11/23/2011. Identify Residents risks for decline to establish programs to stave off decline unless it is clinically unavoidable.

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1 Robin A. Bleier, RN, HCRM-FACDONA Clinical Risk & Operations Consultant R B Health Partners, Inc. 210 So. Pinellas Ave. Suite 260 Tarpon Springs, FL robin@rbhealthpartners.com Restorative care refers to nursing interventions that promote the resident s ability to adapt to living as independently and as safely as possible 1

2 Identify Residents risks for decline to establish programs to stave off decline unless it is clinically unavoidable. OBRA 1987 Hence, not a new concept The concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning (unless decline unavoidable) Intent Definitions Overview 2

3 Restorative programs are typically initiated when a resident is discharged from a formalized physical, occupational, or speech rehabilitation therapy The program may also be started when a resident is admitted to a facility with restorative needs, but is not a candidate for a formalized rehabilitation program The program can also and should always be initiated when a restorative need arises during the course of stay and often detected during the routine OBRA resident assessment instrument (RAI). Does Restorative Nursing require a physician order? No, unless a billable Medicare restorative No, unless a billable Medicare restorative program. 3

4 Restorative Care must meet the following criteria: Measureable objectives and interventions mustbedocumentedintheplanofcareand in the clinical record There must be evidence of periodic evaluation by a licensed nurse in the clinical record If billable restorative needs to show progress Nursing assistants/restorative aides must be trained in the techniques that promote resident involvement in the activity/program These activities/programs are carried out or supervised by members of the nursing staff Sometimes, under the supervision of a licensed nurse, other staff or a volunteer may be assigned to work with specific residents Activities can include the following: Passive Range of Motion Active Range of Motion Splint or Brace Assistance 4

5 Must Include: Bed Mobility Transfer Walking Dressing and Grooming Eating and Swallowing Amputation/Prosthesis Care Communication Other activities to improve or maintain the resident s self performance in functioning, i.e., diabetic management, selfadministration of medications, ostomy care, cardiac rehabilitation Cardiovascular the heart has to work 30% harder when a person is in the recumbent position at risk for thrombosis formation Gastrointestinal reduces energy requirement of the cells and their metabolic process urine pools in the bladder Respiratory the lings shift in the recumbent position causing a decrease in movement of secretions which can also cause pooling of fluids which can then cause an oxygen/carbon dioxide imbalance 5

6 Psychosocial communication and interaction with others is limited Musculoskeletal deterioration resulting in osteoporosis, contractures and pressure ulcers. Regulates restorative nursing Defines restorative as a nursing function Therapy, nursing and the MDS Coordinator must work closely together to insure optimal care for the resident and economic benefits for the facility Each resident must receive, and the facility must provide the necessary care and services to attain or maintain the highest practicable, physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care Very descriptive in that a resident s ability in ADL, eating, toileting, bathing, dressing, grooming, speech, language and functional communication does not diminish unless the individual s clinical condition demonstrates it was unavoidable A resident must be given the appropriate treatment and services to maintain or improve his/her abilities You are challenged to police pressure ulcers, use of foley catheters, limitation in range of motion, and use of physical restraints 6

7 Routine Care to maintain the current level identify and prevent loss Restorative Care to restore to the highest functional level and work with the at risk residents Specialized Care to support specialized rehabilitation services (therapy) Restorative Nursing is NOT a separate program, but rather a part of the facility rehab program Restorative Nursing can be reimbursed under Rehab Low and can be revenue generating Teach the staff to look for and document the resident at his/her worst ADL performance. The MDS uses a dependence model for coding. Missing one instance of a two-person assist can cost you a RUG. 7

8 Don t Mix Them Up: Self Performance measures what the resident actually did in each ADL category over the seven day look back Support Provided measures the highest level of support that the staff provided to the resident in the last seven days even if that support occurred only once Range of Motion active and passive Splints or Brace Assistance Scheduled Toileting Bed Mobility Transfers Walking Dressing and Grooming Eating and Swallowing Amputation/Prosthesis Care Communication An ADL Score is calculated For all assessment Classifications and is one of the determining factors regarding category selection for a Resident. 8

9 Remember Section G remains of Great importance in 2.0 and includes on four domains or late loss ADLs. Bed Mobility Toileting Transferring Eating The ADL scores range from 4 18 Four (4) the most Independent Eighteen (18) the most Dependent G1a bed mobility 9

10 G1b transfer G1h Eating G1i toilet usage 10

11 ACTIVE RANGE OF MOTION Exercises performed by the resident Cueing and/or supervision by the staff Planned and scheduled with specific movements and repetitions Does not include movements during routine ADL performance PASSIVE RANGE OF MOTION Exercises performed by the staff for the resident Planned and scheduled with specific movements and repetitions Does not include movements during routine ADFL performance Range of Motion must be provided more than 15 minutes in a 24 hour period Cannot combine active and passive ROM for total minutes Checking either one or both (active or passive) is counted as one restorative nursing service under PPS If the goals are met then you should place the resident on a nursing maintenance program and encourage participation in appropriate activities 11

