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Updates to the LTC Functional Screen Instructions

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					 Adult Long Term Care Functional                     Updates to the LTC FS Clinical
             Screen                                  Instructions

                                                       Updating the Clinical Instructions
  Updates to the LTC FS Clinical Instructions          •   Internal workgroup – OFCE, COP-W,
                                                           CIP, ORCD, TMG
  Module 6 - Health Related Services:                  •   External Screen Consultation Group –
Requires Nursing Assessment and                            MCOs, ADRCs, Waiver Agencies
          Intervention                                 Content Changes
                                                       •   Expanded definitions
                                                       •   Additional clarification on when it is
                                                           appropriate to select “Requires Nursing
                                                           Assessment and Interventions” (RNAI).

                                                1                                                 2




    Updates to the LTC FS Clinical                   RNAI Objectives: By the end of this
    Instructions                                     section, you should be able to:

      Format Changes                                   Define the 4 criteria for checking
        Items in each section:                         “Requires Nursing Assessment and
           Definition                                  Intervention”
           Check this for a person who:
           Do not check this for a person              Apply the rating system used with
           who:                                        RNAI accurately and reliably. (This
                                                       means that other screeners would
                                                       select the same answer as you did.)

                                                3                                                 4




    Tips for Completing the RNAI Section             Tips for Completing the RNAI
                                                    For a person residing in a nursing
      If a screener is unsure about how or          home or residential facility, assess
      when to mark RNAI, he/she should
      consult with their screen liaison
                                                    the person’s ACTUAL NEED for
      and/or assigned state staff.                  assistance, not just what’s provided
                                                    by policy, etc.
      CONSULT WITH A NURSE!
                                                    If a person has an identified need for
                                                    RNAI, but for some reason is not
                                                    receiving it, the screener should still
                                                    capture the need for RNAI.
                                                5                                                 6
Choosing the Appropriate                        Choosing the Appropriate RNAI Rating
RNAI Rating

     RNAI is precisely defined for the            The frequency of help
     LTC FS. Screeners are to follow              ranges are:
     the definitions precisely in order to
     select the most accurate level of              1 to 3 times/month
     help needed.                                   Weekly
     Always select the answer that most             2 to 6 times/week
     closely describes the person’s need
     for help from another person –                 1 to 2 times/day
     whether they are actually getting              3 to 4 times/day
     that help or not.                     7        Over 4 times a day                 8




   “Requires Nursing Assessment and
   Intervention (RNAI)”                         “Nursing Assessment”

Definition: Is marked to indicate a
CURRENT, usually SHORT-TERM,                    is the systematic collection and
HEALTH INSTABILITY that                         evaluation of data about the
REQUIRES skilled NURSING                        health status of an individual and
ASSESSMENT by a registered nurse                the individual’s response to the
(RN) or nurse practitioner (NP), AND            current medical treatment and
INTERVENTIONS to make or                        nursing interventions.
follow through on CHANGES in the
medical treatment or nursing care
plan.
                                           9                                         10




   “Nursing Interventions”                      “Nursing Care Plan”

 are nursing activities such as                 Includes nursing interventions, plus
                                               tasks delegated or assigned to others,
 administering skilled care;                   plus recommendations regarding the
 delegating tasks; adjusting the care          individual’s health. In
 plan; consultation and education of           interdisciplinary models, it is not a
 individuals, family members, and              separate document, but is part of the
 caregivers; consulting with                   person-centered plan or Individual
                                               Service Plan (ISP).
 physicians and other healthcare
                                                Refers to the nursing aspects of a
 professionals; and providing                  person-centered plan. It does not
 psychosocial counseling.                      include other activities like ordering
                                               supplies or general care management.
                                          11                                         12
   “Short-term”                               No Double Dipping

                                                MOST nursing assessments and
      Means less than 90 days.                  interventions are captured in
                                                other rows of the Health Related
                                                Services (HRS) Table!
                                                The RNAI row is intended only for
                                                a small minority of cases in which
                                                nursing care is not captured
                                                elsewhere in the HRS Table.

                                         13                                            14




The 4 CRITERIA FOR RNAI                         Who’s Called and What’s Changed
All 4 must be met!

