the NAC has a vital role in this, since she is the connecting piece between the care plan and the rest of the IDT.


“She's the hub, they're the spokes,” says McCarthy.


But, she adds, person-centered care has to start before the NAC—it starts with the nurse admitting the resident and with the baseline care plan, which is completed within the first 48 hours after admission.


“From there, the NAC should be verifying what she's collected from that nursing admission assessment when she's putting that care plan together. She should say, ‘When you were first admitted, you told us what your goals would be,’ and then just to verify that the information is correct,” says McCarthy. “And then when we come around the table, we can set up our staff competencies, we can set up our education and discharge planning based on knowing that these goals are appropriate, the resident is in agreement with them, and now the whole team is moving forward in the same direction.”


Looking Toward the Future: Discharge Plans and Care Planning


McCarthy believes that transitions of care will eventually be linked to the person-centered care process.


“When we're discharging to the next entity or level of care, whether it's home health, an outpatient rehab facility, or just a caregiver in the home—I think setting up that discharge plan will involve care-planning goals, to make sure that's available to the next caregiver downstream, so that they'll know exactly where to pick up with this resident,” she says.


For instance, she says, think about a resident who has a shoulder injury and has reached the stage of being able to brush his own teeth but can’t yet squeeze the toothpaste onto the toothbrush.


“The next-level downstream caregiver then knows that they need to start working on the fine motor skills to be able to squeeze the toothpaste. They would know right where to pick up. So I think that the care planning can also help discharge planning in the future, as long as we continue to make it resident-centered, involve the next level of care in that care-planning process, and make sure that it's all set up so the resident doesn’t lose any momentum.”




The long and the short of it is this: as an MDS coordinator, you can’t do your job effectively if you are doing it solely from your desk. As much as it’s your job to fill out the MDS, it is also your job to prevent adverse reactions and promote quality assurance through resident-centered care. In long-term care, quality is everyone’s job. To be an effective quality specialist, consider advancing your skills by becoming a QAPI Certified Professional

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