preparing staff to respond to rising acuity
TRANSCRIPT
1
Managing Aging In Place:
Preparing Staff to Respond to Rising Acuity
Liz Jensen, RN MSN Ray Miller, MSOSH
2
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.
Disclaimer
3
At the conclusion of this session, the participant will be able to:
Objectives
1. Discuss the more common changes that occur with
aging, associated risks involved with those changes and
when the need for additional levels of care and service
may be required.
2.Describe strategies for pro-actively evaluating staff
readiness to respond to the changing service & care
needs for residents as they age in place
3. Explore effective educational & management
strategies to prepare staff to respond to changing
service & care needs
4
1. Introduction
2. Demographics
3. Care Needs and Risks
4. Defining a Framework
5. Implementing Processes
6. Successful Sustainability
Agenda
Colored Paper for “Ah-ha” moments
5
1. Introduction
2. Demographics
3. Care Needs and Risks
4. Defining a Framework
5. Implementing Processes
6. Successful Sustainability
Agenda
6
Preventative Supportive LT Care Acute
7
Threat of litigation
Staff Training
Acuity
Self-reporting requirements
Media-Relations What hasn’t changed?
Family and Resident Expectations
Medications
Regulations – in 2012, aprx.
120,000 state AL-related bills
submitted nation-wide
What Has Changed In YOUR AL World?
You Still Care About
PEOPLE.
osha
Culture
Background and fingerprint check
Electronic payment
Assisted Living vs. Hospice 1,000,000+ AL Residents
8
1. Introduction
2. Demographics
3. Care Needs and Risks
4. Defining a Framework
5. Implementing Processes
6. Successful Sustainability
Agenda
9
Who Are We Serving?
70% are female
More than half are 85 or older,
just 10% are younger than 65
74% receive assistance with
ADLs, 37% have 3 or more ADL
limitations
42% have Alzheimer’s or
dementia
Assisted Living & Residential Care in the United States in 2010;
accessed from www.ahcancal.org 2/1/2013
10 http://www.bls.gov/ooh/healthcare/nursing-assistants.htm#tab-1
Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2012-13 Edition,
Nursing Aides, Orderlies, and Attendants, on the Internet at http://www.bls.gov/ooh/healthcare/nursing-
assistants.htm (visited February 14, 2013).
Quick Facts: Aides, Orderlies, and Attendants
2010 Median Pay $24,010 per year
$11.54 per hour
Entry-Level Education Postsecondary non-degree award
Work Experience in a Related Occupation None
On-the-job Training None
Number of Jobs, 2010 1,505,300
Job Outlook, 2010-20 20% (Faster than average)
Employment Change, 2010-20 302,000
11
NCAL 2011 Assisted Living
Staff Vacancy, Retention, and Turnover Survey, October 2012
Who is Serving Our Residents?
12
Nursing Staff
NCAL 2011 Assisted Living
Staff Vacancy, Retention, and Turnover Survey, October 2012
13
Turnover of Nursing Staff
NCAL 2011 Assisted Living
Staff Vacancy, Retention, and Turnover Survey, October 2012
14
Top Deficiencies
% States Reporting Common Deficiencies
Deficiency % States in 2011 % States in 2012
Medication Administration 83% 86%
Resident Admission Requirements 71% 76%
Ongoing Resident Assessment 54% 73%
Maintenance Building Code 51% 57%
Staff Training 54% 51%
Resident Care 20% 41%
Emergency Preparedness 22% 35%
Food Service 29% 35%
Staff Health 27% 33%
Administrative Record Keeping 34% 31%
ALFA 2012, Top 10 Deficiencies in Assisted Living
15
Top Deficiencies
% States Reporting Common Deficiencies
Deficiency % States in 2011 % States in 2012
Medication Administration 83% 86%
Resident Admission Requirements 71% 76%
Ongoing Resident Assessment 54% 73%
Maintenance Building Code 51% 57%
Staff Training 54% 51%
Resident Care 20% 41%
Emergency Preparedness 22% 35%
Food Service 29% 35%
Staff Health 27% 33%
Administrative Record Keeping 34% 31%
ALFA 2012, Top 10 Deficiencies in Assisted Living
16
SIDEBAR: A new word – “Heyoka” (Heyókȟa)*
Heyókȟa refers to the Lakota concept
of a contrarian …
Exhibits extreme behaviors
Teacher … Mirror
WHY? Force you to examine your
doubts, fears, (habits, processes,
approaches) … and weaknesses
From Wikipedia, the free encyclopedia
An Heyókȟa is also called a Sacred Clown
17
1. Introduction
2. Demographics
3. Care Needs and Risks
4. Defining a Framework
5. Implementing Processes
6. Successful Sustainability
Agenda
18
Age Related Health Changes
Can Increase Risk for:
Arthritis
Hypertension
Heart disease
Diabetes
Osteoporosis
Memory loss
Alzheimer’s & other
dementia related disorders
Vision problems
Incontinence
Hearing loss
Loss of muscle tone,
flexibility and mobility
Decreased strength
Miller, C., (2012) Nursing for Wellness in Older Adults, Sixth Ed. Wolters Kluwer;
Lippincott Williams & Wilkins.
