Ray Miller 8/18/2017 Direct Supply 1 By Ray Miller, MSOSH, Dir. of Risk and Safety, Direct Supply®, in a collaborative effort With Liz Jensen, RNA MSN, RN-BC Clinical Director, Direct Supply®, Inc. 2 Disclaimer The materials, comments and other information contained in this presentation are intended to provide general information but not advice about certain regulations and initiatives. This information is not and not intended as legal or other advice and each situation may vary depending on the particular facts and circumstances. You should not act upon this information without first consulting with qualified legal counsel. Thank You.
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Disclaimer - OHCA 2... · AHCA/NCAL 2001 “National ... 25% per CDC National Survey of Residential Care Facilities (2010) ... Reducing adverse medication events
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Transcript
Ray Miller 8/18/2017
Direct Supply 1
Liz Jen
sen
, R
N, M
SN
, R
N-B
C
Clin
ical D
irecto
r, D
irect Su
pp
ly®
, In
c.
By Ray Miller, MSOSH, Dir. of Risk and Safety,
Direct Supply®, in a collaborative effort
With Liz Jensen, RNA MSN, RN-BC
Clinical Director, Direct Supply®, Inc.
2 2
Disclaimer
The materials, comments and other information
contained in this presentation are intended to provide
general information but not advice about certain
regulations and initiatives.
This information is not and not intended as legal or
other advice and each situation may vary depending
on the particular facts and circumstances.
You should not act upon this information without first
consulting with qualified legal counsel.
Thank You.
Ray Miller 8/18/2017
Direct Supply 2
3 3
Today’s Focus
• Aging (in AL is not new—what’s changed?)
• Frameworks
• Trends (Programs, Building Clinical Capacity and Services)
• Resources
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Here’s what we’ve been told …
Seeking to Answer
“How can I improve the health and well being of my residents?”
• “We are concerned about residents with ______________”
• “Residents move in and quickly need an increased level of
care …”
• “We need to differentiate ourselves from our competitors”
• “Our acuity continues to rise … HELP!”
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What do YOUR Goals look like?
• “Meet the day-to-day needs of my residents”
• “Reduce the frequency of residents moving out”
• “Meet a specific need (memory care …) in my community”
• “I have insurance companies that want us to provide more
services to keep residents from going to the hospital”
• “Improve the health and wellness of my residents so they can
live in our community as long as possible”
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Self-Check: Where are you?
“There is the expectation that we’ll do everything for them…
it’s part of our hospitality commitment”
Or “We are here to be your partner in helping you
live your life and stay healthy.”
At 65 years of age, this where I find myself:
“Everything you do for me you take from me!
“Help me to do it alone!”
Maria Montessori
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Aging in AL is not new…What’s changed?
“Facts & Trends: The Assisted Living Sourcebook”. AHCA/NCAL 2001
“National Survey of Residential Care Facilities”. Centers for Disease Control and Prevention, 2010.
Av. Mon.
in AL
87 2010
80 2001
36 2001
22 2010
735,000 2010
416,768 1998
Moving
into AL
Average age
8 8
Aging in AL is not new…What’s changed?
“Facts & Trends: The Assisted Living Sourcebook”. AHCA/NCAL 2001
“National Survey of Residential Care Facilities”. Centers for Disease Control and Prevention, 2010.
Then
Now
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Assisted Living Residents today…
“Facts & Trends: The Assisted Living Sourcebook”. AHCA/NCAL 2001
“National Survey of Residential Care Facilities”. Centers for Disease Control and Prevention, 2010
Administration on Aging, “Fall Prevention Programs”: http://bit.ly/1zBTba8
70% Female
42% have Alzheimer’s or dementia
Need help with 2-3 ADLs
Have 2-3 chronic conditions such as
• Heart disease, CHF
• Hypertension
• Depression
• Arthritis
• Diabetes
• Osteoporosis
• Cancer
• COPD
• Stroke
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Risks increase for residents 80 & older
American Heart Association, 2015
Administration on Aging, “Fall Prevention Programs”: http://bit.ly/1zBTba8
Adults 85 and older are almost 4x more likely to fall than adults 65-75
CDC; Department of Health & Human Services; National Institute for Occupational Safety & Health: Safe Lifting and
Movement of Nursing Home Residents. (2006)
OSHA Safe Patient Handling Programs (2013)