12 If the goals are not met but the resident is progressing then continue with the current program If the goals have not been met and the resident is not progressing consider emotional, mental and environmental factors: assess for pain and discomfort; review medical status; review medications; evaluate nutritional status; refer to PT/OT; develop alternate approaches in the resident s plan of care If the lack of progress is due to motivational or behavioral response then refer to Social Services and/or Activities Coordinator One of two types of assistance: Staff provides verbal and physical guidance and direction that teaches the resident how to apply, manipulate and care for the brace/splint sessions are planned and scheduled Staff have scheduled program of applying and removing a splint or brace The resident s skin and circulation under the device are assessed 12

13 The resident s limb is repositioned in correct alignment All sessions are planned and scheduled Formalized plan to toilet the resident on a scheduled basis The resident is able to maintain continence the majority of the time due to the plan and interventions This should include habit training and/or prompted voiding Formalized program in which the resident is taught to consciously delay voiding or resist the urge to void Includes assessments or incontinence causes and patterns Usually will take weeks or months to accomplish goal Checking either ST or BR is counted as one restorative nursing service under PPS 13

14 If goals are met and the resident is continent then you should take the resident off the bladder program and continue to remind the resident to toilet after meals, etc. Document the resident s s continued continence in the Nurses Notes/Monthly Summary If progress has been made but the resident is not yet continent then increase the toileting time to every 3-4 hours and develop alternative approaches in the resident s plan of care If the goals are not met and the resident is not cooperating consider a referral to PT?OT and place the resident on an incontinent care program Training and skills practice includes repetition; physical and verbal cueing; task segmentation provided by trained staff; and involves all restorative nursing services Includes activities used to improve or maintain the resident s self performance in bed mobility Moving to and from a lying position g y g p Turning side to side Positioning him/herself in bed 14

15 Includes activities used to improve or maintain the resident s self-performance in walking Can be with or without assistive device Walk and dine program is very popular Checking either walking or bed mobility is counted as one restorative service under PPS If the goals are met then you should place the resident on a nursing maintenance program for ambulation and encourage participation in appropriate activities If goals are not met but the resident is progressing then you should continue the current program If goals are not met and the resident is not progressing you should consider any emotional, mental or environmental factors and evaluate need for an alternative assistive device Review the medical status; evaluate nutritional status and perhaps have the Resident Care coordinator refer to PT for further evaluation/screening You will additionally need to develop alternative approaches to the plan of care If the lack of progress is due to motivational or behavioral response then you should refer to Social Services and/or the Activities Coordinator 15

16 Any activity used to improve or maintain the resident s self-performance in moving between surfaces/places Can be with or without assistive devices If goals are met then place the resident on a nursing maintenance transfer program If goals are not met but the resident is progressing then continue on the current program If goals have not been met and the resident is not progressing consider other factors such as emotional, mental or environmental; review medications; review medical status, evaluate nutritional status, etc. The resident may need to be referred to PT/OT for further evaluation/screening Alternative approaches must be developed for the plan of care Activities used to improve or maintain the resident s self-performance in: Dressing and undressing Bathing and washing Performing other personal hygiene tasks 16

17 If goals are met then you should place the resident in a nursing maintenance ADL program If goals are not met but the resident is progressing continue with the current program If goals are not met and the resident is not progressing evaluate the need for a schedule change as well as other factors: medical status, medications, nutrition, etc. Assess the need to have the resident referred to PT/OT Assess if motivational or behavioral issues are a factor and refer to Social Services Alternate approaches may be necessary and must be indicated in the resident s plan of care Consists of activities used to improve or maintain the resident s self-performance in feeding one s self food/fluids Activities used to improve or maintain the resident s ability to ingest nutrition and hydration by mouth 17

18 When goals are met then you should take the resident off the feeding/restorative dining program If the goals are not met but the resident is progressing then continue with the current goals/approaches If there is no progress noted within the set time frame then you must try different approaches to the established goals If there still continues to be no progress then the resident needs to be referred back to ST for Evaluation/screening and perhaps further swallowing studies If it then determined that therapy is not appropriate the resident should be removed from the eating/restorative dining program either permanently or temporarily The resident s plan of care must be updated accordingly with alternate approaches, etc. Includes activities used to improve or maintain the resident s self-performance in: Putting on and removing a prosthesis Caring for a prosthesis Providing appropriate site hygiene 18

19 When the goals are met you should place the resident on a prosthesis maintenance program If goals are not met but the resident is progressing then continue with the current program If the goals are not met and the resident is not progressing consider all factors: emotional, medical, nutritional, pain and discomfort, etc. Assess the need for further intervention by PT/OT Develop alternative approached for the plan of care Activities used to improve or maintain the resident s self-performance in: Using newly acquired functional communication skills Assisting the resident in using communication skills and adaptive devices Must be under nursing supervision Must be addressed in the plan of care and the clinical record with measureable objectives and interventions Must have periodic evidence of evaluation by a nurse in the clinical record Each restorative nursing service is delivered more than 15 minutes in a 24 hour period Personnel performing restorative care must be trained in restorative techniques 19

