Nursing Home Regulation Kathleen C. Buckwalter, PhD, RN, FAAN Professor of Nursing Emerita, and Co-Director, National Health Law & Policy Resource Center.

Nursing Home Regulation

Kathleen C. Buckwalter, PhD, RN, FAANProfessor of Nursing Emerita, and Co-Director, National

Health Law & Policy Resource Center

Elder Law ColloquiumThe Aging Population, Alzheimer’s and Other Dementias:

Law & Public Policy

University of Iowa College of LawApril 5, 2012

I. BACKGROUND

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Predictors of Institutionalization

Patient Factors

Behavior Problems

Increasing Cognitive Impairment

ADL Impairment

Physical Health Decline

Caregiver Factors

Burden

Physical Health

Effective approaches to enhance QOL should target some of these factors

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Percent of Nursing Home Residents with Cognitive Impairment/ Dementia

• In 2009, 68% of nursing home residents had some degree of cognitive impairment.

• In 2011, 47% of all nursing home residents had a dementia diagnosis in their nursing home record

Source: Alzheimer’s Association, 2012 Alzheimer’s Disease Facts and Figures (2012)

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Quality of Care (QOC)in Persons with Dementia (PWD)

“Providing consistently high quality of care in nursing homes to a variety of frail very old residents … requires that the functional, medical, social and psychological needs of residents be individually determined and met ….”

Institute of Medicine, Improving the Quality of Care in Nursing Homes (1986) at p. 10.

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Medicare/ MedicaidNursing Home Certification:

Quality of Care Requirements

General – Each resident shall receive and each facility shall provide necessary care and services “to attain or maintain the highest practicable physical, mental and psychological well-being” of a resident in accordance with the resident’s comprehensive assessment and plan of care.

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Medicare/ MedicaidNursing Home Certification:

Specific Quality of Care Requirements

• Activities of Daily Living• Vision and Hearing• Pressure Sores• Urinary Incontinence• Range of Motion• Mental and Psychosocial Functioning• Nutrition• Hydration• Nasogastric Tubes• Special Needs• Unnecessary Drugs and Antipsychotic Drugs• Medication Errors• Accidents

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Quality of Care RequirementsUnnecessary Drugs and Antipsychotic Drugs

The facility must ensure residents do not receive unnecessary drugs, defined as a drug use in excessive dosage, for excessive duration, without adequate indications in use, or with adverse consequences. Facilities must ensure residents are not started on antipsychotic drugs unless clinically necessary and that if a resident receives such drugs, efforts are made to discontinue their use.

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Quality of Life (QOL)in Personswith Dementia (PWD)

• Until recently, identifying positive outcomes to maximize QOL was neglected are of research

• View the person with AD as an object or problem to be managed vs. person with thoughts, desires, needs that require attention (Keane, 1994; Kitwood, 1997)

• Stripping of Personhood” (Lawton, 1994) vs. understanding Individual perspective and impact of disease on the individual

• PWD need adequate and continuing treatments in a stable, safe, stimulating environment (Weyer & Schaufele, 2003)

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Promoting emotional well being in persons with dementia (Burgener & Twigg, 2002)

• Relationships/social interactions/human contact vs “’ pulling away”

• Comfort/freedom from pain• Meaningful, pleasant

activities (Whitehouse & Rabins, 1992) –e.g. art, storytelling, TIMESLIPS

• Ability to communicate needs (Malott & McAiney, 1995

• Recognizing & supporting previous skills and positive behaviors (Buckwalter et al. 1996)

• Continued intimacy with family (Parse, 1996)

• Need for “normalcy, sense of continuity and personal control”

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Indicators of Well-Being in People with Dementia (Kitwood & Bredin, 1992)

• Assertion of desire or will

• Ability to express a range of + and – emotions

• Initiation of social contact

• Social security• Self-respect

• Acceptance of other people with dementia (instit setting)

• Humor• Creativity/Self

expression• Showing pleasure• Helpfulness• Relaxation

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QOL for Care Recipient influenced by Caregiver factors (Burgener & Twigg, 2002)

• Relationship between CG factors and CR QOL outcomes- beyond that accounted for by changes in mental ability

• Role stress• Quality of CG/CR relationship• Facilitation of social contacts and activity

participation by CG

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II. SPECIAL CARE UNITS

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Driving Forcesfor Segregated Units

better care fordementia victims

non-dementia residents prefer separate space2

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Should demented be segregated?

