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Involving CNAs in Care Planning

Tip Sheet


WHAT IT IS:
Involving CNAs in care planning means having them as true members of the care team, able to provide timely, actionable information about residents that can have profound effects on the care provided. It requires providing the coaching and support necessary for CNAs to be meaningful and active participants, starting with implementing the practice of consistent assignment. Beyond that, it requires: notifying them when meetings will be occurring and establishing systems of communication and team work among CNAs so that they can comfortably attend care conference with the knowledge their other residents are being cared for during this time; structuring the meetings to maximize CNAs' input; aligning CNA documentation and daily assignment sheets with the MDS items and care planning information; and requesting and using CNAs' daily observations and ideas as part of an on-going process of making needed adjustments to care.

WHY IT IS IMPORTANT
Involving CNAs in the deliberations of the assessment and care planning process brings that process to life and affirms CNAs' central role as the staff closest to the resident. Having their involvement maximizes their good information by making it central to the planning that shapes care delivery.

Consistently assigned CNA's have detailed up-to-date information about residents that is crucial for an accurate assessment and effective care plan. For example, if a resident is experiencing a change in mood or appetite or functional ability, the consistently assigned CNA will note and report it immediately. Over time, through providing care daily for the same people, a consistently assigned CNA will know their residents' likes and their dislikes and their customary routines. They will know what is calming and soothing for each resident in their care, as well as what will surely agitate them. They know the best timing for each care practice and they will note subtle differences that may indicate a budding change in condition. With support, CNAs can come to care conference prepared to make suggestions for adapting the care plan to more effectively support the resident. This kind of information from CNAs transforms assessment and care planning from rote exercises to timely, relevant, effective processes.

CNAs know the details of residents' day-to-day life, activities and recent experiences that families are most interested to hear about at care conference. They are also ready to report needs to family, such as clothing or toiletries or hobby supplies, etc. Having the entire team together at care conference provides residents and families the opportunity to visually observe and join the process of supporting the life the resident wishes to live.

Consistently assigned CNAs are a steady presence in the residents' lives. Residents and families develop such strong relationships with CNAs that they are reassured by CNAs' presence at a care plan meeting. Having someone there that residents and families know and trust because of their day-to-day involvement makes this meeting easier and less intimidating for families. Having the CNA attend the meeting honors this strong bond the resident and family feel for their dedicated CNA and communicates to the resident and family how much the organization values and trusts their CNA's skills and knowledge.

HOW TO DO IT
CNAs involvement in care planning works best when the other foundational practices are in place. Consistent assignments provide CNAs valuable knowledge based on their deep relationship that rotating CNAs don't have. Daily and QI huddles provide for on-the-spot sharing of observations and problem-solving that contribute to and follow-up on the discussions at a care plan meeting. These practices all support critical thinking, communication, collaborative problem solving and a sense of ownership related to resident outcomes.

  • Prepare CNAs to be effective participants: If CNA's have not been a part of care planning in your home, you will need to make a plan to activate their involvement. Offer staff training on the purpose of assessment and care planning, the elements of the MDS, what you are trying to accomplish in the care plan meeting, and how long it will take. Explain how the meeting flows, their role in the meeting, and what to share when. Conduct a mock meeting to familiarize CNAs with the process before they go into a real one. Have any CNAs who have participated in the past share their experiences. This might be a good time to evaluate your care plan meeting process to determine if there are opportunities for improvement in your current process through the addition of the CNA in care planning.
  • Explain what to share: Help the CNAs sort through all of the information they have and understand what information is needed for this meeting. Provide a list of questions and information the CNAs should come prepared to talk about (consider posting it in the break room). The INTERACT II Stop and Watch tool is a good example of the kind of information to share and can be given as a guideline. Show CNAs MDS Sections D – Moods; E – Behavior; F - Customary Routines; and G - Functional Status so they can see what type of information must be documented and reviewed.
  • Notify CNAs when meetings will occur: This can be done in the shift huddle. You can post a list of residents having their care conference that week in a place CNA's will see it so that they are informed if one of their residents is on the schedule. You can note on the CNAs' assignment sheet when one of their residents comes into their Assessment Reference Date - ARD period (consider using a different colored sheet for that week). Encourage CNAs to obtain information with evening and night shift CNA's who also consistently care for the same residents.
  • Free CNAs up to attend: In the daily huddle, discuss which residents are scheduled for a care plan meeting at what time so staff can cover for one another to support their coworkers to attend the care plan meeting. A list of the resident care conference schedule posted in a consistent area can serve as a visual reminder for everyone. Make it an expectation that is non-negotiable that CNAs will attend the meeting. Encourage staff to have a quick huddle to arrange to cover for each other as they attend care plan meetings. If the staff is working with an unscheduled absence on the day of a care plan meeting, have a nurse manager not involved in the care plan meeting provide coverage so the CNA to attend.
  • Timing: Have an expectation of promptness so that CNAs are not losing time waiting. Keep meetings pertinent and on task. Don't have "dead time" when other disciplines are catching up on their records. Have everyone come prepared and use each other's time well.

