| Dementia Program’s Goal: To Change People’s Perceptions | https://www.providermagazine.com/Issues/2015/February/Pages/Dementia-Program’s-Goal-To-Change-People’s-Perceptions.aspx | Dementia Program’s Goal: To Change People’s Perceptions | <div> </div>
<div>Perhaps the long term care management company, Vetter Health Services, Omaha, Neb., with 30 long term care communities across five states, has always been weird. In fact, staff try hard to stand out! </div><div><br></div>
<div>The introduction of the American Health Care Association/National Center for Assisted Living Quality Initiative goal of safely reducing the off-label use of antipsychotics caused staff to look at their current practice of responding to behaviors in a unique way. The very words, “encourage alternative strategies for responding to challenging behavioral expressions in persons living with dementia before considering medications,” were strongly motivating.</div>
<h2 class="ms-rteElement-H2">Here’s What—The Facts</h2>
<div>The national statistics are alarming, as “20 percent of all medications are prescribed off-label, and no medication is currently approved for use in behavioral and psychological symptoms of dementia—all medications used for it are off-label. Up to 90 percent of nursing home patients with dementia present behavioral symptoms,” according to the American Society of Consultant Pharmacists on its website, <a target="_blank" href="http://www.ascp.com/">www.ascp.com</a>.</div>
<h2 class="ms-rteElement-H2">So What Was Needed</h2>
<div>Vetter is setting out to change the view of long term care. Staff began the journey with a Let’s Get Weird tour of their communities. The purpose was to change how caregivers think and act in their profession.</div>
<div>As it relates to dementia care, the team started by changing the way it interpreted behavioral expressions. Rather than searching for methods of response, it wanted to focus on strategies for prevention. Team members then sought out programs and mentors to help them improve the quality of life for their residents with dementia.</div>
<h2 class="ms-rteElement-H2">What Was Done</h2>
<div>Once the team found a program with the framework that made sense to them, they partnered with the creator to build on the framework and create synergy with a three-year futuristic vision. Everyone knows how it feels to introduce a program and watch it go nowhere, but how does a program get enough momentum to survive the long term care environment? Once broken down, it becomes simple. </div>
<div><br>The program needs to: </div>
<div>■ Enhance the way caregivers deliver service without creating additional tasks </div>
<div>■ Ease challenges </div>
<div>■ Gain efficiencies while maintaining proper techniques</div>
<div>■ Break techniques into the most simplified instruction and action </div>
<div>■ Create immediate results.</div>
<div><br>All team members must:</div>
<div>■ Know the residents individually, and personalize care (no routine, cookie cutter processes) </div>
<div>■ Embrace the concepts and learn to speak the same language</div>
<div>■ Identify champions in each community and equip them to carry the program forward </div>
<div>■ Practice the approaches daily and celebrate successes.</div>
<div><br>The home office team had to:</div>
<div>■ Revise company standards on the use of antipsychotic medications </div>
<div>■ Develop ways to perpetuate the program through ongoing training and support</div>
<div>■ Focus on prevention of out-of-character responses</div>
<div>■ Include the new training in general orientation</div>
<div>■ Inform and enlist assistance from medical directors and consulting</div>
<div>pharmacists</div>
<div>■ Establish relationships with consulting psychiatrists and tele-health services that understand and support the vision</div>
<div>■ Provide regular communication that reinforces new techniques to champions and provides a forum for sharing of success stories and best practices</div>
<div>■ Make consistent community visits for support, encouragement, and enhancement of interdisciplinary problem solving.<br></div>
<h2 class="ms-rteElement-H2">Now What—The Results</h2>
<div>Life Enrichment Team members were previously called to <a href="/archives/2015_Archives/Pages/0215/Examples-Of-How-Creative-Intervention-Works.aspx" target="_blank">intervene and take responsibility </a>for residents exhibiting out-of-character responses, pulling those team members away from other responsibilities and creating frustration, as meaningful engagement is almost impossible when a behavioral expression exists.</div>
<div>This no-win situation is being eliminated with team members across all departments working together to identify the causes for the out-of-character response and creating opportunities for meaningful engagement focused on prevention. Everyone is becoming a detective. Knowing and understanding residents on an individual basis has a positive impact on all other work. <br><br></div>
<div>Approach and communication techniques specifically designed for individuals with dementia are helping team members achieve greater levels of success with daily care while preventing confusion and out-of-character responses. </div>
<div><br>Team members create the mood for the household when focused on opportunities for smiles and laughter. These techniques stimulate the release of positive hormones, resulting in self-medication that can set the residents up for success and reduce the need for antipsychotic medications.</div>
<div><br>Nonclinical and clinical team members are becoming natural allies focused on prevention. Their efforts are strengthened by “speaking the same language” and understanding the goal to prevent out-of-character responses through proactive approaches. </div>
<div><br>Therapeutic tools, including personalized music, aroma therapy, and the use of adaptive engagement technology, combine with approach and communication techniques to provide opportunities for moments of joy.</div>
<h2 class="ms-rteElement-H2">Gathered Stories And Data</h2>
<div>Observing residents with out-of-character responses was heartbreaking. </div>
<div><br>At the end of a difficult shift in a memory support neighborhood, the team was noted to look physically drained, walking with their heads down and silent. Equipping team members with these techniques has lightened their loads and made their jobs more joyful. </div>
