Applying Strength Based Care (Part II)

Interactive Exercise:

Part II

More Comprehensive Care Planning using BASICS

If we look at Gerald's problems listed on Worksheet A, we see that the most life threatening problem, being a biological problem, is a weight loss of 4 lbs in one month. If Gerald continues to lose weight at this rate, there is risk of death.

The Resident Need Index (PDF, 23KB, 1pg.) in BASICS illustrates how we might plan more effective care for Gerald by identifying how this one problem affects Gerald's function on every level of BASICS.

The BASICS Problem/Strength menus list problems and strengths identified on Gerald's MDS and create a more thorough picture of who Gerald is as a person, not just as a "problem feeder".

Refer to the title of the MDS section cited for each problem or strength to determine where in the MDS they are addressed. For example: Gerald "had distinct food patterns" is found in section AC - the Customary Routine section under Eating patterns (AC-1i); "Vision adequate able to see food" is under Section D- Vision Patterns (D1-0).

Questions to ask about Gerald during an interdisciplinary care plan meeting to address his problems/strengths on each level of BASICS:

1. What type of a person is Gerald? Can we find out from his MDS? Ask someone from each group to read their part of Gerald's MDS information in the Problem/Strength menus under every level of BASICS.
2. What does this tell us about Gerald?
3. Why do you think Gerald has lost 4lbs. in a month?
4. How does the problem affect every level of BASICS, Biological up to Symbolic?
5. Do we need more information?
6. Where will we find more information to help us plan effective approaches to help Gerald meet the identified goal that he gain weight, and more importantly that will support Gerald to have a quality of life he can enjoy?
7. Is the weight loss Gerald's biggest problem?

It is, because as a Biological need it is the most fundamental, and could be life threatening. That is why we start with the lowest level of BASICS when we assess a resident's needs. This biological need must be met before we look at the next level of need. As you can see this one problem of weight loss affects Gerald on every level:

• on the Biological level he is at risk of a life threatening decline. He went from eating to not eating. (Self-preservation not supported)
• on the ADL level he has had a loss of function because he is not allowed to feed himself in his preferred manner. He went from feeding himself (independence) to not feeding himself (dependence). (Self-dependence not supported)
• on the Societal level he expresses feeling a loss of self worth because his view of himself has been diminished. He went from doing something that helped retain his identity as a capable older adult to doing something that he feels means that he is a childish, dependent person. (People food vs. baby food).(Self-identity not supported)
• on the Interpersonal level he has lost valuable contact with good friends who satisfy his need to be thought highly of by others, causing a loss of self esteem. He went from socializing with significant friends to no socializing at meals. (Self-esteem not supported)
• on the Creative level he lost the opportunity to make choices and solve his own problems about how he would eat, skills he always prided himself on. He went from solving his own eating problems (couldn't use utensils, used his hands effectively) to not being given the opportunity to exercise autonomy. (from meals being best time of day to worse time of day) He lost that "spark of life" (eyes went from being alive with purpose to dull with defeat). (Self-expression not supported)
• on the Symbolic level he lost his lifelong feeling of hopefulness and that he was able to lead a worthwhile life. He went from feeling like "somebody" in a hopeful world to feeling like a "nobody" in a world that encouraged hopelessness. (Self-actualization not supported)

Instead of supporting Gerald to reach for the next level of BASICS need, Gerald's caregivers unknowingly allowed him to slip to a lower level of function on the BASICS Hierarchy.

Has Gerald changed his basic philosophy of life since he entered the facility? Or did this crisis precipitate a change in the way he sees himself in the community and as a person, causing him to try to cope in the best way he could which resulted in a change in his usual behavior?

Consider:

1. Would some care planning methods label Gerald as disruptive and try to treat the symptoms instead of the man?
2. Can we find out the real cause of the problem and what it means to Gerald without looking at who he is as a person and what his strengths are as indicated on the MDS as well as from all the other sources we considered in this exercise?
3. Do you think strength based care planning will work for Gerald?
4. How would you react if you were Gerald?
5. What other strengths might he have and which other approaches might be used to solve the identified problems under each level of BASICS.

The strengths listed on the right side of each of the sample problem/strength menus for each level of BASICS target categories of resident functions that can be used to plan the interventions the team may use to address each problem. Goals can be stated as quantitative (a number of times in a day or week) or qualitative (with less anger) once a problem has been identified and described in the problem column, or can be written as a strength to be maintained or improved through use of the approaches chosen by the team.

Sample Problem/Strength Menus For Each Level of BASICS

1. Biological (PDF, 83KB, 1pg.)
2. Activities and Daily Living (PDF, 79KB, 1pg.)
3. Societal (PDF, 83KB, 1pg.)
4. Interpersonal (PDF, 83KB, 1pg.)
5. Creative (PDF, 80KB, 1pg.)
6. Symbolic (PDF, 81KB, 1pg.)