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Define, Clarify, Track
1. Understand the role of your AL in the health care continuum.
2. Define what you are able AND willing to provide.
3. Focus on improving in the following areas:
Chronic disease management / heart failure and heart disease
Reducing adverse medication events
Staff competencies & capabilities
Engaging residents and families
Services post-op hip/knee
Preventing infections
Addressing frailty
Reducing fall risk
TRACK
OUTCOMES
(worth repeating)
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Self Check:
What does rising acuity impact?
Attracting and retaining staff?
Regulatory citations?
Risk / Litigation?
Occupancy?
…
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FRAMEWORKS
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Keeping in Mind--the Nursing Care Dilemma in AL
• Assisted Living Regulations
Varies by state
Limits on “skilled care”, care delivered by nurses
Often limits ability of nurses to practice at “Top of License”
• Nurse Practice Act
Understanding how to practice at “Top of License”
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Adapting existing models
• Population Health
• Naylor’s Transitional Care Model
• Community Health Nursing Model
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Population Health
What is population health?
Health outcomes for a group of individuals
How are health outcomes defined in Assisted Living?
Health-related and Quality of Life
(No real standard definitions)
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Naylor’s* “Transitions of Care Model”
Hirschman, K., Shaid, E., McCauley, K., Pauly, M., Naylor, M., (September 30, 2015) "Continuity of Care: The Transitional Care Model" OJIN: The Online Journal of Issues in Nursing Vol. 20, No. 3, Manuscript 1.
1. Screening
2. Staffing
3. Maintaining Relationships
4. Engaging Patients & Caregivers
5. Collaborating
6. Assessing / Managing Risks &
Symptoms
7. Educating/Promoting Self-
Management
8. Promoting Continuity
9. Fostering Coordination
Mary D. Naylor, PhD, RN, FAAN 1] Architect of the Transitional Care Model
2] Marian S. Ware Professor of Gerontology at the Univ. of PA. School of
Nursing, Philadelphia 3] Dir. of the New Courtland Center for Transitions and
Health at the Univ. of PA School of Nursing, Philadelphia, PA.
The Transitions of Care Model
encompasses a broad range of
services and environments
designed to promote the safe and
timely passage of patients
between levels of health care and
across care settings (Coleman &
Boult, 2003; Naylor, 2003).
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Resident &
AL Team
ADLs
Exercise
Therapy
Nutrition Med
Mgmt
Nursing Care
MD/NP
AL
Nurse
Level of Care / Care Coordination
Home Health
Nurse
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Ideas
Applying
principles of
“Community
Health Nursing”
A team
approach to
chronic disease
management
Tips for
reducing re-
hospitalization
Tips for
reducing risks
associated with
frailty
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Building on Assisted Living Philosophy
Social
Spiritual
Physical
Emotional
Intellectual
Occupational
Environmental
Wellness
Prevention & Monitoring
Medication Assistance
ADL Support
Health
Chronic Disease Management
Home Health Nursing
Physician / NP visits
Social Services
Pharmacy
Therapy
Dietitian
Community
Health Nursing
HOW?
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Elements of Community Health
US Dept. Health & Human Services and the National Center for Chronic Disease and Health Promotion; Dec. 2010.
