Transcript Long Term Residents

Mobility
LeadingAge National Convention
October 20, 2014
Doug Pace, LNHA
Jo A. Taylor, RN, MPH
Adrienne Mihelic, PhD
www.nhqualitycampaign.org
OUR MISSION
OUR VISION
Making nursing homes better places to live, work and visit
Every nursing home resident in America experiences personcentered quality of life as a result of a stable and empowered
workforce, dedicated to improving clinical and organizational
outcomes, and engaging in open communication and transparency.
AE Campaign Overview
• Largest national coalition of stakeholders working
together to help nursing homes (NHs) improve care
• Voluntary for nursing homes
• FREE online resources
• Based on measurement of meaningful goals
• The data shows the AE Campaign works!
Organizational Members
WHO WE ARE
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AALTCN - American Association for Long
Term Care Nursing
AANNET - American Academy of Nursing
ACHCA - American College of Health Care
Administrators
AGS – American Geriatrics Society
AHCA - American Health Care Association
AHFSA - Association of Health Facilities
Survey Agencies
AHQA - American Health Quality
Association
AMDA – The Society for Post-Acute and
Long-Term Care Medicine
The Commonwealth Fund
NAB - Foundation of the National
Association of LTC Administrator Boards
GAPNA – Gerontological Advance
Practice Nurses Association
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The Fenwick Foundation
The GREEN HOUSE® Project
Hartford Institute for Geriatric Nursing
The Joint Commission
LeadingAge
NADONA/LTC - The National Association
Directors of Nursing Administration/LTC
NAHCA - National Association of Health Care
Assistants
NASOP - National Association of State LongTerm Care Ombudsman Programs
National Consumer Voice for Quality LongTerm Care
NGNA – National Gerontological Nursing
Association
Pioneer Network
Advisory Members
WHO WE ARE
ACL – Administration for Community Living
• Director, Office of Long-Term Care Ombudsman
Programs
AHRQ - Agency for Healthcare Research and
Quality
• Health Scientist Administrator, Center for
Quality Improvement and Patient Safety
ASPE – Office of the Assistant Secretary for
Planning and Evaluation
• Director, Division of Long-Term Care Policy. U.S.
Department of Health & Human Services
CMS – Centers for Medicare and Medicaid Services
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Deputy Chief Medical Officer, Center for
Clinical Standards and Quality
Patient Safety GTL, National Patient Safety
Initiative, Quality Improvement Group
Deputy Director of Nursing Homes
Program Manager and Government Task
Leader, Quality Improvement Group
Nurse Consultant, Clinical Standards and
Quality, Survey and Certification Group,
Division of Continuing Care Providers
VA - Department of Veterans Affairs
CDC - Centers for Disease Control and Prevention
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Medical Epidemiologist for Long-term Care,
Division of Healthcare Quality Promotion
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National Director for VA Community Living
Centers
Supporting Members
WHO WE ARE
• GOLD
– Medline
• BRONZE
– eHealth Data Solutions, LLC
– Harmony Healthcare International
– It’s Never 2 Late
Provider & Individual
Members
WHO WE ARE
Provider Members
• The Evangelical Lutheran Good
Samaritan Society
• Evergreen Living Center
• Hi’Olani Care Center at Kahala Nui
• Jewish Home Lifecare
• Parker Jewish Institute for Health
Individual Members
• Dheeraj Mahajan
• Theresa Schmidt
• Dayne DuVall
Participants
WHO WE ARE
• More than 62% (9,763) of nation’s nursing homes have
registered since 2006
• 26% (4,074) of nation’s nursing homes currently registered
in AE Campaign (selected 2 or more goals)
• 3,805 consumers
• 3,673 nursing home staff members
• 53 state-based Local Area Networks of Excellence (LANEs)
Four Organizational Goals
Five Clinical Goals
Hospitalizations
Staff Stability
Pressure Ulcers
Medications
Antipsychotics
Consistent
Assignment
Infections
C. difficile
Mobility
PersonCentered
Care
Pain
Management
Registering & Participating
 Registrants: Sign up, select 2 goals (one from each category)
 Consistent Assignment
 Infections
 Hospitalizations
 Medications
 Person-centered Care
 Mobility
 Staff Stability
 Pain
 Pressure Ulcers
 Participants: Demonstrate commitment to principles of
performance improvement by
 Data uploaded to AE website monthly for 6 consecutive months +
 2nd year, data for two goals uploaded to AE website.
Circle of Success
How do I know where I am?
Where do I want to be?
What processes are
associated with my
outcome?
When I change a process,
how do I know it had the
effect I wanted?
How am I doing compared
to other nursing homes
working on this goal?
www.nhqualitycampaign.org
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Root-Cause Analysis of Hospital
Transfers
ROOT-CAUSE ANALYSIS
• An analytic tool that can be used to perform a
comprehensive, system-based review of critical
incidents and adverse health events
• Goal is to determine:
– What happened?
– Why did it happen?
– What can be done to reduce the likelihood of
recurrence?
Root-Cause Analysis of Hospital Transfers
ROOT-CAUSE ANALYSIS
• Systematic approach to problem solving
– Identify issues as a team
– Frequently ask 5 “Why?” questions
• Don’t stop at symptoms
• Get to deeper layers to find root cause
• Identify relationships between different root causes
QA and PI
Quality Assurance
Performance Improvement
Reactive
Proactive
Episode or event-based
Aggregate data & patterns
Prevent recurrence
Optimize process
Sometime anecdotal
Always measurable
Retrospective
Concurrent
Audit-based monitoring
Continuous monitoring
Sometimes punitive
Positive change
Tracking Tools Support QA and PI
Easy view of individual records allows
resident-level view
Matrix of individual data allows scanning
for patterns
Summary information helps identify
opportunities to improve at system level
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November 12- Webinar