<div><br>Since the program was implemented, they say, “Work is fun again.” They look forward to discussing techniques and ideas to continually improve the lives of their residents.</div>
<div><br>Since the introduction of the comprehensive dementia care program one year ago, the communities with memory support households have experienced a 14 percent reduction in the use of off-label antipsychotic medications, a 31 percent reduction in behaviors affecting others, and a 31 percent reduction in pain.</div>
<div>This three-year journey goes beyond residents with dementia. Vetter staff will continue sharing and growing long after their three-year goal has been met. It is becoming less of a “program” and more of a way of life in Vetter communities.</div>
<h2 class="ms-rteElement-H2">Now What—Future Plans</h2>
<div>Champions in each community will work with home office coaches to learn new skills, teach them to their team members, and oversee programming at the facility level. Ongoing education, including site visits to celebrate successes and continue problem-solving as an interdisciplinary team, will provide necessary boosts of encouragement and enthusiasm. </div>
<div>Vetter staff firmly believe that they are changing the view of long term care by rethinking, reimagining, and recreating the way they serve their residents with dementia. </div>
<div> </div>
<div><em>Cameo Rogers, CTRS, CDP, CDCM, is life enrichment coordinator for Vetter Health Services, Omaha, Neb. She has a bachelor’s degree in therapeutic recreation and corporate wellness and has completed the Dementia Practice Guidelines for Recreational Therapy: Treatment of Disturbing Behaviors and the NEST Approach through the American Therapeutic Recreation Association. Cameo has experience working with individuals with severe and persistent mental illness and elders in short-term rehabilitation, skilled nursing centers, and memory care settings. She has been awarded the Nebraska Healthcare Association Best Programming Award for National Nursing Home Week in 2009. She provides mentoring, support, and coaching to life enrichment professionals, recreational therapists, and memory support team members serving in Vetter independent, assisted living, and skilled nursing communities across five states.</em><br><br></div>
<div><em></em></div>
<em>K. Miekka Milliken, CSW, NHA, is social services and admissions coordinator for Vetter Health Services. She oversees and provides programming for Vetter Health Service’s 30 long term care facilities across a five-state region. She has participated in dementia training with NCCDP, completed the NEST Approach training, and has served as the co-lead in the roll-out of Vetter Health Services’ three-year initiative toward best practices in dementia care—including the implementation of the Buddies Forever dementia communication coaching system. </em><em></em> | The introduction of the American Health Care Association/National Center for Assisted Living Quality Initiative goal of safely reducing the off-label use of antipsychotics caused staff to look at their current practice of responding to behaviors in a unique way. | 2015-02-01T05:00:00Z | <img alt="" src="/Issues/2015/February/PublishingImages/Milliken_Rogers.jpg" style="BORDER:0px solid;" /> | Clinical | Special Feature |
| Parkinson’s Disease Psychosis: Common, Yet Confounding | https://www.providermagazine.com/Issues/2015/February/Pages/Parkinson’s-Disease-Psychosis-Common,-Yet-Confounding.aspx | Parkinson’s Disease Psychosis: Common, Yet Confounding | <div> </div>
<div>Over 1 million Americans are living with Parkinson’s disease (PD). Although typically thought of as a neurological disorder affecting movement with characteristic tremor, slowness, stiffness, and walking difficulty, many patients are also troubled by other, nonmotor symptoms. These commonly include memory impairment, psychosis, depression, vivid dreams, constipation, and orthostatic hypotension. </div>
<div> </div>
<div>Parkinson’s Disease Psychosis (PDP) is particularly troubling, as it is a major risk factor for increased mortality and for long term care placement. In fact, the single most important precipitant for placement of PD patients in a long term care facility is psychiatric dysfunction, particularly psychosis, and once placed in a nursing home for PDP, patients are likely to remain there permanently.</div>
<h2 class="ms-rteElement-H2">New Status Uncovered</h2>
<div>Over the past several years there has been a shift in thinking about the underlying cause of PDP. Rather than merely recognizing PDP as a side effect of medications used to treat PD, more recently it has become apparent that PDP is really part of the underlying disease process of PD. Approximately 50 percent of patients with PD will develop PDP during the decades-long course of their disease, yet many caregivers and providers are surprised by the onset of psychotic symptoms. <br></div>
<div><br>These symptoms may initially be mild, but tend to gradually increase in frequency and severity. </div>
<div>Typical symptoms may include visual hallucinations (for example, seeing children or visitors at dinner), delusions (spousal infidelity, stealing money), and paranoia (being watched).</div>
<div><br>Few patients will spontaneously report their psychosis symptoms. It is therefore sometimes difficult to get an accurate patient history. Specific questioning about psychosis symptoms of hallucinations, paranoia, and delusions is often needed to identify PDP. Often, patients and caregivers will not associate pyschosis symptoms with PD.</div>
<h2 class="ms-rteElement-H2">Patients Reluctant To Report Symptoms</h2>
<div>Many patients are much more troubled by PDP than physicians may recognize in the clinical setting. The hallucinations, delusions, and paranoia associated with PDP impact a patient’s general emotional state and relationships with family and caregivers and also limit their participation in daily activities.</div>
