Consistent Assignment: The Prerequisite for Individualized Care

1. Consistent Assignment:The Prerequisite for Individualized Care David Farrell, MSW, LNHA Director, Care Continuum

2. Nationwide Turnover RNs = 50% LPNs = 50% CNAs = 70% 96,000 Vacant FTEs 52,000 CNAs 25,100 LPNs 13,900 RNs Turnover and Vacancies AHCA, 2002

3. Cost of Nursing Home Staff Turnover • Average $2,500 replacement costs per employee • Nursing homes are spending $2.5 billion annually • Direct costs • Advertisement costs • Staff time to interview, check references, etc. • Drug screen, pre-employment physical • Classroom orientation • Cost of coverage of the vacant position Seavey, D., “The Cost of Frontline Turnover in LTC.” 2004

4. SNF Nursing Hours PPD • Total hours per patient per day = 3.4 • California = 3.7 HPPD • Increase of .28 HPPD since 1999 • RN hours have decreased by .06 HPPD • LPN hours have increased by .08 HPPD • C.N.A. hours up by .26 HPPD AHCA, 2007

5. Institute of Medicine • Quality of care depends on the performance of the caregiver • Staffing levels are necessary • Other key factors: • Education • Supervision • Job satisfaction • Turnover • Leadership • Organizational culture Wunderlich G. S., “Improving the Quality of Long Term Care,” IOM, 2000

6. The Impact of Leaders Healthcare organizations • Fragile ecosystems • Leader’s actions influence: • Culture • Relationships • Retention • Clinical outcomes • Quality of life

7. Principles NATURAL LAWS OR FUNDAMENTAL TRUTHS: • Universal, timeless • Produce predictable outcomes • External to ourselves • Operate with or without our understanding FP-06

8. StaffingModels Consistent Assignment = Consistently assigning the same caregivers to the same nursing home residents every day Rotating Assignment = Rotating caregivers from one group of residents to the next after a period of time

9. Why do nursing homes rotate staff assignment?

10. Studies have repeatedly confirmed that residents and their family members value the quality of the relationships they have with the frontline caregivers higher that the quality of the medical care and the quality of the food. NCCNHR, PHI

11. Evidence Supporting Consistent Assignment

12. Support for Consistent Assignment • Results from 12 research studies: • Enhanced relationships • Improved staff attendance • Improved staff, resident, family satisfaction • Lower staff turnover • Improved accuracy, timeliness: • screening and assessments • Improved clinical outcomes • Improved quality of life Allow for individualized care

13. Evidence: Bowers BJ. “Turnover Reinterpreted: CNAs Talk About Why They Leave.” Journal of Gerontological Nursing 29.3 (March 2003): 36-44. • Change staffing and personnel policies to better demonstrate respect and appreciation. • reducing turnover • enhancing quality of work and care • Rotating staff made certified nurse’s aides (CNAs) feel less valued for their skill and knowledge. • CNAs defined ‘good caregiving’ as based on the establishment and maintenance of good relationships with residents. • CNAs felt any disruption to these relationships was detrimental to the quality of the care provided and the quality of residents’ lives. • Even with verbal recognition of a job well done, CNAs felt the management’s staffing decisions were contradictory to the acknowledgement.

14. Evidence:Bowers BJ, Fibich B, Jacobson N. “Care-as-service, care-as-relating, care-as-comfort: understanding nursing home residents' definitions of quality.” The Gerontologist 41.4 (August 2001): 539-45. • Focus of study - explore how nursing home residents define quality: • Divided into three groups: • care-as-service, care-as-relating, and care-as-comfort • Of the study population, 16 identified relating as most important. • Care-as-relating residents identified aides’ willingness to share information about their personal lives ... as an example of high-quality care. • These residents “saw reciprocity as evidence of good relationships and thus of good quality care.” • Six care-as-comfort residents also mentioned the importance of having good relationships with staff.

