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Making a difference in the lives of those we serve

TODAY’S PRESENTER:

Wendy Underwood, COTA/L

Clinical Excellence CoordinatorCE AdministratorHedgehog AmbassadorCertified Dementia Care SpecialistPelvic Muscle Dysfunction and Bowel & Bladder Heath Certified

wunderwood@therapymgmt.com 1-800-804-9961

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WHAT IS RESTORATIVE NURSING?

RNP RAI Definition:

Nursing interventions that promote the resident’s ability to adapt and adjust to living as independently and safely as possible

Program focuses on achieving and maintaining optimal physical, mental and psychosocial functioning

A Program is defined as a specific approach that is planned, documented, monitored and evaluated

5 STAR RATING IMPACT

Health Inspection:

TAG F311• ADL’s• Facility is responsible for providing maintenance

and restorative programs

TAG F154• Planning and implementing care• Includes restorative potential in total health status

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5 STAR RATING IMPACT

Quality of Resident Care:• Restorative Programs can relate to

every quality measure • Most impactful areas are:

• Falls• Weight loss• ADL Help• Skin Integrity• Pain• UTI• Mobility

LONG STAY RESTORATIVE PROCESS

Resident

TherapyD/C

FMPand/or

RNP

ResidentReview

Meeting

Therapy Eval and

Treat

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WHAT HAS CHANGED FOR SHORT STAY?

PPS AND RESTORATIVE

• Therapy and Restorative Nursing could only be combined for a skilled patient if they were in the rehab low (RL) category at minimal reimbursement

PDPM AND RESTORATIVE

• Therapy and Restorative Nursing can be combined to enhance the skilled patient’s rehab outcomes and this impacts reimbursement

PDPM AND RESTORATIVE

PDPM total daily rate

facility gets paid

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WHAT DOES NOT CHANGE?

SKILLED PATIENT GOALS• To return to previous setting

• To maximize positive outcomes during their rehab stay, feel supported and well cared for

• To decrease risk of re-hospitalization

COMMUNITY/FACILITY GOALS• To promote patients return to their

previous setting

• To provide highest quality of care and meet all needs of each patient

• To decrease patient’s risk of re-hospitalization

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CURRENT INDUSTRY RESTORATIVE OPTIONS

LEVEL ONE

LEVEL TWO

LEVEL THREE

LEVEL 2 & LEVEL 3 RNP BENEFITS

COMMUNITY/FACILTY THERAPY COMPANY

• Decreased risk of residents returning to hospital due to decline in function

• An additional solution driven service to improveinterprofessional collaboration

• Improved resident outcomes to promote efficient length of stay and improve quality measures related to your 5 star rating

• Therapy companies are experts in providing programs to exceed quality measure outcomes efficiently

• Under PDPM Restorative and Therapy can be included to adequately capture all possible reimbursement opportunities

• Therapy teams can ensure restorative programs are person centered and carried out effectively

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WHAT CONSTITUTES A RNP?

A RNP MUST:

• Be one of the CMS qualifying programs

• Skilled patients will need to be provided with at least 2 qualifying programs

• Programs must be at least 15 min each and provided 6 out of a 7 day look back

• Be carried out by a trained staff member competent to implement person centered, individualized programs

• No more than 4 in a group

CMS QUALIFIYING PROGRAMS:

• Walking and/or Bed Mobility

• Splint or Brace Assistance

• Range of Motion (ROM)• Active (AROM)

• Passive (PROM)

• Active-Assistive (AAROM)

• Transfer Training

• Communication Training

• Dressing and/or Grooming

• Eating and/or Swallowing

• Amputation/Prosthesis Care

• Toileting: Bowel and/or Bladder

RNP: WHERE TO BEGIN

1. Complete a community/facility needs assessment

2. Ensure proper staffing, location and equipment needs are met

3. Provide comprehensive training with good return demonstration competencies

4. Collaborate with therapy team to ensure all understand program regulations

5. Designate a weekly review meeting

6. Discuss regularly with interprofessional team on what could improve the program

7. Implement a community/facility wide SNF wellness program

8. Make sure documentation is meeting standards and complete quarterly audits

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1. COMPLETE A NEEDS ASSESSMENT

• Are you adequately staffed?