<div><br><img src="/archives/2015_Archives/PublishingImages/0215/caregiving_treatment.gif" class="ms-rtePosition-1" alt="" style="margin:5px 10px;" />The stigma that many patients and families attach to the presence of these delusions, paranoia, and hallucinations makes them less likely to talk about PDP or to make use of supportive services. They may not view PDP as part of the progression of PD itself, but rather (incorrectly) as the emergence of an end stage of the disease.</div>
<div><br>Also, as patients and their families research PDP, they may learn that untreated PDP often leads to placement in a long term care facility. This can also make it difficult to try to get an accurate history because the patient or caregiver will not want to highlight symptoms that may hasten facility placement.</div>
<div>Given this, there is a need for health care professionals across the long term care facility to understand how these types of symptoms, particularly hallucinations and delusions, present in PD patients. Of note, these patients are different than those who may have other psychiatric or neurologic disorders, such as dementia or schizophrenia. </div>
<div><br>Patients may be embarrassed or reluctant to admit that they are experiencing hallucinations or delusions, or may attribute them to poor vision. </div>
<div><br>Caregivers may not be aware that psychosis has emerged until it becomes disruptive to daily life. </div>
<h2 class="ms-rteElement-H2">Seeing And Believing</h2>
<div>Visual hallucinations are the most common psychotic symptoms of PDP and often consist of nonthreatening figures of familiar people and/or animals. For example, often patients report that they see a group of people in a room talking, but when the patient tries to engage them, they are ignored. The patient may try several times to engage, but eventually gives up. The hallucination isn’t usually harmful or scary, but it is disturbing, nonetheless. The same visual hallucination tends to reappear at regular times during the day.<br><br></div>
<div>Although visual hallucinations are most common, other hallucinations can occur, including auditory hallucinations (such as hearing voices in the hallway); tactile hallucinations (like a sensation on the skin); or, more rarely, taste hallucinations.</div>
<div><br>PDP patients may also experience delusions. A common delusion is when a patient inexplicably believes that his or her spouse is committing adultery, even when there is no evidence to support this thinking. Unfortunately, as PD progresses and the psychosis worsens, the delusions tend to become more bothersome, at times threatening and debilitating, for patients and their families. For example, many delusional patients become convinced that their loved ones are in physical danger or under assault and may even take action, such as calling police for help. <br></div>
<h2 class="ms-rteElement-H2">Puzzling Out PDP</h2>
<div>When caring for patients with PD, especially as the disease advances, it is important to keep in mind that PDP is common yet under-recognized. Often patients or their caregivers may not bring these symptoms up, especially when they are not bothersome. While patients may not initially be troubled by PDP symptoms, it is not normal to see things that are not there or believe things that are not real. Since undetected PDP will usually progress, it is important to ask specific questions about psychosis symptoms so PDP can be diagnosed and treated before symptoms worsen. </div>
<div><br>While all patients with PD can develop PDP as their disease progresses, patients are at an increased risk for PDP as they age, develop memory impairment or depression, or if they act out vivid dreams. Psychotic symptoms may also be brought out by infections, especially urinary tract infections, and by medications used to treat PD or other disorders (such as narcotics or bladder medications).</div>
<h2 class="ms-rteElement-H2">Compassionate Caregiving </h2>
<div>Earlier recognition of the emergence of PDP in patients with PD is needed. Patients and caregivers should not let the stigma of psychosis, fear of long term care placement, or tolerance of mild symptoms delay recognition. Practitioners should be vigilant about the rather common emergence of PDP symptoms, querying patients and their caregivers regularly. Providers and administrators in the long term care setting should be aware that PDP patients and their caregivers have usually reached their breaking point in terms of their ability to cope at home with the persistent hallucinations and delusions of PDP. As family and caregivers begin to feel overwhelmed, the decision to seek long term care placement is often made. </div>
<div><br>The long term care facility can be challenged to care for a patient with PDP. However, monitoring for PDP symptoms and earlier recognition of PDP symptoms will allow PDP to be treated before it worsens and becomes disruptive. </div>
<div><br>Treatment includes evaluation of medical causes (including medications and underlying infections), reduction of PD medications (unless motor function and balance worsen), and consideration of an antipsychotic medication that does not worsen PD motor symptoms.</div>
<div><br><img width="102" height="135" class="ms-rtePosition-1" alt="Stuart Isaacson" src="/archives/2015_Archives/PublishingImages/0215/StuartIsaacson.jpg" style="margin:5px;" />Although initially psychotic symptoms in PD may be considered mild, it is typically progressive over time. <br><br></div>
<div>As PDP progresses, hallucinatory activity tends to increase, delusions become more prominent, and symptoms generally become more troubling and disabling. Health care providers and caregivers should thus continue to be vigilant in their detection of symptoms so PDP can be addressed earlier to maintain daily activities and overall quality of life. </div>
<div> </div>
<div><em>Stuart Isaacson, MD, is associate professor of neurology at FIU Herbert Wertheim College of Medicine and director of the Parkinson’s Disease and Movement Disorders Center of Boca Raton, Fla.</em></div> | Over 1 million Americans are living with Parkinson’s disease (PD). Although typically thought of as a neurological disorder affecting movement with characteristic tremor, slowness, stiffness, and walking difficulty, many patients are also troubled by other, nonmotor symptoms. These commonly include memory impairment, psychosis, depression, vivid dreams, constipation, and orthostatic hypotension.