  1. A current health instability that
                                                  If person HAS in-home nursing
  2. requires skilled nursing                     services, RNAI criteria apply to
    assessment and interventions,                 those nurses’ assessments,
    AND                                           interventions, & changes to
  3. involves changes in the medical              nursing care plan.
    treatment or nursing care plan,               For people who do not currently
    AND                                           have in-home nursing, RNAI
  4. cannot be captured in other HRS              criteria can be applied to changes
    rows.                                         in medical orders & clinic nurses’
                                         15       interventions.                       16




   RNAI is generally a short-term need
   because:                                     RNAI Is Usually Short-Term
  RNAI includes only those skilled
  nursing assessments and interventions            If RNAI is checked for short
  that are needed to address a current            term instabilities, a Change
  health INSTABILITY requiring
  CHANGES to the medical treatment or
                                                  in Condition Screen is
  nursing care plans.                             expected to be completed
  Nursing interventions are either                after the individual has
  effective over several weeks or                 stabilized.
  months, or other plans must be
  established to ensure the individual’s
  safety and health.
                                         17
                                                   Examples of RN services captured on OTHER
                                                   rows of HRS Table

  ALMOST ALL needs for ongoing                       79-year-old on numerous medications
 health-related or RN services can                 for atrial fibrillation, congestive heart
 and must be recorded elsewhere on                 failure, hypertension, arthritis, and
                                                   diabetes. Frail and unstable, with
 the HRS Table                                     medication changes based on vital signs
     Especially Medication Management              and comfort level. However, on-going
    and/or Administration                          nursing assessments are all related to
                                                   her medications.
                                                       These are captured in the Medication
                                                       Management row, not the RNAI row.
                                              19                                              20




Examples of RN services captured on other             Examples of RN services captured on
rows of HRS Table (cont’d)                            other rows of HRS Table (cont’d)


    Individual has a Stage 3 ulcer. RN                If the individual is on oxygen or
  does comprehensive wound care,                      getting respiratory treatments
  which includes assessments and                      any related nursing assessment
  interventions concerning healing,                   and interventions of the oxygen
  nutritional status, fluid status,                   level checks are captured under
  mobility, cognition, coping, etc.                   Oxygen or Respiratory
      All of this assistance is captured in the
                                                      Treatments, NOT the RNAI row.
      Ulcer Stage 3 row, not the RNAI row.


                                              21                                              22




  Examples of RN services captured on                 Check RNAI for a person who:
  other rows of HRS Table (cont’d)

  Dialysis treatments at a clinic                    Meets the 4 RNAI criteria,
  include comprehensive nursing                      including an individual who:
  assessments 3 times/week. Check                      Has a current medical or
                                                       psychiatric instability that
  Dialysis, 2 to 6 days/week, not
                                                       requires skilled nursing
  the RNAI row.                                        assessment, intervention, and
                                                       changes in medical treatment or
                                                       nursing care plan that are not
                                                       captured in other rows of the
                                                       HRS Table.
                                              23                                              24
Check RNAI for a person who (con’t)                     Do NOT check RNAI for a person who:

  Meets the 4 RNAI criteria,                                Has other HRS Table rows
including an individual who:                                checked recording all nursing
   Was recently discharged from a hospital                  assessment and interventions the
 or nursing home, is weak and unstable, with                individual needs, or
 new limitations and new medications,
 requiring nursing visits several times a
 week for assessments, care planning, and                   Has a cognitive impairment, but
 skilled nursing interventions. This individual             does not have an acute, unstable
 has instabilities likely requiring changes                 health condition requiring nursing
 to medical treatment or nursing care plan, at
 least for a few weeks, that go beyond
                                                            assessments and interventions, or
 Medications and other rows of HRS Table.       25                                                          26




                                                            Examples of long term instabilities without
Do NOT check RNAI for a person who:                         changes– i.e., “Standing Orders”

  Does NOT have an acute, unstable                          PRN (as needed) medications or
  health condition requiring nursing                        treatments for chronic pain or other
  assessments and interventions                             chronic conditions.
  Has a need for nursing interventions                      Sliding scale insulin (when each
  but without changes in the nursing                        insulin dosage is adjusted based on
  care plan                                                 the blood sugar test result).
                                                            Why:
  Has long-term “instabilities” but no                       These are “stable”—without changes
  changes in nursing care plan.                              in the care plan. (They don’t meet
    This includes people with an established                 Criteria #3.)
    plan of care (“standing orders”) in place for            Check Medication Management and/or
    a long-term instabilities.                               Medication Administration if
                                                  27         appropriate.                       28




 Examples of long term instabilities without changes–       Examples of long term instabilities without changes–
 i.e., “Standing Orders” (cont’d)                           i.e., “Standing Orders” (cont’d)

