Conflict of Interest Statement

Conflict of Interest Statement RESTORATIVE NURSING: A WIN WIN for Everyone Involved! (Almost) Everything You Ever Wanted to Know About Restorative Nursing But Were Afraid to Ask! HealthCap s educational activities are developed by an educational committee using evidence based content in a balanced and bias-free manner. If you believe an educational session was presented in a manner compromising these requirements, please contact the HealthCap office at 734.996.2700 to notify HealthCap s Lead Nurse Planner and Educational Committee This session s developers and presenters have no commercial interests in the topic. No commercial support was provided for this session. HealthCap RMS Criteria for Awarding Contact Hours Licensed nurses will be awarded 1.0 contact hours per completion of 60 minutes of educational sessions. Upon completion of the session complete the post-session quiz and earn at least 80% passing rate; complete the evaluation; and follow the directions to add your license number to the certificate of achievement. The quiz may be retaken if a successful score was not attained. You will have 14 days from the time of registration to complete the session without re-registering. Learner Objectives Define Restorative Nursing Services Evaluate the need for a restorative program Design a restorative program Compare restorative program options

OBRA Guidelines Define restorative nursing as the continuation of therapy by nursing following rehabilitation with nursing responsible for both maintaining the status of the resident after discharge from rehabilitation and documenting efforts to restore as much functional independence as possible. Restorative and Reimbursement Restorative Nursing Programs are a component of the following three RUG categories: Rehabilitation Behavioral Symptoms and Cognitive Performance Reduced Physical Function What is Restorative Nursing? Defining Restorative Nursing Services Making sure we are all on the same page - Nursing interventions to promote a resident s ability to adapt and adjust to living as independently and safely as possible Actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning

Who Is It For? A resident may be started in a restorative nursing program when: Admitted to the facility with restorative needs but not a candidate for formalized rehabilitation therapy When restorative needs arise during the course of a long-term stay or in conjunction with formalized rehabilitation therapy Generally Speaking Restorative nursing programs are often initiated when a resident is discharged from formalized physical, occupational or speech therapy and remains a resident of the facility/community Restorative Nursing Programs per the MDS H0200, H0500, O0500 Technique and Training and Skilled Practice Technique Activities Provided by Restorative Nursing Staff O0500A, O0500B Passive and/or active range of motion** O0500C, Splint or Brace Assistance **Count as one service even if both provided (MDS 3.0 Manual 6-48, October 2015)

Training and Skill Practice Activities including repetition, physical or verbal cueing, and/or task segmentation provided by any staff member under the supervision of a licensed nurse. O0500D,O0500F - Bed mobility and/or walking training** O0500E - Transfer O0500G, Dressing and/or grooming training O0500H - Eating and/or swallowing training O0500I - Amputation/Prosthesis Care O0500J Communication **Count as one service even if both provided (MDS 3.0 Manual 6-48, October 2015) Toileting Programs Separate Category H0200C ** - Urinary toileting program H0500 ** - Bowel toileting program **Count as one service even if both provided (MDS 3.0 Manual 6-48, October 2015) Components of a Restorative Program Measurable objectives established for activity performance Interventions documented and care planned Licensed nurse evaluates program including documentation on a scheduled basis Staff members trained and supervised by a licensed nurse Role of Restorative Nurse Aides Under the supervision of the licensed Restorative Nurse the RNAs provide and assist in delivery of restorative services. Can include swallowing techniques at mealtime for specific residents as recommended by speech therapy. RNAs are responsible for monitoring and documenting the resident s progress or regression

Choosing the RNAs Highly motivated Energized Self-directed Good learners Evaluating the Need for Restorative Programming Also known as improving resident functional status and CASPER report ratings The Facility Assessment Your Facility Assessment should be used The Facility Assessment should provide you with an overview of your residents specific needs It should also identify your areas of expertise RESTORATIVE NURSING IS NOT AN AFTER THOUGHT Evaluate the Hazards of Immobility Musculoskeletal System Cardiovascular System Integumentary System (Skin) Respiratory System Genitourinary System Gastrointestinal System Central Nervous System

Immobility and Dependence Older adults fear the loss of mobility and independence Functional Dependence Bedfast Eating dependent Transfer dependent Incontinent Not Only Negative for Resident Quality Measures for the STAR rating and CMS Nursing Home Compare (available for consumers and prospective residents) use: Increased ADL needs Falls and falls with major injury Low-risk incontinence UTIs Pressure wounds Evaluating the Need - Choosing the Leader A licensed nurse Able to direct care and supervise staff Able to MOTIVATE the staff to work with unmotivated or underachieving residents Creative and innovative ONGOING Professional Development to keep the programs fresh

