1. From Clinical Assessment Protocols and Outcome Scales to Care Planning
Data Quality:
From Clinical Assessment Protocols and Outcome Scales to Care Planning
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2. Agenda
The benefits of using the interRAI CHA CAPs and Outcome Scales to enhance the care planning process
Review of selected resources in the interRAI CAPs manual and care planning binder
Share some tips on how to create a care plan
Discuss short care planning scenarios
Share examples of how HSPs have incorporated the CAPs and Outcome Scales into their daily work flow

3. Objectives
Understand the impact of using the CAPs and Outcome Scales when creating individualized care/service plans
How to incorporate CAPs and Outcome Scales into the care planning process to enhance client outcomes
Introduce strategies other HSPs have used to enhance their care planning process

4. Back to the Basics

5. What is the interRAI CHA?
interRAI Community Health Assessment (CHA) helps identify adults needing supports to prevent or stabilize early functional or health decline
An electronic standardized comprehensive assessment
Modular format
Not all inclusive – “minimum” data set
Data elements designed to be used for:
Care planning
Quality improvement using quality indicators
Outcome measures based on clinical scales

6. Assessment Process Flow
Core CHA
Care Plan
Review
Review: phone call or visit to review any
aspect of the care/service plan
CAPs &Outcome Scales
Supplements
Reassessment
Reassessment: face to face comprehensive assessment 6 6

7. Outcome Scales/Measures & Clinical Assessment Protocols
interRAI CHA Outputs
Outcome Scales/Measures
&
Clinical Assessment Protocols

8. Outcome Scales / Measures
Used to evaluate the clinical status of a client or group of clients and track their changes over time
Software generated
Derived from data collected by the completion of the interRAI CHA assessments
Evidence based for decision making

9. Outcome Scales Outcome Scale Range Description
Cognitive Performance Scale (CPS)
0-6
Indicator of Cognitive Status
Based on sections C - Cognition & D - Communication & Vision
Depression Rating Scale (DRS )
0-14
Indicator of Depression
Based on seven items from Section E1 - Indicators of Possible Depressed , Anxious or Sad Mood
Pain Scale
0-4
Predictor of Pain
Based on 2 pain questions - Pain Frequency & Intensity
ADL Self-Performance Hierarchy Scale
Is a measure of ADL performance
Calculated from Core CHA & Functional
Changes in Health, End-stage disease and Signs and Symptoms (CHESS)
0-5
Measures medical complexity & health instability
Calculated from Core CHA & Functional
Self-Reliance Index (SRI)
0 or 1
Categorizes clients as being either self-reliant or impaired
Method of Assigning Priority Levels
(MAPLe)
1-5
Is used to categorize clients into five levels of risk for adverse outcomes
Instrumental Activities of Daily Living Involvement Scale ( IADL)
0-21
Is a measure of IADL involvement
Based upon a sum of seven IADL Self-Performance

10. Clinical Assessment Protocols
Structured, problem
oriented frameworks to
organize information
and support care
planning
Specific clinical characteristics are used to identify clients who could benefit from further evaluation of specific problems either because they are:
at risk for decline or
show potential for improvement
Trigger links to a series of problem oriented assessment protocols
Clinical expertise and choice is important
Not care path/care maps
Adapted with expressed permission from ideas for health, University of Waterloo, June 2010

11. Benefits of CAPs
Enable client’s strengths, needs and preferences to be taken into consideration when developing the care plan
Guide the care plan to:
resolve potential problems
reduce the risk of decline
or increase the potential for improvement
Helps the assessor to visualize a complete picture of the client by taking into consideration internal and external factors
Will work with all of the interRAI assessment tools

