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Falls in Nursing and Personal Care Homes Looking at Culture and Collaboration Paula A. Bracken, PCHA, MHA Affinity Health Services, Inc. November 30, 2010 PHCA Webinar Affinity Health Services, 2010 Overview The Elderly and where they live Falls definition and MDS 3.0 Regulations Various Risk Factors & Interventions What difference does a change in culture make? We need a different approach Affinity Health Services, 2010 The Elderly Community-Dwelling Personal Care / Residential Nursing Home Affinity Health Services, 2010 Falls A very broad issue with many factors involved There is no simple solution Falls are a result of complexities within a person as well as within the environment in which they dwell Affinity Health Services, 2010 Falls Definition ◦ An unintentional change in position coming to rest on the ground, floor or onto the next lower surface – MDS 3.0 Examples Coming to rest on the foot rests of a wheelchair Knees give out and the person has to be lowered to the floor Affinity Health Services, 2010 MDS 3.0 G0300: Balance During Transitions and Walking G0400: Functional Limitation in Range of Motion G0600: Mobility Devices G0900: Functional Rehabilitation Potential Affinity Health Services, 2010 Impaired Balance -planning for care Evaluate Assess to identify all risk factors Care Plan to Prevent further decline in function and/or return of function ◦ Depends on resident-specific goal(s) Affinity Health Services, 2010 MDS 3.0 J1700 :Fall History on Admission J1800: Any Falls Since Admission or Prior Assessment (OBRA or PPS), whichever is more recent J1900: Number of Falls Since Admission or Prior Assessment (OBRA or PPS), whichever is more recent Affinity Health Services, 2010 Falls – planning for care Evaluate potential need for further assessment and intervention Evaluate the environment Evaluate staffing in relation to residents at risk for falls Affinity Health Services, 2010 Consequences of falling Injury ◦ 20-30% suffer serious injuries ◦ 2-6% suffer fractures Fear of falling in daily life activity Restricted mobility and activity Loss of independence Increased social isolation Admission to residential care/nursing home Affinity Health Services, 2010 Falls are Most frequent accident in PC/AL and NHs 40% of all NH residents fall each year Several fall 1+ times 35% occur with those who cannot walk 10-20% cause serious injuries Fall history / fall injury before admission Prevalence of falls in NH higher than among community-dwelling elderly Affinity Health Services, 2010 Inadequate supervision Frequently cited by state in both PC and NHs Occurs when there is failure to ◦ Recognize signs and symptoms of fall risk ◦ Intervene appropriately ◦ Plan interventions to prevent future falls Affinity Health Services, 2010 Personal Care Homes Prevalence of falls depends on ◦ ◦ ◦ ◦ Population characteristics Personal Care Home practices Staff skills Systems established Affinity Health Services, 2010 Nursing Home Regulation & Practices Affinity Health Services, 2010 The Nursing Home Institutional by nature and background A medical-model that focuses on tasks and routine Affinity Health Services, 2010 The Institutionalized Culture The underlying “risk factor” F 252 Environment ◦ “a homelike environment is one that deemphasizes the institutional character of the setting . . .A personalized homelike environment recognizes the individuality and autonomy of the resident . . . . Affinity Health Services, 2010 Institutionalized Culture Standardized “treatments” based on medical dx Schedules and routines designed by and for staff Task-oriented work and rotation of assignments “sterile” environment Activities only available when activity staff are on duty -Pioneer Network, 2008 Affinity Health Services, 2010 Typical Interventions Investigate incident first ◦ Ideally - details from investigation determine what interventions are put into place Alarms ◦ Chair ◦ Bed ◦ Motion detect Padded mattress beside bed Shoes on, etc. Affinity Health Services, 2010 F 323 Accidents The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. Affinity Health Services, 2010 Accidents and Supervision Falls related to ◦ ◦ ◦ ◦ ◦ ◦ Alarm use or misuse Misuse of Equipment Improper Supervision and Assistance Lack of proper Assessment Lack of new interventions Poor communication Affinity Health Services, 2010 Why not Alarms? False sense of security Residents learn to turn them off Can malfunction; battery goes out A Dignity issue Contributes to institutionalized atmosphere Survey deficiencies related to alarms Affinity Health Services, 2010 Why not Alarms? Staff respond to the alarm and not the resident Creates confusion from startling noise which increases agitation Everyone can become desensitized Potentially “immobilizes” resident ◦ Decline in ADLs ◦ Can act as a “restraint” Interrupts sleep Affinity Health Services, 2010 Why not Alarms? Wide spread and long-term use A false-assurance for staff Startles the resident Constrains resident from normal re-positioning movements – may contribute to ◦ Pressure sores ◦ Weakened muscles Affinity Health Services, 2010 Examples of deficiencies Alarm did not sound Nurse aide forgot to turn alarm on/attach alarm to resident Resident turned alarm off Resident removed clothing to which alarm attached Lack of monitoring alarms