Restorative Nursing Workshop

Restorative Nursing Learning Objectives Welcome and introductions Restorative Nursing basics and foundation Regulatory requirements for Restorative Program Roles and responsibilities of the Restorative Team Functional training components and equipment of a successful Restorative Program Focus on common restorative programs & competencies

Introduction to restorative nursing

Long Term care current snapshot of Ltc 96% need help bathing 87% need help with dressing and grooming 66% require help with bed to chair transfers 66% need help with ambulation 63% need help toileting 46% require assistance with eating

Omnibus budget reconciliation act (OBRA ‘87) Landmark legislation Forever changed our legal expectations of Nursing homes & care Quality of LIfe Dignity Choice Self Determination Quality of Care Attain or maintain highest practical: physical mental psychosocial Comprehensive Care Plan “Resident should not decline in health or well being as a result of the way a nursing facility provides care” Forever changed our legal expectations of nursing homes and their care. “Resident should not decline in health or wellbeing as a result of the way a nursing facility provides care.

CMS survey Regulations F241 Dignity F221 Physical Restraint F222 Chemical Restraint F242 Comprehensive assessments F279 Comprehensive care plans F309 Quality of Care F310 Activities of Daily Living F311 Provide Services F314 Skin Management F315 Urinary incontinence F317 No limited ROM F318 Limited ROM F323 Accident prevention F325 Nutritional status maintained

continuum of care Restorative Nursing Routine Nursing Care Formal Therapy Routine Nursing Care

Types of programs Teaching and Skill Practice: Bed mobility Transfer Walking Dressing and/or grooming Eating and/or swallowing Amputation/Prosthetic Care Communication Techniques: Passive Range of Motion Active Range of Motion Splint or brace assistance Other: ?

What is Restorative Nursing and what makes a program? THERAPEUTIC MODALITY Nursing Interventions that promote the resident’s ability to adapt through physical, mental, and psychosocial health to adjust to living as independently and safely as possible Planned, systematic, organized program that builds on strengths OBRA ‘87

What is Restorative Nursing and what makes a program? Therapeutic modalities Therapeutic = “treatment to cure or restore health” Modality = “treatment to make a person better” Turns daily skill into specific activities Not mixed into other care Not new procedures

Who’s appropriate for a restorative program? Newly admitted clients with restorative needs, with or without formalized rehabilitation therapy Restorative needs arise over time during a custodial stay After discharge from physical, occupational, or speech rehabilitation therapy

Detecting needs for a Restorative program Fall assessment Bowel and Bladder assessment Braden skin assessment Contracture risk Pain assessment Mood assessment Behavior tracking records Skin assessment BIMS ADL flow records

QAPI monitoring systems for identification QM Report 24 hour report Incident & accident tracking & trending Weight variance Restraint tracking Catheter tracking Utilization Management Wound reports Contracture tracking

Quality measures and 5 star rating Short Stay % of residents with pressure ulcers that are new or worsened Long Stay % that need increased help with ADL % high risk with pressure sores % with physical restraints % of residents with falls with major injury

roles of the restorative team

Physical Therapy A consultant to the restorative program ambulation, mobility, exercise, seating, positioning, ROM, motor skills, ADL, adaptive devices, orthotics and splint fabrication Identifies needs for restorative nursing at the time of discharge or complementary programs while receiving skilled PT services Teaches and in-services staff about the principles and practice of Physical Therapy interventions

Occupational Therapy A consultant to the restorative program progressive mobility, exercise, seating, positioning, ROM, motor skills, feeding, ADLs, adaptive devices, orthotics, and splint fabrication Identifies needs for restorative nursing programs at the time of discharge or complementary restorative nursing programs while receiving skilled OT services Teaches and in-services staff about the principles and practice of Occupational Therapy

Speech language pathology Consultant to restorative program in swallowing, cognition and communication disorders. Identifies resident needs for restorative nursing at time of discharge from therapy or complementary ST services Teaches and in-services staff

social services Acts as a consultant to the restorative program in behavior management and mental health issues Addresses issues such as income, family relationships, and environment that affect restorative care Coordinates all discharge planning and community resources Teaches and provides in-services for staff

Restorative Nurse manager Licensed nurse with education & experience in LTC, Restorative Nursing & OBRA requirements Coordinates and oversees the entire restorative nursing program & all participating team members Identifies resident’s with restorative needs Coordinates IDT involvement to establish goals & interventions to meet needs Sets up Program, Kardex, Care Plan, and Completes documentation

Restorative CNA Education and experience in LTC, restorative nursing, and OBRA requirements Signed job description & competency proof in restorative activities Resource for team members in restorative techniques Completes restorative activities as documented Monitors progress or decline of program effectiveness Complete daily documentation of activities and reports issues to Restorative Nurse Manager

MDS Coordinator Manages overall processes for tracking all Medicare, Medicaid case mix records and reimbursement services for the facility Provides RAI guidance to ensure compliance in billing, coding practice per guidelines

differences between therapy & restorative

continuum of care Restorative Nursing Routine Nursing Care Formal Therapy Routine Nursing Care

Types of programs Techniques: Passive Range of Motion Active Range of Motion Splint or brace assistance Teaching and Skill Practice: Bed mobility Transfer Walking Dressing and/or grooming Eating and/or swallowing Amputation/Prosthetic Care Communication Types of programs

What is the difference between therapy & restorative? Skilled Therapy services Medically based rehabilitative care provided by PT, OT, SLP, to improve and restore function Services must occur with a physician order and supervision Services require a comprehensive therapy evaluation/plan which must be certified by a physician Services must require therapist skill Services are billable to Medicare or other payers

What are therapy skilled services? Level of complexity and sophistication requiring a therapist or be under the supervision of a therapist Expectation of improvement or must be necessary for safe and effective maintenance program Amount, frequency, duration of services must be reasonable under accepted standard of practice Medicare Benefit Policy Manual Chapter 8

Therapy & Restorative complement each other, not compete. Restorative Nursing “Non-skilled” rehabilitative care provided by restorative aides and restorative nurses aimed to improve or maintain function Does not require a physician order Can be established and modified by a therapist and/or by a licensed nurse Not a directly reimbursable service Therapy & Restorative complement each other, not compete.