19
Common Care Needs
Activity / Care Need % Residents needing
assistance
Bathing 64%
Dressing 39%
Toileting 26%
Transferring 19%
Eating 12%
Help with meal preparation 87%
Assistance with medications 81%
Data compiled from “2009 Overview of Assisted Living”. Collaborative report of
American Association of Homes and Services for the Aging, Assisted Living Federation
of America, American Seniors Housing Association, National Center for Assisted Living
and the National Investment Center for the Seniors Housing & Care Industry.
20
Mental Health Considerations
Study compared residents residing in a Dementia-specific
AL (DSAL) vs. Traditional AL (TAL)
Similar demographics, frequency of anxiety & depression
symptoms
Lack of documented dementia diagnosis to support level of
impairment in both
DSAL staff were provided more specific dementia care
training
Kang, H., Smith, M., Buckwalter, K.C., Ellingrod, V., & Schultz, S.K. (2010). Anxiety,
depression and cognitive impairment in dementia-specific and traditional assisted living.
Journal of Gerontological Nursing, 36(1), 18-30.
Teri, L., McKenzie, G.L., LaFazia, D., Farran, C.J.,Beck, C., Huda, P., Pike, KC.(2009).
Improving dementia care in assisted living residences: Addressing staff reactions to training.
Geriatric Nursing, 30,153-163.
21
1. Introduction
2. Demographics
3. Care Needs and Risks
4. Defining a Framework
5. Implementing Processes
6. Successful Sustainability
Agenda
22
Understanding the Rules
State regulations & licensure requirements
□ Nursing Services
□ Education requirements
Medication Assistance
Dementia Care
State Nurse Practice Acts
Business or corporation standards
Scope of Care & Services to be provided
23
Defining Your Framework
What is the level of care and service you are
providing?
What are the educational backgrounds, skills and
experiences needed to care for your residents?
What is the availability of the professional nursing
and caregiver workforce in your community?
24
Defining Your Commitment
How do you define your commitment to staff
development?
Availability of resources to support education
□ NCAL Guiding Principles
□ Online education services
□ Community partners; NPs, Hospitals, SNF
□ Vendor partners
25
Defining Structures & Processes
for Resident Evaluation
Pre-move in assessment
Move-in assessment
Service Plan—initial & ongoing review/updates
Daily interactions
□ INTERACT “Stop & Watch”
Wellness checks
26
27
1. Introduction
2. Demographics
3. Care Needs and Risks
4. Defining a Framework
5. Implementing Processes
6. Successful Sustainability
Agenda
28
Supervision Expectations: Authority v. Familiarity
http://www.apbs.org/conference/denver/files/A18-Bird.ppt#369,13,Federal Regulations: Potential areas of citations
29 http://www.apbs.org/conference/denver/files/A18-Bird.ppt#369,13,Federal Regulations: Potential areas of citations
Supervision Expectations: Authority v. Familiarity
30
Defining Staff Education & Development Model
Hiring
□ Defined job descriptions, roles & responsibilities
Orientation
□ Defined training for high risk, problem prone issues
□ Medication Administration
□ Accidents/Incidents—Drills
□ Clues & Cues / Change in Condition
Mentoring
Check-in
Annual review
SIDEBAR
31
Models for Education Delivery
Live
□ In-house
□ Local or National opportunities
Online
□ Self-paced
□ Assigned courses
Blended
Workshops
Who is Your
Education
Coordinator?
