This is the second of a two-part series related to challenging perceptions about alternatives to chemical restraints in the long term care setting for residents with Alzheimer’s or other causes of dementia.
Below are recommendations that afford the opportunity to use alternatives to chemical restraints with this unique population.
1. Approach is everything...make the resident your focus, determine what he/she likes as a reward.
2. Build rapport; help resident to recognize you as a person who is friendly and supportive.
3. Modify the environment- eliminate distractions to increase focus, know the residents personal, cultural history.
4. Work closely with staff; know what works, and what doesn't.
5. Use multi-sensory cues.
6. Use positive statements and praise for efforts leading to completion of task.
7. Do not use terms of endearment; honey, sweetie, sugar, or dear.
8. Problem solve with caregivers to find effective strategies.
9. Use non-threatening body language.
10. Use calm, audible voice, use one step requests, avoid giving too much information, don't ask yes or no questions...the answer most of the time will be "no".
11. Realize your thoughts are real, and automatic negative thoughts - ANT's - don't always tell the truth.
12. Train your thoughts to be positive and hopeful.
13. Replace the negative with the positive.
14. Psychotropic medications are among the most frequently prescribed agents for elderly nursing home residents.
15. Older people, and people suffering from a dementing illness are susceptible to overmedication and negative reactions from a combination of drugs.
16. To get the needed results, doctors can't always eliminate the side effects. You and your doctor must work closely to achieve a balance.
17. Ask what side effects to watch out for, and communicate what you see.
18. The focus should be to eliminate the underlying cause of the behavior rather than medicate the behavior.
19. In cases where medication cannot be eliminated, the focus should be to; maximize the resident’s potential and wellbeing, and minimize the hazards associated with medication side effects.
20. Increase understanding of non-medication treatment, and approach strategies.
21. Change the approach, redefine the problem, if the behavior doesn't cause harm, don't medicate the behavior.
22. Ask yourself, "What's my goal," this is to improve resident’s quality of life.
23. Ask resident "What is troubling you, and how can I help"... if you find you are getting impatient or angry, leave.
24. Remind caregivers they can make a difference.
25. Decide how to respond, rather than react, to the behavior., don't take behavior personally.
26. Be confident, yet flexible in your approach, avoid frustration and negativity.
27. Think safety first.
28. Staff training regarding antipsychotic medications is key to any efforts to reduce drug use in long term care.
29. Resident quality care improves with staff empowerment.
30. We can't change the person, so we have to change our approach.
"Antipsychotic medications pose a great risk for elderly residents, especially those with dementia. They can increase the risk of death in these residents and may put elders with dementia at greater risk for a stroke. They also have many negative side effects such as weight gain, agitation, sleepiness, gastrointestinal problems, dry mouth, worsening cognitive problems, and fatigue to name a few.
These drugs must help stabilize or improve the person's clinical outcomes, quality of life, and functional capacity. The FDA regulations indicate that these drugs cannot be used simply for behaviors of wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, unsociability, fidgeting, nervousness, uncooperative behavior, verbal outbursts, and behaviors that don't endanger the resident or others.
They should be used to treat an enduring condition only when target behaviors are clearly and specifically identified and monitor, and usage must be documented over time. The behavioral issues must be re-evaluated periodically to determine if medication dose reduction or discontinuation are viable options."
From July 2012 issue of Provider; The Troubling Role of Antipsychotics. Solving The Mystery, Providers are finding alternatives to antipsychotics by doing some old fashioned detective work. by Joanne Kaldy
This two part series will challenge perceptions about alternatives to chemical restraints in the long term care setting for residents with Alzheimer’s or other types of dementia.
There are four basic keys to utilizing alternatives to chemical restraints with this unique population. Understanding, Communication, Attitude, and Willingness. Each area needs to be addressed to achieve successful outcomes.
Understanding
Understanding, is critical: understanding the diagnosis that increases the potential for adverse, agitated, even combative behavior; understanding role delineation with nursing and therapy regarding chemical restraint reduction; understanding the triggers for the behavior; understanding that behavior is a form of communication often times resulting from an unmet need; understanding adverse behavior occurs when the demand on a person exceeds the person's ability at any given time; understanding the importance of resident centered approach strategies.
Communication
Communication can be the basis for implementing resident specific approach strategies. Communication is as important among direct care staff, nursing, dietary, therapy, physician, social services, and other departments, as it is with the resident and family members. Communication is effective when each member of the interdisciplinary treatment team has the opportunity to provide feedback throughout the entire day. This resident centered care approach empowers all staff to take ownership and share strategies to decrease the risk of adverse behavior.