12. Clinical Assessment Protocols Functional Performance
Cognition & Mental Health
Social Life
Clinical Issues

13. * CAP Triggered when Functional Supplement is completed
Functional Performance
Physical Activity Promotion CAP
IADL CAP
ADL CAP
Home Environment Optimization CAP *
Institutional Risk CAP *
Cognition & Mental Health
Cognitive Loss CAP
Communication CAP
Mood CAP
Abusive Relationships CAP
Delirium CAP*
Behaviour CAP*
Social Life
Informal Support CAP
Social Relationships CAP
Clinical Issues
Falls CAP
Pain CAP
Cardio-respiratory conditions CAP
Dehydration CAP
Prevention CAP
Appropriate Medications CAP
Tobacco and Alcohol Use CAP
Urinary Incontinence CAP
Pressure Ulcer CAP*
Undernutrition CAP*
Feeding Tube CAP*
Bowel conditions CAP*
* CAP Triggered when Functional Supplement is completed

14. How CAPs are Triggered
CAPs link the information gathered in the assessment with the goal of:
Problem resolution
Reducing the risk of decline
Or increasing the potential for improvement
interRAI CHA Core
Physical Activities
Promotion
CAP
Triggers:
1st: G4a – Activity level less
than 2 hrs
2nd: G2f- Locomotion-Independent 14

15. Summary of CAPs Triggers

16. Client CAPs Summary - Sample

17. Summary of CAP Trigger Levels
* See the interRAI Clinical Assessment Protocol s Manual for description of levels

18. Using CAP Trigger Levels
Clinical Assessment Protocols
Trigger Level
Urinary Incontinence
3 = Triggered to Facilitate Improvement in Bladder Function
2 = Triggered to Prevent Decline- Higher Rate of Decline Expected
1 = Not Triggered-Continent
0 = Not Triggered-Poor Decision-Making
Prevention
2 = Triggered Because Preventive Strategy Not Pursued and No Recent Physician Visit
1 = Triggered Because Preventive Strategy Not Pursued, Despite a Recent Physician Visit
0 = Not Triggered
Cognitive Loss
2 = Triggered To prevent Decline
1 = Triggered to Monitor for Risk of Cognitive Decline
Institutional Risk
1 = Triggered

19. In the interRAI Clinical Assessment Protocol Manual
How CAPs are Organized
In the interRAI Clinical Assessment Protocol Manual

20. CAP Information is Organized by 4 Parts
Manual
Tips
Problem
(Client Need)
Provides information to help the assessor identify and / or understand how an issue can affect the client or the client population as a whole
Overall Goals
Of Care
(Grey Box)
Vary but include the possibility of:
(1) Resolving Problem;
(2) Reducing Risk;
(3) Increasing Potential for improvement
Triggers
Link the information gathered in the assessment to the problem referenced by the CAP
Assessor should validate each CAP against specified criteria in manual to confirm if it makes sense for the client
Guidelines
(Service Provision)
Help to think through relevant underlying issues and move toward a plan of care
Utilize best practices to promote optimal client care planning outcomes, in conjunction with your agency protocols.

21. From CAPs to Care Planning
All triggered CAPs must be addressed in a care/service plan
Validate triggered CAPs with client to ensure that they are relevant and important
Prioritize triggered CAPs with client for the development of the care plan
Adapted with expressed permission from ideas for health, University of Waterloo 21

22. Sharing their Journey
HSPs share how they have incorporated CAPs and Outcome Scales into the care planning process
Tips for success
Resources used or developed

23. Enhancing the Care/Service Planning Process
Overview

24. Putting It All Together

25. What is a Care/Service Plan
Roadmap to provide direction and guidance to all those involved in the clients care
Essential communication tool
A collaborative plan of service created with input from client and assessor

26. Characteristics of a Care/Service Plan
Client Centered
Current
Accurate
Clear
Relevant
Collaborative

27. Components of a Care/Service Plan
Care/service plans are generally organized by four categories:
Problem statement/client needs
Client goals
Service provision/interventions
Review date

