1. Four Part CMS Satellite Broadcast From Institutional to Individualized Care 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 Part 1 Integrating Individualized Care and Quality Improvement

2. Quality Partners of Rhode Island 2 CMS Satellite Broadcast Series: From Institutional to Individualized Care Today: Integrating individualized Care with Quality Improvement Part 2, Feb. 2007: Transforming Systems to Achieve Better Clinical Outcomes Part 3, April 2007: Clinical Case Studies in Culture Change Case Examples Part 4, Fall 2007: The How of Change

3. Quality Partners of Rhode Island 3 Goals: To help surveyors, providers, and consumers understand how individualized care is the basis for good care To provide examples from providers who have changed their systems to support individualized care, and have seen better care outcomes as a result

4. Quality Partners of Rhode Island 4 Quality Improvement Practices: Root cause analysis of clinical concerns Pilot tests of new practices Evaluation of their impact Mid-course adjustments Spread of good practices

5. Quality Partners of Rhode Island 5 § 483.25 Quality of care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental,and psychosocial well-being, in accordance with the comprehensive assessment and plan of care.

6. Quality Partners of Rhode Island 6 Practicable vs. Practical Innate capability – based solely on the individual’s abilities, limitations, and potential – independent of external limitations Capability based on resources available to support a person’s abilities and potential, and to address their limitations

7. § 483.25 Quality of care “ A resident’s abilities … do not diminish unless circumstances of the individual’s clinical condition demonstrate that diminution is unavoidable”

8. Iatrogenesis = We caused it Greek Origins: Iatro = of or by a physician Genesis = beginning

9. Quality Partners of Rhode Island 9 Culture Change Journey Institutionalized Care Task Oriented Depersonalized Fragmented Schedule-driven One size fits all Individualized Care Care systems and daily routine focus on needs, interests, life- style, preferences, choices, and abilities and strengths of resident

10. Quality Partners of Rhode Island 10 Institutional Care Individualized Care Risk Prevention Health Promotion Old Practice New Practice

11. Your Systems are Creating Your Outcomes What you’re doing is getting you what you’re getting. To get something different, you have to do something different.

12. Quality Partners of Rhode Island 12 Science of Change: Root-cause analysis Small pilot-tests Evaluation and Re-evaluation Mid-course adjustments Evidence-based solutions Collaborative Learning, Spread

13. Quality Partners of Rhode Island 13 Psychology of Change: Build on Intrinsic Motivation Holistic Approach - Personalize Start where people are Build capacity for change Experiential learning Climate Where Truth is Heard

14. Quality Partners of Rhode Island 14

15. Quality Partners of Rhode Island 15 Home: A strong, intimate, fluid relationship between the individual and their environment Judith Carboni 1987

16. Quality Partners of Rhode Island 16 Home Identity Connectedness Lived Space Privacy Power/Autonomy Safety Predictability Journeying Judith Carboni, 1987

17. Quality Partners of Rhode Island 17 Homelessness The predominate state that occurs when an individual’s relationship with the environment has been severely damaged

18. Quality Partners of Rhode Island 18 Homelessness Non-Personhood Disconnectedness Meaningless Space Without boundaries Powerless/Dependence Insecurity/Uncertainty Placelessness Judith Carboni, 1987

19. Quality Partners of Rhode Island 19 Home – Homelessness Continuum Relationship of Person to Environment HOME Strong, intimate, fluid Weakened, impaired Damaged HOMELESS NESS Severely damaged Judith T. Carboni, 1987

20. Homelessness Severely damaged and tenuous relationship between person and environment

21. Home Strong, intimate, fluid relationship with the environment

22. Quality Partners of Rhode Island 22 Institutional Care Individualized Care HomelessHome

23. Quality Partners of Rhode Island 23 Institutional Care Individualized Care Risk Prevention Health Promotion

24. Quality Partners of Rhode Island 24 Institutional Care Individualized Care Risk Prevention Health Promotion Old Practice New Practice

25. Case Study: Nursing Home Alarm Elimination Program – It’s Possible to Reduce Falls by Eliminating Resident Alarms www.masspro.org/NH/casestudies.php

26. Quality Partners of Rhode Island 26 Way of Inquiry IrritantCatalystAwakening Hope vs. Despair ActionImmobilization

27. Quality Partners of Rhode Island 27 Phase 1: Irritants We come to accept it even though it doesn’t feel quite right. We rationalize why it should be so and the reasons why it can not change. Example: Reality Orientation

28. Quality Partners of Rhode Island 28 Phase 2: Catalyst Causes us to begin to ask why Alerts us to new possibilities Example: Hearing a success story from others in an article or at a conference

29. Quality Partners of Rhode Island 29 Phase 3: Awakening We can no longer ignore the need to change the irritant. Dawn of hope.

30. Quality Partners of Rhode Island 30 Hope Gives rise to growth, action, & our greatest humanity vs. Despair Produces resignation & surrender

31. Hope If we choose hope, we unleash our energy to take action to bring about change. We find ourselves putting our energy into finding out what to do and how to do it. We grow in the process.

32. Despair If we go the route of despair, we feel resigned to how things are and surrender any hope of changing them. We are immobilized and continue on our current course.

33. Quality Partners of Rhode Island 33 The How of Change Personalize the situation: How would you need it to be if you lived or worked here? Compare what you would need to what is currently happening Bring people together to figure out how to make changes. Pilot changes

34. Quality Partners of Rhode Island 34 Risk Prevention Health Promotion Individualized Care Institutional Care Old Practice New Practice! Action!

35. Quality Partners of Rhode Island 35 Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.