Attitude
Attitudes can negatively, as well as positively, affect the work place. "When people look at the past, they feel regret. When they look at the future, they feel anxiety and pessimism. In the moment they're bound to find something unsatisfactory. They are suffering from automatic negative thoughts, ANTS, which are cynical, glooming, and complaining thoughts A "Can-do", positive attitude is critical to the success of any organization, effecting all departments.
Willingness
Willingness is the key to changing our understanding of resident specific triggers. Willingness is the key to always challenging, while striving to improve our understanding of residents entrusted to our care. Willingness helps to improve our communication with each other, with our residents, families. Willingness ties to ongoing staff training and trying new approaches including interdisciplinary treatment team regular weekly meetings. This treatment team may consist of the medical director, consultant, pharmacist, director of nursing, unit nurse manager, MDS nurse, social services and therapy representative.
The focus of this team is to review each dementia resident on antipsychotic medications to determine if the need still exists. Resident concerns and adverse drug reactions - negative side effects should be discussed, along with recommendations to reduce or discontinue the use of psychotropic drugs, while ensuring that each psychotropic drug used has a specific diagnosis linked to it.
While psychotropic medications can decrease the need for physical restraints, they aren't the only or necessarily the first treatment strategy. It is effective to incorporate intervention strategies including therapy, effective communication, environmental modifications to manage the behavior, instead of medicating the behavior to fit in the environment. Look to identify the cause of the behavior, first, and then determining how to proceed.
--You have it easily in your power today, to increase the sum total of this world happiness, now. How, by sharing a few words of sincere appreciation, to someone who is lonely or discouraged. Perhaps tomorrow, you will have forgotten the kind words you said today, but the recipient will cherish them for a lifetime." Dale Carnegie.
--You CAN make a difference in the care and life of the person with dementia!
Article by Tom Conrad, OTA/L, is a Clinical specialist for Cognition and Behavioral Approach strategies for HealthPRO Rehabilitation. In addition to providing daily treatment for clients with dementia and other psychiatric disorders, he develops and delivers continuing education seminars nationwide.
CMS has issued a decision memo for TENS for chronic low back pain (CLPB). This decision was released on June 8, 2012.
For the purposes of this decision CLBP is defined as:
- an episode of low back pain that has persisted for three months or longer; and
- is not a manifestation of a clearly defined and generally recognizable primary disease entity. For example, there are cancers that, through metastatic spread to the spine or pelvis, may elicit pain in the lower back as a symptom; and certain systemic diseases such as rheumatoid arthritis and multiple sclerosis manifest many debilitating symptoms of which low back pain is not the primary focus.
The final decision is TENS is not reasonable and necessary for the treatment of CLBP under section 1862(a)(1)(A) of the Social Security Act.
To read the entire document, click on the link below.
http://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=256
The CMS launched the re-designed Nursing Home Compare website on July 19th. CMS adopted industry best practices for design and usability while incorporating a significant amount of new information.
Below is a list of new types of information that can be found on the site.
- Quality measures based on MDS 3.0 data. The MDS 3.0 assessments will replace the MDS 2.0-based quality measures previously posted on Nursing Home Compare. In addition, CMS will post data on two measures of use of anti-psychotic medication use (short-stay incidence and long-stay prevalence).
- Detailed Inspection Reports (Form CMS-2567).
- Ownership information. CMS will post information on the legal business names of nursing homes.
- Information on Physical Therapist staffing levels. Physical Therapist hours per resident day will be reported.
One of the most challenging documentation areas in the nursing home setting is Activities of Daily Living or ADL coding. There are many reasons for this; a vast number of staff members contribute to the documentation, the terminology can be confusing, many ADL’s have sub-sets of tasks that impact the coding level and staff members may under estimate how much they assist the patient.
Factors to Consider:
- ADL score is a driver of both the Medicare and Case Mix rates
- Does Staff have a clear understanding of the scoring definitions
- Staff should document resident ADL at the end of their shifts to ensure that they are capturing the correct scores. Resident ADL capabilities change throughout the course of the day
- Do you begin your ADL assessment on day of admission
- Do you consider ADL scoring on a daily basis? Weekly in your UR/PPS meeting
- Do you have a system in place to know when someone is on the border with their ADL score and go back to review the record, interview staff, review therapy notes, etc. to try to find support for the one extra point needed to capture the higher level
- Is there a discussion around ADL scores among the interdisciplinary team to validate general accuracy
- A lot can change within your assessment time frame, so make sure that you are capturing the best ADL score by choosing the best date
A number of factors can have an impact ADL status:
- Fatigue
- Weakness
- Acute illnesses
- Exacerbation of chronic illnesses
- Cognitive deficits
- Medication effects
- Behaviors such as resistance with care or agitation
- Pain
- Lack of motivation
- Falls
ADL coding is a complex process that involves many staff members & has a significant impact on quality measures & reimbursement. It can be overwhelming if only one or two people are responsible for ensuring the accuracy of the documentation. Accurate ADL coding will result in better Quality Measures, can improve the 5 Star ranking & provides reimbursement for the care that is actually delivered. A comprehensive program utilizing the talents of many people can make your program successful.