Action steps to improve performance Designing A Restorative Program MDS O0500 Restorative Nursing Program Requires 15 minutes in a 24 hour period; ONE program can be totaled across the 24-hour period Each program must be separate Cannot combine minutes of two or more programs Groups of 4 or less per caregiver Successful Programs Integrate specialty therapy, RNs and CNAs working with clear restorative therapy responsibilities Document the resident s restorative needs on the MDS Develop and tie resident specific care plans back to the MDS Program objectives are realistic and achievable with respect to resident needs and caseload Successful Staffing As long as they are trained, activity staff, Social Workers or other team members, can assist with the Restorative Program They provide the Restorative Programming under direction of the Restorative Nurse Key to using non-cnas includes: Training, execution, documentation, and dedicated restorative nurse oversight

Successful Staffing Using the CNAs Effectively Dedicated Restorative CNAs Desirable position for CNAs RESTORATIVE IS IMPORTANT FOR MAXIMIZING RESIDENT WELL BEING Program Implementation Evaluation of need determines priorities, benchmarking, and goals Which existing staff are the best fit for restorative? Program Implementation Program Implementation Based on the evaluation priorities determine how many Restorative Team members are needed How many programs will run on each shift How many Restorative staff will be needed each shift Determine how many staff need to be trained on each shift Establish a standardized training and competency verification program for the Restorative Nurse Assistants (RNAs) Plan and communicate discharges from therapy to provide an RNA and Restorative Programming Train CNAs to support restorative by managing basic care needs to allow RNA focus on the continuity of services

Implementation The Moving Parts Therapy should be involved in resident assessment, determination of restorative needs, training nursing staff, identifying feeding program candidates, etc. The goal is to have as much specialty therapy involvement as possible without limiting resident care Each resident with restorative needs should be evaluated by nursing and therapy and classified into one of four categories Remember! The restorative program must meet the criteria in O0500 to code it on the MDS Some programs may be good for the resident and should continue even if they do NOT meet the MDS Restorative criteria Documentation Measurable objectives/interventions Goals should be specific to that resident and to what you are trying to achieve with that program Comparing Programming Options Use your needs assessment to determine the priorities and implementation plan What do your residents need?

Categories of Residents Category 1 = Active Participants Category 2 = Maintenance Participants Category 3 = Residents Awaiting Active Status Category 4 = Discharged Residents Category 1 Active Participants Active participants receive care from RNAs under the oversight of therapy Most have been discharged from rehabilitation and require continued support with: Ambulation Orthotic daily wear Feeding assistance, etc. Residents requiring orthotic devices should be evaluated by skilled therapy to establish a wearing schedule and released to nursing for care plan development Category 2 Maintenance Participants Have been following a restorative care plan for several weeks with good compliance and established progress/maintenance Care consists of: Ambulation assistance Range of motion (massage and slow, gentle stretching MSGS) Proper positioning and functional alignment Orthotic device application and removal. Category 2 Maintenance Participants Maintenance care plans have a clear delineation of responsibilities regarding time schedules, etc. Care plans are prepared and signed by the CNAs responsible for implementing the restorative care Care plans should be reviewed and updated as needed RNAs should carefully monitor each maintenance participants status ongoing

Category 3 Residents Awaiting Active Participant Status Residents with identified restorative nursing needs who are awaiting active participant status receive short-effects restorative therapy from trained CNAs This care is documented on the resident care plan Category 4 Discharged Participants Participants are discharged from the program for various reasons When a resident is discharged and readmitted, an evaluation is indicated as the resident s condition can change significantly when restorative therapy is not provided daily Active or maintenance participants who progress significantly may qualify for discharge from the restorative program and admission to rehabilitation Category 4 Discharged Participants Alert and oriented restorative program participants have the right to refuse treatment If participants are combative or uncooperative, maintenance status may be indicated Documentation as to the reasons a participant with cognitive difficulties is discharged from the program should be in the medical record Program Option Examples Full program operating in dedicated restorative space and equipment Many residents receiving services in the restorative space as well as their rooms A full program requires the RNAs be well trained and supervised Restorative programming generally occurs during 1 st and some of 2 nd shift at least 6-days per week

Program Option Examples Some homes provide specific portions of Restorative Nursing such as: Restorative Dining Walking Program Splint Program Specific enough to meet regulatory requirements Documentation Examples Electronic Health Records EHRs generally have systems for capturing Restorative Nursing services Include Restorative Nursing documentation review in the QAPI and/or Corporate Compliance process Educate Restorative Nursing Assistants AND Certified Nursing Assistants on documentation protocols FYI: Terminology and Coding Care plan language must match the MDS 3.0 If you use language such as Stand By Assist (SBA) and other therapy terms, define them in a key or glossary A RESTORATIVE PROGRAM IS A NURSING PROGRAM AND SHOULD USE NURSING LANGUAGE