28. CLIENT NEED* (Problem Statement)
Components of a Care/Service Plan
DATE
TRIGGERED CAP
CLIENT NEED* (Problem Statement)
CLIENT GOAL
SERVICE PROVISION**
(Guidelines)
RESPONSIBLE PROVIDER
REVIEW DATE
*Client Needs = Problems in interRAI CAPs Manual
**Service Provision = Guidelines in interRAI CAPs Manual 28 28 28

29. Care/Service Planning

30. Sample Scenario #1 Mr. K
Mr. K is an 81 year old who lives alone. He attends Cedar Village Adult Day Program twice a week and is independent with ADLs but requires assistance with meal preparation and shopping. His daughter visits him twice per week, prepares some meals and does the grocery shopping. He no longer drives.
Staff noticed that Mr. K could only see large print when reading the newspaper and was asking for the volume of the TV to be raised.
Reason for assessment:
Routine reassessment - completed after 1 year.

31. Using the interRAI CAPs Manual
Prevention
CAP
Triggered Level:
Preventative Strategy not Pursued AND no Recent Physician Visit
Problem
“alerts the health care professional to the need to determine if the person has unmet preventive health requirements”
“Immunizations are designed to prevent illness, screening is designed to detect unrecognized illness at an early and treatable stage”
“Early detection and treatment of problems that interfere with functioning may result in functional deficits being postponed or even prevented altogether”.
Overall Goals of Care
“To ensure that persons who have not received preventative measures are identified and appropriate action taken”
Triggers
“No recent physician visit & one or more prevention strategies not followed: “
no eye exam (1 year), hearing exam (2 years), influenza vaccine (1 year)
Guidelines /
Interventions
“Sensory Impairments”
“recommend annual ophthalmologic evaluation in older persons”
“provision of hearing aides and other assistive devices may produce dramatic improvement in function”
“Vaccinations “
“influenza…5th leading cause of death in this age group”
“Older persons should be vaccinated each year before the flu season except…”
“..have shown to be on average 70% effective in preventing influenza..30% often having milder illness than unvaccinated ..”

32. Sample Care Plan -scenario #1 Mr. K
Triggered CAP
Client Need*
Client Goal
Service Provision**
Responsible
Provider
Review Date
Prevention CAP
Preventative Strategy not Pursued AND no Recent Physician Visit
Triggers:
Eye exam,
Hearing exam,
Influ shot
Mr. K did not have an eye exam in the last year, a hearing exam in past 2 years or influenza vaccine in past year
Mr. K will complete eye and hearing exams.
Mr. K will have his annual influenza vaccine in October 2015
Daughter to make an apt for Mr. K with family Physician to have an eye and hearing test completed.
Daughter to take Mr. K for annual Influenza vaccine in Oct 2015
Daughter
Oct
*Client Needs = Problems in interRAI CAPs Manual
**Service Provision = Guidelines in interRAI CAPs Manual 32

33. Sample Scenario #2 –Rosa
Rosa is a senior who lives alone with her cat Fluffy. She receives help from her neighbor to brush her hair and put on her shoes as well as support from a Homemaker for shopping once every two weeks. Rosa recently fell at home and bruised her right arm. The Homemaker contacted the Case Manager to report that Rosa was not feeling well.
Rosa had a flare-up of Rheumatoid Arthritis in her (Rt) Hip and (Rt) Hand. Rosa said the pain was severe and was present on a daily basis. Rosa now requires physical assistance with getting in and out of the tub.
Reason for assessment:
Significant Change in Status (ex. Fall ) completed after 4 months

34. Sample Care Plan - Scenario #2 Rosa
Triggered CAP
Client Need*
Client Goal
Service Provision**
Responsible
Provider
Review Date
Activities of Daily Living CAP
Triggered to Facilitate Improvement
Triggers:
some help with ADLS
Flare up of chronic condition
Fall
Rosa requires extensive assistance with bathing and supervision for dressing lower body and combing hair.
Prevent further functional loss resulting from flare up of arthritis and treat associated pain
Rosa will be able to put on her shoes and complete personal hygiene tasks.
Arrange for PSW to visit once per week (1 hour) to assist Rosa with Bathing.
Neighbour agrees to assist with personal hygiene and dressing lower body until pain is controlled.
- See Pain CAP details
See Falls CAP details
Assessor
PSW
Neighbour
2 weeks
July
*Client Needs = Problems in interRAI CAPs Manual
**Service Provision = Guidelines in interRAI CAPs Manual 34