32
Enhancing Education Planning
Evaluate established educational calendars for
opportunities to enhance learning
Partnership ideas
□ Nurse Practitioners
□ Hospital Nurse Educators
□ Local University—Student led sessions
Certification / Specialty programs
33
Medication Assistance
Understand state rules and regulations
Educational preparation:
□ Follow state mandated training, as applicable
□ Include observation and competency demonstration by a
nurse
□ Include scenarios and problem solving opportunities.
Focus on high risk medication issues
□ Expectations for documentation and communication of
variances
Focus on medication safety
34
SIDEBAR: Clues & Cues – “Itchy Vigilance”
Opportunity to identify a change early and respond
□ Less visible in the community
□ Check for changes in meds
□ Recent trip to the physician
□ Off patterns or habits
□ Change in routines
□ Posture change
□ “Color” change
□ New cough
□ Pain
35
Let’s Apply It: Mrs. M
Moved In December 2011
85 years old, widowed
Teacher, mother of 5,
grandmother of 17
Arthritis, osteoporosis
History of heart failure
Episodes of confusion
Takes 4 medications
Requires assistance with
□ Bathing
□ Dressing
□ Medication management
January 2013
87 years old
Fell when getting out of bed
to go to the bathroom.
Fractured her hip
Plans to return to AL
36
Opportunity for Staff Learning
“Learning Circles” –ask staff involved in Mrs. M’s
care to meet and discuss what they observed
about her over the past year.
Consider creating a timeline from “Move-In” until
the fall occurred.
Discuss opportunities for improvement
□ Staff communication
□ Nursing & Physician notification
□ Recognition of changes in Mrs. M’s condition
37
Mrs. M
Moved In December 2011
85 years old, widowed
Teacher, mother of 5,
grandmother of 17
Arthritis, osteoporosis
History of heart failure
Episodes of confusion
Takes 4 medications
Requires assistance with
□ Bathing
□ Dressing
□ Medication management
January 2013
87 years old
Fell when getting out of bed
to go to the bathroom.
Fractured her hip
Plans to return to AL
Root Cause Analysis
• Physician had increased her dose
of diuretic medication
• Daughters had made comments
to staff that she seemed “more
confused that usual”
• Last service plan was reviewed in
December 2012
• Communication gap between staff
38
SIDEBAR: RCA
1. WHY? Incident; Injury (Near-Misses & Prospectively)
2. What Areas Do You Focus On?
a. People
b. P&P&P
c. Training
d. Equipment
e. Environment
f. Management
3. Who should participate?
39
1. Verbal contracting with Residents (each shift):
Example: “Good Morning Mrs. Smith. I don’t want you fall, OK.
Will you be sure to put on your slippers …”
2. Tips to share with Family Members:
Example: “Do you understand that your Mom is at higher risk for
falling? Will you reminder to her always wear her slippers?”
http://www.mnhospitals.org/index/tools-app/tool.362?view=detail
“Daily Contracting” with Residents SAFE from FALLS Toolkit -- http://www.mnhospitals.org/index/tools-app/tool.362?view=detail
40
“Daily Contracting” with Residents
Sample tips:
1. Ask for help! It is OK. (weak or dizzy)
2. Wear glasses or hearing aids, use them.
3. Sit at the bed side for a few minutes before you stand up.
4. Use your walker/cane/WC.
5. Wear shoes or non-skid slippers.
6. Make sure your pathway is clear.
7. Tell us about puddles/piles/pieces.
8. Use the handrails!
9. Keep important things within easy reach.
http://www.mnhospitals.org/index/tools-app/tool.362?view=detail
41
“Daily Contracting” with Family*
Sample tips:
