In 2016, the Centers for Medicare and Medicaid Services (CMS) issued its three-phased Final Rule (aka, the Mega-Rule) which made sweeping changes to improve the care and safety of long-term care facilities that participate in the Medicare and Medicaid programs.
As part of this, baseline care plans (BCPs) became a regulatory requirement for skilled nursing facilities (SNFs). What prompted this?
For years, a comprehensive care plan was required within 21 days of a resident’s admission. That care plan is a blueprint for all caregivers in an SNF on how to care for the resident. Problem was, gaps – sometimes weeks – existed between admission and development of the comprehensive care plan. As a result, SNF staff didn’t have clear instruction on care directives during those gaps, which put resident care and health outcomes in jeopardy.
Knowing this, CMS made development of BCPs a requirement as part of the Mega-Rule within 48 hours of admission. The BCP must include detailed instructions needed to provide effective person-centered care, including, but not limited to, initial goals based on admission orders, as well as a reflection of physician orders, dietary orders, therapy services, social services and PASSAR recommendations, if any.
SNFs can approach BCP development in one of two ways—by either developing it as its own assessment – and its own separate document – or by having the baseline care plan feed into what will ultimately become the comprehensive care plan within the EHR system.
At Richter, our clinical consulting team strongly recommends the latter option—i.e., having the BCP flow automatically to the care plan section of the chart. The reasons for this are clear:
Integration helps promote better care and enhanced outcomes. We recommend adding the BCP items directly into the nursing admission assessment in order to streamline the process and document items while they are fresh in your mind.
Integration is easy and saves time. Preparing one document is almost always easier than preparing two. This is no exception. You want your clinical staff serving residents and providing quality care—not spending time crafting separate documents that don’t integrate seamlessly. You’ll still need to create a comprehensive care plan for each resident; but everything you have added to the BCP will flow into the comprehensive care plan, making the task of completing the comprehensive care plan by day 21 that much easier.
Resident-specific treatment information flows better. When all relevant resident data – from diagnoses and conditions to medications, treatments and the BCP – reside in one centralized EHR, that information is organized and easily accessible across the enterprise, which allows all staff to access resident-specific information needed to provide optimal care.
Helping Streamline Your Baseline Care Plan Development and Integration in PointClickCare to Enhance Outcomes
For Richter’s PointClickCare® clients, we can help to streamline the process of developing the BCP and then having that information flow directly into the comprehensive care plan. Specifically, we can build customized BCP information directly into your existing admission nursing assessment or build a stand-alone BCP user defined assessment (UDA). This UDA is a simple checklist of care plan items that will be completed at the time of admission. If the resident has an existing care plan, those items already in the care plan will automatically be checked on the UDA. Once the UDA is completed, the new or updated care plan foci, goals and interventions will automatically flow to the care plan section of the chart. This simplified process will not only meet the Mega-Rule requirements, it will also increase accuracy and decrease the possibility of duplicate entries.