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

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

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

4. 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!! About the Campaign (www.nhqualitycampaign.org) 4

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

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 8

9. 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. 9

10. 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. 10

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

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. 12

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 13

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 14

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 15

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! 16

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 17

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

19. Polling Question Where are you on the mobility scale? Physical restraints Restraint free Alarms  Alarms Antipsychotics (AP)  AP’s 12 3 4 5 6 7 8 9 10 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 20

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) 21

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 22

23. AE I NCREASE R ESIDENT M OBILITY W EBSITE R ESOURCES & T RACKING T OOL Adrienne Mihelic, Ph.D.

24. P lan P lan D o S tudy A ct 24

25. Explore the Goal www.nhqualitycampaign.org 25

26. 26 www.nhqualitycampaign.org

27. Why choose mobility? 27 www.nhqualitycampaign.org

28. D o P lan D o S tudy A ct 28

29. 29 Where am I? www.nhqualitycampaign.org

30. S tudy P lan D o S tudy A ct 30

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

32. 32 Examine Processes www.nhqualitycampaign.org

33. A ct P lan D o S tudy A ct 33

34. 34 Improve www.nhqualitycampaign.org http://www.nhqualityc ampaign.org/star_inde x.aspx?controls=Mobili tyImprove

35. 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? 36

37. QA and PI Quality AssurancePerformance Improvement ReactiveProactive Episode or event-basedAggregate data & patterns Prevent recurrenceOptimize process Sometime anecdotalAlways measurable RetrospectiveConcurrent Audit-based monitoringContinuous monitoring What went wrong?How can we be excellent?

38. 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 the system level Tracking Tools Support both QA and PI

39. The Tracking Tool AE_MobilityTrackingTool.xls 39 www.NHQualityCampaign.org

40. Thank you pilot testers!

41. Step 1: Monthly mobility assessment on every resident you are tracking. 8 items.

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