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slide1

From InstitutionaltoIndividualized CarePart 2:Transforming Systems toAchieve Better Clinical Outcomes

This material was designed by Quality Partners, the Medicare Quality Improvement Organization for Rhode Island, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the US Department of Health and Human Services. Contents do not necessarily represent CMS policy. 8SOW-RI-NHQIOSC-072006

483 15 the quality of life a dignity

483.15 The Quality of Life (a) Dignity

“The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality.”

483 15 b self determination the resident has the right to

483.15 (b) Self-determination The resident has the right to:

  • Choose activities, schedules and health care consistent with his or her interests, assess-ments and plans of care…. and
483 15 b self determination the resident has the right to4

483.15 (b) Self-determination The resident has the right to:

(3) Make choices about aspects of his or her life that are significant to the resident.

de scheduling
Honoring each individual’s choices, desires and unique needs

Individualized pace leads to better care

With a good night’s sleep and a good morning, you feel better all day

Organizing services around residents’ norms helps with clinical interventions

“De-scheduling”
clinical benefits
Just going by the resident’s schedule has resulted in better sleep, nutrition, moods, and other outcomes.

homes have been able to catch clinical problems sooner, while they are still at an early stage

they have a wider array of ways to treat clinical concerns

Clinical Benefits:
premises
Individualized Care is Better Care

Individualized Care creates a Greater Capacity to Respond to Clinical Needs

Premises
sections
Section 1:

Practitioner Experiences in Transforming Care Delivery Systems

Section 2:

How Individualized Systems Increase Your Capability to Meet Clinical Needs

Section 3:

Making it Happen: Barriers and Strategies

Sections
from institutional to individualized care
Part 1: Integrating Individualized Care and Quality Improvement, aired Nov. 3, 2006

Part 2: Transforming Systems to Achieve Better Clinical Outcomes, May 4, 2007

Part 3: Clinical Case Studies in Culture Change, airs May 18, 2007

Part 4: The How of Change, Sept. 2007

From Institutional toIndividualized Care
our goal is to demonstrate how
to achieve better clinical outcomes through individualized care;

an individualized approach broadens the options to meet residents’ clinical needs; and

consistent assignment and participatory management are key

Our goal is to demonstrate how:
section 1

Section 1

Transforming

Care Delivery Systems

slide14

Government & Regulations

Family

Leadership

Community

HOLISTIC APPROACH TO TRANSFORMATIONAL CHANGE

(HATCH)

slide15

Health Promotion

New Practice!

Action!

Action!

Institutional Care

Individualized Care

Action!

Action!

Old

Practice

Risk Prevention

definition of home

Definition of Home:

a fluid and dynamic, intimate relationship between the individual and the environment

Judith Carboni, 1987

definition of homelessness

Definition of Homelessness

the negation of home, where the relationship between the individual and the environment loses its intimacy and becomes severely damaged.

Judith Carboni, 1987

home homelessness continuum
Home – Homelessness Continuum

HOMELESSNESS

Severely damaged and tenuous relationship between person and environment

HOME

Strong, intimate, fluid relationship with the environment

Weakened, impaired relationship between individual and environment

Damaged relationship between person and environment

Judith T. Carboni, 1987

common themes
Consistent Assignment

Participatory Management -- involving staff in deciding how to go forward

Common Themes
interrupting sleep every two hours
Turning on lights, physically checking for incontinence and probably talking too loud

Contributed to residents then attempting to get up

Generating falls

Interrupting Sleep Every Two Hours
two tracks
the care planning process through which we determined each resident’s individual patterns

a personal understanding where we talked about how none of us would want to be disturbed while sleeping

Two tracks
how we did it
Conducted a bladder assessment for each resident

Night shift documented the patterns for each resident during the night

Looked at their sleep-awake times and incontinence.

Dedicated staff assignments, which enhanced the resident-specific knowledge of the staff

How we did it
toileting plan for each resident

Toileting Plan for Each Resident

normal waking, sleeping, and voiding patterns of each resident so that the night staff could follow their patterns and do individualized rounds.

summary
By moving to consistent assignment your staff know your residents better and can individualize care.

by changing your systems for meal service you’re able to provide breakfast when people wake up

individualized bladder assessments

Summary
slide27

Instead of waking people all night long, your staff are tending to residents when they need care and making sure they are able to sleep the rest of the time.

leadership process
talking things through

addressing people’s concerns,

then putting systems in practice to support individualized care.

Leadership Process
slide29

Glenridge video“Culture Change in Long-Term Care:A Case Study”Produced by the American Health Quality Association

Available through the

National Technical Information Services

fewer falls individualize bladder care
You know when people need to go to the bathroom.

You don’t have people trying to get out of bed unassisted because they have to go.

Now staff are aware of each resident’s voiding patterns and we’re able to get to the residents before they might try to get out of bed on their own.

Fewer Falls: Individualize bladder care
fewer falls know each resident
why they are trying to get out of bed, and we try to anticipate their individual needs

which residents might be hungry when so we are there when they normally start to awaken and are ready to guide them to where they can eat

Fewer Falls: Know Each Resident
fall prevention at night

Fall Prevention at Night

Understanding a resident’s needs and patterns and being alert to meeting their needs.

spontaneity

Spontaneity

Knowing residents

and relating to them individually

alarms at night
Disturbing people

Creating Agitation

Disrupting Sleep

Creating Anxiety

Startling Residents

Alarms at Night
surveys
Because of the changes, the resident's in the facility have had better outcomes.

When you have residents who are sleeping better and eating better and feeling better, you naturally have positive outcomes.

The survey findings reflect that.

Surveys
two points
People who didn’t communicate before are communicating now.