| 2015-02-01T05:00:00Z | <img alt="" src="/Issues/2015/February/PublishingImages/caregiving_t.jpg" style="BORDER:0px solid;" /> | Caregiving | Column |
| An Overlooked Demographic? | https://www.providermagazine.com/Issues/2015/February/Pages/An-Overlooked-Demographic.aspx | An Overlooked Demographic? | <div> </div>
<div style="text-align:center;"><img width="411" height="274" class="ms-rtePosition-4" src="/archives/2015_Archives/PublishingImages/0215/GoodSam_plank.jpg" alt="" style="margin:5px;" /> </div>
<div> </div>
<div>In Loveland, Colo., an 88-year-old woman is on the floor. But she hasn’t fallen. Quite the opposite, actually. She’s balancing on her hands and toes in a core-strengthening plank during a floor balance class at her Good Samaritan Society–Loveland Village home. </div>
<div> </div>
<div>She’s one of hundreds of wellness participants at the Loveland Village senior living campus, where staff have spent nearly a decade pioneering a fall-prevention program specifically targeted to people in their 80s and 90s. And it’s working.</div>
<h2 class="ms-rteElement-H2">The Statistics Aren’t Good</h2>
<div>“There’s an epidemic that affects more than 50 percent of people in this demographic—and we’re not doing enough to address it,” says Jeff Finer, wellness director. “Once we look at that oldest-adult demographic, more than half of them will fall every year.”<br><br></div>
<div>Of those, more than half will fall again within a year, and an alarming percentage will never recover from their fall-related injuries, he says. “If this were a disease, where more than half of a population would go into a quick decline, people would be freaking out.”<br><br></div>
<div>Building up from a handful of classes he volunteered to lead as a part-time employee 13 years ago, Finer has helped establish a thriving wellness community at Loveland Village. Nearly 250 people attend more than 600 classes each month at the campus, where residents’ average age is 85.<br><br></div>
<div>It’s through these specially tailored classes that they’re improving their balance, endurance, coordination, and—perhaps most prevalent—their willingness to try new things.</div>
<h2 class="ms-rteElement-H2">Fears Can Lead To Isolation </h2>
<div>According to Finer, a successful fall-prevention program must address much more than a person’s physical well-being. The program must also take an older person’s fears about exercise into consideration, recognize the loss many older people feel when they can’t do everything on their own, and challenge the widely accepted notion that falling is inevitable as people age.<br><br></div>
<div>“People in their 80s and 90s still have a lot to give us,” Finer says. “And when they isolate themselves because they’re afraid of falling, it’s not a solo act. They harm the whole culture around them, because we’re then not able to learn from them and their experiences. They are full of life, and we need to help them live it.”<br><br></div>
<div>Finer believes the entire senior care community must work together to prevent falls and keep seniors active.<br><br></div>
<div>“Physical therapy can’t do it alone. Walking won’t save us,” he says. “There’s no magic piece of equipment. Asking people to follow an at-home regimen isn’t realistic. We have to work together to create a culture where sitting in front of the TV and resigning to a life of stagnation isn’t OK anymore.”<br></div>
<h2 class="ms-rteElement-H2">Generalized Exercise A Nonstarter</h2>
<div>A common recommendation to the general population is to exercise 20 to 30 minutes a day to stay fit. But as Finer points out, once people are in their 80s or 90s, their neuromuscular systems aren’t nearly as responsive as 60- and 70-year-olds. <br><br></div>
<div>“You can be an active, good walker—maybe even a great walker—and still lose the postural, hip, and ankle responses necessary for safe reactions in this world,” Finer says. By not targeting weaknesses and compensations, “what you become, then, is a ‘strong faller,’ with unspecific, uncoordinated, and undependable strength.”<br><br></div>
<div><img width="196" height="244" alt="The Finers" class="ms-rtePosition-2" src="/archives/2015_Archives/PublishingImages/0215/GoodSam_TheFiners.jpg" style="margin:5px 10px;" />And this general exercise recommendation only improves the rate of falls by 13 percent for those 80+ seniors.<br><br></div>
<div>“That’s just not good enough,” says Finer. Besides, he says, “the word ‘exercise’ is too noncommittal and passive to make any real difference to the people who need our help the most. It doesn’t give them the tools they need to relearn how to live their lives the way they’re meant to.”</div>
<h2 class="ms-rteElement-H2">Tailoring Program To Each Individual</h2>
<div>It’s difficult to pinpoint the root cause of a person’s fall risk; factors like age, medication, eyesight, past physical ailments, environmental obstacles, and mental obstacles all play a role. So Loveland Village staff members take each individual’s whole lifestyle and history into account when recommending classes, and they tailor their programs to the specific needs and hesitations of the oldest-adult population.<br><br></div>
<div>Staff members from physical therapy, dietary, nursing, activities, and wellness classes all collaborate to address the physiological—and even emotional—roadblocks each person faces. It’s an approach that’s shown improvements of up to 50 percent in fall rates.<br><br></div>
<div>At Loveland Village, there’s beginner, intermediate, and advanced levels for each of the wellness classes. “No one can progress in a one-size-fits-all program,” Finer says. “Individual needs are seen and responded to on a daily basis.”<br><br></div>
<div>Beginner classes focus a lot on small, digestible bits like sitting correctly, breathing deeply, or mindfully observing surroundings.<br><br></div>
<div>“We tend to take these basic skills for granted,” Finer says. “And we start to lose them and compensate around them. So once those skills are relearned to their fullest potential, you can branch out and become more than you thought possible.”</div>
<h2 class="ms-rteElement-H2">Imagery Smooths Moves</h2>
<div>A particularly effective method Finer and the other wellness instructors have found is using imagery to teach movements and concepts. “When you give the brain an image during a particular exercise, the person’s nervous system and imagination attempt to complete it. It gives the mind a project that manifests in physical responses we might not otherwise be able to tap into,” he says.<br><br></div>
<div>Finer says he uses the Franklin Method for these types of visualizations.<br><br></div>