15. Evidence:Bowers BJ, Esmond S, Jacobson N. “The Relationship Between Staffing and Quality in Long-Term Care Facilities, Exploring the Views of Nurse Aides.” Journal of Nursing Care Quality14.4 (July 2000): 55-64. • Examined how adequate staffing levels and ensuring quality of care are linked • Used participant observation and in-depth interviewing of nurse CNAs • The relationship between the nurse aide and the resident was deemed the central determinant of quality of care by CNAs. • High-quality care is care that is given “affectionately” or “individually.” • Familiarity and relationships are necessary for quality of care. • Adequate and consistent staffing help foster relationships.

16. Evidence:Burgio LD, Fisher SE, Fairchild JK, Scilley K, Hardin M. “Quality of Care in the Nursing Home: Effects of Staff Assignment and Work Shift.” The Gerontologist 44.3 (2004): 368-377. • Compared two nursing homes with permanent assignments to two nursing homes with rotating assignments • Residents living in permanent assignment nursing homes received significantly higher ratings of personal appearance and hygiene than residents in rotating assignment homes. • Nurse aides working in permanent assignment homes reported higher job satisfaction than those working in rotating assignment homes.

17. Evidence:Campbell S. “Primary nursing: It works in long-term care.” Journal of Gerontological Nursing 8 (1985): 12-16. • Evaluate effectiveness of primary nursing assignment: • Care Outcomes • One year after implementation - 75% reduction in the incidence of decubitus ulcers • 18% decrease in patient death rate • 11% increase in patient discharge to lower levels of care • Two years after - 36% increase in the number of ambulatory patients • Nursing Staff Outcomes • One year after implementation - turnover rate declined by 29% • After implementation nurses reported: • feeling more accountable by 26%

18. Evidence:Caudill M. “Turnover Among Nursing Assistants: Why They Leave and Why They Stay.” The Journal of Long-Term Care Administration 29 (1991–1992): 31. Focused on the responses from a questionnaire given to nurse assistants: • Effects on tenure: • Longer tenure ensures that staff becomes more familiar with the residents. • Bonding occurs. • Responsibility for the residents is enhanced. • Quality of care improves. • Staff input: Of those nursing assistants who said they had input into the planning of care for their patients, 84% planned to stay in their jobs. • Relationships: When asked “What is most important to you?” • The nurse assistants planning to stay in their jobs reported “their own personal feelings for their patients” were most important to them. • Changing assignments: Changing patient assignments daily was correlated with those nursing assistants who were planning to leave.

19. Evidence:Cox CL, Kaeser L, Montgomery AC, Marion LH. “Quality of life nursing care: An experimental trial in long-term care.” Journal of Gerontological Nursing 17 (1991): 6-11. • Quality of Life Nursing Care (QLNC) model: • Four components: • permanent assignment • focus on the resident’s choice and control • provide case-managed nursing care • permanent resident-centered scheduling • From pre- to post-test - residents on the experimental units reported significant increases in control, choice, and well-being. • Experimental unit staff perceived: • quality of care to be higher • expressed a more positive attitude toward resident choice

20. Evidence:Eaton S. “Beyond Unloving Care - Linking Human Resource Management and Patient Care Quality in Nursing Homes.” International Journal of Human Resource Management 3 (June 11, 2000): 591-616. • Lower Quality homes: • Staff feel overwhelmed by demands. • Manage as if cost efficiency is main goal • “The relationship of turnover to patient care is clear and well documented: higher turnover interrupts continuity of care and is associated with lower patient-care outcomes.” (Harrington 1996) • Higher Quality homes: • “In higher-quality homes, the amount of social engagement between residents and staff, and among residents, is far higher.” (Mor et al., 1995) • Have adequate staffing, nurse aides assist each other, teamwork approach on the unit • “Patient-specific knowledge is crucially important in ensuring quality of life, safety, and adequate care.”

