Transcript Nursing Home Regulation

Nursing Home Regulation
Kathleen C. Buckwalter, PhD, RN, FAAN
Professor of Nursing Emerita, and Co-Director,
National Health Law & Policy Resource Center
Elder Law Colloquium
The Aging Population, Alzheimer’s and Other Dementias:
Law & Public Policy
University of Iowa College of Law
April 5, 2012
I
I. BACKGROUND
I
Predictors of Institutionalization
 Patient Factors
 Caregiver Factors
Behavior Problems
Burden
Increasing Cognitive
Impairment
Physical Health
ADL Impairment
Physical Health Decline
Effective approaches to
enhance QOL should target
some of these factors
Percent of Nursing Home Residents
with Cognitive Impairment/ Dementia
• In 2009, 68% of nursing home residents had
some degree of cognitive impairment.
• In 2011, 47% of all nursing home residents
had a dementia diagnosis in their nursing
home record
Source: Alzheimer’s Association, 2012 Alzheimer’s Disease
Facts and Figures (2012)
I
Quality of Care (QOC)
in Persons with Dementia (PWD)
“Providing consistently high quality of care in
nursing homes to a variety of frail very old
residents … requires that the functional,
medical, social and psychological needs of
residents be individually determined and met
….”
Institute of Medicine, Improving the Quality of Care in Nursing
Homes (1986) at p. 10.
I
Medicare/ Medicaid
Nursing Home Certification:
Quality of Care Requirements
General – Each resident shall receive and each
facility shall provide necessary care and services
“to attain or maintain the highest practicable
physical, mental and psychological well-being”
of a resident in accordance with the resident’s
comprehensive assessment and plan of care.
I
Medicare/ Medicaid
Nursing Home Certification:
Specific Quality of Care Requirements
•
•
•
•
•
•
•
•
•
•
•
•
•
Activities of Daily Living
Vision and Hearing
Pressure Sores
Urinary Incontinence
Range of Motion
Mental and Psychosocial Functioning
Nutrition
Hydration
Nasogastric Tubes
Special Needs
Unnecessary Drugs and Antipsychotic Drugs
Medication Errors
Accidents
I
I
Quality of Care Requirements
Unnecessary Drugs and Antipsychotic Drugs
The facility must ensure residents do not
receive unnecessary drugs, defined as a drug
use in excessive dosage, for excessive duration,
without adequate indications in use, or with
adverse consequences. Facilities must ensure
residents are not started on antipsychotic drugs
unless clinically necessary and that if a resident
receives such drugs, efforts are made to
discontinue their use.
Quality of Life (QOL)in Persons
with Dementia (PWD)
• Until recently, identifying positive outcomes to
maximize QOL was neglected are of research
• View the person with AD as an object or problem to be
managed vs. person with thoughts, desires, needs that
require attention (Keane, 1994; Kitwood, 1997)
• Stripping of Personhood” (Lawton, 1994) vs.
understanding Individual perspective and impact of
disease on the individual
• PWD need adequate and continuing treatments in a
stable, safe, stimulating environment (Weyer &
Schaufele, 2003)
I
Promoting emotional well being in
persons with dementia (Burgener & Twigg, 2002)
• Relationships/social
interactions/human
contact vs “’ pulling
away”
• Comfort/freedom from
pain
• Meaningful, pleasant
activities (Whitehouse &
Rabins, 1992) –e.g. art,
storytelling, TIMESLIPS
• Ability to communicate
needs (Malott & McAiney,
1995
• Recognizing & supporting
previous skills and
positive behaviors
(Buckwalter et al. 1996)
• Continued intimacy with
family (Parse, 1996)
• Need for “normalcy,
sense of continuity and
personal control”
I
Indicators of Well-Being in People with
Dementia (Kitwood & Bredin, 1992)
• Assertion of desire or
will
• Ability to express a
range of + and –
emotions
• Initiation of social
contact
• Social security
• Self-respect
• Acceptance of other
people with dementia
(instit setting)
• Humor
• Creativity/Self
expression
• Showing pleasure
• Helpfulness
• Relaxation
I
QOL for Care Recipient influenced by
Caregiver factors (Burgener & Twigg, 2002)
• Relationship between CG factors and CR QOL
outcomes- beyond that accounted for by
changes in mental ability
• Role stress
• Quality of CG/CR relationship
• Facilitation of social contacts and activity
participation by CG
I
II
II. SPECIAL CARE UNITS
Driving Forces
for Segregated Units
1
better care for
dementia victims
2
non-dementia residents
prefer separate space
II
II
Should demented be segregated?
