Texas Department of Aging and Disability Services

Texas Department of Aging and Disability Services DADS Involvement in the Culture Change Journey Dorothea Raiford, Regional Director, Region 4/5 DADS Involvement in the Culture Change Journey Dorothea Raiford, Regional Director, Region 4/5

Prominent Initiatives • Green House Project • Culture Change CoalitionImages: girl feeding a kitten, a plant, a puppy

Benefits to Culture Change • Improved Clinical Outcomes • Improvements in Quality Measures/Indicators • Meaningful Family Involvement • Increased Time in Social Interaction • Less Depression • Reduced Medications • Improved Nutritional Health • Lower Mortality • Improved Employee Retention • Increased Cost Effectiveness • Improved Reputation

What is Texas doing to get our nursing homes involved? • Joint training. • The Centers for Medicare and Medicaid Services (CMS) promotes the Culture Change Initiative. • The Texas Quality Improvement Organization (QIO), Texas Medical Foundation (TMF), provides mentoring and guidance to nursing homes seeking to improve quality. • OBRA ’87 provides the regulatory basis for person-directed care. Many nursing homes perceive the regulations to be a barrier to change, in practice, those nursing homes that have implemented culture change have observed positive resident outcomes, which translate into positive survey outcomes.

Regulatory Barriers • One aspect of culture change that providers often find challenging is making the connection between the principles and values of culture change and regulatory compliance. • We will be discussing myths about culture change and look at some of the regulations and how your nursing home can incorporate culture change. If you have questions about how any of the regulations impact culture change in your nursing home, please contact the regional director in your area.Picture of a road barrier

Regional DirectorsFigure is of Regional Directors and their phone numbers: Region 1, Steve Shotts (806) 472-2504: Regions 2/9/10 Roger Barnes (325) 795-5550: Region 3 Kay Savant (817) 792-7229: Regions 4/5 Dorothea Railford (409) 951-3236: Region 6 Brenda McCoy (713) 767-2291: Region 7 Alice Powell (512) 908-9641: Region 8 Carol Ahmed (210) 438-6300: Region 11 Jim Anderson (361) 878-7712

Why Change? According to studies, millions of people would rather die than live in a nursing home. Staff turn over suggest that the majority of people who work in nursing homes would prefer not to.

Image Slide 1 Approximately 92,000 Texans live in nursing homes. Dr. William Thomas leads the Green House Project, and he believes that older people will thrive in a nursing home if it is built to resemble living in one’s own home. Thomas said, “I believe that [in nursing homes] in America, really every year, thousands and thousands of people die of a broken heart. They die not so much because their organs fail but because their grip on life has failed. At the center of the Green House is Quality of Life—meaning worth and dignity.”

Myths about Culture Change • If I try to incorporate culture change in my nursing home the survey team will penalize me. Culture Change initiatives have buy-in from the Centers for Medicare and Medicaid Services • I want to move away from the institutional model nursing home, but I can’t afford to reconstruct my entire home. Improvements can be initiated one step at a time, at your own pace.

Culture Change Topics of Discussion & How They Relate to State & Federal Regulations • Resident Rights • Quality of Life • Dignity • Activities • Quality of Care • Hydration • Nutrition & Food Preparation • Frequency of Meals • Infection Control

F-151 Exercise of Rights The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. A facility must protect and promote the rights of each resident… Exercising rights means that residents have autonomy and choice about how to live their lives and receive care to the fullest possible extent within regulatory requirements and the nursing home’s policies.

F-240 Quality of Life A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life. Each nursing home has a responsibility for creating and sustaining an environment that humanizes and individualizes each resident. How well a nursing home complies with F-240 is determined by the quality of life each resident experiences. Adhering to the principle of community is the key to meeting the intent of this regulation.

F-241 Dignity The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Assuring dignity means that all staff maintain and promote the self-esteem and self-worth of the residents. Promoting dignity is a sign of respect.

F-248 Activities The facility must provide for an ongoing program of activities designed to meet, in accordance with the comprehensive assessment, the interests and the physical, mental, and psychosocial well‑being of each resident. The principle of choice is key to complying with F-248. Activities can occur at any time and are not limited to formal activities provided by activity staff. Others involved may include other staff, volunteers, and visitors.

F-309 Quality of Care Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The principle of respect is key to complying with F-309. Individualized care plans demonstrate respect for the resident as an individual and acknowledge the individual factors that contribute to the resident's health conditions. Continually striving for the highest practicable level empowers the resident to live as independently as possible.

F-327 Hydration The facility must provide each resident with sufficient fluid intake to maintain proper hydration and health. Demonstrating respect for residents, in terms of understanding their preferences and habits regarding fluid consumption, is the key to complying with F-327.

F-364 Food Each resident receives and the facility provides food prepared by methods that conserve nutritive value, flavor, and appearance; and food that is palatable, attractive, and at the proper temperature. Demonstrating respect for residents, in terms of understanding their food preferences and eating habits, is the key to complying with F-364.

F-368 Frequency of Meals (1) Each resident receives and the facility provides at least three meals daily, at regular times comparable to normal mealtimes in the community. (2) There must be no more than 14 hours between a substantial evening meal and breakfast the following day, except as provided in (4) below. (3) The facility must offer snacks at bedtime daily. (4) When a nourishing snack is provided at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span, and a nourishing snack is served. Adhering to the principle of community can help a nursing home focus its culture change efforts in this area.

F-441 Infection Control The facility must establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. The key to complying with F-441 is to assure that the nursing home has an infection control program which is effective for investigating, controlling and preventing infections.

Regulation and Legislation • CMS and DADS Regulatory are both looking at Culture Change and regulatory compliance in nursing homes. • No significant barriers have been identified. • Nursing Homes can actually reduce their deficiencies by: • Seeking positive resident-centered outcomes. • Care planning according to resident wishes.

Image Slide 2 We are looking at our elders through new eyes with culture change. We see them from a position of strength, not weakness. They are creative, rich with history, and filled with ideas for the future. They reach across generations to build a better society. They are spiritual and they take the time to fully explore this dimension of their life. We are learning to understand that we do not sustain our elders – their presence sustains us.

RESOURCESPictures of books, computers using the web, a rolodex

Informational Websites • Joint Training Opportunities http://www.dads.state.tx.us/providers/training/jointtraining.cfm • Quality Matters http://mqa.dads.state.tx.us/qmweb/ • DADS Policy http://www.dads.state.tx.us/providers/index.cfm

DAD Policy Representative Culture change questions regarding the rules can also be directed to: Hannah Ndika Nursing Facility Rule Writer (512) 438-2133

Other ResourcesWeb Links Regulatory Services’ Long-term Care Policy Web Page- http://dadsview.dads.state.tx.us/rsd/policy/ • Alerts/Bulletins • S&C, RS&C, S&CC, Provider Letters and Policy Interpretations • Regulations • Advisory and Board Meetings • Centers for Medicare and Medicaid Services Link • Board of Nurse Examiners Link • Frequently Needed Telephone Numbers

Final Thoughts FOCUS: Focus: Obstacles are those frightful things you see when you take your eyes off your goals. Change: When you see boundaries as opportunities, the world becomes a limitless place! CHANGE:

Texas Department of Aging and Disability Services