1. Before you leave, make sure the call light and the bed stand is within reach. (Phone, Kleenex, etc,)
2. Some medications may produce weakness or dizziness.
3. Consider staying with Mom if they are at a high risk for falling or are confused.
4. Notify staff before leaving if you notice confusion or disorientation in your Dad.
5. Remind Mom to ask for help when getting up.
42
1. Introduction
2. Demographics
3. Care Needs and Risks
4. Defining a Framework
5. Implementing Processes
6. Successful Sustainability
a. Change Management
b. Mentoring
Agenda
43
PI
Performance Improvement
44
Successful Sustainability
(Read more: Strategies for Managing Change in Nursing | eHow.com
http://www.ehow.com/way_5870000_strategies-managing-change-nursing.html#ixzz2Oy1UeTQN)
1. How many of you are “change managers”?
2. Have you ever thought about how you “manage change”?
3. What if I said to you that there are both “good ways” and
“bad ways” of managing change?
4. Strategies for Managing Change in Nursing By Ngozi
Oguejiofo, eHow Contributor, December 12, 2012
a. Choose your “Change Theory” …
45
400+ Available Theories of Change Management
A -0 - E - - K - - R - - U -
Acquiescence Effect Ego Depletion Kin Selection see Prosocial Behavior Rationalization Trap Ultimate Attribution Error
Acquired Needs Theory Elaboration Likelihood Model - L - Reactance Theory Ultimate Terms
Activation Theory Empathy-Altruism Hypothesis Lake Wobegon effect Reasoned Action, see Planned Behavior Theory Uncertainty Reduction Theory
Actor-Observer Difference Endowed Progress Effect Language Expectancy Theory Realistic Conflict Theory Unconscious Thought Theory
Affect Infusion Model Endowment Effect Law of Attraction Recency Effect Urban-Overload Hypothesis
Affect Perseverance Epistemological Weighting Hypothesis Lazarus Theory see Appraisal Theory Reciprocity Norm - V -
Aggression Equity Theory Leader-Member Exchange Theory Regret Theory Valence Effect
Ambiguity effect ERG Theory Learned Helplessness Theory Reinforcement-Affect Theory VIE Theory see Expectancy Theory
Amplification Hypothesis Escape Theory Learned Need Theory see Acquired Needs Theory Relative Deprivation Theory - W -
Anchoring and Adjustment Heuristic Expectancy Violations Theory Least Interest Principle Relationship Dissolution, see Terminating Relationships Weak Ties Theory
Anticipatory Regret see Regret Theory Expectancy Theory Linguistic Inter-group Bias Representativeness Heuristic Wishful Thinking see Valence Effect
Appraisal Theory Explanatory Coherence Locus of Control Repulsion Hypothesis Worse-Than-Average Effect see Below-Average Effect
Attachment Theory Extended Parallel Process Model Looking-glass Self Restraint Bias - X - Attachment Style External Justification Love Risk Preference - Y -
Attitude Ethnocentric Bias see Group Attribution Error - M - Risky Shift Phenomenon Yale Attitude Change Approach
Attitude-Behavior Consistency Extrinsic Motivation Matching Hypothesis Roles
Attribution Theory - F - Mental Models see Schema - S -
Automatic Believing False Consensus Effect Mere Exposure Theory Sapir-Whorf Hypothesis
Augmenting Principle False Memory Syndrome Mere Thought Effect Satisficing
Availability Heuristic Fatigue Minimum Group Theory Scapegoat Theory
- B - Focalism Minority Influence Scarcity Principle
Balance Theory see Consistency Theory Focusing Effect Mood-Congruent Judgment Schema
Barnum Effect see Personal Validation Fallacy Forced Compliance Mood memory Selective Exposure
Belief Bias Forer Effect see Personal Validation Fallacy Multi-Attribute Choice Selective Perception
Belief Perseverance Four-factor Model - N - Self-Affirmation Theory
Below-Average Effect Filter Theory Negative Face see Politeness Theory Self-Completion Theory
Ben Franklin Effect Framing Neglect of probability bias Self-Determination Theory
Bias blind spot Friendship Non-Verbal Behavior Self-Discrepancy Theory
Bias Correction Frustration-Aggression Theory Normative Social Influence Self-Enhancement see Impression Management
Biased sampling Fundamental Attribution Error Norms see Social Norms Self-Enhancing Bias see Self-Serving Bias Body language see Non-verbal Behavior - G - - O - Self-Evaluation Maintenance Theory
Bounded Rationality Gambler's Fallacy Objectification Self-Fulfilling Prophecy