21. Evidence:Goldman BD. “Nontraditional staffing models in long-term care.” Journal of Gerontological Nursing 24 (1998): 29-34. • Advantages to implementing primary nursing care: • Residents feel more comfortable and secure. • Resident care is improved; staff take responsibility for the care provided. • Increase in job satisfaction • Staff can anticipate residents’ needs. • Staff is accountable for their residents, taking pride in resident improvements and successes. • Summary: “A supportive, homelike environment exists when residents and staff build strong relationships and when residents’ needs can be responded to in a timely, consistent manner.”

22. Evidence:Mueller C. “A Framework for Nurse Staffing in Long-Term Care Facilities.” Geriatric Nursing 21.5(September-October 2000): 262-7. • Framework for Nurse Staffing in Long-Term Care Facilities: • Provides ways to evaluate staffing needs and to develop staffing approaches that are specific to their facility • Each resident’s needs vary emotionally and physically. • Technical assistance and time required of staff will also vary. • Accurately and consistently identifying each resident’s multidimensional and comprehensive needs is integral.

23. Evidence:Patchner MA. “Permanent assignment: A better recipe for the staffing of aides.” Successful nurse aide management in nursing homes Phoenix, AZ; Oryx Press, 1989: 66-75. • Goal: Decreasing the turnover rate to reduce costs of orientation, education, and hiring new employees • Changes in staffing assignment, job satisfaction, motivation, and performance • Benefits: • An increase in productivity of nurse aides • Good method of measuring productivity • Good method of orienting nurse aides

24. Evidence: Mary Lescoe-Long and Michael Long: “Identifying Behavior Change Intervention Points to Improve Staff Retention in Nursing Homes.” Family Member Perspective – • Personal empathy – know my mom as a person • Knowing only comes about with consistency • Facilitates getting to know and trust caregivers • Helps to know who to go to with questions • Gives family members peace of mind

25. Same SNF – Different Units • Consistent Assignment: • Top Five Stressors • Preventing Falls • Stubborn Residents • Terminal Residents • Depressed Residents • Death as Emotional Stress • Rotating Assignment: • Top Five Stressors • Low Wage • Abusive Residents • Heavy Workload • Disagreements w/ Coworkers • Lack of Staff Gruss, V. et al., 2004

26. Evidence Against Rotating Assignment Experts estimate 80% of SNFs nationwide rotate staff from one group of residents after a duration of time. High Rate of Burnout: • 70% feel burned out some of the time • 60% feel they sometimes treat the residents impersonally • 40% feel that they have become hardened emotionally Pillemer, K. “Solving the Frontline Crisis in LTC.” 1996

27. Burnout “The true cause of burnout is the deadening effect of closing one’s emotions to people who are in obvious need of a human connection. Human life is sustained by affection.” Dr. Bill Thomas Thomas, W., “What Are Old People For? How Elders Will Save The World.” 2004

28. Evidence Against: Injury Perils of Long-Term Care Staff • Lost-time injuries are twice the U.S. average. • More likely to be injured on the job than: • Construction workers • Policemen • Firefighters • Coal miners • Manufacturing plant employees • Primarily due to short staffing • Significant cost to providers Wunderlich, 1996 OSHA, 2002

29. Who Preaches the Benefits? Those who support consistent assignment: • Pioneer Network, Eden, LEAP • CMS • ActionPact • Mt. Saint Vincent, Meadowlark Hills • PHI • National Commission on Nursing Workforce for LTC • Quality Improvement Organizations (QIOs) • Advancing Excellence Campaign Goal #8

30. Staff Satisfaction = Family Satisfaction • Satisfied employees report: • Better supervision • Better training • Better work environments • Satisfied families report: • Quality of life • Quality of care • Quality of service Grant, L., “Organizational Predictors of Family Satisfaction in Nursing Homes.” Seniors Housing & Care Journal. 2004.

