From Institutional to Individualized Care Part 2: Transforming Systems to Achieve Better Clinical Outcomes

1. From InstitutionaltoIndividualized CarePart 2:Transforming Systems toAchieve Better Clinical Outcomes 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

2. 483.15 The Quality of Life (a) Dignity “The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality.”

3. 483.15 (b) Self-determination The resident has the right to: • Choose activities, schedules and health care consistent with his or her interests, assess-ments and plans of care…. and

4. 483.15 (b) Self-determination The resident has the right to: (3) Make choices about aspects of his or her life that are significant to the resident.

5. Honoring each individual’s choices, desires and unique needs Individualized pace leads to better care With a good night’s sleep and a good morning, you feel better all day Organizing services around residents’ norms helps with clinical interventions “De-scheduling”

6. Just going by the resident’s schedule has resulted in better sleep, nutrition, moods, and other outcomes. homes have been able to catch clinical problems sooner, while they are still at an early stage they have a wider array of ways to treat clinical concerns Clinical Benefits:

7. Pilot: Integrating Individualized Care with Quality Improvement

8. Individualized Care is Better Care Individualized Care creates a Greater Capacity to Respond to Clinical Needs Premises

9. Section 1: Practitioner Experiences in Transforming Care Delivery Systems Section 2: How Individualized Systems Increase Your Capability to Meet Clinical Needs Section 3: Making it Happen: Barriers and Strategies Sections

10. Part 1: Integrating Individualized Care and Quality Improvement, aired Nov. 3, 2006 Part 2: Transforming Systems to Achieve Better Clinical Outcomes, May 4, 2007 Part 3: Clinical Case Studies in Culture Change, airs May 18, 2007 Part 4: The How of Change, Sept. 2007 From Institutional toIndividualized Care

11. to achieve better clinical outcomes through individualized care; an individualized approach broadens the options to meet residents’ clinical needs; and consistent assignment and participatory management are key Our goal is to demonstrate how:

12. Individualizedcare@riqio.sdps.org

13. Section 1 Transforming Care Delivery Systems

14. Government & Regulations Family Leadership Community HOLISTIC APPROACH TO TRANSFORMATIONAL CHANGE (HATCH)

15. Health Promotion New Practice! Action! Action! Institutional Care Individualized Care Action! Action! Old Practice Risk Prevention

16. Definition of Home: a fluid and dynamic, intimate relationship between the individual and the environment Judith Carboni, 1987

17. Definition of Homelessness the negation of home, where the relationship between the individual and the environment loses its intimacy and becomes severely damaged. Judith Carboni, 1987

18. Home – Homelessness Continuum HOMELESSNESS Severely damaged and tenuous relationship between person and environment HOME Strong, intimate, fluid relationship with the environment Weakened, impaired relationship between individual and environment Damaged relationship between person and environment Judith T. Carboni, 1987

19. Consistent Assignment Participatory Management -- involving staff in deciding how to go forward Common Themes

20. A Good Night’s Sleep

21. Turning on lights, physically checking for incontinence and probably talking too loud Contributed to residents then attempting to get up Generating falls Interrupting Sleep Every Two Hours

22. the care planning process through which we determined each resident’s individual patterns a personal understanding where we talked about how none of us would want to be disturbed while sleeping Two tracks

23. Conducted a bladder assessment for each resident Night shift documented the patterns for each resident during the night Looked at their sleep-awake times and incontinence. Dedicated staff assignments, which enhanced the resident-specific knowledge of the staff How we did it

24. Toileting Plan for Each Resident normal waking, sleeping, and voiding patterns of each resident so that the night staff could follow their patterns and do individualized rounds.

25. to maximize bladder care to maximize sleep Goals

26. By moving to consistent assignment your staff know your residents better and can individualize care. by changing your systems for meal service you’re able to provide breakfast when people wake up individualized bladder assessments Summary

27. Instead of waking people all night long, your staff are tending to residents when they need care and making sure they are able to sleep the rest of the time.

28. talking things through addressing people’s concerns, then putting systems in practice to support individualized care. Leadership Process

29. Glenridge video“Culture Change in Long-Term Care:A Case Study”Produced by the American Health Quality Association Available through the National Technical Information Services

30. You know when people need to go to the bathroom. You don’t have people trying to get out of bed unassisted because they have to go. Now staff are aware of each resident’s voiding patterns and we’re able to get to the residents before they might try to get out of bed on their own. Fewer Falls: Individualize bladder care

31. why they are trying to get out of bed, and we try to anticipate their individual needs which residents might be hungry when so we are there when they normally start to awaken and are ready to guide them to where they can eat Fewer Falls: Know Each Resident

32. Fall Prevention at Night Understanding a resident’s needs and patterns and being alert to meeting their needs.

33. Spontaneity Knowing residents and relating to them individually

34. Disturbing people Creating Agitation Disrupting Sleep Creating Anxiety Startling Residents Alarms at Night

35. When you individualize care, you minimize the need for alarms

36. Mornings

37. Suppositories

38. Because of the changes, the resident's in the facility have had better outcomes. When you have residents who are sleeping better and eating better and feeling better, you naturally have positive outcomes. The survey findings reflect that. Surveys

39. Food service

44. People who didn’t communicate before are communicating now. The pace has changed. You’ve slowed down so now you’re at the resident’s pace. By changing how you deliver the food, you’ve changed how people are able to eat it and enjoy it! Two Points

45. Section 2: How Individualized Systems Increase Your Capability to Meet Clinical Needs

46. Susan Wehry, Geriatric Psychiatrist

47. Can cause declines to residents’ physical functioning and muscle condition Can cause contractures, increased incidents of infections and development of pressure ulcers, delirium, agitation, and incontinence Physical Restraints: Serious Potential Negative Outcomes

48. Residents can experience loss of autonomy, dignity, and self-respect, and may show symptoms of withdrawal, depression, and reduced social contact Can reduce independence, functional capacity and quality of life Potential negative impact on residents’ psychosocial well-being

49. ‘what is the resident trying to tell me?’ rather than with “how can I get them to stop?’ The communication of a resident who screams or repeatedly calls out at night may be “I’m cold, afraid, in pain, confused, alone.” “Behaviors” Communicate a resident’s needs

50. By better understanding the resident’s behavior, staff can often anticipate needs or change the environment or their own behavior. By changing the environment, the challenging behavior often goes away. The restraint becomes unnecessary