<div>“I could say, ‘Move your arms up and down.’ But if I say, ‘Imagine you were a bird, flying against a thick headwind,’ or ‘Imagine I’ve tied a balloon to your wrists, and your arms are now floating up to the sky,’ I’m going to see a much different, more engaged movement from class participants.”</div>
<h2 class="ms-rteElement-H2">Experience Transforms Residents</h2>
<div>Finer has seen many participants in the wellness program go through a transformation.<br><br></div>
<div>“You see their eyes light up, their sense of humor come back. Their vocabulary improves. They invite people to join them for meals or entertainment or activities. They share with others about their latest successes and joys. They encourage life.”<br><br></div>
<div>Finer says too many people in their 80s and 90s feel the world has left them behind. “They believe all that’s left is a life of either a passive vacation mindset, or a defeated sitting disease. They forget their value.” It’s this perception that Finer hopes to shatter with better wellness program options.<br><br></div>
<div>“If we create a culture where they have soulful choices to make every day, where they choose and commit to who they want to be, we can make a real difference,” he says. </div>
<div> </div>
<div><em>Megan Baldridge is a communications coordinator, writer, and editor for The Evangelical Lutheran Good Samaritan Society, Sioux Falls, S.D.</em></div>
| According to Jeff Finer, a successful fall-prevention program must address much more than a person’s physical well-being. The program must also take an older person’s fears about exercise into consideration, recognize the loss many older people feel when they can’t do everything on their own, and challenge the widely accepted notion that falling is inevitable as people age.
| 2015-02-01T05:00:00Z | <img alt="" src="/Issues/2015/February/PublishingImages/GoodSam_t.jpg" style="BORDER:0px solid;" /> | Caregiving;Management | Column |
| MDS Accuracy, Staffing Are New Survey Focus | https://www.providermagazine.com/Issues/2015/February/Pages/MDS-Accuracy,-Staffing-Are-New-Survey-Focus.aspx | MDS Accuracy, Staffing Are New Survey Focus | <div> </div>
<div>In a Survey and Certification memo (S&C: 15-06-NH) issued to state survey agency directors in late 2014, the Centers for Medicare & Medicaid Services (CMS) announced that in 2015 the Minimum Data Set (MDS) Focused Survey process will be expanding nationwide. The target number of surveys to be conducted will vary from state to state. CMS and the state survey agencies will work together to determine which facilities in each state will be selected for participation in the expanded pilot test. </div>
<div> </div>
<div>The 2015 MDS Focused Survey pilot will be conducted in each state by at least two surveyors who have been specifically trained to assess the accuracy of the MDS assessment data. </div>
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<div>The surveyors will spend approximately two days in the facility and will conduct an exit conference at the end of the survey to detail their findings with facility staff. This new survey process could result in survey deficiencies being issued to the facility for inaccurate MDS coding and negative resident outcomes.</div>
<h2 class="ms-rteElement-H2">Pilot Reveals Deficiencies</h2>
<div>Highlights of the initial pilot test were released as part of the memo’s background information. A total of 25 facilities were surveyed for MDS coding accuracy, accurate MDS-based reimbursement levels, and Resident Assessment Instrument (RAI)-focused care planning that matches resident needs and promotes person-centered care. </div>
<div><br>Of the 25 facilities surveyed in the pilot, 24 received deficiencies for errors related to MDS coding, CMS cited inaccurate staging and documentation of pressure ulcers, lack of knowledge regarding the classification of antipsychotic drugs, and poor coding regarding the use of restraints (CMS, 2014).<br><br></div>
<div><img src="/archives/2015_Archives/PublishingImages/0215/mgmt_resources.gif" class="ms-rtePosition-1 ms-rteImage-1" alt="" style="margin:5px 10px;" />While the survey process continues to be refined, field reports from facilities in the initial pilot test indicate that upon arrival at the facilities the survey teams issued an instructional letter to the nursing home administrator outlining the survey process. Facility staff were asked to immediately provide the current census, an alphabetical resident census with room numbers, and a copy of the floor plan. </div>
<h2 class="ms-rteElement-H2">Surveyor Requirements</h2>
<div>Within one hour of the entrance, staff were asked to provide 1.) the 10 most recently completed MDS assessments—required by the Omnibus Budget Reconciliation Act of 1987 (OBRA)—that had been submitted for current residents, as well as 2.) any subsequent correction requests that had been submitted for those assessments, and 3.) medical records to support the MDS coding. OBRA assessments that included coding decisions based on the Prospective Payment System were part of the 10-assessment survey process. Facility staff were also asked to provide:<br> ■ Copies of policies and procedures related to the RAI, the MDS, and the Quality Measures;</div>
<div> ■ The staffing schedules for all staff involved in scheduling, coding, and transmitting MDS data, with their roles in the assessment process delineated;</div>
<div> ■ The name and contact information for the quality assessment and assurance coordinator;</div>
<div>■ A list of all residents who had fallen in the past 12 months (date of the fall and any resulting injury); and</div>
<div> ■ Focused Survey Facility Worksheet (form provided by the surveyor) to reflect a list of current residents (names and room numbers) with any of the following conditions and/or devices in use in the past 90 days (note that if a resident had more than one of the conditions listed below, he or she would be listed separately on the worksheet):</div>
<div> — Pressure ulcers</div>
<div> — Indwelling catheters (including urethral catheters, suprapubic catheters, and nephrostomy tubes)</div>
<div> — Restraints other than side rails, including those used on an as-needed basis</div>
<div> — Urinary tract infections</div>
<div> — Antipsychotic medications.<br></div>
<h2 class="ms-rteElement-H2">What Providers Can Expect</h2>
<div>CMS indicated that during the 2015 pilot testing, surveyors will conduct a record review, augmented by resident observations and staff and/or resident interviews, in order to validate MDS 3.0 coding and staffing levels.<br><br></div>
