Disclaimer - OHCA 2... · AHCA/NCAL 2001 “National ... 25% per CDC National Survey of Residential Care Facilities (2010) ... Reducing adverse medication events

Ray Miller 8/18/2017

Direct Supply 1

Liz Jen

sen

, R

N, M

SN

, R

N-B

C

Clin

ical D

irecto

r, D

irect Su

pp

ly®

, In

c.

By Ray Miller, MSOSH, Dir. of Risk and Safety,

Direct Supply®, in a collaborative effort

With Liz Jensen, RNA MSN, RN-BC

Clinical Director, Direct Supply®, Inc.

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Disclaimer

The materials, comments and other information

contained in this presentation are intended to provide

general information but not advice about certain

regulations and initiatives.

This information is not and not intended as legal or

other advice and each situation may vary depending

on the particular facts and circumstances.

You should not act upon this information without first

consulting with qualified legal counsel.

Thank You.


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Today’s Focus

• Aging (in AL is not new—what’s changed?)

• Frameworks

• Trends (Programs, Building Clinical Capacity and Services)

• Resources

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Here’s what we’ve been told …

Seeking to Answer

“How can I improve the health and well being of my residents?”

• “We are concerned about residents with ______________”

• “Residents move in and quickly need an increased level of

care …”

• “We need to differentiate ourselves from our competitors”

• “Our acuity continues to rise … HELP!”


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What do YOUR Goals look like?

• “Meet the day-to-day needs of my residents”

• “Reduce the frequency of residents moving out”

• “Meet a specific need (memory care …) in my community”

• “I have insurance companies that want us to provide more

services to keep residents from going to the hospital”

• “Improve the health and wellness of my residents so they can

live in our community as long as possible”

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Self-Check: Where are you?

“There is the expectation that we’ll do everything for them…

it’s part of our hospitality commitment”

Or “We are here to be your partner in helping you

live your life and stay healthy.”

At 65 years of age, this where I find myself:

“Everything you do for me you take from me!

“Help me to do it alone!”

Maria Montessori


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Aging in AL is not new…What’s changed?

“Facts & Trends: The Assisted Living Sourcebook”. AHCA/NCAL 2001

“National Survey of Residential Care Facilities”. Centers for Disease Control and Prevention, 2010.

Av. Mon.

in AL

87 2010

80 2001

36 2001

22 2010

735,000 2010

416,768 1998

Moving

into AL

Average age

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Aging in AL is not new…What’s changed?


“National Survey of Residential Care Facilities”. Centers for Disease Control and Prevention, 2010.

Then

Now


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Assisted Living Residents today…


“National Survey of Residential Care Facilities”. Centers for Disease Control and Prevention, 2010

Administration on Aging, “Fall Prevention Programs”: http://bit.ly/1zBTba8

70% Female

42% have Alzheimer’s or dementia

Need help with 2-3 ADLs

Have 2-3 chronic conditions such as

• Heart disease, CHF

• Hypertension

• Depression

• Arthritis

• Diabetes

• Osteoporosis

• Cancer

• COPD

• Stroke

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Risks increase for residents 80 & older

American Heart Association, 2015

Administration on Aging, “Fall Prevention Programs”: http://bit.ly/1zBTba8

Adults 85 and older are almost 4x more likely to fall than adults 65-75

http://bit.ly/1zBTba8

http://bit.ly/1zBTba8


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RESPONDING TO

RISING ACUITY

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Avoid Hospitalizations

10% more likely to die within a year if hospitalized due to:

Cardiac conditions (arrhythmia, heart failure, atherosclerosis)

Complications related to diabetes

Fall-related injuries

Infections

COPD

30% more likely to die within a year if readmitted within 30 days

Pneumonia

Congestive heart failure

Acute myocardial infarction

Lum et al. J Gen Intern Med 2012; 27(11): 1467-74.


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Reduce risk for injury

• What % of residents need assistance with transferring in AL?

□ 25% per CDC National Survey of Residential Care Facilities (2010)

• Estimates that up to 25% of all worker’s comp claims are

related to patient handling injuries.

• Safe patient handling programs significantly reduce risk

and costs.