• Do you have a designated nurse?

• Is your MDS staff trained in coding restorative?

• Does your therapy team have a plan to assist you in successful implementation?

• What qualifying programs do you offer now and which do you want to add?

2. ENSURE PROPER STAFFING

• Designated RN or LPN to supervise program

• MDS nurse responsible for accurately submitting RNPs to CMS

• Designated Aides to carryout programs

• Administration committed to holding staff accountable and not pulling for other duties

• Expert Therapy staff to provide support, training and competencies

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RESTORATIVE NURSERESPONSIBILITIES

• Restorative programs can be under the supervision of an RN or LPN

• Restorative nurse is a resource to the restorative aides and communicates with therapy team for program needs

• Signs off on RNP forms and restorative aide grids and completes monthly summary note on each resident

• Discusses with Interdisciplinary team on a regular basis to determine if programs are still appropriate for each resident

• Monitors staffing needs to ensure RNA is not pulled for other duties unnecessarily to ensure RNP standards are met each day

• MDS Nurse will code restorative upon admission assessment under PDPM

RESTORATIVE AIDE RESPONSIBILITIES

• Each restorative aide must be trained to carryout each restorative nursing program or RNP with good return demonstration

• They are expected to understand, implement and document for each resident on program and ask for any clarifications needed

• Restorative aides work under the restorative nurse and with therapy to identify what programs are working well and which need to be reviewed

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2. ENSURE PROPER LOCATION

• Designated restorative treatment area or areas• Main dining room

• Day or activity room

• Therapy gym

• Restorative room

• Documentation room

2. ENSURE PROPER EQUIPMENT

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3. PROVIDE COMPREHENSIVE TRAINING WITH COMPETENCIES

• Trainings must include:• Education on what standards a RNP has to meet to be captured accurately on MDS

• What are the qualifying programs and which programs are in addition to the qualifying ones

• How to effectively and efficiently complete each program for each resident

• Who to alert with concerns or any program questions

• How to document each program for each resident

• A lab portion for return demonstration performance and hands on training

• A skills competency document to ensure effective ability to begin carrying out programs

• Some type of system to review programs and collaborate with team on continuing, discharging or requesting a therapy screen

SKILLS COMPETENCY

Should include:

• Cognitive approach ideas and techniques to meet all resident needs

• Safe body mechanics and transfer training

• Any other duties RNAs are responsible for within the community/facility

• Facility specific safety measures, procedures and/or policies

• Include all staff required to execute RNPs• Restorative Aides

• Activity Aides

• And Nurses assigned to program

• Can be completed upon hire, quarterly, annually or when the need arises

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4. COLLABORATE WITH THERAPY

LEVEL ONE• Traditional• Recommend Programs

and Educate

LEVEL TWO• Attend review meetings• Comprehensive Training

and support• Recommend Programs

and Educate

LEVEL THREE• Hire own staff• Document on Program

daily• Attend review meetings• Comprehensive Training

and Support• Recommend Programs

and Educate

• In this model, Therapy staff assist the interprofessional team by attending meetings and reviewing progress and outcomes

• Therapy may provide education, training and competencies for our customer to ensure safe and effective delivery of restorative programming is achieved

• The designated Facility Restorative Nurse supervises the restorative programs that therapy recommends for each patient/resident

• Therapy is a support and resource to the Facility hired Restorative Aide(s) and Restorative Nurse

LEV

EL 2

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• The therapy company assists in the recruitment, interviewing and hiring of restorative aides

• They monitor accountability and program delivery in compliance with CMS standards to ensure quality program outcomes

• The restorative aide may be an employee of the Therapy company hired to deliver qualifying programs for your facility

• They ensure all documentation, participation grids and program details are completed timely and efficiently

• The designated Facility Restorative Nurse still supervises the restorative program delivery, progress and continuation

LEV

EL 3

THERAPY’S ROLE

• Therapists are available for any questions or concerns to the restorative aides and restorative nurse

• Short Stay: When appropriate each skilled patient will receive a RNP specific to them and designed to enhance their rehab outcomes

• Long Stay: When appropriate after a resident completes their therapy services, a therapist will create a RNP and educate restorative aides and nurse on program specifics