<div>If deficient practices are noted during the MDS Focused Survey, facilities might be cited under the RAI F-Tags F272 through F287. Information about these tags is located in the “State Operations Manual (SOM) Appendix PP.” These F-Tags outline the requirements for MDS assessment accuracy and the completion and timing of OBRA assessments. They also stipulate that individuals who complete a portion of the assessment must sign and certify the accuracy of that portion of the assessment and that a registered nurse must sign and certify that the assessment is completed (CMS, 2014).<br><br>
</div>
<div>Additionally, the Code of Federal Regulations (42 CFR 483.20[j]) indicates that civil monetary penalties could be issued for falsification of assessment data. Facilities could be cited if deficient practices are noted in survey tags related to quality of care, quality of life, or nursing services.<br><br></div>
<div>Accuracy of the MDS data is linked to Medicare and Medicaid payment, Quality Measures, Five-Star ratings, and optimal person-centered care planning, the memo said, referencing a 2013 Office of Inspector General report indicating that 37 percent of facilities did not develop a care plan that met federal requirements and did not provide services according to the care plan.</div>
<h2 class="ms-rteElement-H2">Self-Reported Staffing Scrutinized</h2>
<div>The S&C-15-06-NH memorandum also announced that as part of the MDS Focused Survey process, surveyors will be conducting a review of the facility’s self-reported staffing levels. “This assessment will aim to verify the data self-reported by the nursing home and identify changes in staffing levels throughout the year,” the memo said. According to federal regulations (42 CFR 483.30[a]), sufficient staffing is critical to meeting resident care needs. <br></div>
<div><br>During each annual survey, facility staff are required to fill out the CMS-671 form (CMS, 2002). This form identifies staffing during the two weeks prior to the beginning of the survey. Since facility managers self-report their staffing levels, surveyors will conduct independent verification of form data during the MDS Focused Survey. <br></div>
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<div><div>Nursing home managers often increase survey preparation when their annual survey window draws near. With the MDS Focused Survey pilot being conducted in each state, providers should let their staff know that the facility is always in its window. Surveyors could be knocking on the door this coming Monday. </div>
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<div style="text-align:center;"><span><a title="Join AANAC!" target="_blank" href="http://www.aanac.org/join"><img width="559" height="134" class="ms-rtePosition-4" src="/archives/2015_Archives/PublishingImages/0215/2015_AANAC.jpg" alt="" style="margin:5px;" /></a></span> </div></div></div>
<div> <br><em>Judi Kulus, NHA, RN, MAT, C-NE, RAC-MT, is vice president of curriculum development for the American Association of Nurse Assessment Coordination. She can be reached at (800) 768-1880.</em></div>
<div> </div> | The 2015 MDS Focused Survey pilot will be conducted in each state by at least two surveyors who have been specifically trained to assess the accuracy of the MDS assessment data. | 2015-02-01T05:00:00Z | <img alt="" src="/Issues/2015/February/PublishingImages/mgmt_t.jpg" style="BORDER:0px solid;" /> | Management | Column |
| How Can QIS Methods Improve Everyday Care? | https://www.providermagazine.com/Issues/2015/February/Pages/How-Can-QIS-Methods-Improve-Everyday-Care.aspx | How Can QIS Methods Improve Everyday Care? | <br>It is correct to assume that faithfully replicating the QIS may lead to identifying “deficient practice,” but to improve care requires going beyond what is contained in the QIS forms. <br><br>In fact, the way you implement the QIS methods to improve care is very different than the way surveyors conduct the QIS.<br><br>Rather than replicating a one-time quality survey, administrators need to use the QIS methods in performance improvement cycles. <br><br>To do this, administrators should conduct quarterly cycles, beginning each one by drawing a random sample of 40 residents residing in the building and a random sample of 30 admissions from the past six months or however far back is needed to obtain 30 admissions.<br><br>In the first month of the quarterly cycle, conduct the Stage 1 assessments on these residents. <br><br>While there are some situations that you will want to look into and correct immediately while conducting assessments, such as allegations of abuse, do not try to correct everything you identify from these assessments while you are conducting them. <br><br>Rather, compile the findings from all assessments for the sample of residents and then generate reports based on these Stage 1 data, preferably using an automated system. <br><br>If properly calculated, you will then have rates at which different types of potential quality problems occurred. <br><br>Using the Stage 2 QIS forms can help determine the root cause of the potential problems you have identified, as well as inform you how surveyors will determine if the identified potential problem is considered to be deficient practice. But there is a more challenging task: improving the care you provide. <br><br>This requires you first to change something, and then to assess again—completing the cycle. <br><br>The first step in correcting the problem is developing a better understanding of the findings. Is this a problem related to a single resident that occurs rarely, such as a fall with a fracture? Or is it a more pervasive issue, such as residents not being treated with dignity by a particular staff member or several staff members? Or is it a widespread issue such as not offering residents preferences on when and how often they receive a bath or shower?<br><br>All of these are important, and none are easy to resolve. Each administrator must approach each problem as if it is not a single incident, or multiple unrelated incidents, but rather a breakdown in the care process. <br><br>People often want to blame an individual staff person, but quality problems are more often than not system or organizational culture problems, which is why resolving them takes thoughtful analysis and then a solution that works for all concerned.<br><br>Once you think you have identified and implemented a solution, then you must reassess using new samples to ensure that you were successful in improving care. Only then have you completed the cycle.<br><br><em>Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey (QIS).</em><br> | People often want to blame an individual staff person, but quality problems are more often than not system or organizational culture problems, which is why resolving them takes thoughtful analysis and then a solution that works for all concerned.