YES
Reduce level & complexity of stimuli
Protect the nondemented
Focus programming
Staff believe care is better
Some evidence of improved outcomes
II
When Lucid and Demented
Elders are Housed Together
Problems for Lucid Elders:
Invasion of privacy
Lost or damaged personal property
Decreased socialization as resident attempts to avoid
encounters with the confused
Interrupted sleep
Fear of physical harm from the agitated resident
II
When Lucid and Demented
Elders are Housed Together
Problems for Demented Elders:
Tranquilizing medication causes decreased mobility,
loss of appetite, and dependence in activities of daily
living
Exclusion from traditional planned activities and
subsequent decreased socialization
II
When Lucid and Demented
Elders are Housed Together
Problems for Demented Elders:
Negative feedback from caregivers and other residents
Increased fear and agitation leading to the use of softtie restraints
Negative family response to the use of restraints,
possible decreased visiting
II
What makes Special Units Special?
Special
“It Depends.”
II
What is a Special Unit?
No Standard Definition
No Uniform Terminology
No Standardized Criteria
II
SCU…………………………..
“a distinct part of a health care facility which is
clearly identifiable, containing contiguous
rooms in a separate wing or building or on a
separate floor of the facility, and for which a
special program of care has been approved.”
(ADRDA Unit Rules Committee, 1988)
II
Five Characteristics of “Special” Units
1)
2)
3)
4)
Staff selection and training
Activity programming
Family programming
Physical environment and decor, including
separation
5) Admission criteria
II
Special vs. Segregated
7 dimensions of care (AAHA)
Commitment
Philosophy
Therapeutic care
Physical design
Staff
Communication
Research and education
II
Management Modalities
for SCUs
THERAPEUTIC PROGRAMS
Approaches and activities appropriate for resident
cognitive and functional status
Focus on resident strengths and familiar activities, such
as religious, cultural, ethnic rituals
II
Management Modalities
for SCUs
THERAPEUTIC PROGRAMS
Group occupational, physical, and activity therapy
programs, such as cooking, gardening, dancing,
exercise, and sensory stimulation
One-on-one activities, such as ball throwing, review of
photo albums, and hand massage
II
Management Modalities
for SCUs
INVOLVEMENT OF FAMILIES
Encouragement of family participation in activities and
care
Provision of information and support groups
II
Management Modalities
for SCUs
PHYSICAL ENVIRONMENT
Reduction of noxious stimuli
Provision for safe wandering
Access to outdoors
Wayfinding cues
Visual, tactile, musical, and other sensory stimulation
II
Management Modalities
for SCUs
STAFF APPROACHES TO CARE
Individualized care planning and provision
A team approach to care with consistent staffing
Behavior modification
Minimization of physical and pharmacologic restraints
Emphasis on patient dignity
II
SCUs -- Legal and Public Policy Issues
II
III. Atypical Antipsychotic Drugs
II
Pharmacological Interventions
For mild-mod BPSD non-drug approaches 1st
Psychotropic meds (short term) for severe
behavior
Manic sxs: Mood stabilizers (anti-convulsants)
Agitation/aggression: SSRIs, Mood stabilizers,
trazadone
Psychotic sx/severe aggression (danger to self/others)
-- IM Haldol in crisis. Atypical Antipsychotics
Depressive sxs/anxiety: S SSRI antidepressants/benzos
II
Meds, con’t
Adjust to non-pharm approaches
Side Effects
Black box warnings
Off-Label
Cognitive Enhancers (Chol. Inhibitors)
 Modest benefit
(Donepezil, rivastigmine, galantamine,
memantine)
Non-Pharmacological Management of
Behavioral and Psychological Symptoms of
Dementia (BPSD): Best Practices
• Interventions
– No “easy” answers
– Complicated by changing clinical course
• Principles of Care:
–
–
–
–
Adjust daily routines
Change reaction and responses to behaviors
Monitor and adjust the environment, remove triggers
Adjust interaction and communication strategies Gould (2007)
Williams (2005)
(Ballard et al., 2009; Burgener & Twigg, 2002; Smith & Buckwalter, 2005)
II
Cochrane Reviews and Protocols Selected for
Nonpharmacological Interventions
II
These reviews and protocols can be found at:
http://dementia.cochrane.org/
orhttp://dementia.cochrane.org/our-reviews
Aroma therapy for dementia
Cognition-based interventions for healthy older people and people with mild cognitive impairment
Cognitive rehabilitation and cognitive training for early-stage Alzheimer's disease and vascular dementia
Homeopathy for dementia
