Yes! Careplans from the libary can be downloaded into Excel or Word, then modifiled. Careplans built in the client module can also be modified. Be sure to adapt outcomes and actions to align with your client’s individual situation.

Yes, but they should be adapted to meet the specific needs of your client and comply with your institution’s policies and guidelines.

Absolutely yes!

Imagine a shared family office where multiple family members work together to manage information about certain projects. Here’s how it works:

• The "Account" is like the office itself. It’s a central hub where all the work is organized.
• "Members" are the family members (e.g., Mom, Dad, or a sibling) who have access to the office. Each member can walk into the office and work on the projects.
• "Clients" are the projects (e.g., a grocery list, vacation plans, or bills) that the family members are managing together.

How They Connect

The relationships work like this:

• Multiple family members (Members) can use the same office (Account) to access the same projects (Clients). For example, both Mom and Dad can access the grocery list or vacation plans in the office.
• The office (Account) connects everyone, so all authorized family members can see and work on the same set of projects without needing separate offices.

This setup allows multiple people (Members) to share access to the same information (Clients) through one central system (Account), making collaboration easy and organized.

No, this site does not include NANDA-I Nursing Diagnoses. While we previously licensed the NANDA-I library, we discontinued this for two main reasons:

1. The majority of our members did not utilize the NANDA-I content.
2. The NANDA-I library was available for free at https://nandadiagnoses.com.

Given this accessibility, we determined that maintaining a recurring license fee for data readily available online was not a sustainable choice for our platform.

Update 3/23/25: The above URL was taken down and now redirects to the NANDA-I website.

EHRs have streamlined care planning by providing templates, real-time updates, and easy access to client data. However, nurses must ensure that care plans remain individualized rather than relying solely on pre-built templates.

Care plans typically follow this structure:
- Assessment: Gather client data (history, physical exam, lab results, etc.).
- Issues Identification: Identify the client's health problems or nursing issues.
- Outcomes: Define what improvement or changes are expected in the client’s condition.
- Actions: List nursing interventions that will help achieve the outcomes.
- Evaluation: Assess whether the outcomes were met and adjust the plan as needed.

To evaluate effectiveness:
- Compare the client’s current status with the defined outcomes.
- Assess whether the actions were implemented as planned.
- Determine if adjustments are needed to improve results.

Writing a care plan involves these steps: 1. Identify the client’s issues (e.g., ineffective airway clearance). 2. Determine measurable outcomes (e.g., client will maintain oxygen saturation above 95% within 48 hours). 3. Develop specific, evidence-based actions (e.g., administer oxygen as prescribed, monitor respiratory rate hourly). 4. Evaluate the outcomes and revise as necessary.

Yes. CarePlans.com membership is very inexpensive and can be cancelled anytime.

If outcomes are not met:
- Reassess the client’s condition for any new issues.
- Modify or adjust actions as needed.
- Consider if the outcomes were realistic given the client’s condition.

PDPM and Its Relation to MDS in Long-Term Care

PDPM, or the Patient-Driven Payment Model, is a reimbursement system implemented by the Centers for Medicare & Medicaid Services (CMS) for skilled nursing facilities (SNFs) under Medicare Part A, effective October 1, 2019. It replaced the Resource Utilization Group (RUG-IV) system and ties payments to patient characteristics and care needs, as documented in the Minimum Data Set (MDS) assessments.

Key Points about PDPM and MDS

1. Purpose of PDPM:
   • Aligns Medicare payments with clinical complexity and resident needs, not service volume (e.g., therapy minutes).
   • Improves payment accuracy, reduces administrative burden, and encourages holistic care.
2. Role of MDS in PDPM:
   • The MDS is a standardized tool collecting clinical data on diagnoses, functional status, cognitive status, and care needs.
   • MDS data drives reimbursement by determining case-mix classifications for payment components.
3. PDPM Components:

   PDPM calculates reimbursement based on six components, each with case-mix groups derived from MDS data:

   • Physical Therapy (PT): Based on primary diagnosis, functional status (MDS Section GG), and cognitive status.
   • Occupational Therapy (OT): Similar to PT, using diagnosis, functional status, and cognitive status.
   • Speech-Language Pathology (SLP): Based on swallowing disorders, speech/language deficits, cognitive impairment, and diagnoses (e.g., stroke).
   • Nursing: Determined by clinical conditions, functional status, and nursing care needs (e.g., IV medications, wounds).
   • Non-Therapy Ancillary (NTA): Accounts for high-cost ancillary services (e.g., medications, supplies) based on comorbidities.
   • Non-Case-Mix: Fixed component for facility overhead, not tied to MDS clinical data.
4. MDS Assessments Under PDPM:
   • 5-Day Assessment: Initial MDS within 8 days of Medicare Part A stay, sets payment rate.
   • Interim Payment Assessment (IPA): Optional if resident’s condition changes significantly, adjusting payment.
   • Discharge Assessment: Captures status at end of Medicare Part A stay.
   • Accurate coding of diagnoses (ICD-10), functional scores (Section GG), and comorbidities (Section I) is critical.
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5. Impact on Long-Term Care:
   • Clinical Focus: Incentivizes focus on clinical needs and comorbidities, not therapy minutes.
   • Documentation: Requires precise MDS coding to avoid underpayment or audit risks.
   • Interdisciplinary Approach: Encourages collaboration among nursing, therapy, and medical staff.
6. Key MDS Sections for PDPM:
   • Section GG: Functional abilities (mobility, self-care) influence PT, OT, and nursing.
   • Section I: Diagnoses and comorbidities drive PT, OT, SLP, and NTA rates.
   • Section O: Special treatments (e.g., ventilator care, IV medications) impact nursing and NTA.
   • Section C and B: Cognitive status (e.g., BIMS) affects SLP and other components.

Summary

PDPM uses MDS data to classify residents into case-mix groups determining Medicare Part A reimbursement for SNFs. The MDS captures clinical and functional data reflecting care needs. Accurate, timely, and comprehensive MDS assessments ensure appropriate payment and compliance.

Care plans should be grounded in evidence-based practice, meaning actions should be based on the latest research and clinical guidelines. This enhances the quality and effectiveness of client care.

A care plan is typically developed by healthcare professionals such as nurses, doctors, or case managers, often in collaboration with the client and their family. In some cases, interdisciplinary teams contribute to its development.