20 Restorative therapy can be provided by RNA s, CAN s or other personnel who have been trained The following pairs are counted as one: Active/Passive ROM Bed Mobility/Walking Scheduled Toilet Training/Bladder Retraining Group Restorative Care is acceptable, i.e., make-up applications, nail care, hairstyling, use of adaptive equipment, restorative dining, transfer/balance, etc. Each resident receives credit for total treatment time 20

21 It is the responsibility of ALL staff to prevent the resident from deterioration and further functional loss OBRA defines restorative nursing as the continuation of therapy by nursing following rehabilitation and documenting efforts to restore as much functional independence as possible Each resident s restorative needs must be documented (MDS) and resident specific care plans that tie into the MDS must be developed Therapy should be involved in resident assessment, determination of restorative need(s), training nursing staff, identifying feeding program candidates, etc. The goal should be to have as much specialty therapy involvement as possible without limiting resident care Designate a person and/or a position Supervise restorative nursing program 24/7 Performed by RNA/CNA Other departments can assist, i.e., Activities can assist with exercise or grooming groups Job descriptions delineating duties Positions specific for Restorative Nursing Restorative Nurse/ RNA 21

22 Duties specific for Restorative Nursing Include restorative nursing responsibilities under staff nurse and CNA job descriptions Staff must be clear on when and what they are doing is considered d a restorative ti nursing service Policies and Procedures for each Restorative Nursing service Make them easy to understand and follow Scheduled and well defined on-going education for person(s) providing restorative nursing 22

23 Develop a documentation system Plan of Care Flow sheets to capture service and time RNA/ CNA assignment sheets Weekly charting by the nurses to evaluate residents progress Physician order protocols Who is responsible to check that documentation is done time and accurately Interact with PT/OT/ST ongoing Resident assessment and ongoing evaluation of appropriate placement in the program Formal interdepartmental communication for resident placement and movement in the program Overall daily supervision of restorative program Review documentation at weekly rehab meetings/standards of Care meeting Consult with therapy Always have appropriate RNA coverage 23

24 There are Six Restorative Factors: Disease Diagnosis Behavior Pattern Cognitive Patterns Hearing/Vision Patterns Physical function (Upper & Lower) Too many residents and not enough RNA s Lack of knowledge regarding what a restorative program consists of Non-supportive Administration Using the RNA as an extra hand to fill staff shortages Lack of formal education of RNA s Lack of leadership to maintain program Program handled only by the RNA no teamwork no interdisciplinary coordination no management or nursing support The lack of restorative nursing documentation No accountability or follow-up 24

25 Interdepartmental Communication Assessment/Data Collection Active Restorative Program Waiting List Maintenance Program Documentation Achievable Approaches/goals in the Plan of Care Development of a process for the operation of the integrated restorative nursing program THINK OF THE RESTORATIVE NURSING PROGRAM AS A RECIPIE FOLLOW THE STEPS AND ADAPT THE RECIPIE TO YOUR RESIDENTS NEEDS AND TO THE INGREDIENTS EN YOU HAVE AVAILABLE (THERAPY, RNA S, CNA S) Receive their care from RNA s under the oversight of therapy and supervision of a licensed nurse Most have just been released from rehab and require continued ambulation, orthotic daily wear, feeding assistance, etc. Some participants may have returned from a hospital stay and need restorative care to be brought back to maintenance status 25

26 The number of active participants should not exceed the RNA s ability to provide comprehensive care Specialty therapy should closely monitor the caseload and provide assistance as needed These participants have been following a restorative plan for several weeks, with good compliance and have established their goals and progress Care consists it of ambulation blti assistance it and range of motion, proper positioning and functional alignment, and orthotic device application and removal RHA s are available to assist and work closely with CNA s as the resident is transitional from active to maintenance status These are residents who have been identified as needing restorative care and are awaiting active status They receive short-effects restorative therapy, i.e., ROM, ambulation, proper positioning, etc. from trained CNA s Once space is available they are transitioned into active or maintenance participant status, depending on their needs 26

27 Any significant change in condition must immediately be brought to the attention of the supervisor, and if warranted, the plan of care and the resident s status in the program is modified df d all interdisciplinary team members must be informed Participants are discharged from the program for various reasons such as hospital stays or transfers out of the facility A resident evaluation is usually indicated upon readmission, as the resident s condition can change significantly when restorative therapy is not provided outside the facility. THE FUTURE OF A FACILITY S WORTH AND ITS EXISTENCE WILL DEPEND UPON THE DEPTH OF ITS RESTORATIVE PROGRAMS AND ITS COMMITMENT TO RESTORATIVE R PRACTICES CE 27

28 Our mission is to promote quality outcomes through education, support and partnership. Robin A. Bleier is the Principal of RB Health Partners, Inc & Care Resources, which is a full spectrum Geriatric Care Management and Homemaker Companion Service Group. her at robin@rbhealthpartners.com or call