The pace has changed. You’ve slowed down so now you’re at the resident’s pace. By changing how you deliver the food, you’ve changed how people are able to eat it and enjoy it!

Two Points
section 2

Section 2:

How Individualized Systems

Increase Your Capability

to Meet Clinical Needs

physical restraints serious potential negative outcomes
Can cause declines to residents’ physical functioning and muscle condition

Can cause contractures, increased incidents of infections and development of pressure ulcers, delirium, agitation, and incontinence

Physical Restraints: Serious Potential Negative Outcomes
potential negative impact on residents psychosocial well being
Residents can experience loss of autonomy, dignity, and self-respect, and may show symptoms of withdrawal, depression, and reduced social contact

Can reduce independence, functional capacity and quality of life

Potential negative impact on residents’ psychosocial well-being
behaviors communicate a resident s needs
‘what is the resident trying to tell me?’ rather than with “how can I get them to stop?’

The communication of a resident who screams or repeatedly calls out at night may be “I’m cold, afraid, in pain, confused, alone.”

“Behaviors” Communicate a resident’s needs
the restraint becomes unnecessary
By better understanding the resident’s behavior, staff can often anticipate needs or change the environment or their own behavior.

By changing the environment, the challenging behavior often goes away.

The restraint becomes unnecessary
risks of a fall
Physical restraints contribute to unstable gait by leading to loss of muscle strength.

The medications residents take may cause unsteady gait or lightheadedness when they stand.

The challenge of wandering is to insure a safe place to walk and a good pair of shoes.

Risks of a Fall
agitation address the source
Residents who exhibit what we call agitated behaviors are generally expressing that something is wrong – often times it’s an expression of pain or discomfort.

They may want simply to stay in bed, or get out of bed.

Agitation: Address the source
our institutional routines often induce agitation

Our institutional routinesoften induce agitation

When we tune in and have a consistent caregiver and know each person, we will likely reduce the agitation.

restore normalcy

Restore Normalcy

What we have known for a long time in terms of eliminating behavioral problems is that if you go with people’s basic nature, their frustrated behaviors diminish or go away.

slide56
Restoring efficacy, that is the resident’s belief that what they do makes a difference, aids in recovery from depression
slide57

The Kupfer Curve

Response Remission Recovery

slide58

LATE LIFE DEPRESSION

Protective Measures

FAMILY /COMMUNITY

SUPPORT

COPING SKILLS

CONNECTION

CONFIDANT

PROTECTIVE

FACTORS

PURPOSE

EXERCISE

CONTROL/

SELF-EFFICACY

relationships and efficacy

Relationships and Efficacy

To reduce risk of getting depressed and improve outcomes in treating, we must enhance relationships and personal efficacy through:

individualized care

choice

consistent assignments

december 21 2006 cms surveyor memorandum

December 21, 2006CMS Surveyor Memorandum

Nursing Home Culture Change Regulatory Compliance Questions and Answers:

Question 11:

“Is it possible for staff and residents to dine together?”

slide64

Consistent, supportive relationships, individualized care and personal efficacy are key ingredients not just to mental health but also to physical health.

turnover
Turnover

2004

2006

49%

27.6%

slide66

I get positive recognition when I do something well

20% increase

Staff from different depart- ments work well together

16% increase

Staff from different back- grounds work well together

22% increase

Supervisor considers staff

opinion before making decisions

21% increase

Staff morale is good

19% increase

six risk factors for a pressure ulcer

Sensory Perception

Moisture

Physical Activity

Mobility

Six Risk Factors for a Pressure Ulcer

Nutrition

Friction and Sheer

slide71

Ann Cleary is 95 years old with a history of heart disease, diabetes mellitus and severe peripheral vascular disease. She weighs 98 pounds and is 5’0” feet tall and, by the way, she also has dementia. Mrs. Cleary scoots around the facility in her wheelchair, using her left foot to propel herself. Her right leg is amputated above the knee.

slide72

When staff attempt to reposition her, she refuses and says “Leave me alone, will ya”? She eats small amounts of finger foods, spits out most of her pills, and is hard to slow down because of her activity level. Prior to her residence at the nursing home, she was an avid gardener and enjoyed spending time in the park. 

slide73

Health Promotion

New Practice!

Action!

Action!

Institutional Care

Individualized Care

Action!

Action!

Old

Practice

Risk Prevention

our question is

Our question is:

How do we:

build on her strengths

promote her mobility and

support her natural inclinations?

slide75
Optimally what we want is to support her own natural shiftsin her body weight that relieve pressure as she feels it.
slide76

Case Study: Nursing Home Alarm Elimination Program – It’s Possible to Reduce Falls by Eliminating Resident Alarms

www.masspro.org/NH/casestudies.php

section 3

Section 3

Making it Happen –

Barriers and Strategies

talking it through
Talk it through, not to force them, but to hear people’s concerns and address their fears.

You heard people’s thoughts on how to go forward and you took the time to have people think through how their fears and concerns could be addressed.

Talking it Through
lessons
positive energy unleashed by the changes

Even though people had initial fears, it doesn’t sound like any of them would go back to the old ways

talk things through, to let people get used to an idea, and to be able to help shape how to go forward

Lessons
slide84

Health Promotion

New Practice!

Action!

Action!

Institutional Care

Individualized Care

Action!

Action!

Old

Practice

Risk Prevention

slide85

Government & Regulations

Family

Leadership

Community

HOLISTIC APPROACH TO TRANSFORMATIONAL CHANGE

(HATCH)

national technical information services ntis

National TechnicalInformation Services (NTIS)

5285 Port Royal Road

Rm. 1008, Sills Bldg.

Springfield VA 22161

(703) 605-6186

http://cms.internetstreaming.com