483.15The Quality of Life (a) Dignity
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Transcript of 483.15The Quality of Life (a) Dignity
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From Institutionalto
Individualized Care
Part 2:
Transforming Systems to
Achieve Better Clinical Outcomes
From Institutionalto
Individualized Care
Part 2:
Transforming Systems to
Achieve 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
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
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483.15 The Quality of Life (a) Dignity483.15 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.”
“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.”
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483.15 (b) Self-determination The resident has the right to:483.15 (b) Self-determination The resident has the right to:
(1) Choose activities, schedules and health care consistent with his or her interests, assess-ments and plans of care…. and
(1) Choose activities, schedules and health care consistent with his or her interests, assess-ments and plans of care…. and
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483.15 (b) Self-determination The resident has the right to: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.
(3) Make choices about aspects of his or her life that are significant to the resident.
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“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
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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
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Pilot: Integrating Individualized Care with Quality Improvement
Pilot: Integrating Individualized Care with Quality Improvement
Holistic Approach to Transf ormational Change HATCh
Leadership
Government & Regulations
Community
Family
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PremisesPremises
• Individualized Care is Better Care
• Individualized Care creates a Greater Capacity to Respond to Clinical Needs
• Individualized Care is Better Care
• Individualized Care creates a Greater Capacity to Respond to Clinical Needs
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SectionsSections• 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
• 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
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From Institutional toIndividualized Care
From Institutional toIndividualized 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
• 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
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Our goal is to demonstrate how: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
• 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
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Section 1Section 1
Transforming
Care Delivery Systems
Transforming
Care Delivery Systems
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HOLISTIC APPROACH TO HOLISTIC APPROACH TO
TRANSFORMATIONAL CHANGETRANSFORMATIONAL CHANGE
(HATCH)(HATCH)
HOLISTIC APPROACH TO HOLISTIC APPROACH TO
TRANSFORMATIONAL CHANGETRANSFORMATIONAL CHANGE
(HATCH)(HATCH)
Leadership
Government & Regulations
Community
Family
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Risk PreventionRisk Prevention
Health PromotionHealth Promotion
Individualized Care
Individualized Care
Institutional Care
Institutional Care
New Practice!
Action!Action!
Action!Action!
Action!Action!
Action!Action!
OldPractice
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Definition of Home:Definition of Home:
a fluid and dynamic, intimate relationship between the individual
and the environment
a fluid and dynamic, intimate relationship between the individual
and the environment
Judith Carboni, 1987Judith Carboni, 1987
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Definition of HomelessnessDefinition of Homelessness
the negation of home, where the relationship between the individual
and the environment loses its intimacy and becomes severely
damaged.
the negation of home, where the relationship between the individual
and the environment loses its intimacy and becomes severely
damaged.
Judith Carboni, 1987Judith Carboni, 1987
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Home – Homelessness ContinuumHome – Homelessness Continuum
HOME
Strong, intimate,
fluid relationship
with the environment
HOME
Strong, intimate,
fluid relationship
with the environment
Weakened, impaired
relationship between
individual and environment
Weakened, impaired
relationship between
individual and environment
Damaged relationship
between person and
environment
Damaged relationship
between person and
environment
HOMELESSNESS
Severely damaged and tenuous relationship between person and environment
HOMELESSNESS
Severely damaged and tenuous relationship between person and environment
Judith T. Carboni, 1987Judith T. Carboni, 1987
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Common ThemesCommon Themes
• Consistent Assignment
• Participatory Management -- involving staff in deciding how to go forward
• Consistent Assignment
• Participatory Management -- involving staff in deciding how to go forward
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A Good Night’s Sleep
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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
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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
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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
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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.
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Goals
• to maximize bladder care
• to maximize sleep
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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
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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.
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Leadership Process
• talking things through
• addressing people’s concerns,
• then putting systems in practice to support individualized care.
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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
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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.
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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
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Fall Prevention at Night
Understanding a resident’s needs and patterns and being alert to meeting their needs.
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Spontaneity
Knowing residents
and relating to them individually
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Alarms at Night
• Disturbing people
• Creating Agitation
• Disrupting Sleep
• Creating Anxiety
• Startling Residents
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When you individualize care, you minimize the need for alarms
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Mornings
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Suppositories
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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.
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Food service
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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!
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Section 2:Section 2:
How Individualized Systems
Increase Your Capability
to Meet Clinical Needs
How Individualized Systems
Increase Your Capability
to Meet Clinical Needs
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Susan Wehry, Geriatric PsychiatristSusan Wehry, Geriatric Psychiatrist
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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
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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
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“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.”