                                                        •    Group home staff administer PRN Valium
     When the individual’s lower legs                        for uncontrolled seizures, usually several
     retain fluid, he/she is to elevate                      times a month. The staff also record at the
     them for at least 30 minutes;                           end of each shift whether seizures
     When the individual becomes short                       occurred or not. The PRN medication
     of breath, caregiver will help them                     orders have not changed in several
     to use their oxygen as instructed.                      months.
     Why:
                                                        •    Why:
        These are “stable”—without
        changes in the care plan. (They                      •   These are “stable” standing orders, with no
        don’t meet Criteria #3.)                                 changes. (Doesn’t meet Criteria #3.)
        Check Oxygen row for help needed                     •   Check Med Administration 1-3 times a
        with that.                      29
                                                                 month for this.                            30
Do NOT check RNAI for a person who:                Do NOT check RNAI for a person who:

•   Has personal care workers or others who
    perform delegated tasks that need nursing        Has RN or NP participation on an
    oversight and supervision; or                    interdisciplinary team; or
•   Has nursing assessments only because they        Receives skilled nursing care
    are routinely provided by the agency or          provided in a clinic setting for
    residential care facility; or                    dialysis, wound care, transfusions,
•   Has nursing care management activities;          or other services noted elsewhere
                                                     on the HRS Table; or
                                                     Has a history of skin breakdown and
                                                     has an RN or NP check the integrity
                                            31       of their skin; or                   32




    Do NOT check RNAI for a person who:          Do NOT check RNAI for a person who:

    Needs data collection.                         “Needs data collection” examples
                                                   cont’d:
    Examples:                                        The needed measurement of an
      Documenting weights, blood                     individual’s fluid intake and output (I&O)
      pressure, heart rate, blood sugars,            is recorded in the “Other” row of the HRS
      seizure activity, etc. almost always           Table, with description of the care
      involves effectiveness, side effects,          needed added to the notes section;
      or adjustments of medications and              Caregiver(s) documenting an individual’s
                                                     health status, e.g., daily or at the end of
      is recorded in the Medication
                                                     each shift, is not recorded on the LTC FS.
      Management row of the HRS
      Table.                                33                                                 34




Each of the following four criteria
MUST be met for RNAI:                              Phone Contact with Nurse

 1. A current health instability that             Counts for RNAI IF and only IF ALL
                                                  4 RNAI CRITERIA ARE MET!
 2. requires skilled nursing
   assessment and interventions,                  Don’t count as RNAI because MOST calls
   AND                                            with a nurse:
 3. involves changes in the medical                 Do not require RN assessment &
                                                    interventions, or
   treatment or nursing care plan, AND              Don’t involve changes in care plan, or
 4. cannot be captured in other HRS                 Can be captured in other rows, or
   rows.                                            Don’t recur frequently enough for HRS
                                                    table

                                            35                                                 36
  Nursing Contacts that Don’t Meet the 4                        Nursing Contacts that Don’t Meet the 4
  RNAI Criteria:                                                RNAI Criteria:
 Periodic (e.g., monthly)                                        Long-term RN visits to educate
assessments to “monitor.”                                        and/or increase adherence to
  Why Not:                                                       health recommendations.
        They are not acute, short-term                           Why Not:
        instabilities.                                               They are not acute, short-term
        They do not require assessments &                            instabilities.
        interventions.                                               They do not require assessments &
        They do not require changes in care plan.                    interventions.
        They ARE captured in other rows on the                       They do not require changes in care
        HRS Table.                                                   plan.
            Monitoring of the effectiveness and side-                They ARE captured in other rows of
            effects of medications is captured under the             HRS Table.
            Medication Management row.




  Nursing Contacts that Meet the 4 RNAI                       Long-Term Nursing Visits to Improve
  Criteria:                                                   Compliance
   Short-term RN visits to educate
   and/or increase adherence to                                 RN Interventions might count as
   medical treatments or nursing care
                                                                Medication Management if they are
   plan IF:
      In response to acute instabilities                        effective in improving compliance
      Require assessments & interventions                       RN interventions that improve compliance
      Require changes in care plan                              might count on specific tasks on HRS Table
      Not captured in other rows of HRS Table
        Ex: New or recently discharged, unstable, multiple      Dietary compliance/nutrition checks are
        needs, changes in care plan, not all captured in        not included on HRS Table
        other HRS rows—short-term only, then Change in
        Condition Functional Screen




  DHS Contacts for RNAI Questions
                                                                Questions

Nancy Rusch   (608) 266-9303
Nancy.Rusch@dhs.wisconsin.gov

Lindsey Arnold (608) 261-6377
Lindsey.Arnold@dhs.wisconsin.gov




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