Turning Challenging Families into Partners in Care: A Case Study

1. Turning Challenging Families into Partners in Care: A Case Study May 13, 2010

2. Mary Tellis-Nayak VP Quality Initiatives mary@myinnerview.com 773-942-7525

3. Objectives Name 2 issues which families face when they place their loved one in a nursing home. Describe the system a home can put in place to help families be partners in care. Name three items which families feel are very important if they are going to recommend your home to someone else. Name three areas of long-term care which are highly correlated with how the frontline views its work environment.

4. Setting the Stage

5. Difficult Transitions • For family members, the emotional burden of nursing home placement may be greater than death. • Use of anti-anxiety meds increased from 14.6% to 19% after admission • Nearly 50% of families were at risk for clinical depression following admission

6. Family involvement • More than 50% of both spousal and non-spousal caregiver continue to participate in the physical care of the resident. • About half of spousal caregivers visit daily and an additional 45% at least weekly • 25% of Non-spousal caregivers visit daily • 2/3rd report visiting at least weekly

7. The majority of caregivers visit their relatives on a regular basis and perform tasks similar to those carried out when the care recipient was living at home.1. Managing money2. Arranging medical care3. Arranging transportation4. Providing social support

8. NEW tasks for families • Interacting with administration and staff • Advocating for their relative • Advocating for other residents

9. Family reactions to placement • Feelings of guilt complicate their emotional responses to the challenges that occur • Families often fault the facility as their loved one continues to decline • Families’ expectations are often unrealistic • Intensity of one-on-one care • Anger, resentment and sometimes lawsuits

10. Is there a place for education? • Nursing homes do NOT typically promote family education. • In a study in MI, 25% of facilities encouraged family members to attend classes about chronic illness. • 33% of facilities encouraged families to groups to help solve nursing home problems. • 75% of facilities encouraged families participate in medical decision making, nursing homes do little to enhance their knowledge.

11. A Systems ApproachFamilies as PartnersA Case Study

12. Let’s start at the END! Families seem far more apt to come to the staff with concerns, than those that had never met an admitting nurse. Any extra time spent assessing at admission will develop a rapport with the staff that will “save time” in the long run. If a family or resident feels more comfortable and open with their admitting staff, they will tell them and not the DHS or an attorney about their concerns. Even better, we will be able to avoid the “concern” before it grows.

13. Components of this system • The Clinical Assessment • Identification of risk • Implementation of an immediate plan of care • Including the families as partners in care • Educate staff on each component of the system • Educate families on the areas of risk

14. Identify Areas of Risk • Behavior symptoms • Dehydration • Elopement * • Falls • Pain * • Physical restraint • Urinary incontinence • Unintended weight loss

15. The Clinical Assessment • Identify all MDS elements that will trigger one of the areas of risk. • Some will have no MDS elements triggering them • These data elements become the backbone of the clinical assessment tool. • Identify components of a comprehensive geriatric nursing assessment which are NOT included in the MDS.

16. The Clinical Assessment • Not all the MDS elements are included in the initial assessment – only those that trigger an area of risk. • The MDS does NOT assess all areas included in an acceptable geriatric nursing assessment. • The Clinical Assessment is not intended to establish a reference date, a payment level or a Comprehensive Plan of Care.

17. How does it work? • The admitting nurse fills out the clinical assessment • Each section of the assessment has an area for notes • Record any information felt to be important to the assessment process • Record feedback/input from family members

18. What’s next? • Next shift – opens a new MDS and enters those sections of the Clinical Assessment which have been taken from the MDS • This nurse then generates the Trigger Analysis/RAP Summary • This list becomes the list of potential areas of risk for this resident • Be sure to look carefully at areas of risk which may not have been triggered by the MDS (i.e. elopement)

19. Why an Immediate Plan of Care • An IPOC template is created for each of the possible areas of risk. • This creates a standard for the delivery of care to residents identified at risk from day one. • Many accidents and incidents occur prior to the completion of the initial MDS. • Involving family members as our partners in care will reduce our residents’ risk, improve their quality of life and reduce our risk.

20. Components of the IPOC • Problem identified (which MDS elements triggered) • Suggested interventions for each triggered MDS item • Interventions (list all potential interventions and allow space for personalization) • Family/Responsible Party Involvement

21. Immediate Plan of Care • Based on the areas of risk, an Immediate Plan of Care is created for each area. • This information is communicated to the frontline caregivers. • This information is shared with the resident.

22. Stating the Goals • Frequently goal statements may appear to make promises which nurses feel are unrealistic. • “The resident will be orient to time…” • “The resident will not fall” • “The resident will not develop a pressure ulcer” • While clinicians make every attempt to reach these goals, in some cases it is impossible!