OIG Report – Adverse Events in Nursing
Homes
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Hallmark/AE Partnership – Employee
Recognition Program
GETTING INVOLVED
National, Voluntary, Aligned
Registered Participant/Active Participant
1. Register, Update Profile
2. Select Goals
3. Submit Data
Why Is Mobility So Important?
Sense of our well-being as we age is determined in
large part by our mobility status.
 Most significant factor to perceived levels of health and well-being
 Critical component of functional health and self-esteem
Residents view mobility as a means of freedom, choice, and
independence.
“The facility must ensure that the resident obtains optimal improvement or does not
deteriorate within the limits of the resident’s right to refuse treatment, and within the limits
of recognized pathology and the normal aging process.” CMS Survey Manual
www.nhqualitycampaign.org
What Is the Role of Advancing
Excellence?
AE Mobility Goal:
Enhancing and maintaining mobility as a part of
daily care helps to maintain a person’s function
as well as physical and psychological wellbeing.
Improving mobility is a component of the CMS 11th Statement
of Work for all Quality Improvement Organizations.
www.nhqualitycampaign.org
Bigger Definition of Mobility
 Being able to move your own body through space or having
someone help you move
 Strength, flexibility, balance, and endurance
 While walking is the fundamental mobility task, mobility also
includes:
 Turning over in bed
 Getting up from a chair
 Standing
 Using a cane, walker or wheelchair to get around
 Moving from place to place within or outside nursing home
www.nhqualitycampaign.org
1. Excess safety through immobility
2. Therapy and restorative program models
3. All day wheelchair use
4. Family fears and litigation
5. Medical model with high medication use
6. Acuity level of older, frail residents with multiple
co-morbidities
Culture of functional decline
1. Excess Safety through Immobility
 Bed rails
 Restraints
 Alarms
 Immobility reinforced to reduce fall risk rather
than strengthening and balance to reduce risk
of fall related injury
“Now, don’t get up by yourself, Mr. Giles. You might fall.”
www.nhqualitycampaign.org
2. Therapy and Restorative Models
 Therapy as sole owner of mobility
 Focus on specific tasks for reimbursement
 Not integrated into frontline workers’ day-to-day
routine
 Restorative programs that do not impact mobility
Fifteen minutes a day is too little and ambulation 3 times a
week is not enough.
www.nhqualitycampaign.org
3. All Day Wheelchair Use
 Part of effort to reduce fall risk through
immobility
 Task and time culture
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Easier to push rather than to assist resident
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Quicker to push rather than wait for resident
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Greater staff control of environment
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Easy alarm use
 View of aging in long-term care
www.nhqualitycampaign.org
4. Family Fears and Litigation
 Fall at home as reason for admission
 History of fracture with suffering and decline
 Complaints
 Poor survey results
 Threat of litigation
“My mother has already broken one hip. I don’t want her to
fall again. It will kill her to go through that again.”
www.nhqualitycampaign.org
5. Medical Model with High Medication Use
 Psychotropic drug use
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Antipsychotics
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Sedatives/hypnotics
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Antidepressants
 Doubles fall risk and risk of hip fracture
“You have to make my mother stop doing that! She was
never like that before.”
www.nhqualitycampaign.org
6. High Acuity Level
Institutionalization
Usual Aging Changes
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 Immobility
Decreased muscle strength and
aerobic capacity
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Vasomotor instability
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Baroreceptor insensitivity and
reduced total body water
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Decreased bone density
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Decreased ventilation
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Visual changes
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Sensory changes
 Medications
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Sedation, confusion
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Dizziness, syncope,
hypotension
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Impaired gait, blurred vision
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Urinary incontinence
 Environmental changes
Rest and sleep are therapeutically restorative but bed rest is not.
www.nhqualitycampaign.org
7. Culture of Functional Decline
 Many different caregivers
 “Task and time” approach with little resident
participation
 Limited access to environment
 Staff ratios
 Limited scope and content of activities programs
“I will meet you in 10 minutes for break. It won’t take me