Interventions for preventing and reducing the use of physical restraints in long-term geriatric care
Interventions for preventing delirium in hospitalized patients
Light therapy for managing cognitive, sleep, functional, behavioral, or psychiatric disturbances in
dementia
Massage and touch for dementia
Multidisciplinary team interventions for delirium in patients with chronic cognitive impairment
Music therapy for people with dementia
Non-pharmacological interventions for wandering of people with dementia in the domestic setting
Physical activity and enhanced fitness to improve cognitive function in older people without known
cognitive impairment
Physical activity programs for persons with dementia
Reality orientation for dementia
Cochrane Reviews and Protocols Selected for
Nonpharmacological Interventions (cont)
Reviews (cont):
Reminiscence therapy for dementia
Respite care for people with dementia and their careers
Snoezelen for dementia
Special care units for dementia individuals with behavioral problems
Subjective barriers to prevent wandering of cognitively impaired people
Support for careers of people with Alzheimer's type dementia
Transcutaneous Electrical Nerve Stimulation (TENS) for dementia
Validation therapy for dementia
Protocols:
Case/care management approaches to home support for people with dementia
Cognitive and behavioural interventions for carers of people with dementia
Cognitive stimulation to improve cognitive functioning in people with dementia
Functional analysis-based interventions for challenging behaviour in dementia
Information and support interventions for informal caregivers of people with dementia
Multidisciplinary Team Interventions for the management of delirium in hospitalized patients
Physical activity for improving cognition in older people with mild cognitive impairment
Psychosocial interventions for reducing antipsychotic medication in care home residents
II
II
Misuse Atypical Antipsychotic Drugs
Legal and Public Policy Issues
III
IV. Culture change
III
Culture Change Definitions
“Culture change, or a resident-centered
approach, means an organization that has
home or work environments in which:
– care and all resident-related activities are decided
by resident;
– living environment is designed to be home rather
than an institution;
– close relationships exist between residents, family
members, staff, and community;”
III
Culture Change Definitions, cont’d
– “work is organized to support and allow all
staff to respond to residents’ needs and desires
– management allows collaborative and group
decision –making;
– processes/measures are used for continuous
quality improvement.”
Source: The Commonwealth Fund 2007 Survey of Nursing Homes
III
Key Areas of Culture Change
– Establishing inclusive decision-making
– Reinventing staff roles
– De-Medicalizing the physical environment
– Redesigning the organization
– Creating new leadership practices
Source: California Healthcare Foundation, 2008
III
Four Stages of Culture Change
Stage
Features
1-Institutional
Model
The traditional medical model is organized around a nursing unit
without permanent staff assignment. Neither resident nor staff
are empowered in this model. Staffing inconsistency limits
relationship-building between staff and residents, and depresses
job satisfaction.
2- Transformation
Model
Awareness of the key elements of culture change is pushed
throughout the organization via workshops and educational
sessions for various departments and types of staff. Permanent
staff assignments to units may be made to start the development
of communities within the facility. Low-cost physical changes
may be introduced, including new furniture, artwork, plants,
carpeting, and higher-end finishes—such as crown molding.
III
Four Stages of Culture Change, cont’d
Stage
Features
3-Neighborhood
Model
Traditional units are divided into smaller areas. Residentcentered dining may be adopted, eliminating full kitchens.
Neighborhood coordinators are sometimes introduced and
unique names and physical attributes are developed for each
neighborhood.
4-Household
Model
Self-contained living areas have up to 25 residents. Typically, each
household has its own kitchen, living area, and dining area. Staff
are self-directed teams who perform a variety of functions.
Household management is a collaborative process that places
resident preferences first, followed by staff and household
capacities.
Source: Grant, L., Norton, L. (November 2003) A Stage Model of Culture Change in Nursing Home Facilities.
Presented at the 56th Annual Scientific Meeting of the Gerontological Society of America.