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CAAs: How To Maximize Your Process To Produce Quality Care Plans

By Caralyn Davis, Staff Writer - July 23, 2018

The Care Area Assessments (CAAs) are the decision-making process that helps nurse assessment coordinators (NACs) and other interdisciplinary team (IDT) members with the analysis needed to determine what information to pull from the MDS and other resident assessments to develop a clinically relevant, person-centered care plan. The Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual (p. 4-2) explains further:

 “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, Care Area Assessments (CAAs) are triggered responses to items coded on the MDS specific to a resident’s possible problems, needs or strengths. Specific “CAT logic” for each care area is identified under section 4.10 (The Twenty Care Areas). 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.”

Here are eight steps that NACs can implement to get the most out of the CAAs:


Know the value of the CAAs

“Many providers don’t look at the CAAs as a tool to help guide critical thinking,” says Cindy Perrault, RN, RAC-MT, senior consultant for Pathway Health Services in White Bear Lake, MN. “They don’t like them because they don’t see the value in them. As a result, their only focus is paper compliance. They write the CAAs instead of working the CAAs.”

However, the CAAs are essentially the first root-cause analysis tool nursing homes ever had, says Perrault. “If you understand that the intent of the CAAs is not just to reiterate what is on the MDS, you can use these tools to determine whether you have a single root cause of the care area, several big players, or maybe a combination of one or two causes and a handful of smaller issues as well. Utilizing the CAAs to do that root-cause analysis will help you create a care plan that addresses the resident’s underlying concerns and even strengths.”


Don’t fall into the software trap

“Computerization unfortunately has caused the deterioration of the CAA process,” says Robin Hillier, CPA, STNA, LNHA, RAC-MT, president of RLH Consulting in Westerville, OH. “NACs and other IDT members often are trained to simply click through the CAAs generated by their computer systems and then sign them as completed. While the computer can start a care area for you based on items coded on the MDS, it cannot complete a care area without input from the assessor.”

Over-reliance on auto-population is a critical mistake, agrees Perrault. “Too many providers are looking at whatever the software has auto-populated—and stopping there. All of the software programs have some version of the computerized CAA worksheet, but I would estimate that less than 60 percent of the facilities I’ve worked with actually use the worksheet to write an analysis for each CAA.”


Talk to residents and families

“Another very common problem with CAAs is the lack of input from the resident or their family or other representative,” says Hillier. “The RAI User's Manual (p. 4-15) requires this involvement, and it can help provide the valuable history and context necessary to properly complete triggered CAAs.”

Many problems exhibited by residents were present prior to SNF/NF admission, notes Hillier. “Understanding the history of the problem and any interventions that were being used successfully prior to admission to your facility is incredibly valuable to the IDT. In addition, if you start first with obtaining this input, you also will save yourself a lot of time gathering information and doing your root-cause analysis, especially for new admissions or relatively new residents.”

However, obtaining resident/representative input into the CAAs may require some providers to revamp their systems, says Hillier. “Historically, the RAI process has had a certain order: Do the MDS, work on triggered/untriggered care areas, develop the care plan, and then finally sit down with the resident and their family when everything is done.

“But with most residents, you should have an idea within the first few days of admission which care areas will trigger,” she continues. “So even though you don’t have the MDS coded yet, you can talk to the resident and the family and think about the CAA process. You can reverse that typical order for resident/family involvement if you understand that the CAAs aren’t just a paperwork task generated by answering MDS questions.”


Write as you go

A best practice is “to write as you go,” says Perrault. “You should write your analysis as you work through each triggered CAA section, explaining why you decided to pull an issue in or why you decided to weed it out. For example, if you are working the delirium CAA, don’t just say, ‘This is where I found a lab in the medical record.’ Write what you think about that lab. For example, if the lab wasn’t critically low, you told the physician the results, and they chose not to do anything in response to the lab, document that to show your reasoning that the lab results aren’t a key issue for this resident. Writing your thought process as you go instead of writing just at the end of the CAA process means that you won’t forget what you were thinking at the time of your review.”


Find a way for IDT members to talk

“Interdisciplinary communication is often a missing piece in CAAs,” says Hillier. “The RAI User's Manual (p. 4-5) says that the CAA process should help the IDT determine whether and how multiple triggered conditions are related. While the OBRA regulation requires the CAA process to be ‘coordinated’ by an RN, individual care areas are often divvied up and assigned to various IDT members. As each individual completes their assigned CAAs, often there is no interdisciplinary discussion that would allow the team to realize that several of the triggered areas could be related to each other.”