CDC; Department of Health & Human Services; National Institute for Occupational Safety & Health: Safe Lifting and

Movement of Nursing Home Residents. (2006)

OSHA Safe Patient Handling Programs (2013)

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Define, Clarify, Track

1. Understand the role of your AL in the health care continuum.

2. Define what you are able AND willing to provide.

3. Focus on improving in the following areas:

Chronic disease management / heart failure and heart disease

Reducing adverse medication events

Staff competencies & capabilities

Engaging residents and families

Services post-op hip/knee

Preventing infections

Addressing frailty

Reducing fall risk

TRACK

OUTCOMES

(worth repeating)


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Self Check:

What does rising acuity impact?

Attracting and retaining staff?

Regulatory citations?

Risk / Litigation?

Occupancy?

…

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FRAMEWORKS


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Keeping in Mind--the Nursing Care Dilemma in AL

• Assisted Living Regulations

Varies by state

Limits on “skilled care”, care delivered by nurses

Often limits ability of nurses to practice at “Top of License”

• Nurse Practice Act

Understanding how to practice at “Top of License”

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Adapting existing models

• Population Health

• Naylor’s Transitional Care Model

• Community Health Nursing Model


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Population Health

What is population health?

Health outcomes for a group of individuals

How are health outcomes defined in Assisted Living?

Health-related and Quality of Life

(No real standard definitions)

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Naylor’s* “Transitions of Care Model”

Hirschman, K., Shaid, E., McCauley, K., Pauly, M., Naylor, M., (September 30, 2015) "Continuity of Care: The Transitional Care Model" OJIN: The Online Journal of Issues in Nursing Vol. 20, No. 3, Manuscript 1.

1. Screening

2. Staffing

3. Maintaining Relationships

4. Engaging Patients & Caregivers

5. Collaborating

6. Assessing / Managing Risks &

Symptoms

7. Educating/Promoting Self-

Management

8. Promoting Continuity

9. Fostering Coordination

Mary D. Naylor, PhD, RN, FAAN 1] Architect of the Transitional Care Model

2] Marian S. Ware Professor of Gerontology at the Univ. of PA. School of

Nursing, Philadelphia 3] Dir. of the New Courtland Center for Transitions and

Health at the Univ. of PA School of Nursing, Philadelphia, PA.

The Transitions of Care Model

encompasses a broad range of

services and environments

designed to promote the safe and

timely passage of patients

between levels of health care and

across care settings (Coleman &

Boult, 2003; Naylor, 2003).


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Resident &

AL Team

ADLs

Exercise

Therapy

Nutrition Med

Mgmt

Nursing Care

MD/NP

AL

Nurse

Level of Care / Care Coordination

Home Health

Nurse

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Ideas

Applying

principles of

“Community

Health Nursing”

A team

approach to

chronic disease

management

Tips for

reducing re-

hospitalization

Tips for

reducing risks

associated with

frailty


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Building on Assisted Living Philosophy

Social

Spiritual

Physical

Emotional

Intellectual

Occupational

Environmental

Wellness

Prevention & Monitoring

Medication Assistance

ADL Support

Health

Chronic Disease Management

Home Health Nursing

Physician / NP visits

Social Services

Pharmacy

Therapy

Dietitian

Community

Health Nursing

HOW?

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Elements of Community Health

US Dept. Health & Human Services and the National Center for Chronic Disease and Health Promotion; Dec. 2010.

1. Screening

2. Education

3. Interventions

4. Modifications

5. Physical Activity


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Conduct a Community Assessment

WHAT ARE THE TOP:

• 5 health-impacting diagnosis or conditions?

• 5-10 most frequently prescribed medications?

• 3 health/well-being-impacting incident types (past year)?

WHAT % OF RESIDENTS:

_______ Require transfer or mobility assistance by staff?

_______ Exercise at least 2-3 days per week?

_______ Have at least a HS education?

_______ Use oxygen regularly?

_______ Use wheelchairs?

_______ Use walkers?

_______ Smoke?

In my Community:

65%

10%

57%

??%

25%

45%

25%

(HD = 70%; Diabetes = 40%); ???% Arthritis

(Metoprolol, Lasix, Lipitor, Metformin, Aspirin)

(fall w/ injury, fall wo injury, med error)

Community Health Approach

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Screening • Blood pressure checks, Cholesterol screening

Risk Identification • Smoking cessation classes; Medication management

Environmental Modifications • Health stations to check own blood pressure, weight or provide in apartment

• Exercise equipment—improve the gym

Health Education • Speakers, discussion sessions on heart disease, exercise, smoking cessations

• 1:1 Medication education with nurse, NP or pharmacist

Promoting Physical Activity • Daily exercise classes; Walking club; Personal trainer