• Therapy is responsible for educating the restorative aide on programs and communicating specific approaches and needs

• When RNP is no longer able to be addressed or a resident actually does better, therapy will re-screen resident and may decide a new evaluation is warranted

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5. COMPLETE WEEKLY REVIEW MEETING

• Weekly meetings can be held:• After morning stand up meeting

• During utilization review meeting

• At a separate restorative only meeting

• During a new PDPM review meeting

• At the therapy department meeting

• Quarterly review meetings:• Can be held at each resident/patient’s care plan

meeting time

DISCUSS FREQUENCY & DURATION

TYPICAL SHORT STAY:• Frequency:

• At least 6 times a week and begin day of admission if possible

• Needs to be captured upon 5 day PDPM MDS assessment in order to impact Nursing CMI

• Duration:

• Upon admission until discharge from rehab stay if IDT see need

TYPICAL LONG STAY:• Frequency:

• At least 6 times a week in a 7 day lookback

• Needs to be documented for daily participation and on MDS

• Duration:

• Up to 90 days if program continues to be monitored for effectiveness

• Resident specific and may be less or more time or d/c to FMP if more appropriate

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6. CHECK IN WITH TEAM PERIODICALLY

• Administration should:• Discuss how well program is going or changes needed

periodically

• Add to QAPI monthly agenda to discuss

• Attend review meetings monthly to check in with interprofessional team

• Let team know you are there for support and you want to know how things are going

• Ask to be notified if a skilled or cmi resident is refusing program or missing days in order to review if programs are appropriate

7. SNF WELLNESS PROGRAMS

Each trained staff member can complete up to 4 programs during a groupSNF Wellness classes are a great way to improve socialization, mobility and ROM

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DO’S• Have fun with residents/patients

• Smile and ask for help with transport

• Keep upbeat familiar music handy and ready to go before class

• Place residents with hearing deficits close to speaker

• Keep the same location and time for resident scheduling

• Be creative by changing music, using pool noodles, scarves or themes

• Complete qualifying programs during class: ROM, Bladder training exercises and/or walk to/from class

• Bring your participation grid to count your 15 min times with up to 4 residents at a time

DON’TS• Never cancel class at the last minute or change time often if

possible

• Don’t lead exercises that crunch chest or flex spine

• Don’t do standing exercises this is a seated class

SNF WELLNESS ROM CLASS

8. DOCUMENTATION STANDARDS

Quick facts

• Restorative programs are nursing programs

• Restorative programs do not require a physician’s order

• Must be supervised by a licensed nurse (RN or LPN/LVN)*

• Other staff and volunteers can be assigned to work with specific residents under the licensed nurse’s supervision

• Restorative programs do NOT include groups with more than four residents per supervision helper or caregiver

• Do NOT include procedures or techniques carried out by or under the direction of qualified therapists

• Time provided for restorative programs (MDS items O0500A-J) must be coded separately, in time blocks of 15 minutes or more

• All restorative program minutes provided within the 24-hour period are included in the day

• Movements that are incidental to dressing, bathing, or other activities cannot be counted as part of a formal restorative program

• Residents with dementia learn new skills best through repetition that occurs multiple times per day

*Be aware of state-specific requirements (check with your State RAI Coordinator)

Copyright 2018. American Association of Post-Acute Care Nursing, d/b/a American Association of Nurse Assessment Coordination. All rights reserved.

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DOCUMENTATION TIPSRestorative Programs Must:• Be measurable, objective and documented

• Include measurable goals and proper approach strategies or techniques

• Be documented in the care plan and medical record

• Be evaluated ‘periodically’ by designated LPN or RN and this must be documented in medical record

• Monthly would be a good timeframe to meet ‘periodic’ rule

• Weekly meetings will assist in ensuring progress with programs and that they remain measurable and objective

• Document program reviews and whether to continue, refer back to therapy or d/c to standard nursing practice (FMP)

QUALIFYING PROGRAM EXAMPLES: ROM

PT OT

LE ROM EXERCISES UE ROM EXERCISES

LE PROM EXERCISES/STRETCHES

UE PROM EXERCISES/ STRETCHES

BACK OR CORE EXERCISES/ STRETCHES

CERVICAL, BACK OR CORE EXERCISES/ STRETCHES

Includes:• Active ROM (AROM)