For example, the dietician may work the nutrition CAA, and the social worker may complete the mood CAA, says Hiller. “For a resident who is triggering both care areas, these two IDT members never talk with each other to explore whether they could be related problems. This results in not understanding the true root cause of either problem.”

Optimally, facilities will be able to figure out how the entire IDT can meet for a few minutes in a time-efficient manner after each IDT member has individually worked their CAA, says Hillier. “Different IDT members know the resident in different ways, so staff members can have good input on a care area even when it doesn’t seem related to their area of expertise just because of information that they may know about the resident.”

Some providers have achieved IDT communication by reconfiguring workspaces, says Perrault. “For example, at one of the best office spaces I’ve ever seen, the IDT and the MDS coordinator petitioned the administrator for a common work space. The care plans were wonderful because they had so much interdisciplinary communication for the CAAs. Everyone got information from everyone else as they worked.”

However, NACs may need to use their role as a coordinator to boost IDT communication, says Hillier. “For example, as soon as the MDS is done and the CAAs have triggered, the MDS coordinator can look at all of the CAAs that triggered and think about which ones could be related to each other. Then if the MDS coordinator sees a potential relationship between CAAs, they can take the initiative to pair up the IDT members working those CAAs for a brief discussion.”

While many providers cite a lack of time as the reason they don’t have enough IDT communication, that communication actually can save time in the long run, says Perrault. “For example, psychotropic medication use is addressed in many of the care areas. So if each team member knows what the person writing the psychotropic medication use CAA will cover, they can refer back to that CAA without reinventing the wheel in all of the other CAAs.”

Another issue that can hinder IDT communication is that many staff members have been trained to think, “This CAA is my responsibility. It’s my part of the care plan, and I’ll work on it when I have time,” says Perrault. “However, it’s not your care plan. It’s an interdisciplinary care plan for the resident, and you need to see the value in your co-workers’ information so that you are willing to find the time to sit down and talk about it together.”


Review the medical record, but stick with one chart dig

“A strong CAA will show that you have looked at all of the clinical assessments, not just your area of the medical record, to make sure you have addressed all of the components needed for a thorough analysis of the care area,” says Perrault. “If you start thinking critically and take notes documenting the location of information as you go through the medical record to obtain data to code the MDS, you will only need to do one chart dig for the entire RAI process. You may have to go back and doublecheck a few things when you are working on the CAAs or the care plan, but you won’t have to do three separate chart digs for the MDS, the CAAs, and the care plan.”


Look for untriggered care concerns

“The RAI User's Manual (p. 4-7) instructs providers that they are responsible for assessing and addressing all care areas that are relevant, regardless of whether they are triggered from the MDS,” says Hillier. “However, because many facilities are treating the CAA completion process as a technical compliance step and simply signing what is generated by their computer system, they are failing to meet this requirement.”

RAI User's Manual (p. 4-8) also says that a detailed history of a problem is often necessary to correctly identify and address the root cause of that problem, says Hillier. “However, the MDS was not designed to capture that history—it merely captures the resident’s current functional status. So providers need to employ clinical problem-solving and decision-making in order to properly conduct CAAs.”

When working with the computer-generated CAAs, NACs and other IDT members should consider whether the software has triggered relevant CAAs for the individual resident, says Hillier. “Ask yourself, ‘Are some of the CAAs that I expected to trigger missing, and did other CAAs trigger that I did not expect?’ You can have issues that you need to address that your MDS responses don’t necessarily trigger.” Note: For additional information, see the
RAI User's Manual (p. 4-13).

It may even be beneficial to start this review before the software generates the triggered CAAs, suggests Hillier. “Don’t focus on the MDS. If you think about the resident as the forest and what the MDS generates as the trees, sometimes you have trouble seeing the forest through the trees. So think in general terms about the resident and why they are in the facility, what you know are the resident’s day-to-day challenges, and what you know are people’s concerns about the resident. This will help you identify any untriggered care areas that you may need to address.”


Don’t care plan on autopilot for triggered CAAs

“Intellectually, most NACs know that the mere fact that a care area triggered doesn’t automatically mean that it is a problem that has to be care planned,” says Hillier. “However, in practice NACs and other IDT members almost always care plan for every single concern that triggered because, again, they don’t put aside the MDS focus and start with the general question, ‘What do I know about this resident?’”

Many providers could save time using this approach, points out Hillier. “Facilities often spend a lot of time on CAAs without accomplishing what CMS intended. Starting with a resident-specific focus vs. an MDS-only focus probably will make you more efficient.”

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