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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.
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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.
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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.
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Our institutional routinesoften induce agitation
When we tune in and have a consistent caregiver and know
each person, we will likely reduce the agitation.
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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.
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Clinical Depression
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Restoring efficacy, that is the resident’s belief that what they do makes a difference, aids in recovery from depression
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The Kupfer Curve The Kupfer Curve
Response Remission Recovery
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LATE LIFE DEPRESSIONProtective Measures
LATE LIFE DEPRESSIONProtective Measures
CONNECTIONCONNECTION
PURPOSEPURPOSE
EXERCISEEXERCISE
COPING SKILLSCOPING SKILLS
FAMILY /COMMUNITYSUPPORT
FAMILY /COMMUNITYSUPPORT
CONFIDANTCONFIDANTCONFIDANTCONFIDANTPROTECTIVE
FACTORSPROTECTIVE
FACTORS
CONTROL/ SELF-EFFICACY
CONTROL/ SELF-EFFICACY
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Consistent Assignment
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Importance of Relationships
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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
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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?”
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There is a direct link between our emotional well-being
and our physical well-being
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Consistent, supportive relationships, individualized care
and personal efficacy are key ingredients
not just to mental health but also to physical health.
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TurnoverTurnover
27.6%27.6%49%49%
2006200620042004
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19% increase19% increase
Staff morale is good Staff morale is good
21% increase21% increase
Supervisor considers staffopinion before making decisions Supervisor considers staffopinion before making decisions
22% increase22% increase
Staff from different back- grounds work well together Staff from different back- grounds work well together
16% increase16% increase
Staff from different depart- ments work well togetherStaff from different depart- ments work well together
20% increase20% increase
I get positive recognition when I do something wellI get positive recognition when I do something well
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Systemic Change
in the Service Delivery System
to Support Individualized Care
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Pressure Ulcers
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Six Risk Factors for a Pressure Ulcer
Six Risk Factors for a Pressure Ulcer
Friction and SheerFriction and SheerNutritionNutrition
MobilityMobilityPhysical ActivityPhysical Activity
MoistureMoistureSensory PerceptionSensory Perception
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Case Study
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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.
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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.
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Risk PreventionRisk Prevention
Health PromotionHealth Promotion
Individualized Care
Individualized Care
Institutional Care
Institutional Care
New Practice!
Action!Action!
Action!Action!
Action!Action!
Action!Action!
OldPractice
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Our question is:
How do we:
• build on her strengths
• promote her mobility and
• support her natural inclinations?
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Optimally what we want is to support
her own natural shifts in her body weight
that relieve pressure as she feels it.
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Case Study:
Nursing Home Alarm Elimination Program – It’s Possible to Reduce Falls by Eliminating Resident Alarms
Case Study:
Nursing Home Alarm Elimination Program – It’s Possible to Reduce Falls by Eliminating Resident Alarms
www.masspro.org/NH/casestudies.phpwww.masspro.org/NH/casestudies.php
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Plan of care based on an assessment of
her routine, her strengths and her preferences
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Treatment of Pain
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The more we know people, the better we can care for their pain.
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Section 3Section 3
Making it Happen –
Barriers and Strategies
Making it Happen –
Barriers and Strategies
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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.
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one step at a timeand each success
opened up new possibilities
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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
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Risk PreventionRisk Prevention
Health PromotionHealth Promotion
Individualized Care
Individualized Care
Institutional Care
Institutional Care
New Practice!
Action!Action!
Action!Action!
Action!Action!
Action!Action!
OldPractice
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HOLISTIC APPROACH TO HOLISTIC APPROACH TO
TRANSFORMATIONAL CHANGETRANSFORMATIONAL CHANGE
(HATCH)(HATCH)
HOLISTIC APPROACH TO HOLISTIC APPROACH TO
TRANSFORMATIONAL CHANGETRANSFORMATIONAL CHANGE
(HATCH)(HATCH)
Leadership
Government & Regulations
Community
Family
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We did the best we could with what we knew,
and when we knew better, we did better.
We did the best we could with what we knew,
and when we knew better, we did better.
- Maya Angelou- Maya Angelou
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National TechnicalInformation Services (NTIS)
National TechnicalInformation Services (NTIS)
5285 Port Royal RoadRm. 1008, Sills Bldg. Springfield VA 22161
(703) 605-6186
5285 Port Royal RoadRm. 1008, Sills Bldg. Springfield VA 22161
(703) 605-6186
http://cms.internetstreaming.comhttp://cms.internetstreaming.com