long to do Ms. Rodriquez’s A.M. care.”
www.nhqualitycampaign.org
Culture of Functional
Decline
• Sling back wheelchair
• Wheelchair use in middle
of day for sitting
• Alarm use
• Long hallway
• Too many obstacles to
count
• Lighting, glare
• Floor
Where could this resident
ambulate anyway?
Cycle of Immobility
 Cardiovascular deconditioning
 Loss of muscle strength and
power
 Loss of range of motion and
contractures
 Decreased bone density that
increases fracture risk
 Altered perceived health and
well-being
www.nhqualitycampaign.org
Reality of Situation
 Prevent further decline
 Help to maintain ADL function
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Ability to walk
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Ability to transfer
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Ability to use the toilet
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Participation in self care
 Improve strength, balance, endurance, and flexibility in
some residents
 Falls management with emphasis on mobility + injury
prevention instead of immobility + functional decline
Residents that are not using it are losing it.
www.nhqualitycampaign.org
Key driver of functional status as well as
physical and psychological well-being
Mobility
Restorative program
Environment
Integrated therapy
Activities
Frontline staff awareness, training, and
supports
Person-centered care and QAPI to reduce fall risk
Person-centered Care + QAPI
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One of the best ways to reduce the seriousness of falls
is to preserve and enhance resident mobility.
 Exercise to strengthen bones and muscles
reduces risk of injury.
 Practical management of the resident’s fall risk
 Immediate post fall investigation
 Interdisciplinary root cause analysis
 Individualized interventions for identified risk factors
 Person-centered care strategies to meet individual
needs before unsafe behaviors occur
www.nhqualitycampaign.org
Frontline awareness, training, and support
• Changing the culture
• Walking programs
• Education and training
• Exercise programs
• Leadership
• Dining programs
• Tools and resources
• Toileting programs
• Certification programs
• Bed mobility
Frontline caregivers who have the awareness and skills can
encourage independent ADLs, self care behaviors, and mobility.
www.nhqualitycampaign.org
Activities
 Music and movement
 Exercise programs
 Integrating balance into all activities
 Systems for providing activities that promote
mobility and self care behaviors
 24/7 program
Go through your building and count how many residents are
in bed at 10 am and at 4 pm.
www.nhqualitycampaign.org
Integrated Therapy
 Assessment
 Communication
 Individualized seating when wheelchairs are
necessary
 Eliminating wheelchairs when they are not
necessary
Mobility is everyone’s responsibility.
www.nhqualitycampaign.org
Environment
 Floor plan and layout for ambulation – How many steps?
 From room to dining room
 From room to activities
 From room to outside
 Clutter and equipment barriers
 Chairs for sit-stand safety
 Handrails
 Lighting
 Flooring
 Outdoor spaces and gardens
www.nhqualitycampaign.org
This diagram is
courtesy of Dr.
Lorraine Hiatt.
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Restorative Program
Nursing interventions that promote the resident’s ability
to adapt and adjust to living as independently and safely
as is possible
Address barriers:
 Resident – age, frailty, co-morbidities, depression
 Facility or system – staffing, culture of excess safety, old
model, insufficient training, environment
Ambulation 2-3 times per week is not restorative.
www.nhqualitycampaign.org
How Can AE Help?
 Resources and tools
 Circle of Success, a step by step framework
 Mobility measurement tool to track:
 residents’ mobility
 changes in mobility
 timeliness of assessments
 use of alarms and restraints
 frequency and severity of falls
www.nhqualitycampaign.org
Seven Step Process for Change
PDSA Cycle of Change
Plan
Act
Do
Study
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Other Data
 # of wheelchairs in daily use
 Average length of wheelchair use per resident per day
 # of residents in bed at 10 am
 # of residents in bed at 4 pm
 QM Increased need for help with late-loss ADLs
 Data related to your restorative program - # of patients
seen, type of activities, structure, integration with frontline
Mobility tool tracks alarms, restraints, falls, and falls with injury.
www.nhqualitycampaign.org
Required Fields
Examples of root cause analysis
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Why is this resident non-ambulatory?
Why is this resident using a wheelchair 6 hours
per day?
Why is an alarm being used for this resident?
Examples of process mapping
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What is the process for putting a resident in a
wheelchair other than for transport?
How do we engage residents in an exercise
activity? Assessment, criteria, approach?
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Optional Fields
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References