35. Sample Care Plan - Scenario #2 Rosa
Triggered CAP
Client Need*
Client Goal
Service Provision**
Responsible
Provider
Review Date
Pain CAP
High Priority
Triggers:
Severe pain
Rosa has daily severe pain in (Rt) hand and (Rt) Hip due to a flare up of arthritis.
To keep Rosa comfortable and relieve suffering
To lower Pain scale score from 4 to 2 or 1
Schedule appointment for the family doctor for medication review & pain assessment.
Apply ice pack as needed
Arrange transportation for appointment - see Social Relationship CAP
Assessor
Physician
Rosa
1 week
July
*Client Needs = Problems in interRAI CAPs Manual
**Service Provision = Guidelines in interRAI CAPs Manual 35

36. Sample Care Plan - Scenario #2 Rosa
Triggered CAP
Client Need*
Client Goal
Service Provision**
Responsible
Provider
Review Date
Falls CAP
Medium Risk of Future Falls
Triggers:
Single fall
Recent fall at home related to inappropriate footwear
To ensure safety - identify underlying risk factor for falls
- To wear safe shoes
Rosa will have no further falls or falls with injury.
Rosa will wear safe footwear
Rosa will be assisted to put on her walking shoes daily
Rosa
Neighbour
2 weeks
July
*Client Needs = Problems in CAPs Manual
**Service Provision = Guidelines in CAPs Manual 36

37. Sample Care Plan - Scenario #2 Rosa
Triggered CAP
Client Need*
Client Goal
Service Provision**
Responsible
Provider
Review Date
Informal Support CAP
Triggered
Triggers:
Not independent with some IADLs
lives alone
alone for long periods during the day
Rosa requires assistance with shopping, transportation and housework
Rosa is alone for long periods during the day
Rosa will receive
assistance with housekeeping and transportation due to recent decline in these IADL’s
See Social Relationship CAP
Homemaking support will increase to two hours every 2 weeks to provide housekeeping and continue with shopping support.
Homemaker
2 weeks
July 14
*Client Needs = Problems in CAPs Manual
**Service Provision = Guidelines in CAPs Manual 37

38. Sample Care Plan -scenario #2 Rosa
Triggered CAP
Client Need*
Client Goal
Service Provision**
Responsible
Provider
Review Date
Social Relationship
CAP
Triggered
Triggers:
Feels lonely
Reasonable level of cognitive assets - CPS – 0
Ability to understand others – 0 (Understands)
Rosa often feels lonely.
To reduce loneliness and isolation
Increase Rosa’s engagement in social activities.
Rosa wants to attend ADP 3 days per week
Referral will be made to assist Rosa to attend an Adult Day Program in line with Rosa’s preferred level of involvement
Referral will be made for transportation re: medical appointments, ADP
Assessor
4 weeks
July 28
2015
*Client Needs = Problems in interRAI CAPs Manual
**Service Provision = Guidelines in interRAI CAPs Manual 38

39. Summary: Value and impact of using the CAPs and Outcomes Scale reports
Benefits of using interRAI CAPs Manual
Tips and examples of how use the outputs to inform care planning and improve client outcomes
Begin to include the outputs at your regular team meetings, client and family discussions

40. Resources interRAI CHA CAPs and Care Planning Binder
Reassessment Best Practices
Trigger Level Categories
interRAI Clinical Assessment Protocols - For Use with interRAI’s Community and Long Term Care Assessment Instruments Manual
Website
Service Desk
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41. Wrap- up

42. Thank you!
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