31. People Paradigm Focus on Relationships DEMING: • Quality, the result, is a function of quality, the process • Essential ingredients of the process: • Leadership and people • Cannot improve interdependent systems and processes until you progressively improve interdependent, interpersonal relationships

32. Retention is All About Relationships Low turnover facility leaders take measures to nurture relationships: • Between co-workers • Across departments • Between supervisors • Frontline and supervisors • Staff and residents • Between residents • Staff and resident’s family members Eaton, S. 2001

33. Formula for Individualized Care High satisfaction + Retention + Consistent Assignment = Growth of Tacit Knowledge: • Lifting and turning safely • Names of grandchildren • Who wears glasses • Individual preferences • Anticipating needs • Reciprocity Eaton, S., “Beyond Unloving Care.” 2000

34. Why do we rotate staff assignment?

35. Consistent Assignment The question is not if to switch to consistent assignment. The question is how. • CNA shift meetings • Care-giving challenge scale – 1 to 5 • Listen for variation of the individual rating • CNAs select their assignment • Sum total from scale - not the number of elders • Re-visit frequently

36. Bibliography of Supporting Articles Bowers BJ. “Turnover Reinterpreted: CNAs Talk About Why They Leave.” Journal of Gerontological Nursing 29.3 (March 2003): 36-44. Bowers BJ, Fibich B, Jacobson N. “Care-as-service, care-as-relating, care-as-comfort: understanding nursing home residents' definitions of quality.” The Gerontologist 41.4 (August 2001): 539-45. Bowers BJ, Esmond S, Jacobson N. “The Relationship Between Staffing and Quality in Long-Term Care Facilities, Exploring the Views of Nurse Aides.” Journal of Nursing Care Quality14.4 (July 2000): 55-64. Burgio LD, Fisher SE, Fairchild JK, Scilley K, Hardin M. “Quality of Care in the Nursing Home: Effects of Staff Assignment and Work Shift.” The Gerontologist 44.3 (2004): 368-377.

37. Bibliography of Supporting Articles …continued Campbell S. “Primary nursing: It works in long-term care.” Journal of Gerontological Nursing 8 (1985): 12-16. Caudill M. “Turnover Among Nursing Assistants: Why They leave and Why They Stay.” The Journal of Long-Term Care Administration 29 (1991–1992): 31. Cox CL, Kaeser L, Montgomery AC, Marion LH. “Quality of life nursing care: An experimental trial in long-term care.” Journal of Gerontological Nursing 17 (1991): 6-11. Eaton S. “Beyond Unloving Care Linking Human Resource Management and Patient Care Quality in Nursing Homes.” International Journal of Human Resource Management 3 (June 11, 2000): 591-616.

38. Bibliography of Supporting Articles … continued Goldman BD. “Nontraditional staffing models in long-term care.” Journal of Gerontological Nursing 24 (1998): 29-34. Mueller C. “A Framework for Nurse Staffing in Long-Term Care Facilities.” Geriatric Nursing 21.5(September-October 2000): 262-7. Patchner MA. “Permanent assignment: A better recipe for the staffing of aides.” Successful nurse aide management in nursing homes Phoenix, AZ; Oryx Press, 1989: 66-75. This material was prepared by Lumetra, the Medicare Quality Improvement Organization for California, 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. Contract number HHSM-500-200-CA02. 8SOW-CA-1A-07-51

39. Quality Improvement Resources • Lumetrawww.lumetra.com • Advancing Excellence Campaignwww.nhqualitycampaign.org/ • MedQICwww.medqic.org

40. Setting Targets – Achieving Results (STAR) • A password-protected Web site created for nursing homes • View current performance trends for six Quality Measures (QMs): • High-risk pressure ulcers • Post acute pressure ulcers • Chronic care pain • Post acute pain • Depression • Physical restraints • Set annual performance targets. • Set your QM targets at www.nhqi-star.org.

41. To Get Your CEU Credit • The CEU evaluation form is now electronic. • The link to the CEU evaluation form and instructions will be provided in your registration confirmation and reminder e-mails. • You will automatically receive the e-mails if you register online at www.lumetra.com/nursinghomes. • A CEU certificate will be sent to you after you complete a brief online survey. • Please complete the survey even if you are not requesting CE credit. • The survey will remain open for two weeks.