Reduce level & complexity of stimuliProtect the nondementedFocus programmingStaff believe care is betterSome evidence of improved outcomes

YES

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When Lucid and DementedElders are Housed Together

Problems for Lucid Elders:

Invasion of privacyLost or damaged personal propertyDecreased socialization as resident attempts to avoid

encounters with the confusedInterrupted sleepFear of physical harm from the agitated resident

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When Lucid and Demented Elders are Housed Together

Problems for Demented Elders:

Tranquilizing medication causes decreased mobility, loss of appetite, and dependence in activities of daily living

Exclusion from traditional planned activities and subsequent decreased socialization

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When Lucid and DementedElders are Housed Together

Problems for Demented Elders:

Negative feedback from caregivers and other residentsIncreased fear and agitation leading to the use of soft-

tie restraintsNegative family response to the use of restraints,

possible decreased visiting

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What makes Special Units Special?

“It Depends.”

Special

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What is a Special Unit?

No Standard Definition

No Uniform Terminology

No Standardized Criteria

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SCU…………………………..

“a distinct part of a health care facility which is clearly identifiable, containing contiguous rooms in a separate wing or building or on a separate floor of the facility, and for which a special program of care has been approved.” (ADRDA Unit Rules Committee, 1988)

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Five Characteristics of “Special” Units

1) Staff selection and training2) Activity programming3) Family programming4) Physical environment and decor, including

separation5) Admission criteria

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Special vs. Segregated

7 dimensions of care (AAHA)Commitment

PhilosophyTherapeutic carePhysical design

StaffCommunication

Research and education

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Management Modalitiesfor SCUs

THERAPEUTIC PROGRAMS

Approaches and activities appropriate for resident cognitive and functional status

Focus on resident strengths and familiar activities, such as religious, cultural, ethnic rituals

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Management Modalitiesfor SCUs

THERAPEUTIC PROGRAMS

Group occupational, physical, and activity therapy programs, such as cooking, gardening, dancing, exercise, and sensory stimulation

One-on-one activities, such as ball throwing, review of photo albums, and hand massage

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Management Modalitiesfor SCUs

INVOLVEMENT OF FAMILIES

Encouragement of family participation in activities and care

Provision of information and support groups

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Management Modalitiesfor SCUs

PHYSICAL ENVIRONMENTReduction of noxious stimuliProvision for safe wanderingAccess to outdoorsWayfinding cuesVisual, tactile, musical, and other sensory stimulation

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Management Modalities for SCUs

STAFF APPROACHES TO CARE

Individualized care planning and provisionA team approach to care with consistent staffingBehavior modificationMinimization of physical and pharmacologic restraintsEmphasis on patient dignity

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SCUs -- Legal and Public Policy Issues

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III. Atypical Antipsychotic Drugs

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Pharmacological Interventions

For mild-mod BPSD non-drug approaches 1st

Psychotropic meds (short term) for severe behaviorManic sxs: Mood stabilizers (anti-convulsants)Agitation/aggression: SSRIs, Mood stabilizers,

trazadonePsychotic sx/severe aggression (danger to self/others)

-- IM Haldol in crisis. Atypical AntipsychoticsDepressive sxs/anxiety: S SSRI antidepressants/benzos

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Meds, con’t

Adjust to non-pharm approachesSide Effects

Black box warningsOff-Label

Cognitive Enhancers (Chol. Inhibitors) Modest benefit(Donepezil, rivastigmine, galantamine,

memantine)

Non-Pharmacological Management of Behavioral and Psychological Symptoms of Dementia (BPSD): Best Practices

• Interventions– No “easy” answers– Complicated by changing clinical course

• Principles of Care:– Adjust daily routines– Change reaction and responses to behaviors– Monitor and adjust the environment, remove triggers– Adjust interaction and communication strategies Gould (2007)

Williams (2005)

(Ballard et al., 2009; Burgener & Twigg, 2002; Smith & Buckwalter, 2005)