Affinity Health Services, 2010 Conclusion There is a lack of evidence that support the use of alarms to prevent falls Alarms cannot be used in place of supervision Institutionalized care demoralizes the individual and contributes to poor clinical outcomes Affinity Health Services, 2010 Therefore Change is Needed “… A “homelike” or homey environment is not achieved simply through enhancements to the physical environment. It concerns with striving for person-centered care that emphasizes individualization, relationships, and a psychosocial environment that welcomes each resident and makes her/him comfortable . . .” - CMS, 2009 Affinity Health Services, 2010 Interventions and approaches Considering Culture and Collaboration Affinity Health Services, 2010 S.e.r.v.i.c.e. - A Leadership model Service Education Respect Vision Inclusion Communication Enrichment Leadership is "the art of influencing and engaging colleagues to serve collaboratively toward a shared vision” ◦ -S. Gilster, “Changing Culture, Changing Care”, 2009 Affinity Health Services, 2010 Collaboration “a team, with each individual contributing unique talents in such a way that all are used to accomplish the goals and vision.” “people coming together as one . . . To create a culture or outcome consistent with the vision” -S. Gilster, “Changing Culture, Changing Care”, 2009 Affinity Health Services, 2010 What does “Person-Centered” mean? The Person is the focus Build relationships among care-givers Gain insight to individualize care routines Knowing residents and relating to them as an individual allows for spontaneity and creativity in the approach Affinity Health Services, 2010 Person-Centered Approach Puts the Resident first, and tasks second Identify patterns of resident needs ◦ Toileting, walking, stretching, pain treatment ◦ Identify discomfort related to positioning ◦ Change staffing patterns on 3-11 to better meet resident needs Affinity Health Services, 2010 Person-Centered Culture Resident- Choice is critical Meeting the personal wishes of the resident helps to create the foundation for care-giving relationships Direct care staff can have input into the care-planning for a resident Affinity Health Services, 2010 Other Positive Culture-Oriented Approaches PHI National ◦ A “Relationship-centered" culture that first and foremost supports Resident choices and all relationships Supervisor – Staff Staff- Staff Staff – Resident Core skills, particularly those related to communication, problem-solving and relationship building are needed Affinity Health Services, 2010 Results are a far more empowering and satisfying environment for both staff and residents When you individualize care, you minimize the need for alarms Affinity Health Services, 2010 Changing Care Routines Mornings – allow to sleep in – individualize care routine per person - this will affect other systems and processes, such as meals, when medications are given, when treatments are done, etc. Bladder care – individualize- follow patterns Medication Pass – a nursing task – can change medication policies for administration time from ◦ “8 a.m.” to “upon rising” ◦ BID to “upon rising” and “before dinner” ◦ TID to “upon rising”, “before lunch” and “before bed” Affinity Health Services, 2010 Changing Care Routines Suppositories – do not awaken early to give – go back to the basics – high fiber & fluids & exercise Pain management – individualize ◦ MDS 3.0 – tells us characteristics of a resident’s pain and it’s affect on function and mood Foodservice – Provide a time range (i.e. ) 8 a.m. – 10 a.m. - personalize service Affinity Health Services, 2010 A Resident “Right” to a Safe Environment It is the Right of a Resident to live in a safe, structured, and predictable environment: ◦ ◦ ◦ ◦ ◦ ◦ Designed around the needs of the person Safe and well lit, Offer areas for walking or wandering, Be uncluttered, Be pleasant Provide a structured schedule of activities and meals ◦ Stimulating the senses, yet providing a sense of security Bell & Troxel, 1997 Affinity Health Services, 2010 Environmental Re-design If it is financially feasible, an internal environment that is re-designed to facilitate the ◦ Supervision of residents ◦ Movement of individuals throughout the area ◦ Creation of a homelike environment that resembles more of a “home” versus an institution – smaller gathering places According to the Pioneer Network, more documented research in this area is needed -Pioneer Network, 2008 Affinity Health Services, 2010 Neighborhoods vs. ‘Units’ Resembles a town Rooms are a “home” Community or “country” kitchen ◦ Creation of a “hearth” – place to gather ◦ Improved intake and nutrition – overall health Affinity Health Services, 2010 Therapy and Activities as an Intervention Provides supervision Exercise improves blood circulation Increase strength and endurance Improved sense of well-being Improved sense of self-worth Improved function Affinity Health Services, 2010 Affinity Health Services, 2010 Treatment and Prevention of Osteoporosis in LTC Setting Based on Clinical Practice Guideline from AMDA ◦ Dx. of Osteoporosis , Osteomalacia or Osteopenia ◦ Order a Vitamin D level (25-OH- D3 or 25hydroxy D3) Sufficient is 32 ng/ml or greater 25 –OH-D3 Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting, 2009 Affinity Health Services, 2010 Institute measures to improve function