1. The AE Goal to Increase Resident Mobility
Advancing Excellence in
America’s Nursing Homes
Keep Moving!!
The AE Goal to Increase Resident Mobility

2. Karen Tritz Acting Director, Division of Nursing Homes OCSQ
A Word from CMS
Karen Tritz
Acting Director, Division of Nursing Homes
OCSQ

3. Mobility Goal Work-group Chair: Mary Jane Koren, M.D., MPH
Overview
Mobility Goal Work-group Chair:
Mary Jane Koren, M.D., MPH

4. It’s National, Voluntary, Aligned, and Free
About the Campaign (
It’s National, Voluntary, Aligned, and Free
Registrant:
 Register/Update Profile
Select Goals (at least 2 – 1 organizational & 1 clinical)
Work hard to improve performance!
Take it up a notch - be an Active Participant!!
All of the above PLUS
Submit Data so you can compare your results to others (see QAPI element 3: “review findings against benchmarks”)
Get credit: be recognized as a participant!!

5. Quality Improvement Resources for NINE Goals
Mobility
Person-Centered
Care
Consistent
Assignment
Infections
C. difficile
Pressure Ulcers
Staff Stability
Medications
Antipsychotics
Hospitalizations
Pain Management

6. Thank you to the entire workgroup
Mary Jane Koren, M.D., M.P.H.
Jo A. Taylor, R.N., M.P.H.
Mary Tinetti, M.D.
Jennifer Brach, PT, Ph.D.
Kris Mattivi, M.S., P.T.
Lisa Bridwell
Linda Sue Davis, R.N. M.S.N.
Lorraine Hiatt, Ph.D.
Melanie McNeil
Urvi Shah, M.P.H.
Adrienne Mihelic, Ph.D.
Carol Scott
Elaine McMahon, M.S., R.N.
Tammy Rolfe, R.N., L.N.H.A., M.S., H.P.M. 
Carol Benner, Sc.M.
Ruta Kadonoff
Chris Condeelis

7. Understanding “Why Mobility?”
Jo A. Taylor, R.N., M.P.H.
Carolinas Center for Medical Excellence

8. Two Models Poor Clinical Outcomes Falls Restraints Pressure ulcers
Urinary tract infections
Pain
Dehydration
Poor nutrition
Delirium
Medical Model
Quality of Care and Resident Life
Quality relationships
Workforce stability
Consistent assignment
Effective leadership
Teamwork
Critical thinking
Real time problem solving
Individualized care strategies
Person Centered Care Model

9. In a person centered care model, mobility moves out ahead.
Two Models
In a medical model, fall prevention makes the most sense, at any cost.
In a person centered care model, mobility moves out ahead.

10. fundamental strategies of person centered care
Individualized Care
Practical management of the resident’s fall risk
post fall investigation
interdisciplinary root cause analysis
individualized interventions for identified risk factors
fundamental strategies of person centered care
The Mobility Goal contains information to implement a practical falls management program.

11. Mobility
One of the best ways to reduce the seriousness of falls is to preserve and enhance resident mobility.

12. What is mobility?
Mobility means being able to move your own body or having someone help you move from place to place.
Mobility is not just walking. It is about strength, flexibility, balance and staying power.
It 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 the nursing home.

13. Why is mobility important?
For residents maintaining or improving mobility
Strengthens muscles and bones
Improves appetite
Gives a sense of confidence and well-being, which improves mood
Reduces serious falls
Improves sleep and energy level
Makes it easier for residents to socialize and participate in group activities

14. Why is mobility important?
For staff, helping to keep a resident mobile
Facilitates self-care so residents can do more for themselves
Makes transfers easier and safer for staff as well as residents
Promotes safer walking, fewer serious falls
Enables residents to access toilets more quickly and easily to promote continence