On the most recent SNF Open Door Forum, CMS clarified how to code the start and end of therapy. The MDS coding systems have the ability to simply copy everything over so that the MDS coordinators can change the items that need to be changed. The start and end of therapy dates will carry over until there is a new start and end of therapy. This pertains to both Part A and Part B start and end dates.
Please see the CMS clarification below:
CMS reiterated that the start and end date of therapy must be coded, even if there were no minutes of therapy. If there are no minutes of therapy, the latest start and end dates of therapy should be used.
CMS created the Five-Star Quality Rating System to help consumers, families, and facilities evaluate performance of nursing homes. Included in the ratings are Quality Measures which are derived from resident assessment data collected at specified intervals during a stay in the nursing home. The intended purposes of the Quality Measures are:
- Provide information about the Quality of Care at nursing homes to help the public choose a nursing home
- Prompt consumers to talk to nursing home staff about the Quality of Care
- Provide data to the nursing home to help with Quality Improvement efforts
- Provide data to the State Survey Agency for Inspection
With the implementation of the MDS 3.0, Quality Measures have changed. The new Quality Measures will become an enhanced set of publicly reported information available on Nursing Home Compare in mid-July. Providers will have a 1-month preview before the data is publicly released.
The Quality Measures continue to be categorized into two types: short stay (or post-acute) and long stay (or chronic) measures.
Short stay measures are related to:
- Self-reported moderate to severe pain
- Provision of flu vaccine
- Provision of pneumococcal vaccine
Long stay measures are related to:
- Provision of flu vaccine
- Provision of pneumococcal vaccine
- Self-reported moderate to severe pain
- High risk residents with pressure ulcers
- Utilization of physical restraints
- Falls with major injury
- Depressive symptoms
- Urinary tract infection
- Catheter inserted and left in bladder
- Low risk residents who lose Bowel/Bladder control
- Excessive weight loss
- Increase in need for help with ADL’s
Although the measures do not appear to be significantly different from those based on the MDS 2.0, there are changes in the resident and record selection processes.
Resident Sample Selection
An episode is a period of time consisting of one or more stays. It starts with a new admission and ends with a permanent discharge. During that time, the resident may be out of the facility for a hospitalization, leave of absence, etc. These days are not counted in calculating Cumulative Days in Facility (CDIF).
A stay is the time that a resident is physically in the facility or CDIF. When the resident leaves the facility for any reason, this completes a stay and when the resident returns a new stay begins.
The Cumulative Days in Facility (CDIF) defines the resident sample, with Short Stay CDIF up to 100 days and Long Stay CDIF counting from 101 days. As a result of the methodological shift, more residents are included in the Short Stay measures. The MDS 2.0 measures were limited, using PPS assessments to Day 14. Now all assessments, including OBRA and PPS assessments for residents are included for Short and Long Stays.
Record Selection
Requirements for a qualifying assessment are not based on having an ARD within the Target Period, but are based on the resident’s Episode. Due to this, as assessment can be included even if the ARD is not in the Target Period. In addition, some measures include a look-back scan, in which all assessments within an episode are included. For example, the measure for falls with major injury could include assessments going back to one year if they are contained in an episode.
As a result of these changes, it is critical that providers know where residents are in terms of episodes and stays. Providers must have a reliable, effective means of using clinical data to determine trends, challenges and risks, and promote quality improvement. Being quality focused will improve clinical outcomes, reduce professional liability claims, potentially lower insurance premiums, and improve resident satisfaction. Well performing facilities benefit from fewer survey deficiencies, higher occupancy rates and a positive public perception.
The development of a strong Part B program can not only benefit the functional abilities of patients, but is also a critical component of optimizing reimbursement and creating downstream revenue opportunities. A focused Part B program impacts a patient's ability to maintain the highest functional level, while also assisting to decrease medical complications. This cultivates positive clinical outcomes, which can also translate into a positive impact to your bottom line.
Benefits of Part B & Outpatient Programming:
*Coordination of care throughout the disease management process promotes optimal functional independence, measurable progress, enhanced quality of life, and helps individuals age in place.
* Coordination with home care and other community resources promotes continuity of care and helps to stabilize occupancy.
Compliance & Part B Reimbursement:
Medical Necessity" is "THE" hot topic as a result of the increase in pre-payment and post-payment audits being conducted by Medicare and third party payers. Given that Medicare Part B documentation requirements are more stringent that other payers, qualifying residents for this care and appropriately documenting progress that includes medical necessity is critical.