Creditor, MC. Hazards of hospitalization of the elderly. Annals of Internal Medicine. 1993;118(3):219-223.

Bourret EM, Bernick LG, Cott CA, Kontos PC. The meaning of mobility for residents and staff in long-term care
facilities. Journal of Advanced Nursing. Issues and Innovations in Nursing Practice. 2002.

Schnelle JF, MacRae PG, Ouslander JG, Simmons SF, Nitta M. Functional incidental training, mobility performance,
and incontinence care with nursing home residents. Journal of the Amer Geriatrics Soc. 1995;43:1356-1362.

Bates-Jensen B, Schnelle JF, Alessi CA, Al-Samarrai NR, Levy-Storms L. The effects of staffing on in bed times
among nursing home residents. Journal of the Amer Geriatrics Soc. 2004; 52:931-938.

Resnick B, Simpson M, Galik E, Bercovitz A, Gruber-Baldwin AL, Simmerman S, Magaziner J. Making a difference:
Nursing assistants’ perspectives of restorative care nursing. Rehabil Nurs. 2006; 31(2):78-86.

Kitson AL, Athlin AM, Conroy T. Anything but basic: Nursing’s challenge in meeting patients’ fundamental care
needs. Journal of Nursing Scholarship. 2014;46(5):331-339.

Taylor JA, Parmelee P, Brown H, et al. A model quality improvement program for the management of falls in nursing
homes. JAMDA 2007;8:S26-S36.
www.nhqualitycampaign.org
Your Experiences and Input Are Key
Please let us hear from you.









