IDT organization

[TigerxLiLy]

Hi,

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I am looking for ideas to better organize our IDT team.* I know each building has their own ways of communicating and "getting things done", but I am researching and would like to know a little about how your IDT functions.

My facility currently practices the "Silo" team= each department does a generic assessment,then the MDS coordinators gather the info, throws it the assessment and the coordinator develops the CAAs solely on that information and the coordinators own assessment. No input from other departments.. The care plan meetings do not feel "coordinated".. They are usually just "sit down with family,discuss what's happening in therapy and current Dx and treatments,and what the dc plan is" not much talking about interventions that resident/family initiates.

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Just a few questions:

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1. Do you guys involve the SS, ACT, Dietary into completing some of the CAA's? Or do you guys develop the CAA's based off their assessments alone?

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2. During your IDT care plan meetings, Do you bring the list of CAA's to the careplan meetings to discuss interventions?

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3. Are there instances where you complete a care plan meeting with the family before the CAA's are developed?

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4. What CAA resources do you use? The RAI CAA tool sheet? or just based off nursing knowledge and experience?

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5. How do you guys incorporate indvidualized interventions into your careplans? Sometimes I feel most of our interventions are protocol/policy based or generic.

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Im not sure if these questions will make complete sense, But I am looking forward to hearing what other MDS/PPS coordinators are doing to better develop their team and Careplans.

[vintagemother, BSN, CNA, LVN, RN]

May I ask, what is CAA?

I attend IDT meetings at my job as well as write and implement care plans...however I work in LTC psychiatric.

[TigerxLiLy]

Care Area Assessment.. It's on the comprehensive MDS (Admission,Annual,Sig change assessments).

[vintagemother, BSN, CNA, LVN, RN]

Darn, I can't be of assistance as I am not an mds coordinator and my facility doesn't have to deal with reimbursements. I'll keep following this post to see if I can learn more. (-:

[NurseMellie]

I do keep watch over the different sections; SS, dietary. It has been my experience that things don't always get marked like they should. I have had to do modifications based on others mistakes. Sometimes the CAAs are done before the CC not always, it depends on the resident and the circumstances like how much and how good the information is that I have from the hospital. SS, activities, dietary and nursing are all responsible for sections in the MDS and CAAs and CPs. A lot of the time, I am writing my own CAAs which I use the tool in the RAI manual a lot it gives a lot of good reminders for things to look for while writing and developing your care plans. Its basically wanting you to state yes we know this person is at risk for x, y ,z. We use PCC for our software, there is a button in the CAA area after the CAAs are completed that you can go into to assist with CP development. It gives us the problem, goals, interventions, we can take those and tailor it to our resident. Many are generic but as you get to know your resident and their condition you can tweak it to be your own.

In Care plan meetings, most families from my experience want to use that time to make sure their loved one is meeting all their goals, no changes in adls, if there were any changes in medications. Its basically a catch up from the quarter. Now I do bring up changes that I see when gathering my data so the family isn't caught off guard. I also allow them time to express any concerns that they may have about care, about their loved one and what their course might be for the next quarter, etc. If its a new admit and they are skilled and receiving therapies, I most certainly have one of our therapists there who have been working with the resident. I take the time to learn what their goal is for going home or for staying. And anything else we can determine before working on DC. There are times I have 2 or more CC in a quarter for those skilled folks maybe the plan didn't work out and the resident didn't progress, we need to change our game plan.