advancing excellence in americas nursing homes keep moving!! the ae goal to increase resident...
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Overview Mobility Goal Work-group Chair: Mary Jane Koren, M.D., MPHTRANSCRIPT
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Advancing Excellence
inAmerica’s Nursing Homes
Keep Moving!! The AE Goal to Increase Resident
Mobility
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A Word from CMS
Karen TritzActing Director, Division of Nursing Homes
OCSQ
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Overview
Mobility Goal Work-group Chair: Mary Jane Koren, M.D., MPH
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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)
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MobilityPerson-
CenteredCare
ConsistentAssignment
InfectionsC. difficile
Pressure UlcersStaff Stability
MedicationsAntipsychotics
Hospitalizations
Pain Management
Quality Improvement Resources for NINE Goals
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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
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Understanding “Why Mobility?”
Jo A. Taylor, R.N., M.P.H.Carolinas Center for Medical Excellence
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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
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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.
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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.
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Mobility
One of the best ways to reduce the seriousness of falls is to preserve and enhance resident mobility.
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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.
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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
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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
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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
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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!
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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
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This diagram is courtesy of Dr. Lorraine Hiatt, a member of the Mobility work group
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Polling Question
Where are you on the mobility scale? Physical restraints Restraint freeAlarms AlarmsAntipsychotics (AP) AP’s
1 2 3 4 5 6 7 8 9 10Schedule focus Resident focusLittle time/staff for ambulation Staff encourage self care & movementRole of therapy Frontline staff monitor resident mobilityLimited areas for walking Exercise activities W/C seating all day Environment for mobilityExcess safety Walking and dining programs
Medical model Person Centered Model
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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
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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)
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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
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AE INCREASE RESIDENT MOBILITY WEBSITE RESOURCES & TRACKING TOOL
Adrienne Mihelic, Ph.D.
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PlanDoStudyAct
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Explore the Goalwww.nhqualitycampaign.org
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www.nhqualitycampaign.org
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Why choose mobility? www.nhqualitycampaign.org
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PlanDoStudyAct
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Where am I?www.nhqualitycampaign.org
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PlanDoStudyAct
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Studywww.nhqualitycampaign.org
www.nhqualitycampaign.org
Examine Processes
Probing Questions
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Examine Processeswww.nhqualitycampaign.org
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PlanDoStudyAct
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Improvewww.nhqualitycampaign.org
http://www.nhqualitycampaign.org/star_index.aspx?controls=MobilityImprove
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Engagewww.nhqualitycampaign.org
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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?
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QA and PI
Quality Assurance Performance Improvement
Reactive Proactive
Episode or event-based Aggregate data & patterns
Prevent recurrence Optimize process
Sometime anecdotal Always measurable
Retrospective Concurrent
Audit-based monitoring Continuous monitoring
What went wrong? How can we be excellent?
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• 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
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The Tracking Tool
AE_MobilityTrackingTool.xls
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www.NHQualityCampaign.org
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Thank you pilot testers!
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Step 1: Monthly mobility assessment on every resident you are tracking. 8 items.
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Thank You For making our nursing homes better places to live, work, and
visit!