| 2015-02-01T05:00:00Z | <img alt="" src="/Issues/2012/PublishingImages/Headshots/AKramer_rollup.jpg" style="BORDER:0px solid;" /> | Quality | Column |
| Let’s Hear It: Customers Set The Bar | https://www.providermagazine.com/Issues/2015/February/Pages/Let’s-Hear-It.aspx | Let’s Hear It: Customers Set The Bar | <div class="ms-rteThemeForeColor-5-4"><em>This is Part 4 in a periodic series of articles linking the Centers for Medicare & Medicaid Services (CMS) impending Quality Assurance and Performance Improvement (QAPI) procedures with the requirements of the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) National Quality Award Program.</em></div>
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<div>The focus of this month’s QAPI feature is bringing meaningful resident and family voices into setting goals and evaluating progress. In the Baldrige Criteria, the core value of Patient-Focused Excellence says that because customers are the ultimate judges of performance and quality, the organization should take into account all features and characteristics of patient care delivery and all modes of customer access and support that contribute value to customers.<br><br></div>
<div>A truly patient-focused organization addresses the health care service characteristics that meet basic patient and other customer requirements as well as characteristics that differentiate the organization from its competitors. Patient-focused excellence promotes patient and other customer retention and loyalty, referral of new patients, customer engagement, and market share gain. </div>
<h2 class="ms-rteElement-H2">Relationship To Bronze Criteria</h2>
<div>At the Bronze award level, applicants are required to identify their key customer groups, the requirements these customer groups have of the organization, and the methods they used to determine these requirements.<br><br></div>
<div>■ Key customer groups always include residents, and an accurate understanding of their requirements is at the heart of the Baldrige Health Care criteria.<br><br></div>
<div>■ Requirements of different patient and customer groups might include accessibility, continuity of care, safety, security, accurate and timely billing, socially responsible behavior, cultural preferences, and multilingual services. <br><br></div>
<div>■ Applicants must think systematically about the methods used to understand customer requirements. For example, if informal listening is a key feedback source, the center should ensure it is being done systematically and all voices receive appropriate attention. If a few vocal residents dominate the feedback, how does the center ensure that it understands the needs of more quiet/reserved residents? </div>
<div>At the Bronze level, applicants are simply asked to describe their key market segments, including patient and other customer groups, and list the key requirements and expectations of each. However, at the Silver and Gold levels, organizations should also focus on engaging and building relationships with patients and other customers.</div>
<h2 class="ms-rteElement-H2">Relationship To Silver Criteria</h2>
<div>At the Silver award level, applicants are asked to respond to the “basic” and “overall” questions in the Baldrige Health Care Criteria, which can be considered an outline of the full criteria.</div>
<div>In the first section of Category 3, Customer Focus, applicants are asked how they systematically and effectively obtain information from their patients and other customers. Applicants must clearly explain the steps they take to gain accurate information on their customers’ satisfaction, dissatisfaction, and engagement. Examiners are looking for a clear, systematic approach to obtaining these data in order to establish its accuracy.<br><br></div>
<div>The second section builds on the first, asking applicants to explain how they use this information to serve their patients’ and other customers’ needs and build better relationships with them.<br><br></div>
<div>In the first part of Category 4, Measurement, Analysis, and Improvement of Organizational Performance, applicants are asked to describe their methods for using customer data to support decision making.</div>
<div>In Category 6, Operations Focus, providers begin to see the relationship between customer feedback and improving their community’s key health care services. Category 6 asks how the organization designs its health care processes to deliver value for residents and other customers to achieve success and sustainability. <br></div>
<h2 class="ms-rteElement-H2">Relationship To Gold Criteria</h2>
<div>The Gold criteria delves more deeply into the concepts discussed at the Silver level and fully embodies the fourth feature of QAPI. Gold applicants respond fully to the Baldrige Health Care Criteria, including addressing the basic- and overall-level questions that are required of Silver applicants, with the addition of more detailed multiple-level questions. <br><br></div>
<div>■ In Category 1, senior leaders are expected to create a workforce culture that delivers a consistently positive experience for patients and other customers and foster customer engagement, create and promote a culture of patient safety, and focus on creating and balancing value for patients and other customers.<br><br></div>
<div>■ In Category 3, Gold applicants describe in great detail how they listen to residents and other stakeholders, both current and future.<br><br></div>
<div>In the first part, they are asked how listening methods may vary among patient and other customer groups, how social media might be used, and how those interactions may vary with different groups of residents and other customers. Satisfaction, dissatisfaction, and engagement even are further explored in this category.<br><br></div>