Jo A. Taylor, R.N., M.P.H. [email protected]
Adrienne Mihelic, Ph.D. [email protected]
Carol Scott
[email protected]
Mary Tinetti, MD
Jennifer Brach, PT, Ph.D.
Lisa Bridwell
Linda Sue Davis, R.N. M.S.N.
Lorraine Hiatt, Ph.D.
Melanie McNeil
www.nhqualitycampaign.org
The Advancing Excellence Mobility Tracking Tool
The key to a data-driven quality improvement project
Start Small & Grow Your Project
One group of residents
One project
Engage your team,
identify short term goals
Test on a small scale,
learn, tweak, expand
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Follow the process
The Domestic Lean Goddess - PDSA Video
The Domestic Lean Goddess video shows how the Plan-DoStudy-Act (PDSA) cycle, a common quality improvement
method, can be used in an everyday domestic situation (why the
children are always late for school). This six-minute video shows
how applying the four steps of the PDSA cycle pinpoints the root
cause and allows effective action to take place. This video helps
nursing homes consider the multitude of ways in which the
PDSA structure can improve processes. Six-minute video.
The Domestic Lean Goddess - Eliminating the 7
Wastes (Muda) Video
The Domestic Lean Goddess is back! And this time she's
helping a mom get lean by eliminating waste (Muda) and making
her laundry days more efficient. Join the DLG in a fun
exploration of how to analyze and eliminate the 7 Wastes in any
process to improve it and make it more lean. This video can help
nursing homes eliminate duplication, re-work, or waste in their
day-to-day operations. Seven-minute video.
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Get More QI
Resources!
Mobility Assessment EVERY MONTH
Activities of Daily Living Functional Limitation in
(ADL) Assistance
Range of Motion
MDS 3.0 G0110
MDS 3.0 G0400
Bed mobility
Transfer
Walk in room
Walk in corridor
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Upper Extremity
Lower Extremity
Locomotion
MDS activities but
NOT MDS scoring
Locomotion on unit
Locomotion off unit
What does it mean?
Life Space
Mobility
Personal
Movement
Tinetti ME, Ginter SF. The nursing home life-space diameter. A
measure of extent and frequency of mobility among nursing
home residents. J Am Geriatr Soc. 1990 Dec;38(12):1311-5.
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Individual Change & Stability
Change Scores for Each
Resident with Two
Consecutive Mobility
Assessments (assess every
30-days)
0 = Stable (no change)
>0 = Improvement
<0 = Decline
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Aggregate Change and Stability
Monthly
Mobility Profile
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Monitor
www.nhQualityCampaign.org
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What is/isn’t working?
Raised bed garden
project
Upgrade courtyard and integrate
outdoor venue for concerts and daily
activities
RCA: loss of engagement? Need
to revitalize? Find other options
for other interests/abilities.
Daily walking program for
ambulatory residents
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Look for opportunities to improve
Areas of Strength in Long Term Residents
100%
80%
60%
40%
20%
0%
Bed Mobility
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Transfer
Walk in Room
Walk in
Corridor
Upper
Extremity
Lower
Extremity
On Unit
Locomotion
Off Unit
Locomotion
Look for opportunities to improve
Long Term Care Residents
LTC * Independence in Activities
number independent number assessed
Bed Mobility
Transfer
Walk in Room
Walk in Corridor
LTC * Full Range of Motion
Upper Extremity
Lower Extremity
LTC * Daily Locomotion
(more than once per day)
On Unit Locomotion
Off Unit Locomotion
60
percent independent
9
6
6
6
67
67
67
67
13.4%
9.0%
9.0%
9.0%
number full ROM
number assessed
percent full ROM
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36
67
67
73.1%
53.7%
number with daily
locomotion
65
64
number assessed percent daily locomotion
67
67
97.0%
95.5%
Falls
frequency and Severity
Long Term * Falls
LTC Falls
100.0%
90.0%
80.0%
70.0%
60.0%
No falls
Fall with no injury
Fall with injury, not major
Fall with major injury
Not recorded
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1
2
0
4
Total
71
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
No falls
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Fall with no injury
Fall with injury,
not major
number
Fall with major
injury
Not recorded
percent
90.1%
1.4%
2.8%
0.0%
5.6%
100.0
%
Alarms and Restraints
type and frequency
LTC Restraint Frequency
Long Term Residents
100%
Daily, 0.0%
Less than
daily, 0.0%
Not
recorded,
4.2%
80%
60%
40%
None,
95.8%
20%
0%
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Getting Started
One: Register & Select Goals
Two: Download Tracking Tool
Three: Learn More
Four: Access support and activities In Your State and HelpDesk
63
This material was prepared by Telligen, the Medicare Quality Improvement
Organization for Colorado, under contract with the Centers for Medicare & Medicaid
Services (CMS), an agency of the U.S. Department of Health and Human
Services. The contents presented do not necessarily reflect CMS policy.
Thank you!!
National Center fo r Emerging and Zoo no tic Infec tious
Diseas e s Divisio n o f Healthcare Quality Pro m otion
Thank you!
Visit Us
www.nhQualityCampaign.org
Connect Online
Contact Us
[email protected]
[email protected]