Skilled vs non-skilled services Skilled Intervention/Services Non-Skilled Interventions and Services Patient Observations Routine tasks with the patient Assessment Cueing patient during a task Treatment Techniques Supervising a patient performing a learned treatment routine Patient/family/caregiver training Repetitive exercises Establishment of a Maintenance Program Implementation of a Maintenance Program

restorative documentation

RAI recognized Restorative programs Teaching and Skill Practice: Bed mobility Transfer Walking Dressing and/or grooming Eating and/or swallowing Amputation/Prosthetic Care Communication Techniques: Passive Range of Motion Active Range of Motion Bracing/Splint

RAI guidelines (O0500) Measurable objectives & interventions must be documented in the care plan & medical record Evidence of periodic evaluation by licensed nurse CNA must be trained in techniques in the activity License nurse must supervise activities Can only include groups no more than 4 Time blocks of 15 minutes or more

Restorative Nursing care plan IDT process to identify resident’s individualized problems strengths goals interventions Should be simple, focused on resident’s ability and kept to a time frame

purpose of restorative goals Improve, maintain, or prevent declines in condition Slow rate of decline in chronic disease Complement a current therapy program Teach safety Address risk factors and reduce the risk that will cause complications Prevent new or additional complications Help a resident adjust to new problems or limitations Teach the resident a new way of performing ADL skills or use new equipment Enhance dignity and improve well- being and quality of life

Goals Useful Outcome based Realistic & attainable reasonable time frame Focus on function potential not diagnosis and limitations Individualized to the resident Focused on strengths Measurable Important to the resident Based on real needs Easy to understand

Care plan interventions Restorative interventions should be activity based, measurable, and can occur during the resident’s normal daily care activities but should be specifically designed to help the resident meet their goals.

care plan Interventions Setup preparing equipment & supplies Verbal cues hints, clues, simple commands Demonstration motioning, gestures, showing Hand over hand technique placing hand over resident’s hand guiding through step/activity Encourage independence allows trial before intervening

Example of Restorative Intervention Mr. C will walk to and from the bed to the bathroom (25 feet) using his rolling walker with 1 person assist. Mr. C does this activity twice a shift and it takes 5 minutes each time. This adds up to 30 minutes in a 24 hour period. Total feet ambulated was 50 feet/shift or 150 feet total/24 hour period.

Restorative Nursing form

Restorative Nursing form

motivation & keeping engagement

Motivation techniques and resident rights Coach a mental attitude of “I can or I will try”. Positive attitude! Give a sense of control with opportunities to make decisions Incorporate family/caregivers Look at timing and routine care opportunities Break down tasks (segmentation), Short term goals related to the ADL : AM & PM care, mealtimes, hygiene pre & post meals & bath times Concentrate on the whole person ie. monitor pain Make it FUN!

How can you make it fun? What else? Music Positive rewards Celebrate accomplishments Chart progress Explain purpose Know what motivates them Be creative Participate with others What else?

task analysis Example Handwashing Identifies need to clean hands Goes to sink Approaches sink Turns on hot water Turns on cold water Adjusts water temp Places hands under water Applies soap Lathers soap on hands Rinses hands well Turns off cold water Turns off hot water Removes towel Uses towel Disposes towel Assessment of ability to complete each step of an ADL. Restorative Nurse or therapist will evaluate ability to perform each step of a procedure

restorative Meeting

Restorative meeting Regularly scheduled at least monthly; weekly suggested Assess abilities and level of participation Assess if program should be modified to meet goals Restorative Nurse Manager reviews reports/progress, and updates prior to the meeting as needed Attendees: Restorative Nurse Manager, MDS, DOR, RCNA, other CNAs as indicated

Monthly meeting topics Review charted progress toward goal & clinical outcome Updated care plans for revision, continuation or additional interventions Review for discontinuation & evaluation of maintenance programming Discussion of transfer to/from therapy to restorative Review all residents that have Quarterly, Annual, Significant Change MDS planned Review all new admissions/readmissions for needs Review Quality Measures data to identify residents appropriate for a Restorative Program

Monthly Progress note Describe progress or setbacks based on time spent, what is being done for the resident & response to what is done. example: Mr. C has been successful feeding himself using the scoop dish and coated spoon for an average of 15 minutes each meal, but tires rapidly and cries during dinner meal. Notes should be linked and tied to the Care Plan

Next steps...

Ongoing expectations Consistent and effective restorative program with supportive documentation and care plan Competencies completed and signed Upon Hire Annually With new unfamiliar programs from referrals Dynamic process based on: Census Compliance Case Mix

Summary Successful Restorative Nursing Programs will improve quality care and quality of life Consistent, efficient, and effective restorative meetings paired with relevant pertinent documentation are crucial to a successful restorative program Needs a strong partnership and communication between Skilled therapy and Restorative Nursing

Master Clinician - Gerontology Lisa Crowell MPT In partnership with Genesis Rehab Services Ravi Hunjan OTR/L Master Clinician - Gerontology Lisa Crowell MPT Clinical operations Area Director Kendra Coco MPT, NHA, RAC-CT Director of Clinical Reimbursement