15. How will mobility be measured?
Uses 2 new composite measures constructed from MDS-3 items
% of Residents with Improvement in Personal Movement
looks at how independently an individual can move in bed, transfer, or walk in their room and corridor. It is the individual who is “responsible” for, or carries out, the movement.
% of Residents with Improvement in Life Space Mobility
considers area within the entire NH through which an individual moves during a set period of time. Movement can be independent or assisted by another person or device (such as a w/c). Greater life-space mobility would theoretically relate to greater involvement in life situations or greater participation in social activities

16. What happened to physical restraints?
Why were residents being restrained?
To control “problem behaviors”
To prevent falls
What have we learned?
“Problem behaviors” are symptoms of unmet needs and most often can be managed with non-pharmacologic interventions and person centered care
Physical restraints do not eliminate falls – they can actually make falls more serious and have devastating consequences
The Mobility Goal contains information to continue to make nursing homes restraint free – it can be done!

17. Isn’t this goal really just for the therapy staff?
No, this is not just a job for therapists!!
Keeping residents as physically functional and independent as possible is:
Everybody’s job – aides, nurses, dietary, housekeeping, administration … the whole team
As important a part of routine daily care as skin care or vital signs
As much about the environment as it is about care

18. This diagram is courtesy of Dr
This diagram is courtesy of Dr. Lorraine Hiatt, a member of the Mobility work group

19. Where are you on the mobility scale?
Polling Question
Where are you on the mobility scale?
Physical restraints Restraint free
Alarms  Alarms
Antipsychotics (AP)  AP’s
Schedule focus Resident focus
Little time/staff for ambulation Staff encourage self care & movement
Role of therapy Frontline staff monitor resident mobility
Limited areas for walking Exercise activities
W/C seating all day Environment for mobility
Excess safety Walking and dining programs
Medical model Person Centered Model

20. QAPI Five Elements
Element 1: Design and Scope
Element 2: Governance and Leadership
Element 3: Feedback, Data Systems and Monitoring
Element 4: Performance Improvement Projects
Element 5: Systematic Analysis and Systemic Action

21. What the workgroup developed or identified
Use the Mobility Goal “package” of resources to improve care and become QAPI compliant
AE’s Circle of Success – PDSA change framework for systematic performance analysis leading to systemic action (QAPI Element 5)
Data measurement & tracking tools (QAPI Elements 3, 4 and 5)
Root cause analysis tools – called “Probing Questions” (QAPI Element 5)
Consumer, staff, and leadership fact sheets (QAPI Element 2)

22. Mobility Resource Package
Evidence-based or field tested educational materials and clinical practice tools (QAPI Element 1)
Walking programs
Dining programs
Exercise programs
Environmental design
Bed mobility
Transfer
Wheelchair seating & mobility
Balance, endurance, strength
Restraint reduction
Falls management

23. AE Increase Resident Mobility Website Resources & Tracking Tool May 30, 2013
Adrienne Mihelic, Ph.D.

24. PlanDoStudyAct

25. Explore the Goal www.nhqualitycampaign.org

27. Why choose mobility?

28. PlanDoStudyAct

29. Where am I? www.nhqualitycampaign.org

30. PlanDoStudyAct

31. Study www.nhqualitycampaign.org Examine Processes Probing Questions

32. Examine Processes www.nhqualitycampaign.org

33. PlanDoStudyAct

34. Improve www.nhqualitycampaign.org

35. Engage www.nhqualitycampaign.org

36. Data and the Quality Improvement Process
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?

37. 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

38. Tracking Tools Support both QA and PI
Easy view of individual records allows resident-level RCA of events
Matrix of individual data allows scanning for patterns
Summary information helps identify opportunities to improve communication and optimize processes at the system level

39. The Tracking Tool AE_MobilityTrackingTool.xls

40. Come fly with us?
Pilot testers needed for the new AE Mobility Tracking Tool
May 30 through June 13
Enter data on 15+ residents for 2 months (2 times for each resident)
Provide feedback on what’s working well, what needs to be improved, what will make the tool the best it can be
Send us your completed, de-identified tracking tool
contact:

41. Thank You For making our nursing homes better places to live, work, and visit!