Interprofessional Collaboration in Defensible Documentation

Presented by Ellen R. Strunk and Maureen McCarthy

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Video Runtime: 35 Minutes; Learning Assessment Time: 23 Minutes

Skilled nursing facilities are required to develop a care plan for each beneficiary and provide services in accordance with the care plan. Several studies and investigations have found that SNFs had deficiencies in doing just that, resulting in inadequate care to those residents. This course will describe the purpose for and principles of care planning. Entry-level and intermediate-level clinicians will be able to describe how care plans ensure the team is working in tandem toward the patient’s goals. The course will provide examples of how incorporating resident-centered goals requires interprofessional collaboration and how successful interprofessional collaboration requires a shared, patient-centered vision.

Meet your instructors

Ellen R. Strunk

Ellen R. Strunk has worked in various roles and settings as a clinician, manager/director, and policy expert. Ellen is an expert at helping customers understand the Centers for Medicare & Medicaid Services (CMS) prospective payment systems in the skilled nursing facility and home health settings, as well as outpatient therapy…

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Maureen McCarthy

Maureen is the president of Celtic Consulting, LLC, a clinical reimbursement, clinical operations, and compliance advisory firm. She is also the CEO of MDSRescue, an organization that provides temporary MDS completion services across the country. Recognized as an industry leader in clinical reimbursement for long-term care,…

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Chapters & learning objectives

Purpose of Care Planning

1. Purpose of Care Planning

This chapter will present the key concepts of care planning and the differences between the baseline care plan, the therapy plan of care, and the comprehensive interprofessional/interdisciplinary care plan. An overview of the federal requirements will be included. This information is important for SNF nurses and therapists to understand in order to ensure compliance with state and federal requirements of participation.

Creating Goals That Address Resident Goals

2. Creating Goals That Address Resident Goals

Goals for therapy and nursing should help to drive the plan of care to the destination the resident desires. This chapter will provide practical strategies for ensuring the resident’s goals are reflected adequately in the care plan and in specific enough terms to ensure the care team is on the same page and delivering effective care.

Interdisciplinary Management of the Care Plan

3. Interdisciplinary Management of the Care Plan

Today’s residents have complex health needs and typically require more than one discipline to address their health issues, but that doesn’t mean we work alone. This chapter will tackle the real-life conundrum facing all therapists and nurses in the SNF setting—how can we achieve truly collaborative care?—and provide learners with examples and resources to assist them in their journey to achieve an interprofessional team.