Community Health Approach / Heart Disease (Team-based approach – a proven model)


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Community Health Approach /

Arthritis & Other Mobility Issues

Screening • Fall Risk Assessments—Individual, Environmental

• Transfer Assessment

Risk Identification • Medication changes

• Pain management / functional activities, exercise and sleep

• Wheelchair, walker, cane checks

Environmental Modifications • Transfer devices, Lifts, Grab bars bathrooms, Lighting, Exercise equipment

Health Education • Speakers, discussion sessions

• 1:1 Medication education with nurse, NP or pharmacist

Promoting Physical Activity • Exercise classes, massage therapy, stretching

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Ideas

Tips for

reducing re-

hospitalization

Tips for

reducing risks

associated with

frailty

Applying

principles of

“Community

Health Nursing”

A team

approach to

individual

chronic disease

management


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Framework for Individual Care

Assisted Living Nursing: A Manual for Management and Practice edited by Dr. Ethel Mitty, EdD, RN, Dr. Barbara Resnick, PhD, CRNP, FAAN, Sandra Flores, RN

• Optimizing function -- Self-

care assistance and

support

• Decision making capacity

• Medication Management

• Service/Care Planning

• Health promotion

• Assessments

“Help me to do it alone!” Maria Montessori

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Individual Care / Heart Failure

Define, Understand, Educate (Resident & Staff):

□ Exacerbation: Causes & Symptoms

□ Care Considerations & Monitoring

□ Engagement & Exercise

□ Nutrition & Fluid Intake

□ Advance Directives

□ Medications

REALITY:

A resident with

HF is at high risk

for a decline in

health


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Exercise Is Important

Heart Failure Management in Skilled Nursing Facilities A Scientific Statement From the American Heart Association and the Heart Failure Society of America; Journal of Cardiac Failure

Vol. 21 No. 4 2015

IF heart failure, THEN aerobic exercise & resistance training (recommended)

□ Aerobic Exercise

Walking, exercise classes, recumbent cycling

Light to moderate activity

□ Resistance Training

Low intensity, high-repetition

4-6 exercises of major muscle groups, 1-2 sets each, 2 times per week

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Team Approach / Example Heart Failure

CHF Self AL Nurse MD/NP HH Nurse Rehab Pharm

BP X X X X X

HR X X X X

O2 sat X X X X

Wt X X X X

Meds X X X X X

Labs X X

Nutrition X X X

Exercise X X X X

Education X X X X X X

Consider defining who is involved in resident’s care. Review with resident and family


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Resident Education

• Medications—identification,

purpose, side effects

• Signs and symptoms

• Weight

• Diet changes

• Exercise

• Follow up appointments

• Staying well—immunizations,

alcohol intake, smoking cessation

“Help me to do it alone!” Maria Montessori

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Ideas

Tips for

reducing risks

associated with

frailty

Applying

principles of

“Community

Health Nursing”

A team

approach to

chronic disease

management

Tips for

reducing re-

hospitalization


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Care Models & Expanded Services – What we’ve seen

EXPAND:

• MD & NP Partnerships (On-site clinic hours; Home visits)

• Nursing staff (Hours; Expertise)

• Therapy services

OFFER:

• Social Service support

• Expanded Dietitians services

ENGAGE: Pharmacist Consultants

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Clinical Competencies / Capabilities – Focus Areas

Knowledge Skill Ability/Attitude

• Community Health

Nursing

• Gerontological Care

• Risk Management

• Care Coordination

• Geriatric Nursing

Assessment

• Clinical / Technical

• Documentation

• Communication

• Delegation

• Education & Training


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Ideas for Improving Competencies – How To Focus

Knowledge

• Gero Nurse Preparation Course http://app1.unmc.edu/geronurseprep/

• Hartford Institute for Geriatric Nursing http://www.hartfordign.org/ (free)

• INTERACT Tools http://interact2.net/ (free)

• Access to MD, NP, PA, Therapists

• Online education

Skills

• Skills lab

• Stop & Watch Tool; SBAR Tool

• Simulation learning / manikins, live

Ability/Attitude

• Safe environment

• Opportunity to Practice

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Reducing Re-hospitalization – Evidence-based strategies

Risk Identification / Stratification Process (for return to hospital)

• Risk level identified on move in (ongoing)

• Current or recent / recurring infection

• History of Falling (w/ or w/o injury)

