Care area assessments (CAAs) — several of which are nutrition-related — reflect potential areas of concern for nursing home residents.

However, many registered dietitians and dietary managers may not completely understand CAAs or how to determine whether to address them in a resident’s care plan.

This article provides an overview of nutrition-related CAAs, including what they are, what they mean, and how to use them to improve the quality of care and quality of life of nursing home residents.

Resident assessment instrument (RAI)

Long-term care facilities that participate in Medicare and Medicaid programs must meet certain quality requirements to receive payment under these programs.

As a condition of participation, facilities are required to obtain information on residents’ unique strengths and needs using the resident assessment instrument (RAI).

The RAI uses an interdisciplinary approach to help long-term care staff assess and address residents’ functional status, strengths, weaknesses, and preferences in an individualized care plan.

An individualized care plan is an action plan created between a resident (or representative), the resident’s family, and the interdisciplinary team.

It includes measurable goals and timeframes to meet a resident’s individual medical, nutrition, nursing, and psychosocial needs and wishes.

The RAI consists of three components: the minimum data set (MDS), CAA process, and the utilization guidelines (1).

Minimum data set (MDS)

The MDS is a standardized assessment tool that provides information about a resident’s clinical and functional status.

The tool contains various sections that assess cognitive patterns, mood, behavior, functional status, bladder and bowel, swallowing and nutritional status, and skin conditions, among others.

Nested within these sections are items, that if answered in a certain way, identify potential issues that need additional assessment and review.

MDS assessment data are also used to monitor the quality of care provided.

Care area assessment (CAA) process

The CAA process assists clinicians in systematically interpreting the information recored on the MDS.

Components of the CAA process include:

  • Care area triggers (CATs): These are specific responses from the MDS assessment that identify residents who have potential problems and require further assessment.
  • CAA: This is the further investigation of the triggered area to determine whether it requires interventions and care planning.
  • CAA summary (section V): This is the documentation of the CATs and location of the information used to decide whether care planning is necessary.

Utilization guidelines

The utilization guidelines are instructions for when and how to use the RAI.

They include instructions for completing the RAI and framework for synthesizing MDS data and clinical information.

Care area assessments (CAAs)

CAAs are required for comprehensive assessments, including:

  • Admission assessment
  • Annual assessment
  • Significant change in status assessment
  • Significant correction of a previous comprehensive assessment

They are also required when a Medicare prospective payment system (PPS) statement is combined with a comprehensive assessment.

CAAs reflect conditions, symptoms, and other areas of concern that are common in nursing home residents.

The CAA process is intended to help the interdisciplinary team:

  • Identify causes and risk factors contributing to the CAT.
  • Determine whether and how multiple CAT conditions are related.
  • Identify a need to obtain additional information.
  • Identify whether and how a CAT truly affects the resident’s function and quality of life or whether the resident is at risk for developing the condition.
  • Review the resident’s status with a healthcare provider.
  • Determine whether the resident could benefit from interventions.
  • Develop an individualized care plan to meet a resident’s needs as identified through the comprehensive assessment.

Nutrition-related CAAs

Of the twenty care areas, five are nutrition-related.

12. Nutritional status

The nutritional status CAA triggers when a resident has or is at risk for compromised nutritional status.

Triggers include:

  • Dehydration is elected as a problem health condition
  • Body mass index (BMI) is less than 18.5 or higher than 24.9
  • Presence of significant, unintentional weight loss or gain
  • Parenteral feeding
  • Mechanically altered diet
  • Therapeutic diet
  • Current stage 2 or higher pressure ulcers

13. Feeding tube

The feeding tube CAA focuses on the long-term (greater than one month) use of feeding tubes.

It triggers when the resident has a need for a feeding tube for nutrition.

14. Dehydration/fluid maintenance

The dehydration/fluid maintenance CAA triggers when a resident has or is at risk for dehydration.

Triggers include:

  • Fever, vomiting, dehydration, internal bleeding, or infection is selected as a problem health condition
  • Constipation is present
  • Parenteral feeding
  • Feeding tube

15. Dental care

The dental care CAA addresses a resident’s risk of oral disease, discomfort, and complications.

Triggers include:

  • Broken or loosely fitting dentures
  • No natural teeth or tooth fragments
  • Abnormal mouth tissue
  • Cavity or broken natural teeth
  • Inflamed/bleeding gums or loose teeth
  • Pain, discomfort, or difficulty with chewing

16. Pressure ulcer/injury:

The pressure ulcer/injury CAA triggers when a resident has or is at risk for a pressure ulcer.

Triggers include:

  • Assistance needed with bed mobility
  • Frequent urinary incontinence, bowel incontinence, or both
  • Significant, unintentional weight loss
  • Risk of developing pressure ulcers/injuries
  • Current pressure ulcer
  • Trunk restraint used in bed or chair

Care planning decision

Each triggered item represents an area that requires further evaluation because they can adversely affect a resident’s quality of care and quality of life.

Although a CAA must be completed for each triggered item, not every item needs care planning.

For example, a nutritional status CAA that triggers because an 85-year-old resident with dementia has a BMI of 27 likely does not need to be addressed in a care plan because a higher BMI range may be more appropriate for older adults to reduce the risk of death and fall-related fractures (2, 3).

The decision of whether to address a triggered item in the care plan is guided by the severity, functional impact, and scope of a resident’s clinical issues and needs.

It’s determined with the resident and his or her family, the resident’s physician, and the interdisciplinary team.

A separate care plan is also not required for each area that triggers a CAA, as a single trigger can have multiple causes and contributing factors and multiple items can have a common cause or risk factor.

If it’s decided that a triggered item should be addressed, the care plan should identify what the issue is and its underlying causes or risk factors, a measurable and time-specific goal to prevent or resolve the issue, and any interventions in place to achieve the goal.

You can learn more about how to write a nutrition care plan, here.

The bottom line

The RAI helps clinicians identify resident-specific needs and provides the basis for developing individualized care plans that address those needs.

Several nutrition-related CAAs exist, including nutritional status, feeding tube, dehydration/fluid status, dental care, and pressure ulcer injury.

Registered dietitians and dietary managers can use these CAAs to determine whether an individualized care plan is necessary.


Gavin Van De Walle, MS, RD
Gavin Van De Walle, MS, RD

Gavin Van De Walle, MS, RD is a registered dietitian with a master's of science in human nutrition and bioenergetics. Gavin specializes in nutrition for older adults and regulations surrounding long-term care as they relate to food and nutrition.