BUILDING CULTURE CHANGE ON A QUALITY SYSTEMS FOUNDATION

1. BUILDING CULTURE CHANGE ON A QUALITY SYSTEMS FOUNDATION

2. Elliott Nursing & Rehab Center • We are a Diversicare / Advocat Facility • The facility is a 75 bed facility located in rural Northeastern Kentucky • We are dually certified in Medicare & Medicaid

3. We have been on a journey toward Person Centered Care since 2005 Started with permanent staff assignments, creation of neighborhoods, some increase in choice and staff education about encouraging resident choice and increasing dignity Continued with added food choices with meals and improving the dining experience More effort to request resident feedback and act on their suggestions The Beginnings of Person Centered Care

4. Education & Discussion • Educated administration and entire staff by watching videos and reading books about other homes who had initiated Person Centered Care programs • Held group meetings with all levels of staff about what programs could be implemented in our facility

5. Set Goals • Create more flexible schedules and less regimented routines • Decrease the institutional aspects of our facility • Add choice and variety • Increase resident involvement in everyday decision making for self • Maintain or improve quality of nursing care and key outcomes

6. Identify Staff Related Challenges • Staff feel that a large population of residents cannot make decisions for self • Fear of change • Staff question if the quality of care can be maintained with a less structured regimen

7. Review Quality Measures and Quality Indicators to Identify Trends & Challenges • Large population of Diabetic Patients • Patients at risk for skin breakdown • Many polypharmacy residents • Many patients who exhibit behaviors and receive antipsychotics or behavior modification meds • Large population at risk for falls

8. Identify Proposed Person Centered Care Programs • Sweet Dreams • Rise & Shine Anytime • 5 Meal or Peak Dining • Home-Like Medication Regimen

9. Sweet Dreams Goal is to increase quality of life for all residents by providing a more home-like atmosphere. Also, to decrease behaviors and related medications by modifying our schedules to allow for meaningful sleep time for patients

10. Quiet hours implemented from 9p.m. to 9a.m. Only essential care is performed at night Lights in hallways turned to lowest setting Staff to use quiet voice No overhead lights in resident rooms unless absolutely necessary Overnight briefs Implemented Elimination of unnecessary turning and repositioning at night Sweet Dreams

11. Residents are evaluated for use of overnight briefs • Review Skin Assessments • Bed Mobility • SRNA/Nursing Report • Empower SRNA’s to make immediate status changes • Daily, weekly, and quarterly review ongoing

12. Rise & Shine Anytime Goal is to allow residents to sleep undisturbed until they awaken naturally unless medically contraindicated.

13. Identified preferences of all residents regarding sleep with interview and observation All facility schedules reevaluated and updated to accommodate resident preferences Quiet hour until 9 a.m. Lights stay low and voices quiet until 9a.m. All daily routines reevaluated and updated Update preferences and adjust ongoing Rise & Shine Anytime

14. Outcomes for Sweet Dreams And Rise & Shine Anytime Programs • Fewer combative residents • LTCQ data revealed behavioral symptoms improved from “Needs improvement” to “Exceptional” • Depression decreased from 23% in Sept 2007 to 7% in March 2008. (Programs were implemented Sept 20th, 2007)

15. Outcomes Continued • Identified a decrease in episodes of shear • No negative outcomes from use of overnight briefs

16. 5 Meal or “Peak Meal” Dining Goal is to allow residents more food choices and greater flexibility regarding meal times to accommodate overall preferences. Program is also intended to address the needs of the diabetic population through appropriate monitoring.

17. 5 Meal or “Peak Meal” Dining • Continental Breakfast • Brunch • Siesta Fiesta • Dinner • Night Cap Snack

18. 5 Meal or “Peak Meal” Dining • Housekeeping and activities staff assist SRNA’s in passing trays • All staff assist with meals on their neighborhoods • Meals in dining room as served buffet style with two meals and added choices. • SRNA’s take orders from each table to create a dining out feel and encourage choice

19. 5 Meal or “Peak Meal” Dining • Therapeutic diets are limited to lower concentrated sweets and mechanically altered diets • Choices are honored regardless of diet • Diabetic patients are monitored as needed and A1C levels for all diabetics are tracked and trended.

20. Outcomes of “Peak Meal” Dining • No weight loss in observation period that were not expected outcomes of disease process • Improvement in A1C levels in 11 of 15 diabetic residents • Weight Gain was a negative result in two alert and oriented residents. Their preferences are honored but risks and benefits explained • Some desirable weight gains in patients who were difficult to encourage to eat or ate very small portions

21. Home-Like Medication Regimen Goal is to develop an individualized medication program for each resident while also accommodating daily routines and preferences as much as possible.

22. Home-Like Medication Regimen • Meet with Medical Director & Pharmacist to develop a plan of implementation. • Interview residents to determine current preferences of sleeping, waking, activities,etc. • Review each resident’s MAR to determine if frequencies can be reduced or unnecessary meds eliminated.

23. Home-Like Medication Regimen • All Q day administered once a day as indicated • All BID meds are administered upon rising & at bedtime • All TID meds are administered upon rising, afternoon, and bedtime. • All QID meds are administered upon rising, early afternoon, late afternoon, and bedtime.

24. Home-Like Medication Regimen Outcomes • No survey deficiencies for med pass • Does away with the traditional 2 hour med pass time frame. • Allows flexible resident schedules • Reduced overall number of pills passed

25. Ongoing Monitoring • Continue to utilize methods of monitoring and screening patients for participation in all programs and update as needed based on resident need and assessment. • Track and trend customer satisfaction results, QM’s, QI’s, and other quality information and address negative outcomes or trends • Continue to ask residents and staff about changing needs and preferences

26. Contact Information Benita Adkins, Administrator Nancy Lowe, Dietary Manager Michelle Adkins, LPN Elliott Nursing & Rehab Center P.O. Box 694 Sandy Hook, KY 41171 Phone: 606-738-9400 Email: BAdkins@Advocat-Inc.com