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Cochrane Reviews and Protocols Selected for Nonpharmacological Interventions

These reviews and protocols can be found at:http://dementia.cochrane.org/

orhttp://dementia.cochrane.org/our-reviews Aroma therapy for dementiaCognition-based interventions for healthy older people and people with mild cognitive impairmentCognitive rehabilitation and cognitive training for early-stage Alzheimer's disease and vascular dementiaHomeopathy for dementiaInterventions for preventing and reducing the use of physical restraints in long-term geriatric careInterventions for preventing delirium in hospitalized patientsLight therapy for managing cognitive, sleep, functional, behavioral, or psychiatric disturbances in dementia

Massage and touch for dementiaMultidisciplinary team interventions for delirium in patients with chronic cognitive impairmentMusic therapy for people with dementia Non-pharmacological interventions for wandering of people with dementia in the domestic settingPhysical activity and enhanced fitness to improve cognitive function in older people without known cognitive impairment

Physical activity programs for persons with dementiaReality orientation for dementia

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Reviews (cont):

Reminiscence therapy for dementiaRespite care for people with dementia and their careersSnoezelen for dementiaSpecial care units for dementia individuals with behavioral problemsSubjective barriers to prevent wandering of cognitively impaired peopleSupport for careers of people with Alzheimer's type dementiaTranscutaneous Electrical Nerve Stimulation (TENS) for dementiaValidation therapy for dementia

Protocols:

Case/care management approaches to home support for people with dementiaCognitive and behavioural interventions for carers of people with dementiaCognitive stimulation to improve cognitive functioning in people with dementiaFunctional analysis-based interventions for challenging behaviour in dementiaInformation and support interventions for informal caregivers of people with dementiaMultidisciplinary Team Interventions for the management of delirium in hospitalized patientsPhysical activity for improving cognition in older people with mild cognitive impairmentPsychosocial interventions for reducing antipsychotic medication in care home residents

Cochrane Reviews and Protocols Selected for Nonpharmacological Interventions (cont)

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Misuse Atypical Antipsychotic Drugs Legal and Public Policy Issues

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IV. Culture change

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Culture Change Definitions

“Culture change, or a resident-centered approach, means an organization that has home or work environments in which:– care and all resident-related activities are decided

by resident;– living environment is designed to be home rather

than an institution;– close relationships exist between residents, family

members, staff, and community;”

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Culture Change Definitions, cont’d

– “work is organized to support and allow all staff to respond to residents’ needs and desires

– management allows collaborative and group decision –making;

– processes/measures are used for continuous quality improvement.”

Source: The Commonwealth Fund 2007 Survey of Nursing Homes

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Key Areas of Culture Change

– Establishing inclusive decision-making– Reinventing staff roles– De-Medicalizing the physical environment– Redesigning the organization– Creating new leadership practices

Source: California Healthcare Foundation, 2008

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Four Stages of Culture Change

Stage Features

1-Institutional Model

The traditional medical model is organized around a nursing unit without permanent staff assignment. Neither resident nor staff are empowered in this model. Staffing inconsistency limits relationship-building between staff and residents, and depresses job satisfaction.

2- Transformation Model

Awareness of the key elements of culture change is pushed throughout the organization via workshops and educational sessions for various departments and types of staff. Permanent staff assignments to units may be made to start the development of communities within the facility. Low-cost physical changes may be introduced, including new furniture, artwork, plants, carpeting, and higher-end finishes—such as crown molding.

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Four Stages of Culture Change, cont’d

Stage Features

3-Neighborhood Model

Traditional units are divided into smaller areas. Resident-centered dining may be adopted, eliminating full kitchens. Neighborhood coordinators are sometimes introduced and unique names and physical attributes are developed for each neighborhood.

4-Household Model

Self-contained living areas have up to 25 residents. Typically, each household has its own kitchen, living area, and dining area. Staff are self-directed teams who perform a variety of functions. Household management is a collaborative process that places resident preferences first, followed by staff and household capacities.

Source: Grant, L., Norton, L. (November 2003) A Stage Model of Culture Change in Nursing Home Facilities.Presented at the 56th Annual Scientific Meeting of the Gerontological Society of America.

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