MDS Alert

Nip problems before they morph into F tags.

Think of the facility's quality indicators/measures and MDS assessments as a roadmap to opportunity for using restorative nursing. In fact, if you're not using them in that way, your outcomes may be headed in the wrong direction.

You can use the QIs/QMs related to restorative nursing in two ways, says Rita Roedel, RN, who presented on the topic at the March 2009 American Association of Nurse Assessment Coordinators conference.

One is to address individual resident needs -- the other is to identify where the facility may need more specific types of restorative programs overall. To home in on resident-specific restorative needs, nurses at Extendicare Health Services look to see what QIs/QMs residents are triggering, advises Roedel, national director of clinical reimbursement for the Milwaukee-based chain. Then they use the crosswalk (see p. 88) to assess what type of restorative programming might turn things around for the resident.

Example: Suppose Mrs. Jones has suffered falls and a new fracture. Assessing further, "look at the origin of her falls," Roedel advises. "Did she fall getting out of bed or when transferring or when she was walking?

Based on the answer, a restorative program might look at bed mobility and/or transferring -- or a walking program might be a good idea if she fell while walking." Also look at whether she needs help to improve range of motion or joint flexibility or a splint or brace. "The resident might need a therapy screen or evaluation to see if she needs a splint or brace," Roedel says.

Restorative programs that might help a resident triggering on other QIs/QMs include:

• High-risk pressure ulcers. The resident may benefit from range of motion to increase his circulation -- or perhaps he needs a splint or brace to help maintain his positioning, says Roedel. If the person can move with minimal assistance in bed, he may benefit from a good bed mobility program, she adds. "A transfer program could also help." You could also implement a scheduled toileting or bladder retraining program that helps the person maintain or regain continence the majority of the time, Roedel advises.

• Depression indicators. Restorative can help improve mood and anxiety problems. "Walking has been documented to help depression," advises Roedel. "Improving range of motion, bed mobility, transfer, walking, dressing and grooming can also help improve mood and self-esteem." An eating and swallowing program can also do that, she adds. "What better way to improve someone's self-esteem than to maintain his ability to feed himself."

• Pain. Restorative interventions that may help include active or passive ROM, a splinting program, bed mobility, transfer, walking, dressing and grooming, advises Roedel.

• Behavioral symptoms. If the resident with dementia gets frustrated or acts out because he can't communicate his needs, a restorative communication program might help, advises Diane Atchinson, RN-C, MSN, ANP, president of DPA Associates in Kansas City, Mo. The program would have to be a specific one, using communication boards or pictures displaying a toilet and food items, etc., to help the person indicate what he wants. "You could measure behaviors to see if the program helps the person. If after a couple of weeks, the program didn't help, you'd take the person off of it," advises Atchinson.

Also use the QI/QM reports to identify where restorative might help improve the facility's outcomes in certain areas, Roedel suggests. Take restraint use, as one example. Look at how many people are restrained because they have difficulty trying to get out of the wheelchair or trying to move from one plane to another.

Then ask: "How many of those individuals would benefit from a restorative program focusing on transfer skills? How many people are restrained because they are falling out of bed? How many of [those individuals] are on a bed mobility program with a goal of making them safe and functional in bed?" asks Roedel.

More questions: "How many people are restrained because they aren't safe when ambulating? If they are not safe, could a restorative walking program take them to that level?" Roedel continues.

Work in real time: "If the facility collects data electronically, it could use that data to implement restorative before QIs/QMs get triggered," advises Atchinson. "That way, you stay on top of the issues as opposed to chasing them after they have occurred." Or the facility could use paper forms to collect information to help identify people who need restorative. Examples include forms to capture ADLs, pain, mood, and behavior, Atchinson says.

Editor's note: Read part 2 of this article, "5 Tips to Ensure Your Restorative Program Meets RAI Manual Requirements," in the next MDS Alert.