Assisted Living Nursing: A Manual for Management and Practice edited by Dr. Ethel Mitty, EdD, RN, Dr. Barbara Resnick, PhD, CRNP, FAAN, Sandra Flores, RN
• Optimizing function -- Self-
care assistance and
support
• Decision making capacity
• Medication Management
• Service/Care Planning
• Health promotion
• Assessments
“Help me to do it alone!” Maria Montessori
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Individual Care / Heart Failure
Define, Understand, Educate (Resident & Staff):
□ Exacerbation: Causes & Symptoms
□ Care Considerations & Monitoring
□ Engagement & Exercise
□ Nutrition & Fluid Intake
□ Advance Directives
□ Medications
REALITY:
A resident with
HF is at high risk
for a decline in
health
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Exercise Is Important
Heart Failure Management in Skilled Nursing Facilities A Scientific Statement From the American Heart Association and the Heart Failure Society of America; Journal of Cardiac Failure
Vol. 21 No. 4 2015
IF heart failure, THEN aerobic exercise & resistance training (recommended)
□ Aerobic Exercise
Walking, exercise classes, recumbent cycling
Light to moderate activity
□ Resistance Training
Low intensity, high-repetition
4-6 exercises of major muscle groups, 1-2 sets each, 2 times per week
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Team Approach / Example Heart Failure
CHF Self AL Nurse MD/NP HH Nurse Rehab Pharm
BP X X X X X
HR X X X X
O2 sat X X X X
Wt X X X X
Meds X X X X X
Labs X X
Nutrition X X X
Exercise X X X X
Education X X X X X X
Consider defining who is involved in resident’s care. Review with resident and family
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Resident Education
• Medications—identification,
purpose, side effects
• Signs and symptoms
• Weight
• Diet changes
• Exercise
• Follow up appointments
• Staying well—immunizations,
alcohol intake, smoking cessation
“Help me to do it alone!” Maria Montessori
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Ideas
Tips for
reducing risks
associated with
frailty
Applying
principles of
“Community
Health Nursing”
A team
approach to
chronic disease
management
Tips for
reducing re-
hospitalization
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Care Models & Expanded Services – What we’ve seen
EXPAND:
• MD & NP Partnerships (On-site clinic hours; Home visits)
• Nursing staff (Hours; Expertise)
• Therapy services
OFFER:
• Social Service support
• Expanded Dietitians services
ENGAGE: Pharmacist Consultants
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Clinical Competencies / Capabilities – Focus Areas
Knowledge Skill Ability/Attitude
• Community Health
Nursing
• Gerontological Care
• Risk Management
• Care Coordination
• Geriatric Nursing
Assessment
• Clinical / Technical
• Documentation
• Communication
• Delegation
• Education & Training
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Ideas for Improving Competencies – How To Focus
Knowledge
• Gero Nurse Preparation Course http://app1.unmc.edu/geronurseprep/
• Hartford Institute for Geriatric Nursing http://www.hartfordign.org/ (free)
A “New” Discussion -- Assist Devices in Assisted Living
Readiness Assessment
1. Residents
2. Equipment
3. Culture
4. Management Engagement
5. Program Policy & Procedure
Successful Implementation
1. Mentors
2. Hands-on Training
3. R & S & M Buy--in
4. Sustained Change
5. Safety Committee monitors & modifies
S
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Applying ADLs to Equipment Selection (Assessment)
Category 4: Total Dependent:
□ Floor Lift
Category 3: Moderate / Extensive / Maximum Assist:
□ Sit-to-Stand Assist
□ Floor Lift
Category 2: Minimum Assist:
□ Non-powered assist devices
□ Sit-to-stand Assist
Category 1: Limited Assist
Category 0: Independent
Applying ADLs to Equipment Selection
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CODE 4: Total Dependence
Full staff performance every time
CODE 3: Extensive Assistance
Resident involved in activity, staff
provide weight-bearing support
CODE 2: Limited Assistance
Resident highly involved in activity,
staff provide guided maneuvering of
limbs or other non-weight-bearing
support
CODE 0: Independent
No help or staff oversight at any time
This document is intended to provide general information but not advice about regulations and initiatives. This information is not and not intended as legal or other advice, and each situation may vary depending on the particular facts and circumstances. You should not
act upon this information without first consulting with qualified legal counsel.