Below is a list of the top reasons for denials which stem from inadequate documentation of medical necessity:
- Disorganized charts and missing documentation
- Lack of significant change warranting consideration for therapy services
- Lack of functional outcomes being noted
- Lack of progress noted with justification of skilled need for care
- No discharge summary noted
- Missing and/or incorrect ICD-9 codes
- Incomplete/incorrect daily records of treatment
- No Physician signature
- Need for skilled service lacking in nursing notes
In order to be successful in today's challenging operating environment, providers need to ensure that they are delivering quality care, optimizing reimbursement, and documenting services in a way that will stand up to audit scrutiny. Medicare Part B programs are an important part of clinical and financial outcomes, and require specific documentation practices and consistency in order to maintain compliance. For more information on how to cultivate a successful and profitable Medicare Part B program, contact our
Sr. Vice President, Crista Stark at 410.667.7200 or via email at
cstark@healthpro-rehab.com.
In 1998, the Health Care Compliance Association (HCCA) set out to develop a certification program for health care compliance professionals. We would like to congratulate our very own Alissa Vertes, VP of Clinical Services & Compliance, in successfully passing the Compliance Certification Board Exam! Alissa is now officially Certified in Healthcare Compliance, one of only a handful in the country!! We work in a high risk and challenging environment that demands a proactive approach. Being certified as a Health Care Compliance Professional will help achieve the most optimal results.
Alissa is now known nationwide as professional with knowledge of relevant regulations and expertise in compliance processes sufficient to assist the health care industry to understand and address legal obligations, and promote organizational integrity through the operation of effective compliance programs. The purpose of certification is to promote health care compliance through the certification of qualified health care compliance professionals by encouraging continued personal and professional growth and providing a national standard of requisite knowledge required for certification; thereby assisting employers, the public and members of the health professions in the assessment of a health care compliance professional.
Certification Advances HealthPRO® Expertise by:
- Enhancing the credibility nationwide of the compliance practitioner
- Offers the needed credibility of the compliance programs under this leadership.
- Assures that each certified compliance practitioner has the broad knowledge base necessary to perform the compliance function.
- Establishes professional standards and status for compliance professionals.
- Facilitates compliance work for this elite group of compliance practitioners in dealing with other professionals in the industry, such as physicians and attorneys.
For more information on this certification can benefit your organization, please contact Alissa Vertes, VP of Clinical Services & Compliance, at 410.667.7200 or via email at avertes@healthpro-rehab.com!
As a Skilled Nursing Facility, you have had to prepare for the changes in the MDS forms and coding directions effective April 1, 2012. If you are not prepared for the MDS 3.0 changes that occurred, most experts agree that the consequences could be very expensive.
Below are some tips for your facility to help with the MDS subset changes.
- Ensure that you have an updated RAI manual in your facility.
- Immediate communication should occur (verbal , via e-mail, or written) to the MDS Coordinator any time a resident is in jeopardy(need)of an EOT or COT.
- Daily meetings and notifications should continue to be held to discuss immediate ARD changes, any potential EOTs and potential COTs to avoid default rates.
- MDS Coordinator should notify the Rehab Director of any inactivated MDS's and any ARDs that are different than those provided by therapy.
- Communication should occur in writing IF an inactivated MDS/ARD occurs.
- Once completed, edited, submitted and accepted, you may not inactivate and change an assessment without penalty.
- STRATEGY: Must have a pre-transmission process in place to review- ARD date and Type of Assessment BEFORE any and all submissions are sent. These changes are able to be made during the accepted encoding period before submission. High risk situations for default days- early COT, Late COT, late EOT- the total number of days the assessment is out of compliance including the late ARD date. Default days need only apply until the next assessment is in effect.
- Report suggestions for software include: Recent utilization report with ARD dates highlighted, and OMRA analysis to review EOT, COT, and SOT dates and scores.
- Unscheduled assessments must be set in the system within 2 daysof the MDS window for that assessment Early and Late Unscheduled assessments – ARD dates must be set for the window of the date the miss/error was discovered and default days apply.
- STRATEGY: Consider opening all possible books in advance and editing or deleting books that are not needed. This applies especially to COTs during and assessment that may become active due to acute hospital transfers, COTs on Fridays for weekends and possibly for Fridays and Saturdays over holiday weekends.
- COT window: 2 days after the 7th day.
- EOT window: 2 days after the applicable ARD, which is 1-3 days after the 3rd missed day of therapy, so this window is available for 5 days. Please remember that EOT assessments do not apply to index maximized nursing scores.
- SC window: 14 days after the change was noticed+ 2 days to open the assessment, when completed as an unscheduled PPS assessment.