• Hospitalized in past 12 months

• 2-3 co-morbid conditions

• Community-specific …

INTERACT • Early Identification / STOP & WATCH

• Clinical Decision Support

• SBAR

Root Cause Analysis (Each hospitalization)

http://app1.unmc.edu/geronurseprep/

http://www.hartfordign.org/

http://www.hartfordign.org/


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INTERACT https://interact2.net/assisted_living.aspx

Endorsed by American Assisted

Living Nursing Association

“The advent and use of these

Assisted Living specific tools will

become a standard part of quality

improvement….AALNA sees this

system as an innovative approach to

improving communication by more

directly empowering our caregivers

and improving our relationships with

each other, residents, families and

physicians.”

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Can be completed

by any caregiver

https://interact2.net/assisted_living.aspx


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Can be completed by

non-licensed

caregivers in assisted

living

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What should caregivers be looking for? (heart failure)

• Shortness of breath


when lying flat


at night /cough

• Edema; Ascites

(swelling)

• Fatigue

• Confusion or

delirium

• Nausea, abdominal

pain or distension

• Decline in:

• Exercise tolerance

• Food intake

• Functional status


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Ideas

Applying

principles of

“Community

Health Nursing”

A team

approach to

chronic disease

management

Tips for

reducing re-

hospitalization

Tips for

reducing risks

associated with

frailty

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1. RESIDENT: 70+ yrs. OR Significant, chronic, illness-related weight loss (>5%)

2. PHYSICIAN: “Screened for sarcopenia & frailty?” “Results?” (ICD-10 code M62.84)

3. BY WHO / WHEN: Therapy; move-in

4. HOW: SARC-F tool

5. FOCUS ON:

• Exercise (resistance AND aerobic)

• Caloric and protein support

• Reduced polypharmacy

• Vitamin D

Identifying Sarcopenia, Reducing Risk for Frailty

Morley, J., Vellas, B., et al. Frailty Consensus: A Call to Action. Journal of American Medical Directors Association. June 2013; 14(6): 392-397

*ORIGINALLY: “an age-associated loss of muscle mass …” RECENTLY: “… a decline

in muscle function (either walking speed or grip strength) associated with loss of muscle mass.”

https://www.researchgate.net/publication/243966215_SARC-F_A_Simple_Questionnaire_to_Rapidly_Diagnose_Sarcopenia *

https://www.researchgate.net/publication/243966215_SARC-F_A_Simple_Questionnaire_to_Rapidly_Diagnose_Sarcopenia






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The “E” Word…

“A multi-component exercise intervention program…

of strength, endurance and balance training … best

strategy for: 1] improving gait, balance and strength

… 2] reducing the rate of falls in elderly individuals…

3] maintaining their functional capacity during aging”

Cadore, E.L., Rodriquez-Manas, L., Sinclair, A., Izquierdo, M. (2013). Effects of Different Exercise Interventions on Risk of Falls, Gait

Ability, and Balance in Physically Frail Older Adults: A Systematic Review. Rejuvenation Research. Vol. 16, Number 2, 2013.

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The “E” Word -- Exercise Plan

Cadore, E.L., Rodriquez-Manas, L., Sinclair, A., Izquierdo, M. (2013). Effects of Different Exercise Interventions on Risk of Falls, Gait Ability, and

Balance in Physically Frail Older Adults: A Systematic Review. Rejuvenation Research. Vol. 16, Number 2, 2013.

Resistance Training • 2-3x / wk.; 3 sets of 8-12 reps

• 20-30% intensity and work-up (80%)

• Integrate into daily activities (e.g., sit to stand)

Endurance Training • Start at 5-10 mins first weeks; progress to 15-30 min

• Monitor Rate of Perceived Exertion (RPE) intensity (e.g.12-14 RPE)

• Walking (change pace & direction), step ups, stair climbing, stationary cycling

Balance Training • Integrate multiple exercises(e.g., multi-direction weight shift, heel-toe walking,

standing on one leg, weight transfers, line walking)

How can we

inspire the

desire to

exercise?


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Five Major Motivators

https://www.hindawi.com/journals/tswj/2014/329397/

Eighteen older residents from two nursing homes in Taiwan:

1. 8 participants: to enrich their lives

2. 7 participants: a previously cultivated habit

3. 6 participants: eagerness for returning home

4. 10 participants: fear of becoming totally dependent

5. 6 participants: improving mood state (avoiding / enhancing)

The Scientific World Journal, Volume 2014 (2014), Article ID 329397: Motivators for Physical Activity among Ambulatory Nursing Home Older Residents

“The motivators reported in this study should be considered when

designing physical activity programs. These motivators can be

used to encourage, guide, and provide feedback to support older

residents in maintaining physical activity.”