<div>In the second part of Category 3, applicants should have in place effective systems to manage complaints of patients and other customers and ensure that they are resolved promptly and effectively in order to recover customer confidence.<br><br></div>
<div>■ In the first part of Category 4, applicants are expected to use customer and market data (including aggregated data on complaints and data gathered through social media, as appropriate) to build a more patient-focused culture.<br><br></div>
<div>■ In the second part of Category 5, applicants should ensure their process for managing workforce performance reinforces a focus on patients and other customers.<br><br></div>
<div>■ In Category 6, Gold applicants are asked how they build patient expectations and preferences into the delivery of health care service processes. Applicants should also have effective processes in place to set realistic patient expectations and factor patient decision making and patient preferences into the delivery of health care services.<br><br></div>
<div>Again, the criteria are looking for applicants to describe how they fully incorporate resident needs and expectations into key processes for the organization, as well as determining opportunities for improvement.</div>
<h2 class="ms-rteElement-H2">Following Criteria Gets Results</h2>
<div>Lori Cooper, administrator of 2014 Gold recipient Stonebrook Healthcare Center, talks about the value the Baldrige criteria had in their organization.<br><br></div>
<div>“As an independent facility, taking the Quality Award journey is one of the best decisions we ever made. We utilized the criteria and feedback at every stage to identify, develop, and implement systems to make us a high-performing organization and a leader in our marketplace,” she says.<br><br></div>
<div>As Stonebrook incorporated the Baldrige criteria into its daily routines, staff learned about their organization: the good, the bad, and the ugly, Cooper says. “With that information, we are able to identify what we do best and identify areas where we need to improve our processes,” she says. “We understand the importance and value of being a data-driven organization. By being willing to address the areas where we were not as good as our competitors, our results have improved over time.” <br><br></div>
<em>Barbara Baylis, RN MSN, vice president of clinical services at Sava Senior Care Consulting, is a nurse executive accomplished in clinical and quality improvement systems. She serves as a Quality Award Examiner and is a past member of the Quality Award Board of Overseers. Mark Blazey, EdD, is a leading expert in the application of the Baldrige criteria for performance excellence. Blazey serves as a member of the Quality Award Panel of Judges as well as a current member of the Quality Award Board of Overseers.</em> | The focus of this month’s QAPI feature is bringing meaningful resident and family voices into setting goals and evaluating progress. In the Baldrige Criteria, the core value of Patient-Focused Excellence says that because customers are the ultimate judges of performance and quality, the organization should take into account all features and characteristics of patient care delivery and all modes of customer access and support that contribute value to customers. | 2015-02-01T05:00:00Z | <img alt="" src="/Issues/2014/PublishingImages/1014/trophies_t.jpg" style="BORDER:0px solid;" /> | Quality | Column |
| Nominations Now Open For 20 To Watch 2015 | https://www.providermagazine.com/Issues/2015/February/Pages/Nominations-Now-Open-For-20-To-Watch-2015.aspx | Nominations Now Open For 20 To Watch 2015 | <p class="ms-rteElement-P"><span>Provider</span><span> is thrilled to announce that nominations for its third annual 20 To Watch list are now being accepted. </span></p>
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<p class="ms-rteElement-P"><span>We’re
looking for the rising stars of AHCA/NCAL-member buildings—from CNA to
medical director—who personify the dedication, hard work, and tender
care required for a commitment to improving the quality of life for all
residents. Nominations are due April 17. </span></p>
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<p class="ms-rteElement-P"><span>Finalists will be featured in a summer issue of Provider and commemorated on our special “20 To Watch” website.</span></p>
<h2 class="ms-rteElement-H2 ms-rteForeColor-1"><span>How To Nominate</span><span> <br></span></h2>
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<p class="ms-rteElement-P"><span>Send an email to Senior Editor Bill Myers, </span><a href="mailto:wmyers@providermagazine.com" target="_blank"><span><span>wmyers@providermagazine.com</span></span></a><span>. Tell him:</span></p>
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<span><span>1.)<span> </span></span></span><span>The nominee’s name, title, company, and location;</span>
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<p class="ms-rteElement-P"><span><span>2.)<span> </span></span></span><span>A summary of how your nominee helps residents and staff achieve to the fullest;</span></p>
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<p class="ms-rteElement-P"><span><span>3.)<span> </span></span></span><span>Why the candidate is someone who can become a leader in long term and post-acute care;</span></p>
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<p class="ms-rteElement-P"><span><span>4.)<span> </span></span></span><span>A
list of your nominee’s innovative approaches/ideas/programs and how it
(they) improved the quality of life for residents and/or staff.</span></p>
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</span></p> | | 2015-02-10T05:00:00Z | <img alt="" src="/Articles/PublishingImages/150x150/20TW_2015_t.jpg" style="BORDER:0px solid;" /> | 20 to Watch | Column |