Documenting Restorative Care Increments of 15-minutes per technique during a 24-hour period 10 minutes PROM in morning; 5 minutes PROM in evening 5 minutes of splinting morning, afternoon and evening 15-minute increments CANNOT be obtained by totaling different techniques over 24-hours Restorative Care Plans Measureable objective and interventions must be documented in the care plan and in the medical record. These Goals Do Not Support Services Resident A will maintain current weight Resident B will do 8 arm flexes two times a day Resident C will maintain current strength and flexibility Resident D will be clean, dry and odor free WHAT S WRONG WITH THIS Restorative Nursing Care Plan? Example #1 Goals: 1. Dressing/grooming - Resident will complete ADLS with limited staff assistance 2. Walking training - Resident will move through the environment with staff assistance Approaches: Resident will perform morning/evening ADLs with limited assistance and set up qd 15 minutes Resident will walk/wheel with staff supervision qd x100 feet x15 minutes

What s Wrong With Example #1? Goal #1 is identified as related to Dressing or Grooming Training. The actual goal states will complete ADLs with limited assistance. There is no description of which ADLs. What s Wrong With Example #1? Goal #2 is related to Walking Training; the goal states will move about environment with supervision. What does this mean? How can we better describe our process and measure outcomes? Acceptable Goals - Examples Resident A will walk 100 feet in five minutes with assist of one and rolling walker Resident B will feed self finger foods at 50% or more of meals Resident A will open the fingers of her left hand far enough to hold a spoon (or tennis ball or some other object) Resident C will button the buttons on her shirt with step-by-step cues More About Acceptable Goals The goal needs to link directly to the TECHNIQUE It must logically flow from the TECHNIQUE, to the INTERVENTIONS/APPROACHES Include the HOW and WHERE/WHEN (time references)

Periodic RN Evaluation Documentation Should be comprehensive; avoid met goals, continue program Instead: The resident s goal was to be able to walk 100 feet independently with her walker with cues and encouragement. She has demonstrated this ability every day for the past two weeks. Staff believe she has potential to walk farther however she is afraid and won t attempt to walk further if staff aren t with her. Will revise program to increase the number of feet she walks with cues and encouragement. Will meet with her weekly to talk to her about her fears and talk to her about how much she is achieving. Scenario #1 Good Examples Mr. V lost ROM in right upper extremity: Right hand splint Right hand ROM exercises 15 minutes a day on splint; time is documented 7 days/week 15 minutes a day on ROM; time is documented 7 days/week The goal will open fingers far enough to insert baseball is in the record There is documentation of CNA training on interventions The RN has documented supervision of the program Scenario #2 Good examples Resident is independent in walking but has frequent falls PT works with the resident on strengthening exercises PT discharges resident with goals met Resident receives reminders from staff to complete exercises; documented by CNAs BID RN evaluates the resident s progress and recommends program be maintained Scenario #3 Good examples Resident is independent with walking however experiences falls due to poor balance PT works with the resident on balance exercises Resident requires constant cueing to complete exercises CNAs are taught the exercises and how to cue the resident CNAs document time spent cueing resident BID, 5 days/week

Summary Needs of individual residents are addressed Measurable goals reflect the function the resident is currently working on improving Criteria outlined in the RAI manual must be met Conclusions An organized restorative nursing program is not as complicated as it may seem The easiest and most desirable programs emphasize prevention and are designed to maintain physical and mental health, proper positioning and body alignment Restorative programs should have a constant emphasis on a dignified, home-like atmosphere and be resident centered What To Do NOW? Resources 1. Needs assessment review the current program 2. Include assessment of residents, staff, environment and equipment 3. Prioritize using findings from the needs assessment and your CASPER Report 4. Choose the staff, arrange the environment, order the equipment AND educate, educate, educate 5. Implement low and slow get it right before expanding programming www.health.state.mn.us/divs/fpc/restorativenursinghandouts.pdf www.sweeneylawfirm.com/content/role-of-restorative-nursing www.thefreelibrary.com/restorative+nursing+program

References Acello, B. The Long Term Care Restorative Nursing Desk Reference, HCPro, Inc., 2009. CMS Long Term Care Resident Assessment Instrument 3.0 User s Manual, Version 1.13, October 2015 https://www.cms.gov/medicare/quality-initiatives-patient-assessment- Instruments/NursinghomeQualityInits/MDS30RAIManual.html Martinson, M. Restorative Nursing Coding on the MDS. Minnesota Department of Health. 2012 http://www.health.state.mn.us/divs/fpc/restorativenursinghandouts.pdf Office of Inspector General Review of Restorative Programs, September 2014 http://oig.hhsc.state.tx.us/oigportal/portals/0/publications/reviewofrestorativeprogramssept2014.p df