  • Location: Hold the meeting in the resident's room or nearby where the resident, family, and CNA can easily attend. This saves everyone from the discomfort of being in a potentially intimidating conference room space, from having to travel across the building, and from having to wait idly if the meetings aren't running on time.

  • Maximize CNAs' contribution: Start the meeting with the contributions from the resident, family, and CNA. Use a consistent format. Some CNAs may be shy about adding in comments as the meeting progresses; help them overcome this by asking for their thoughts and suggestions. Have a good process together, including not interrupting each other. Debrief afterwards, especially if the meeting is difficult. Provide feedback with specific examples of how CNAs' contributions made a difference and include them in the follow-up loop after the meeting.

  • Highlight CNAs' involvement to families: Formalize the invitation to families to attend care conference by writing a letter describing the meeting and listing who will be there by name and position, including the CNA. Encourage families to come with their questions and ideas, and facilitate the process so that CNAs speak directly with families about any issues relevant to daily routines, ADL care and support.

  • Schedule pm meetings: Include both day and evening CNA's in training and participation. Schedule the care conference to meet the needs of staff and family but make an effort to schedule some meetings in the afternoon /evening so that the afternoon shift can participate. You'll find that the evening schedule is helpful for some family members.

  • Align daily documentation with MDS codes: Match the coding on the CNAs' assignment sheet and documentation records with MDS sections on functional status and mood. This helps CNAs be conversant with the MDS categories and also supports more consistency between documentation and coding.

  • Link quarterly care planning with daily and QI huddles: Huddles are actually mini-care plan discussions. Daily huddles in which CNAs share pertinent information about their residents' risks and opportunities, and areas where action is needed, prepare CNAs for active participation in care planning meetings. The primary difference is that the discussions in care plan meetings take place from a quarterly perspective instead of a daily perspective. Have the care plan coordinator attend huddles to ensure continuity between daily discussions and the quarterly or change of condition discussions.
RESOURCES:
Pioneer Network
  • Pioneer Network's website provides links to many affiliate resource organizations.
  • Pioneer Network National Learning Collaborative Webinars all contain examples of staff huddles to provide high quality individualized care. They are available for a fee for five on-demand viewings of each webinar. All 12 webinars are also available for purchase as a set of discs, at a discounted rate. To purchase viewings of one or more of the webinars, or the entire package of 12 webinars, go to Pioneer Network store.
    • Webinar 1 includes information about aligning CNA's daily documentation with the MDS.
    • Webinars 2 and 12 include information about involving consistently assigned CNAs in care planning.
  • This tip sheet is from the Pioneer Network Starter Toolkit: Engaging Staff in Individualizing Care. The entire toolkit, with additional tip sheets, starter exercise and resources, is available at www.pioneernetwork.net/Providers/StarterToolkit
Advancing Excellence in America's Nursing Homes www.nhqualitycampaign.org
Data collection can help determine whether the changes being made are working, and continue to work. The Advancing Excellence in America's Nursing Homes campaign has the tools and excel sheets for collecting data on consistent assignment (are we REALLY doing this?) and on Person Centered Care (are the wishes and preferences of the residents actually being delivered, and are the direct care workers attending and participating in the care plan meetings?), as well as other organizational and clinical goals. www.nhqualitycampaign.org

B&F Consulting www.BandFConsultingInc.com
Short videos available under free resources at www.BandFConsultingInc.com
 
Stop and Watch, a nursing home communication tool, at www.interact2.net


Download Involving CNAs in Care Planning Tip Sheet (PDF)

Starter Toolkit Home          Step One          Step Two          Step Three          Self-Assessment
Prepared by B&F Consulting for Pioneer Network's National Learning Collaborative on Using the MDS as the Engine for High Quality Individualized Care. Funded by The Retirement Research Foundation.
All webinars in this series are available as archived recordings at
http://eo2.commpartners.com/users/pioneerlive/all_series.php.
In addition, the full series is available as packaged DVD set in the Pioneer Network store.