Buffer effect of Social Support Goal-Setting Theory Object Relations Theory Self-Monitoring Behavior
Bystander Effect God Terms see Ultimate Terms Operant Conditioning Self-Perception Theory
- C - Group Attribution Error Opponent-Process Theory. Self-Protective Bias see Self-Serving Bias
Cannon-Bard Theory of Emotion Group Locomotion Hypothesis Optimism Bias see Valence Effect Self-Regulation Theory
Cautious Shift see Risky Shift Phenomenon Group Polarization Phenomenon Other-Enhancement see Impression Management Self-Serving Bias
Central Route see Elaboration Likelihood Model Group-serving Attributional Bias see Group Attribution Error Outcome Dependency Self-Verification Theory
Certainty Effect Groupthink Out-Group Bias see In-Group Bias Side Bet Theory
Charismatic Terms see Ultimate Terms - H - Out-Group Homogeneity Sleeper Effect
Choice Shift see Risky Shift Phenomenon Halo Effect Overconfidence Barrier Small World Theory
Choice-supportive bias Hedonic Relevance see Correspondent Inference Theory Overjustification Effect Social Comparison Theory
Choice Theory see Control Theory Heuristic-Systematic Persuasion Model - P - Social Desirability Bias
Classical Conditioning Hostile Media Phenomenon Perceived Behavioral Control see Planned Behavior Theory Social Exchange Theory
Clustering Illusion Hot Hand Phenomenon Perceptual Contrast Effect Social Facilitation
Coercion Hindsight Bias Perceptual Salience Social Identity Theory
Cognitive Appraisal Theories of Emotion Hyperbolic discounting Peripheral Route see Elaboration Likelihood Model Social Impact Theory
Cognitive Dissonance - I - Personal Construct Theory Social Influence
Cognitive Evalution Theory Illusion of Asymmetric Insight Personal Validation Fallacy Social Judgment Theory
Commitment Illusory Correlation Personalism see Correspondent Inference Theory Social Learning Theory
Communication Accommodation Theory Imagination Inflation see False Memory Syndrome Persuasion Social Loafing
Compensation Imagined Memory Persuasive Arguments Theory Social Norms
Confirmation Bias Impact Bias Placebo Effect Social Penetration Theory
Conjunction Fallacy Implicit Personality Theory Planning Fallacy Social Proof see Informational Social Influence
Consistency Theory Impression Management Planned Behavior Theory Social Representation Theory
Constructivism Inattentional Blindness Plasticity Social-Role Theory
Contact Hypothesis Information Bias Pluralistic Ignorance Sociobiology Theory
Control Theory Information Manipulation Theory Polarization Source Credibility
Conversion Information Processing Theory Politeness Theory Speech Act Theory
Contagion Informational Social Influence Positive Face see Politeness Theory Spiral of Silence Theory
Conversion Theory In-Group Bias Positive psychology Stage Theory
Correspondence Bias In-Group Linguistic Bias see In-Group Bias Positive Test Strategy see Confirmation Bias Stereotypes
Correspondent Inference Theory Inoculation Positivity Effect Stockholm Syndrome
Counter-Attitudinal Advocacy (CAA) Insufficient Punishment Post-Decision Dissonance Story Model
Counterfactual Thinking Interpersonal Deception Theory Power Stimulus-Value-Role Model
Covariation Model Interpersonal Expectancy Effect The Pratfall Effect Strategic Contingencies Theory
Credibility Interview Illusion Primacy Effect Subjective Norms see Planned Behavior Theory
- D - Intrinsic motivation Priming Subliminal Messages
Decisions Investment Model Private Acceptance see Informational Social Influence Sunk-Cost Effect
Deindividuation Invisible Correlation see Illusory Correlation Propinquity Effect Symbolic Convergence Theory
Devil Terms see Ultimate Terms Involvement Prosocial Behavior Symbolic Interaction Theory
Disconfirmation bias Ironic Reversal Prospect Theory - T -
Discounting - J - Pseudo-certainty effect see Certainty Effect Terminating relationships
Dissonance see Cognitive Dissonance James-Lange Theory of Emotion Psychological Accounting Theory of Mind
Drive Theory Justification of Effort Public Compliance see Informational Social Influence Three-factor Theory see Acquired Needs Theory
Durability bias Just-world phenomenon Pygmalion Effect see Self-Fulfilling Prophecy Transtheoretical Model of Change
Two-Factor Theory of Emotion
http://changingminds.org/explanations/theories/a_alphabetic.htm
46
So Which One?
