Creating Home: The New Quality of Life Revisions to the LTC Surveyor Guidelines

1. Creating Home: The New Quality of Life Revisions to the LTC Surveyor Guidelines Part 1: Making Changes and Adapting the Physical Environment Barbara Frank B & F Consulting www.BandFConsultingInc.com

2. Developments in the Field of Long-Term Care that Contributed to OBRA ’87, Culture Change, and to continued development of our understanding of good practice

3. National Symposium on Quality Care: The Residents’ Point of View, 1985

4. A Consumer Perspective on Quality Care: The Residents’ Point of View NCCNHR 1985

5. OBRA 87: Each facility must provide care and services to: “attain or maintain the highest practicable physical, mental and psycho-social well-being of each resident.”

6. Physical, mental, and psychosocial well-being Quality of Care +Quality of Life not Quality of Care vs. Quality of Life

7. Health Promotion New Practice Institutional Care Individualized Care Old Practice Risk Prevention B&F Consulting

8. 2004-05, CMS funded QIO pilot, Improving the Nursing Home Culture, staffed by Quality Partners of Rhode Island, in which 254 nursing homes in 21 states, individualized care, significantly reduced turnover and improved clinical outcomes.

9. CMS Surveyor Training Series • “From Institutional to Individualized Care” • Part 1: Individualizing Care (Mornings, Alarms) • Part 2: Transforming Systems (Nights, Meals, Consistent Assignment, Quality Care Implications) • Part 3: Case Studies (Mornings, Meals, Med Pass, Medical Perspective) • Part 4: How of Change (Inclusive Leadership, Consistent Assignment, Staff Stability) Videotapes can be purchased from: www.Pioneernetwork.net

10. From Institutional to Individualized Care Also available from National Technical Information Services 5285 Port Royal Road, Rm. 1008, Sills Bldg. Springfield VA 22161 Phone: (703) 605-6186

11. Additional Resources • RI Dept. of Health Individualized Care Pilot http://www.health.ri.gov/nursinghomes/individualizedcarepilot/ • Quality Partners of Rhode Island www.riqualitypartners.org • HATCh – Change Ideas • Individualized Care Curriculum • Pioneernetwork.net

12. How of Change • Quality, the result, is a function of quality, the process • A people paradigm: Cannot continuously improve interdependent systems and processes until you progressively improve interdependent, interpersonal relationships Covey, 1991

13. Key Systems to Individualize Care Collaborative problem-solving within and across departments: ask “how can we get this done?” Inter-shift Communication So Staff have 24/7 view of residents Start of Shift Rounds So Staff Work Together, Share Information Consistent Assignment So Staff Know Residents Individually

14. F242 Self-Determination and Participation

15. F242 Self-Determination and Participation • Rights to make choices over: • Activities • Schedules • Health care • Interactions with members of the community • Aspects of his or her life that are significant to the resident • Choices over schedules is specified to include schedules of waking, eating, bathing, and going to bed at night, as well as health care schedules

16. Gathering and Using Information • Facility must: • Actively seek information • Be “pro-active” in assisting residents to fulfill their choices • Make residents’ choices known to caregivers

17. Where is Info on Residents’ Choices? • Resident, and family/friends • MDS • Social Work Assessment • Social History You have the information in hand, but do you have it in the hands of those who need it?

18. “Just-in-time” communication • Flow of info – First 24 hours is key • Who needs what information by when? • Is there coordination between Social Worker and hands-on care-givers? • Start-of-shift stand-up • Shift-to-shift hand-offs • Hand-offs to Weekend Staff

19. To honor residents’ choices, you need to know residents well individually. To know residents well individually, you need to use consistent assignment of staff.

20. Basics for Consistent Assignment • Fair distribution of work • Matches work for residents and staff • Adjust as needed • Include nurses, housekeeping, others • Resource: Consistent Assignment Change Idea at www.riqualitypartners.org (HATCh)

21. The “How” of Change • Personalize/See Through Residents’ Eyes • What do you need for a good start to your day? (a good night’s sleep, when do you like to eat what, what’s a good bathing experience for you?) • What happens when you don’t get it? Ask residents: What was your morning routine before you lived here?

22. Quiet time, coffee, and a newspaper

23. How of Change, continued • 2. Compare to what is currently happening. Keep what works. Examine what doesn’t: • How does it work now? • When we individualize now, how do we do it? • What are the obstacles and considerations?