• Active-Assistive ROM (AAROM)

• Passive ROM (PROM)

Can be completed:• In all planes as recommended

• With our without weights/resistance as recommended

• In groups (4 or less)

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PT OT

KNEE IMMOBILIZER HAND/WRIST/FINGER SPLINTS

ANKLE FOOT ORTHOSIS (AFO) CERVICAL COLLAR

CONTRACTURE OR ANKLE BOOT ELBOW SPLINTS

BACK BRACE OR LUMBAR SUPPORT BACK BRACE OR LUMBAR SUPPORT

Includes:• LE braces and/or splints

• UE braces and/or splints

• Cervical collars/braces

• Back, pelvic or girth braces

Can be completed:• Providing cues for resident/patient to don

brace appropriately

• Total donning completed by aide as recommended

• By monitoring for signs of redness, discomfort or edema

• For time ranges designated an recommended for resident/patient

QUALIFYING PROGRAM EXAMPLES: SPLINTING

PT OTSIT TO STAND TOILET TRANSFER

STAND PIVOT W/C PUSH-UPS

BED TO CHAIR/CHAIR TO BED BED TO CHAIR/CHAIR TO BED

PARTIAL STAND TRAINING SHOWER TRANSFER

Includes:• Pre-emptive skills related to transfers

• Supervision, Stand by assist

• Limited Assist - Contact Guard Assist and Min A transfers

• Extensive Assist – Mod and Max A transfers

• Slide board and sit to stand lift transfers

Can be completed:• Upon rising or during care

• With adaptive equipment or devices as recommended

• Several times throughout day to reach 15 min time frame

QUALIFYING PROGRAM EXAMPLES: TRANSFER TRAINING

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PT OT

LOG ROLLING BED MOBILITY RELATED TO DRESSING/BATHING

ROLLING SIDE TO SIDE ROLLING SIDE TO SIDE DURING CARE

BRIDGING TO MOVE UP IN BED

BRIDGING TO IMPROVE BED POSITIONING

WALKING A CERTAIN DISTANCE WITH A CERTAIN DEVICE WITH AMOUNT OF ASSISTANCE

FUNCTIONAL MOBILITY RELATED TO ADLS AND/OR ACTIVITY PARTICIPATION

Includes:• Both programs can be completed but only counts as

one qualifying program

• Rolling side to side in bed

• Rolling over to side in bed

• Getting to side of bed

• All walking programs • Walk to Dine

• Walk to bathroom

• Walk to activities

Can be completed:• Several times throughout day to reach 15 min time

frame

• With our without devices as recommended

• At recommended assistance level

• Always using a gait belt

QUALIFYING PROGRAM EXAMPLES: BED MOBILITY AND/OR WALKING

Includes:• Both programs can be completed but only counts as one

qualifying program

• Typically recommended by OT

• UB and LB Dressing

• Shirt, bra, shoes, socks, under garments, pants, dresses, gowns

• Grooming

• Make-up, washing face/hands, combing or brushing hair and brushing teeth (not denture related)

• Shaving

Can be completed:• Several times throughout day to reach 15 min time frame

• With our without devices as recommended

• With or without equipment as recommended

• At recommended assistance level

QUALIFYING PROGRAM EXAMPLES: DRESSING AND/OR GROOMING

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OT ST

USE OF CLOCK METHOD FOR LOW VISION

CUES REQUIRED AFTER 2 BITES TO TAKE A DRINK

ONE ITEM INTRODUCED AT A TIME

REMIND/CUE TO SLOW WAIT A FEW SECONDS BEFORE NEXT BITE

SECOND HALF OF MEAL ADD LATERAL SUPPORT DUE TO POSTURAL FATIGUE

COMPLETE ORAL MOTOR EXERCISES

Includes:

• Both programs can be completed but only counts as one qualifying program

• Cognitive approach/cues to improve PO intake

• Swallowing exercises/cues to improve meal safety

• Adaptive equipment and techniques to improve meal independence

• Proper set-up and positioning needed throughout meal

• Monitoring food and drink intake rate for safe swallowing

Can be completed:

• Several times throughout day to reach 15 min time frame

• With our without devices, cues and techniques as recommended

• At recommended assistance level

QUALIFYING PROGRAM EXAMPLES: EATING AND/OR SWALLOWING

PT OT

APPLYING SOCK AND SLEEVE APPROPRIATELY

ASSIST WITH WASHING AMPUTATION SITE

CUE TO SEQUENCE DONNING AND DOFFING PROSTHESIS

CUE TO USE MIRROR TO CHECK SKIN AT SITE

ASSIST WITH APPLYING PROSTHESIS

CLEANING AND DRYING SYSTEM FOR SOCK AND SLEEVE

Includes:

• Both programs can be completed but only counts as one qualifying program

• Improving or maintaining the resident/patient’s ability to put on and remove a prosthesis

• Care for the prosthesis

• Provide adequate hygiene at the site where the prosthesis attaches to the body

Can be completed:

• Several times throughout day to reach 15 min time frame

• At recommended assistance level

QUALIFYING PROGRAM EXAMPLES: AMPUTATION/PROSTHESIS CARE

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OT ST

PLACE TOWELS AND SHAMPOO BOTTLE IN LAP AND ASK THEM TO HOLD FOR YOU ON WAY TO SHOWER

KEEP ABC COMMUNICATION BOARD ON TABLE IN FRONT OF THEM TO PROMOTE COMMUNICATION

SAY, ‘IT’S TIME TO GO TO THE BATHROOM’, ACTIVITY ETC VERSUS ‘DO YOU WANT TO GO’

PROMPT TO REQUEST LUNCH ITEMS FROM MENU BOARD AND GIVE 2 SEC BETWEEN ANSWERS

Includes:

• Communicating wants and needs

• Responsive behavior interventions

• Proper cognitive level approach and activity engagement

• Proper communication during bathing/ADL tasks

• Use of communication device/board

• Breath support for speech and communication

Can be completed:

• Several times throughout day to reach 15 min time frame

• At recommended assistance level

• With recommended approach and/or techniques

MILD IMPAIRMENT

Toileting: Limited Assist‘It’s time to go to the

bathroom’

Bathing: Limited Assist‘It’s time for your shower’

Dressing: Limited Assist‘Would you like the red or

the blue shirt today’

MODERATE IMPAIRMENT

Toileting: Extensive Assist‘Let’s freshen up before

lunch’

Bathing: Extensive Assist‘It’s your turn for a

shower, hold this towel for me’

Dressing: Extensive Assist‘Would you like your shirt on or pants on first today’

SEVERE IMPAIRMENT

Toileting: Dependent‘I’m going to roll you

towards me’

Bathing: Dependent‘I am going to take you for

your shower now”

Dressing: Extensive Assist‘I am going to put your

shirt over your head now’

QUALIFYING PROGRAM EXAMPLES: COMMUNICATION

PT OT

COMPLETE PELVIC FLOOR EXERCISE PROGRAM

USE PROMPTED VOIDING TECHNIQUE TO DECREASE EPISODES OF UI AND/OR FECAL INCONTINENCE

UTILIZE CREDE MANEUVER TO IMPROVE EMPTYING OF BLADDER

COMPLETE SCHEDULED TOILETING PROGRAM AS RECOMMENDED

Includes:

• Bowel and/or Bladder re-training

• Prompted Voiding

• Pelvic floor program

Can be completed:

• Several times throughout day to reach 15 min time frame

• At recommended assistance level

• With recommended approach and/or techniques

QUALIFYING PROGRAM EXAMPLES: TOILETING TRAINING

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TAKE AWAYS

• Under PDPM Restorative and Therapy combining skills will improve short stay resident/patient outcomes

• Restorative will impact Nursing CMI under PDPM

• Restorative staff must be properly trained and demonstrate competency to carryout each individualized program

• Your therapy team can be a vital resource for a successful short stay and long stay RNP

• A designated LPN or RN will supervise and document on each person receiving an RNP

• The MDS staff will need to properly code each program to ensure it is captured appropriately

REFERENCES:www.aanac.orgwww.cms.gov

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Making a difference in the lives of those we serve