348 CHAPTER 22 | Federal Regulations


be used when writing the care plan to ensure that all members of the team, especially the resident, under- stand the plan and expectations.


Implementing the Interdisciplinary Care Plan


One of the most effective methods for planning resi- dent care is the IDT conference. This offers an excel- lent opportunity for developing a coordinated plan for each resident. It allows each discipline to share assessments and to gain a greater understanding of the resident’s total needs. Much can be learned by carefully listening to and questioning other team members. Team cooperation is particularly important because implementing the goals often involves more than one discipline. For example, when one of the goals is weight gain, the RDN develops a personal- ized diet plan and counsels the resident; the NDTR or dietary manager makes sure that the food is served correctly and offers support; the activities director plans activities to include the resident’s favorite foods or food-related activities; the nursing staff provides support and reinforcement to the resident; and the social worker works with the resident to develop a discharge plan, if appropriate, that includes congre- gate meals, Meals on Wheels, a home health aide for meal preparation, or identification of a grocery store that will deliver food. A nurse is often the appropriate team member to chair the IDT conference because of their frequent contact with the other disciplines. Experts advise that all disciplines meet as a team at regularly sched- uled intervals. The physician has ultimate responsi- bility for the health care of the resident and may be invited to the conference but generally is not asked to chair the team.3


Even if the resident’s physician


is unable to attend, they must be provided with the information developed by the IDT and document the review and approval.


Each discipline should come to the conference


prepared to share assessment data. Because the con- ference is usually prescheduled, the RDN can prepare by collecting and updating the nutrition assessment data and developing tentative plans for addressing the problems identified.


After the IDT conference, the chair of the team follows up with written information. Many of these items will be suggestions and recommendations made by the disciplines, including the RDN, at the conference. The nutrition care recommendations can most often be found in the progress summary of the assessment and will have been discussed during the team conference. If the RDN is unable to attend the care conference, the dietetics designee signs as a rep- resentative of the department. The facility is ultimately responsible for the overall


care of its residents, including their nutritional care. The role of the RDN is to provide a thorough nutri- tion assessment of the resident, identify problems and concerns, and actively participate in the development of interventions included in the care plan. These pro- cedures ensure that the RDN’s recommendations are included in the care plan if the RDN cannot attend the conference. The care-planning process is used to develop a plan of action to prevent avoidable decline, manage risk factors, and build on the resident’s strengths. Care plans are reviewed and revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.5


If the goal is not


met, changes to the care plan should be developed and implemented to be more realistic and achievable. If the problem has been resolved, this should also be reflected in the care plan, along with the date of resolution. The care plan should reflect the resident’s status or condition at the present time. Although the facility staff develops the care plan, the


resident and the responsible party (eg, family or guard- ian) are also part of this process. Care plan meetings, attended by most of the IDT, are held on a quarterly basis or more frequently when needed if changes occur in the resident’s condition; the resident or responsible party should be invited to attend this meeting.


Discharge Planning


Nursing homes do admit residents for short-term rehabilitation. These residents, and sometimes individuals with longer stays, eventually return to their home or former residence or are transferred to another nursing facility. Education from the various disciplines and information related to services from


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