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Reduce Fall & Injury Risk for Residents

• Consider programs to support transfer and lift assistance

• Evaluate residents for the level of support needed:

□ Level of dependence on care staff

□ Weight bearing ability

□ Cognitive status

□ Size of resident

• Evaluate on move-in, with change in condition and at least

every 6-12 months.




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Reduce Caregiver Injury Risk

1. Assessments: Functional, Posterior

2. Assisting from floor (post-fall)

3. Applying barrier creams

4. Bariatric Residents

5. Vehicle Transfer

6. Hygiene Care

7. Repositioning

8. Transfers

9. Dressing

10. Toileting

11. Weights

12. …

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A “New” Discussion -- Assist Devices in Assisted Living

Readiness Assessment

1. Residents

2. Equipment

3. Culture

4. Management Engagement

5. Program Policy & Procedure

Successful Implementation

1. Mentors

2. Hands-on Training

3. R & S & M Buy--in

4. Sustained Change

5. Safety Committee monitors & modifies

S


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Applying ADLs to Equipment Selection (Assessment)

Category 4: Total Dependent:

□ Floor Lift

Category 3: Moderate / Extensive / Maximum Assist:

□ Sit-to-Stand Assist

□ Floor Lift

Category 2: Minimum Assist:

□ Non-powered assist devices

□ Sit-to-stand Assist

Category 1: Limited Assist

Category 0: Independent

Applying ADLs to Equipment Selection

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CODE 4: Total Dependence

Full staff performance every time

CODE 3: Extensive Assistance

Resident involved in activity, staff

provide weight-bearing support

CODE 2: Limited Assistance

Resident highly involved in activity,

staff provide guided maneuvering of

limbs or other non-weight-bearing

support

CODE 0: Independent

No help or staff oversight at any time

This document is intended to provide general information but not advice about regulations and initiatives. This information is not and not intended as legal or other advice, and each situation may vary depending on the particular facts and circumstances. You should not

act upon this information without first consulting with qualified legal counsel.

Resident Capability &

Lift/Assist Equipment

Matching Options Based on industry best practices

and CMS RAI V 3.0 Section G

Multi-Functional

Lift

DRAFT DOCUMENT

Multi-Functional

Lift

Multi-Functional

Lift

CODE 1: Supervision

Oversight, encouragement

or cueing


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RESOURCES

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Capabilities / Products & Tools

Chronic Disease Management

• Scales

• BP cuffs, stethoscopes

• Vital signs monitor, pulse oximetry

• Resident education / Transitional Care Kits

Improving Endurance, Strength, Balance & Cognition

• Group classes

• Adding “fitness” in addition to rehab space

• In-apartment exercises, hand weights, resistance bands

• Adding equipment to assess & improve balance, cognition, endurance, strength

Reducing risk

• Fall injury / hip protection, adjustable height beds, lifts, grab bars etc;

• Exercise to improve balance, strength and endurance

• Lifts to reduce resident and staff injury


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Summary

• Consider implementing community health principles to guide

the develop of health and wellness programming

• Engage the entire team (both internal and external)

• Engage the Residents in their own care

• Invest in staff education (improved care & retention)

• Utilize your partners, resources, share best practices

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Ideas

Applying

principles of

“Community

Health Nursing”

A team

approach to

chronic disease

management

Tips for

reducing re-

hospitalization

Tips for

reducing risks

associated with

frailty


Direct Supply 30

Liz Jen

sen

, R

N, M

SN

, R

N-B

C

Clin

ical D

irecto

r, D

irect Su

pp

ly®

, In

c.

Ray Miller, MSOSH, in a collaborative effort with

By Liz Jensen, RNA MSN, RN-BC


By Ray Miller, MSOSH, Dir. of Risk and Safety,

Direct Supply, in a collaborative effort

With Liz Jensen, RNA MSN, RN-BC


Thank You

For Your

Participation

Documents

Disclaimer - OHCA 2... · AHCA/NCAL 2001 “National ... 25% per CDC National Survey of Residential Care Facilities (2010) ... Reducing adverse medication events