INTERDISCIPLINARY TEAM

 

POLICY STATEMENT.

The Division of Veterans Healthcare Services (DVHS) requires each of the New Jersey Veterans Memorial Homes (VMH) to establish manuals of policies and procedures for providing services.  Procedures shall permit the organization of committees or teams, as needed, to ensure compliance with the New Jersey Standards for Licensure of Long Term Care Facilities, and with applicable Federal and New Jersey State Administrative Codes, related laws, regulatory and licensing standards.

PURPOSE.

This policy and procedure shall ensure that each VMH establishes and maintains an Interdisciplinary Team (IDT) of staff members who will consistently and accurately gather information regarding resident needs and strengths, which provides the foundation for an individualized plan of care for each resident.
 
DEFINITIONS.

MINIMUM DATA SET (MDS) – The Minimum Data Set is one of several patient assessment tools, the use of which is required by the Federal Government as part of reimbursement and regulation. The MDS captures screening and assessment elements (which includes common definitions and coding categories) needed to comprehensively assess an individual nursing home resident’s functional capabilities, and helps VMH staff identify health problems. The MDS contains items that measure physical, psychological and psychosocial functioning.

RESIDENT ASSESSMENT PROTOCOLS (RAPs) – the RAPs are problem-oriented frameworks for additional assessment based on problem identification items (triggered conditions). They form a critical link to decisions about care planning. The RAP Guidelines provide guidance on how to synthesize assessment information within a comprehensive assessment.

RESIDENT ASSESSMENT INSTRUMENT (RAI) – the RAI helps VMH staff to gather definitive information on a resident’s strengths and needs, which must be addressed in an individualized care plan. It also assists staff to evaluate goal achievement and revise care plans accordingly by enabling the VMH to track changes in the resident’s status. As the process of problem identification is integrated with sound clinical interventions, the care plan becomes each resident’s unique path toward achieving or maintaining his or her highest practicable level of well-being.

INTERDISCIPLIANRY TEAM (IDT) - a group of staff members, both professional and ancillary, representative of each service, coordinated by a Registered Nurse (RN), and responsible for the development of individual resident care and treatment plans, in accordance with the New Jersey Department of Health and Senior Services’ licensing standards. 

PROCEDURE.

  1. New Jersey Veterans Memorial Homes’ Interdisciplinary (IDT) Team

    2.  

    1. The New Jersey Veterans Memorial Homes shall establish, under the direction of a registered nurse (RN), an Interdisciplinary Team (IDT) charged with the mandatory completion of initial, quarterly, and annual comprehensive resident assessments.

      2.  

    2. The Interdisciplinary Team (IDT) is responsible for the development, implementation, and coordination of resident care plans, beginning on the day of the resident’s admission and ending upon the resident’s discharge from the facility. Care plan decisions are reached by consensus.

      3.  

      1. Interdisciplinary Team (IDT)
        1. IDT membership shall be representative of the following services:

          2. Registered Nurse (Assessment Coordinator)
          Quality Assurance and Improvement Coordinator
          Nursing Personnel (RN, LPN, CNA)
          Dietary Representative
          Social Services Representative
          Activities Representative
          Other healthcare professionals, when ordered by the physician or advanced practice nurse

        2. The Interdisciplinary Team will meet at the time of the resident’s admission, quarterly, annually, and when changes in the resident’s condition occur, in accordance with applicable Federal and State rules, regulations, and standards, to develop a care plan, review the resident’s progress, and plan for the possible discharge of a veteran home resident as required.

          3.  

        3. The Interdisciplinary Team is charged with the task of coordinating the Minimum Data Set (MDS) and the Resident Assessment Instrument (RAI) in accordance with regulatory requirements, and with electronically transmitting this data to the appropriate governmental agency for regulatory review.
        4. The Quality Improvement Coordinator manages this entire process.

 

Revised:   July 2005
Revised:   July 2007
Revised:   July 2009

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