From Institutional to Individualized Care Part 2: Transforming Systems to Achieve Better Clinical Ou

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From InstitutionaltoIndividualized Care Part
2Transforming Systems toAchieve Better
Clinical Outcomes
This material was designed by Quality Partners,
the Medicare Quality Improvement Organization for
Rhode Island, under contract with the Centers for
Medicare Medicaid Services (CMS), an agency of
the US Department of Health and Human Services.
Contents do not necessarily represent CMS policy.
8SOW-RI-NHQIOSC-072006
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483.15 The Quality of Life (a) Dignity

• The facility must promote care for residents in
  a manner and in an environment that maintains or
  enhances each residents 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

• 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

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

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De-scheduling

• Honoring each individuals choices, desires and
  unique needs
• Individualized pace leads to better care
• With a good nights 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 residents 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
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Premises

• Individualized Care is Better Care
• Individualized Care creates a Greater Capacity to
  Respond to Clinical Needs

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Sections

• Section 1
• Practitioner Experiences in Transforming Care
  Delivery Systems
• Section 2
• How Individualized Systems Increase Your
  Capability to Meet Clinical Needs
• Section 3
• Making it Happen Barriers and Strategies

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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

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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

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Individualizedcare_at_riqio.sdps.org
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Section 1

• Transforming
• Care Delivery Systems

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HOLISTIC APPROACH TO TRANSFORMATIONAL
CHANGE (HATCH)
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Health Promotion
New Practice!
Action!
Action!
Individualized Care
Institutional Care
Action!
Action!
Old Practice
Risk Prevention
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Definition of Home

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

Judith Carboni, 1987
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Definition of Homelessness

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

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

• Consistent Assignment
• Participatory Management -- involving staff in
  deciding how to go forward

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A Good Nights 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 residents 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 youre
  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 peoples concerns,
• then putting systems in practice to support
  individualized care.

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Glenridge videoCulture Change in Long-Term
CareA Case StudyProduced 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 dont have people trying to get out of bed
  unassisted because they have to go.
• Now staff are aware of each residents voiding
  patterns and were 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 residents 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 didnt communicate before are
  communicating now.
• The pace has changed. Youve slowed down so now
  youre at the residents pace. By changing how
  you deliver the food, youve changed how people
  are able to eat it and enjoy it!

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Section 2

• How Individualized Systems
• Increase Your Capability
• to Meet Clinical Needs

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Susan 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 residents 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 Im cold,
  afraid, in pain, confused, alone.

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The restraint becomes unnecessary

• By better understanding the residents 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 its 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 peoples basic nature, their frustrated
  behaviors diminish or go away.

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Clinical Depression
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Restoring efficacy, that is the residents belief
that what they do makes a difference, aids in
recovery from depression
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The Kupfer Curve
Response Remission Recovery
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LATE LIFE DEPRESSION Protective Measures
FAMILY /COMMUNITY SUPPORT
COPING SKILLS
CONNECTION
CONFIDANT
PROTECTIVE FACTORS
PURPOSE
EXERCISE
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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Turnover
2006
2004
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27.6
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Systemic Changein the Service Delivery
Systemto Support Individualized Care
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Pressure Ulcers
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Six Risk Factors for a Pressure Ulcer
Friction and Sheer
Nutrition
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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 50 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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Health Promotion
New Practice!
Action!
Action!
Individualized Care
Institutional Care
Action!
Action!
Old Practice
Risk Prevention
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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 Its Possible to Reduce Falls by
Eliminating Resident Alarms

• www.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 3

• Making it Happen
• Barriers and Strategies

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Talking it Through

• Talk it through, not to force them, but to hear
  peoples concerns and address their fears.
• You heard peoples 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 doesnt
  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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Health Promotion
New Practice!
Action!
Action!
Individualized Care
Institutional Care
Action!
Action!
Old Practice
Risk Prevention
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HOLISTIC APPROACH TO TRANSFORMATIONAL
CHANGE (HATCH)
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We did the best we could with what we knew, and
when we knew better, we did better.

• - Maya Angelou

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National TechnicalInformation Services (NTIS)
http//cms.internetstreaming.com

• 5285 Port Royal Road
• Rm. 1008, Sills Bldg.
• Springfield VA 22161
• [phone]