CMS Hand in Hand Training Series for Nursing Homes

1. CMS Hand in Hand Training Series for Nursing Homes Maria Fisher, MSW &Jo Taylor, MPH, RN CCME Care Improvement Specialists January 2014 www.ccmemedicare.org

2. Transforming Dementia Care Photo by Clay Walker

3. The Person-Centered Approach “By improving dementia care through the use of individualized, person-centered care approaches, CMS hopes to reduce the use of unnecessary antipsychotic medications in nursing homes and eventually other care settings as well.” – CMS, 2013

4. Content • Overview of CMS Hand in Hand: A Training Series for Nursing Homes • Using CCME’s “How-to” Guide for CMS Hand in Hand Training for Dementia Care

5. ‘Problematic Behaviors’ vs. Unmet Needs “Evidence shows that a large proportion of these so-called behavior problems stem from an incongruence between the needs of people who suffer from dementia and the degree to which their environment fulfills those needs. Thus, many ‘problematic behaviors’ represent a cry for help, a result of unmet needs, or an inadequate attempt to fulfill those needs.” Cohen-Mansfield, J. & Mintzer, J. E. (2005). Time for change: The role of non-pharmacological interventions in treating behavior problems in nursing home residents with dementia. Alzheimer’s Disease and Associated Disorders, 19(1), 37-40.

6. Affordable Care Act Dementia and Abuse Prevention Training Section 6121 • Requires annual nursing assistant training in dementia care and abuse prevention • CMS 6-hour curriculum, Hand in Hand • One part of the CMS National Partnership to Improve Dementia Care in Nursing Homes

7. Purpose of Six 1-hour Modules • Improve staff skills in caring for residents with dementia through an individualized, person-centered approach • Prevent resident abuse • www.cms-handinhandtoolkit.info

8. Four Modules on Dementia Care • Module 1 – Understanding the World of Dementia: The Person and the Disease (pages 5–106) • Module 3 – Being with a Person with Dementia: Listening and Speaking (pages 5–100) • Module 4 – Being with a Person with Dementia: Actions and Reactions (pages 8–162) • Module 6 – Being with a Person with Dementia: Making a Difference (pages 5–106) • Glossary and References

9. In Just a Few Steps CCME’s ‘How-to’ Guide to CMS Series • Step 1: Assign a staff member as trainer • Step 2: Make key decisions • Where classes will be held? • Who will attend? • How long will each session be? • How often will classes occur?

10. In Just a Few Steps CCME’s ‘How-to’ Guide to CMS Series • Step 3: Gather training resources and equipment • TV with DVD player • DVDs of modules 1, 3, 4, 6 • Instructor guides • Easel, chart, and markers • Pens, pencils, and crayons • Writing tablets • Prizes (optional) • Post-it notes (Module 4 only) • Name tags – 2 per participant (Module 6 only)

11. In Just a Few Steps CCME’s ‘How-to’ Guide to CMS Series • Step 4: Prepare • Review instructor’s guide (page 4 of each module) • Watch all four DVDs • Select exercises and practice • Print copies of handouts • Rehearse your presentation using the DVDs • Record your time

12. CCME’s ‘How-to’ Guide to CMS Series

13. Module Organization in CMS Hand in Hand • Lecture, interactive discussion, and exercises • Videos of resident and staff interactions • Opportunities for discussion and problem solving • Time allotted for content • Handouts • Equipment and resources • Instructor guidance for slide groups • Instructor dialogue and action slide by slide • An Introduction for Facilitators and Administrators

14. Module 1 – Understanding the World of Dementia: The Person and the Disease • Comprehensive overview • Types of dementia • Individual effects of dementia • Person-centered approach Understanding = Foundation for skill-building

15. Module 3 – Being with a Person with Dementia: Listening and Speaking • How dementia affects communication • Searching for meaning • Individualized approach • Strategies for communicating Changes in brain chemistry = Changes in behaviors

16. Module 4 – Being with a Person with Dementia: Actions and Reactions Understanding behaviors Identifying needs Ways to prepare for, prevent, and respond to actions and reactions Behaviors = Actions and reactions

17. Module Six – Being with a Person with Dementia: Making a Difference • Making connections • Meeting residents where they are • Focusing on strengths and abilities • Your role Making connections = Making a difference

18. Applying CMS Hand in Hand Content • Continuous modeling by leadership • Unit-based team huddles • Problem-solving in real time • Root cause analysis • Non-pharmacologic strategies • Case studies/real-life examples • Small teams • Read case study or use real-life unit example • Conduct huddle to problem-solve and develop interventions

19. CCME’s ‘How-to’ Guide to CMS Series Team Huddle Exercise The patient: Mrs. Jones, 83-year-old widow • Admitted to dementia care unit last month from assisted living where she fell, resulting in hip fracture and hospitalization • Former homemaker with three children, played the organ in church, liked to garden • One daughter visits 1-2x/week • Moderate to severe dementia with no safety awareness and lower extremity weakness

20. Team Huddle Exercise (cont.) • The last two weeks, has become increasingly agitated during showers. • Today she tried to hit a nurse aide. • At times, especially in the late afternoon, she moans loudly and cries out. • Staff members use a pressure alarm in her bed during the night and in the wheelchair during the day.

21. Team Huddle Exercise (cont.) • Describe behavior using action verbs. • Identify what the resident is communicating and her possible unmet needs. • Determine possible triggers (e.g., events, persons, equipment, routines, noises). • Note underlying medical conditions and medications that may be important. • List at least five non-pharmacologic interventions to try.

22. Training Tips • Personalize content to your needs. • Use informal leaders. • Use content with families. • Make sure supervisors and leadership know content and how to reinforce it. • Use stand-up or huddles to do a 10-minute training. • Pick a video clip, show on a laptop or iPad, then discuss. • Repeat clip on all shifts and share strategies and insights.

23. Training Tips (cont.) • Commit to full hour once a week for six weeks for an interdisciplinary class. • Get one person from each shift to lead training for each shift for next six weeks. • Perform a 30-minute training and follow up with reminders throughout facility. • Be prepared.

24. Training Tips (cont.) • Award prizes for participation. • Allow for interaction and creativity. • Ask open-ended questions. • Model problem-solving. • Know your barriers. • Time • Money • Boredom • Competing priorities • Low leadership support

25. Questions? This material was prepared by The Carolinas Center for Medical Excellence (CCME), the Medicare Quality Improvement Organization for North and South Carolina, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 10SOW-NC-C7-13-147