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

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Title: PowerPoint Presentation Author: SDPS Last modified by: Barbara Frank Created Date: 2/28/2003 7:38:18 PM Document presentation format: On-screen Show – PowerPoint PPT presentation

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


1
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
2
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.

3
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

4
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.

5
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

6
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

7
Pilot Integrating Individualized Care with
Quality Improvement
8
Premises
  • Individualized Care is Better Care
  • Individualized Care creates a Greater Capacity to
    Respond to Clinical Needs

9
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

10
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

11
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

12
Individualizedcare_at_riqio.sdps.org
13
Section 1
  • Transforming
  • Care Delivery Systems

14
HOLISTIC APPROACH TO TRANSFORMATIONAL
CHANGE (HATCH)
15
Health Promotion
New Practice!
Action!
Action!
Individualized Care
Institutional Care
Action!
Action!
Old Practice
Risk Prevention
16
Definition of Home
  • a fluid and dynamic, intimate relationship
    between the individual and the environment

Judith Carboni, 1987
17
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
18
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
19
Common Themes
  • Consistent Assignment
  • Participatory Management -- involving staff in
    deciding how to go forward

20
A Good Nights Sleep
21
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

22
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

23
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

24
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.

25
Goals
  • to maximize bladder care
  • to maximize sleep

26
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

27
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.
28
Leadership Process
  • talking things through
  • addressing peoples concerns,
  • then putting systems in practice to support
    individualized care.

29
Glenridge videoCulture Change in Long-Term
CareA Case StudyProduced by the American
Health Quality Association
  • Available through the
  • National Technical Information Services

30
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.

31
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

32
Fall Prevention at Night
  • Understanding a residents needs and patterns and
    being alert to meeting their needs.

33
Spontaneity
  • Knowing residents
  • and relating to them individually

34
Alarms at Night
  • Disturbing people
  • Creating Agitation
  • Disrupting Sleep
  • Creating Anxiety
  • Startling Residents

35
When you individualize care, you minimize the
need for alarms
36
Mornings
37
Suppositories
38
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.

39
Food service
40
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41
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42
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43
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44
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!

45
Section 2
  • How Individualized Systems
  • Increase Your Capability
  • to Meet Clinical Needs

46
Susan Wehry, Geriatric Psychiatrist
47
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

48
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

49
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.

50
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.

51
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.

52
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.

53
Our institutional routinesoften induce agitation
  • When we tune in and have a consistent caregiver
    and know each person, we will likely reduce the
    agitation.

54
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.

55
Clinical Depression
56
Restoring efficacy, that is the residents belief
that what they do makes a difference, aids in
recovery from depression
57
The Kupfer Curve
Response Remission Recovery
58
LATE LIFE DEPRESSION Protective Measures
FAMILY /COMMUNITY SUPPORT
COPING SKILLS
CONNECTION
CONFIDANT
PROTECTIVE FACTORS
PURPOSE
EXERCISE
CONTROL/ SELF-EFFICACY
59
Consistent Assignment
60
Importance of Relationships
61
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

62
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?

63
There is a direct link between our emotional
well-being and our physical well-being
64
Consistent, supportive relationships,
individualized care and personal efficacy are
key ingredients not just to mental health but
also to physical health.
65
Turnover
2006
2004
49
27.6
66
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67
Systemic Changein the Service Delivery
Systemto Support Individualized Care
68
Pressure Ulcers
69
Six Risk Factors for a Pressure Ulcer
Friction and Sheer
Nutrition
70
Case Study
71
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.
72
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. 
73
Health Promotion
New Practice!
Action!
Action!
Individualized Care
Institutional Care
Action!
Action!
Old Practice
Risk Prevention
74
Our question is
  • How do we
  • build on her strengths
  • promote her mobility and
  • support her natural inclinations?

75
Optimally what we want is to support her own
natural shifts in her body weight that relieve
pressure as she feels it.
76
Case Study Nursing Home Alarm Elimination
Program Its Possible to Reduce Falls by
Eliminating Resident Alarms
  • www.masspro.org/NH/casestudies.php

77
Plan of care based on an assessment of her
routine, her strengths and her preferences
78
Treatment of Pain
79
The more we know people, the better we can care
for their pain.
80
Section 3
  • Making it Happen
  • Barriers and Strategies

81
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.

82
one step at a timeand each success opened up
new possibilities
83
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

84
Health Promotion
New Practice!
Action!
Action!
Individualized Care
Institutional Care
Action!
Action!
Old Practice
Risk Prevention
85
HOLISTIC APPROACH TO TRANSFORMATIONAL
CHANGE (HATCH)
86
We did the best we could with what we knew, and
when we knew better, we did better.
  • - Maya Angelou

87
National TechnicalInformation Services (NTIS)
http//cms.internetstreaming.com
  • 5285 Port Royal Road
  • Rm. 1008, Sills Bldg.
  • Springfield VA 22161
  • (703) 605-6186
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