http://rapidbi.com/kurt-lewin-three-step-change-theory/
47 File:Iceberg.jpg (From Wikipedia, the free encyclopedia)
http://en.wikipedia.org/wiki/File:Iceberg.jpg
UNFREEZE = Decide, Plan, Strategize, use data, ENGAGE; let go of old patterns
CHANGE = Engage and Communicate; Implement Your Plan:
= Create AWARENESS and BUY-IN
RE-FREEZE = Manage Resistance
= Beat the Drum
= Monitor and Modify the “Changing” Environment
= Without refreezing, it is easy to backslide into the old ways.
http://www.ehow.com/way_5870000_strategies-managing-change-nursing.html
Strategies for Managing Change in Nursing By Ngozi Oguejiofo, eHow Contributor
48
49
Who is the “Change Leader”?
The Change Leader
incorporates each step
of the “chosen” change theory
to bring about planned change.
DON/Nurse │ Corporate │ Administrator │ TEAM
http://www.ehow.com/way_5870000_strategies-managing-change-nursing.html
Strategies for Managing Change in Nursing By Ngozi Oguejiofo, eHow Contributor
1 2 3 4
How can you apply this to today’s discussion?
50
1. Introduction
2. Demographics
3. Care Needs and Risks
4. Defining a Framework
5. Implementing Processes
6. Successful Sustainability
a. Change Management
b. Mentoring
Agenda
51
VISIT & LISTEN
EDUCATE & DEVELOP
ENGAGE & HARVEST
MENTORING
52
MENTORING
VISIT ↔ LISTEN
EDUCATE ↔ DEVELOP
ENGAGE ↔ HARVEST
1. Relationship questions
2. Round with them
3. What went well?
4. What didn’t go well?
1. Do you have the tools,
training and resources to
do your job?
2. What is working well?
1. How can we “fix” “this”?
2. Who is doing a good job?
3. What systems can work
better? HOW?
53
Sow a thought, reap an action.
Sow an action, reap a habit.
Sow a habit, reap a character.
Sow a character, reap a destiny.
SIDEBAR: WHY do we “mentor” others? *
(In Bill Sands, The Seventh Step (1967), 9)
If you want to make QAPI, Care, Choice, Compassion or ANY
OTHER important principle strong in your community,
then “make” your Staff strong in those same things.
Here is my belief --
54
“Take-Away” Ideas
Be clear on what you can and can’t provide
Dedicated educator or education coordinator for
staff
Defined curriculum for all staff with an emphasis
on identifying common changes in resident
condition and expectations for communication
Health & Wellness programs for residents with
emphasis on “early identification and action”
55
“Take Away” Ideas
Consider establishing an “Advisory Board” to
discuss policies, procedures and practices to
address the health and wellness needs of your
residents & provide recommendations to
community leadership
□ Nurse
□ Physician
□ Nurse Practitioner
□ Nurse Aides/Care Assistants
□ Pharmacist
56
Agenda In Review – Did We Hit Them?
1. Introduction
2. Demographics
3. Care Needs and Risks
4. Defining a Framework
5. Implementing Processes
6. Successful Sustainability
Any “AH-HA’s”?
57
Thank You.