24. Individualizing Mornings:Obstacles and Considerations • Breakfast times and central delivery • Early risers’ coffee – breakfast cart, carafe • Late risers’ breakfast – decentralize food supplies and equipment • Breakfast buffets • Clinical and Operational Benefits • Less agitation, better appetite, less plate waste

25. A breakfast buffet allows you to extend hours of services

26. You can provide equipment and food to cook and serve where residents live

27. Equipment is inexpensive, easy to use and meets fire safety standards

28. “My name is Ilda Ford. I am 95 years old. I have been eating my eggs soft side up most of my life and I am not dead yet”

29. Resources for Individualized Mornings • From Institutional to Individualized Care (FIIC) Parts 1 and 2 • Culture Change: A Case Study, available thru your QIO or with FIIC Part 1 • QPRI Change Idea: Waking and Sleeping

30. Individualizing Food (not just meals) • What do you like to eat, when? • Breakfast foods available – time and place • Staff access to sandwich foods and soups • Microwaves, coffee pots, Forman Grill • In-room refrigerators • Late night snacks • Resource: FIIC 2 & 3; Change Idea on Dining

31. A pantry where residents and their families can get anything they want, that’s stocked with the foods they like

32. Steam table allows a longer period for meal service and more resident choice

33. Individualize the Med Pass • Individualize schedule • “upon rising” and “before going to sleep” • Before meal/after meal • Benefits: Opens schedule, frees up nurses • Resources: • FIIC, Part 3 • Pioneer Network Newsletter, Summer 2008

34. Individualized Bathing • Dignity – Webinar Part 2 • Bath, shower, bed bath, wash-up • Time of day and Frequency – Opening rising and bed times, opens possibilities for evening bath, morning shower. • Methods Resource: www.bathingwithoutabattle.unc.edu/

35. How of Change, continued 3. Bring people together to figure out how to make changes. • What issues do they see? • Encourage open dialogue and debate. • Use concerns as “to-do” list

36. Include People Affected by Change • Individualized Mornings: • Residents and their families • CNAs and nurses working nights and days • Housekeeping • Maintenance (floor cleaning) • Food services • Therapies (esp. important for short-term rehab) • Medical Director (for med pass and diet Q’s)

37. How of Change, continued 4. Pilot changes • Start with easy changes that are building blocks (one care area, coffee cart, residents who can easily tell you) • Evaluate impact on residents and staff (weight loss, agitation levels, staff time, med pass) • Adjust operations and evaluate again • Learn and spread • Resource: FIIC Part 4

38. Remember: • Residents’ choices can change • Residents may have special needs on a given day • Residents have adapted to your schedule. You’ll have to make sure they know that they can have their own schedule without losing out on meals, appointments

39. Individual Routines Improve Outcomes • Better Sleep – Better Mood • Better Healing • Improved Appetite • Reduced Agitation; Less Depression • Fewer Falls; Better Balance and Mobility • Fewer Pressure Ulcers • Better transition home from sub-acute care

40. F246 Accommodation of Needs

41. Accommodation of Needs Tips • About relationship of person to environment • Consistent assignment is key • Use red flags like falls (do root cause analysis) • Special focus when a resident moves in • Interdisciplinary collaboration

42. Creating Home: The New Quality of Life Revisions to the LTC Surveyor Guidance Part 2: Feeling at Home

43. Home Identity Connectedness Lived Space Privacy Power/Autonomy Safety Predictability Journeying Judith Carboni, 1987

44. Homelessness • Non-Personhood • Disconnectedness • Meaningless Space • Without boundaries • Powerless/Dependence • Insecurity/Uncertainty • Placelessness Judith Carboni, 1987

45. Home – Homelessness Continuum HOMELESSNESS Severely damaged and tenuous relationship between person and environment Damaged relationship between person and environment Weakened, impaired relationship between individual and environment HOME Strong, intimate, fluid relationship with the environment Judith T. Carboni, 1987

46. Feeling at Home: A strong, intimate, fluid relationship between the individual and their environment

47. Health Promotion HOME Institutional Care IndividualizedCare Home-less Risk Prevention B&F Consulting 2006

48. For more information, contact: Barbara Frank B & F Consulting bfrank1020@aol.com www.BandFConsultingInc.com