By Frances W. “Billie” Sills, RN, MSN, ARNP
© The Medical-Legal News 2007
The nature and scope of nursing practice is influenced by the needs of the patients in a given setting. The range of health and illness that older people experience covers the health/illness continuum. The focus of nursing care for this particular population is always changing depending on where the client is on the continuum. A thorough assessment of functional losses in addition to the medical conditions that underlie and contribute to these losses is imperative for nurses to provide quality nursing care to this population. In 1986 Congress requested a study be instituted by theInstitute of Medicine to examine the care received by patients in nursing homes as a result of the increasing complaints of inadequate care. The proposed reforms as a result of the study became law in 1987. It is the Nursing Home Reform Act, part of the Omnibus Budget Reconciliation Act of 1987. The basic objective of the act was to ensure that residents receive quality care that will result in their achieving or maintaining their “highest practicable” physical, mental, and psychosocial well-being.
There are required resident services which include…
• Admission and periodic assessments for each resident.
• Comprehensive care plan.
• Nursing services.
• Social services.
• Rehabilitation services.
• Pharmaceutical services.
• Dietary services.
• Compliance with the Resident’s Bill of Rights stated in the act.
Enter the Resident Assessment Instrument (RAI) and the Minimum Data Set (MDS): The instrument is a simple standardized approach for what clinicians have been doing or should have been doing in the areas of patient assessment and care planning with the provision of individualized care. It assists the staff in gathering definitive information on a resident’s strengths and needs. It assists the staff in evaluation of resident goal achievement, with revision of the plan as indicated. It provides the staff with a unique “pathway” or “map” that leads to achieving or maintaining his or her highest practicable level or well-being or to a peaceful death. With the interdisciplinary use of the instrument an emphasis on quality of care and quality of life can be achieved.
Problem identification process of the RAI
1. The first step in the process is a complete assessment which includes all information, observations and knowledge about the resident and family. It is also important to understand the resident’s limitations, strengths and feelings about the situation they are in and what they want to see happen.
2. Step two is the decision-making phase in which the interdisciplinary team determines the severity, functional impact and scope of a resident’s problems. The understanding of “causes and relationships between the resident’s problems and discovering the “what’s and why’s” of the problems leads into the third step.
3. Care planning establishes a course of action that moves a resident toward a specific goal utilizing individual resident strengths and interdisciplinary expertise.
4. The fourth step is implementation or putting the course of action (specific interventions) from the various disciplines into practice by the staff that is knowledgeable about the resident care goals and stated approaches.
5. The last step of the process is evaluation, at which time the team critically reviews the care plan goals and determines if there is a need to modify the plan of care depending on if the resident’s status has changed from improvement, status quo or decline. The process is a continuous assessment of the resident’s quality and quantity of life. The three components of the RAI are 1) Minimum Data Set, 2) Resident Assessment Protocols and 3) Utilization Guidelines. Each component flows naturally into the other giving a complete picture of the resident and provides a documentation “map” to follow that will demonstrate that everyone should be speaking the same language and that residents and families agree and support the plan of care and the expected outcomes. The opportunity for misunderstanding and/or error is greatly diminished.
The real key to understanding the RAI process is for each of us to believe that the structure is designed to enhance the resident’s care and promote the quality of the resident’s life. This occurs because the staff across shifts is involved in the “hands on” approach for each resident and allows for “good” communication and tracking of the resident’s care, which includes progress or decline. The expected outcome of the process is that we will see residents responding to individualized care. The staff communication among all the various disciplines will be more effective. Residents will benefit from the families’ involvement in their care and there will be an increased clarity of documentation that will benefit all. It is the belief of the individuals that developed the RAI/MDS that with its use everyone would be speaking the same language. Again, when residents and families agree with the plan of care and expected outcomes, the opportunity for misunderstanding and/or error will greatly be diminished.
The amount of information that is gathered with this instrument can be overwhelming. However, understanding the process, realizing that it is a continuous process in which communication between the disciplines, the resident and the family are critical, will result in quality care for the resident. Residents in long-term care facilities have the right to expect quality care, thus ensuring their quality of life in their later years.
Pearl S. Buck once said, “Somehow our society must make it right and possible for old people not to fear the young or be deserted by them, for the test of a civilization is in the way that it cares for its helpless members.”
It appears that here in the 21st century we have a long way to go.
Part 2 of “Demystifying the RAI/MDS” will explain the other components of the instrument and how by following the “map” that is laid out for caregivers we will see a picture of quality care or abuse and neglect. •
Part 2 of this article will appear in the next issue, in which there will be a fax-back or mail-in form to score yourself and send into The Medical-Legal News for three CE hours.
Frances W. (Billie) Sills, RN, MSN, ARNP, is an assistant professor at ETSU College of Nursing inTennessee ; email@example.com.