Encourage exercise to increase muscle strength in leg muscles Use restorative services to improve strength, balance and ambulation Discontinue or reduce medications that affect balance or level of consciousness Administer Vitamin D and Calcium supplements Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting, 2009 Affinity Health Services, 2010 Affinity Health Services, 2010 Treatment and Prevention of Osteoporosis in LTC Setting To Maintain or improve Calcium Balance ◦ Calcium Calcium Carbonate Calcium Citrate Vitamin D Cholecalciferol (D3)– best absorbed Ergocalciferol (D2) 1,25 di-hydroxyvitamin D Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting, 2009 Affinity Health Services, 2010 Treatment and Prevention of Osteoporosis in LTC Setting Anti-resorptive Medications ◦ Calcitonin ◦ Raloxifene ◦ Bisphosphonates Anabolic Medications ◦ Parathyroid hormone Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting, 2009 Affinity Health Services, 2010 When not to treat Osteoporosis Terminal condition /palliative care Unable to tolerate pharmacologic tx Unwilling to accept treatment Has been tx’d with Biphosphonates for past 5 years Patient is non-weight bearing and requires maximal care No evidence of Treatment efficacy Source: AMDA, Osteoporosis and Fracture Prevention in the Long Term Care Setting, 2009 Affinity Health Services, 2010 Fall Risk Assessment Assess characteristics of the resident ◦ ◦ ◦ ◦ Hx. of a fall Recent illness and multiple co-morbidities Dx. Osteoporosis and/or Vitamin D deficiency Medications and drugs that impact balance, cognition, etc ◦ Restorative nursing ◦ Therapy received ◦ MDS 3.0 data and process Affinity Health Services, 2010 Example of an Intervention Program using a Fall Risk Assessment General /Medical Assessment Fall Risk Assessment ◦ ◦ ◦ ◦ ◦ At Admission After a Fall Incident At the request of a health-care professional On a change in condition Periodic review Fall Prevention Meeting – evaluate Medical and Fall Risk Assessment data together From Neyens et al. (2008) Affinity Health Services, 2010 Fall Prevention Team Evaluate Fall Prevention Activities ◦ General – Facility-related ◦ Specific – Resident-related Fall Prevention Meeting ◦ Evaluate general and specific fall prevention activities ◦ Minimum twice a year From Neyens et al. (2008) Affinity Health Services, 2010 Individual Fall Prevention Activities Anticipating the circumstances & causes of falls Critically reviewing medication intake ◦ Type, number, dose and time of intake Individually designed exercise programs Careful reassessment of need for assistive aids ◦ Promotion of correct use of these aids From Neyens et al. (2008) Affinity Health Services, 2010 Investigation Keep it “Person-centered” – not just a process Critical thinking of what went wrong Details surrounding the incident Current interventions during the incident New interventions added after ◦ Add to care plan Affinity Health Services, 2010 We can no longer take a cookie-cutter approach to addressing the issue of Falls and expect improvement “Insanity is doing the same thing over and over again, and expecting different results.” -Albert Einstein Affinity Health Services, 2010 Making Changes Trial changes in one area Trial one change at a time Communicate to all involved the “what” and “why” of the change ◦ i.e. - to Reduce Falls, Improve Care, etc Track and Trend Fall data for evidence of reduction Evaluate and Re-adjust accordingly Affinity Health Services, 2010 References American Medical Directors Association. Osteoporosis and Fracture Prevention in the Long-Term Care Setting Clinical Practice Guideline. Columbia, MD: AMDA 2009 Bell, V. & Troxel, D. (1997). The Best Friends Approach to Alzheimer’s Care. Baltimore, MD: Health Professions Press, Inc. Bishop, M. D., et al, (2010). Improved Fall-Related Efficacy in Older Adults Related to Changes in Dynamic Gait Ability. American Physical Therapy Association. Retrieved November 1, 2010 from http://ptjournal/apta.org/content/90/11/1598 Clemson, L, et al. (2008). Environmental Interventions to Prevent Falls in Community-Dwelling Older People: A Meta-Analysis of Randomized Trials. J Aging Health, 20:954, Sage Publications. Retrieved November 1, 2010 from http://jah.sagepub.com/content/20/8/954.refs.html CMS Internet Training. (2007) From Institutional to Individual Care Part III: Clinical Case Studies in Culture Change. Retrieved from http://www.cmstraining.info/pubs/VideoInformation.aspx?cid=1061 Affinity Health Services, 2010 References Centers for Medicare & Medicaid Services. (2009). Code of Federal Regulations. State Operations Manual, Appendix PP. Glister, S.D., (2005). Changing Culture, Changing Care: S.E.R.V.I.C.E . FIRST. Cincinnati Book Publishing, Jarndyce & Jarndyce Press Neyens, J. C. L. , et al., 2009. A multifactorial intervention for the prevention of falls in psychogeriatric nursing home patients, a randomized controlled trial. Age and Ageing, 38:194+. Oxford University Press. Social Care Institute for Excellence. (2005). SCIE Research Briefing 1: Preventing falls in care homes. Retrieved November 1, 2010 from http://www.scie.org.uk/publications/briefings/briefing01/index.asp Pioneer Network, 2008. Creating Home Background Paper. Retrieved July 1, 2010 from http://www.pioneernetwork.net/Data/Documents/CreatingHome-Bkgrnd-Paper.pdf Affinity Health Services, 2010