23. RE-Stating the Goals • State the goal in a way which better describes what nursing is setting out to do • Examples: • Urinary Incontinence: Goal – To manage incontinence….. • Pressure Ulcers: Goal – To manage the risk factors which contribute to pressure ulcer development.

24. Families as Partners • Family members need to be informed soon after admission about issues related to their loved one. • What can I expect to happen? (Successes/risks) • What can I do to help? (Partner in caring) • The IPOC ‘s need to contain information which will serve to educate families about potential risks as well as promote and support their involvement in care.

25. Families as Partners • Discussion with a member of the family should take place either in person or by telephone within 4 days of the initial assessment • Possible staff who might have this conversation could include: charge nurse, admitting nurse, social services, MDS Coordinator etc.

26. Families as Partners • The IPOC’s outline ways in which a family member can be a partner in care • What can family members do to help? • What further information can family members provide to help you provide better care? • What worked at home? • What didn’t work at home? • What was their schedule at home?

27. Families as Partners • Documentation of this conversation, by phone or in person, should be entered ON the IPOC in spaces provided on the form: • Date of discussion • Check: In person____ On the phone ___ • Family member’s name • Signature of staff who contacts the family • Check the box to indicate this was discussed with the resident.

28. Educating through Brochures • Develop a small education brochure for each area of risk in your program • Contents • Introduction – an overview of the area of risk (i.e. what is dehydration; what causes pain etc.) • Effects on Aging – what are the special aspects of this area of risk which are exacerbated by age. • Symptoms • Treatment • Prevention • What you can do as a partner in care

29. Using Brochures • Intended to teach families about some of the risks connected with aging • Should be used at the time the staff person speaks with the family member • If in person, they are given to the family • If on the phone, they are sent to the family

30. Documented Results One family was admitting a mom, having previously had their dad in our home. “We feel more comfortable approaching the staff with problems and suggestions as we know you are interested in our mom as an individual”.

31. So – what do families want?

32. My InnerView 8,500+ providers in all 50 states and District of Columbia use our tools Skilled team of professionals with extensive senior care operational, clinical, regulatory and academic experience Sent more than 2 million surveys in 2008 Recommended by: 5 national associations 40 state associations

33. To provide long-term care leaders evidence-based management tools to better achieve their organization’s goals

35. PredictingPerformance

36. KEY PERFORMANCE DRIVERS higher family satisfaction lower nursing assistant turnover higher employee satisfaction higher family satisfaction

37. KEY PERFORMANCE DRIVERS higher satisfaction among families and employees higher occupancy rates

38. KEY PERFORMANCE DRIVERS higher satisfaction among families and employees better clinical outcomes related to falls, pressure ulcers and catheters

39. Qualityof care Stability Turnover Resident/Family Satisfaction FinancialHealth SUMMARY OF RELATIONSHIPS Staff Satisfaction

40. Resident, Familyand EmployeeSatisfaction Surveys

41. Meeting thedesires ofresidents

42. When you don’trememberanything,you’re satisfied! Loyalty is generated by memorable thingsthat happen that we didn’t expect

43. The Law of Memorable Events • Though it takes somebody doing something special beyond what is expected, it doesn’t take everybody doing something special all the time • It takes only one brief experience on only one day of a stay to determine dissatisfaction or loyalty

44. Understanding the patient’s mind • Satisfaction and loyalty are not won on field of best clinical quality • Clinical and process outcomes is not where battle for consumer’s mind is being waged • Residents judge their experience by the way they are treated as a person, not by how they are treated for their disease • Perceptions of personal treatment are more highly correlated than clinical competence

45. Loyalty is generatedby memorable thingsthat happen thatwe didn’t expect. These cause a personto give score of“Excellent,” not “Good”

46. “Research shows that, in most industries, there is a strong correlation between a company’s growth rate and the percentage of its customers who are raving fans — that is, those who say they are extremely likely to recommend the company to a friend or colleague.” For My InnerView users,this is “Excellent”

47. The Law of Memorable Events • Though it takes somebody doing something special beyond what is expected, it doesn’t take everybody doing something special all the time • It takes only one brief experience on only one day of a stay to determine dissatisfaction or loyalty

48. Loyaltycomes fromcompassion What words on comment cards madethe patients love the staff?

49. If one were topick out thesynonyms forcompassion, there is an amazing consistency in the qualities that have the greatest impact on patient loyalty

50. Compassion • Questions from survey companies that have questions with “care,” “compassion” or “concern” in them have the highest correlation with overall satisfaction and loyalty • Compassion dramatically influences overall satisfaction