Advancing Excellence

inAmerica’s Nursing Homes

Keep Moving!! The AE Goal to Increase Resident

Mobility

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A Word from CMS

Karen TritzActing Director, Division of Nursing Homes

OCSQ

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Overview

Mobility Goal Work-group Chair: Mary Jane Koren, M.D., MPH

It’s National, Voluntary, Aligned, and Free• Registrant:

Register/Update ProfileSelect Goals (at least 2 – 1 organizational & 1 clinical) Work hard to improve performance!

• Take it up a notch - be an Active Participant!!All of the above PLUSSubmit Data so you can compare your results to others

(see QAPI element 3: “review findings against benchmarks”)

Get credit: be recognized as a participant!!

About the Campaign(www.nhqualitycampaign.org)

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MobilityPerson-

CenteredCare

ConsistentAssignment

InfectionsC. difficile

Pressure UlcersStaff Stability

MedicationsAntipsychotics

Hospitalizations

Pain Management

Quality Improvement Resources for NINE Goals

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Thank you to the entire workgroup

• Mary Jane Koren, M.D., M.P.H. • Jo A. Taylor, R.N., M.P.H.• Mary Tinetti, M.D.• Jennifer Brach, PT, Ph.D.• Kris Mattivi, M.S., P.T.• Lisa Bridwell• Linda Sue Davis, R.N. M.S.N.• Lorraine Hiatt, Ph.D.• Melanie McNeil

• Urvi Shah, M.P.H.• Adrienne Mihelic, Ph.D.• Carol Scott• Elaine McMahon, M.S., R.N.• Tammy Rolfe, R.N., L.N.H.A.,

M.S., H.P.M. • Carol Benner, Sc.M. • Ruta Kadonoff• Chris Condeelis

Understanding “Why Mobility?”

Jo A. Taylor, R.N., M.P.H.Carolinas Center for Medical Excellence

Two Models

Poor Clinical Outcomes

• Falls• Restraints• Pressure ulcers• Urinary tract infections• Pain• Dehydration• Poor nutrition• Delirium

Medical Model

Quality of Care and Resident Life

• Quality relationships• Workforce stability• Consistent assignment• Effective leadership• Teamwork• Critical thinking• Real time problem solving• Individualized care strategies

Person Centered Care Model

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Two Models

In a medical model, fall prevention makes the most sense, at any cost.

In a person centered care model, mobility moves out ahead.

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Individualized Care

• Practical management of the resident’s fall risk – post fall investigation – interdisciplinary root cause analysis – individualized interventions for identified risk factors

fundamental strategies of person centered care

The Mobility Goal contains information to implement a practical falls management program.

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Mobility

One of the best ways to reduce the seriousness of falls is to preserve and enhance resident mobility.

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What is mobility?

• Mobility means being able to move your own body or having someone help you move from place to place.

• Mobility is not just walking. It is about strength, flexibility, balance and staying power.

• It includes: – Turning over in bed– Getting up from a chair – Standing – Using a cane, walker or wheelchair to get around – Moving from place to place within or outside the nursing home.

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Why is mobility important?

For residents maintaining or improving mobility •Strengthens muscles and bones

•Improves appetite

•Gives a sense of confidence and well-being, which improves mood

•Reduces serious falls

•Improves sleep and energy level

•Makes it easier for residents to socialize and participate in group activities

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Why is mobility important?

For staff, helping to keep a resident mobile

•Facilitates self-care so residents can do more for themselves

•Makes transfers easier and safer for staff as well as residents

•Promotes safer walking, fewer serious falls

•Enables residents to access toilets more quickly and easily to promote continence

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How will mobility be measured?

Uses 2 new composite measures constructed from MDS-3 items

% of Residents with Improvement in Personal Movement– looks at how independently an individual can move in bed, transfer, or

walk in their room and corridor. It is the individual who is “responsible” for, or carries out, the movement.

% of Residents with Improvement in Life Space Mobility– considers area within the entire NH through which an individual moves

during a set period of time. Movement can be independent or assisted by another person or device (such as a w/c). Greater life-space mobility would theoretically relate to greater involvement in life situations or greater participation in social activities

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What happened to physical restraints?

Why were residents being restrained? • To control “problem behaviors”

• To prevent falls

What have we learned? • “Problem behaviors” are symptoms of unmet needs and most often

can be managed with non-pharmacologic interventions and person centered care

• Physical restraints do not eliminate falls – they can actually make falls more serious and have devastating consequences

The Mobility Goal contains information to continue to make nursing homes restraint free – it can be done!

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Isn’t this goal really just for the therapy staff?

No, this is not just a job for therapists!! Keeping residents as physically functional and independent as possible is:

• Everybody’s job – aides, nurses, dietary, housekeeping, administration … the whole team

• As important a part of routine daily care as skin care or vital signs

• As much about the environment as it is about care17

This diagram is courtesy of Dr. Lorraine Hiatt, a member of the Mobility work group

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Polling Question

Where are you on the mobility scale? Physical restraints Restraint freeAlarms AlarmsAntipsychotics (AP) AP’s

1 2 3 4 5 6 7 8 9 10Schedule focus Resident focusLittle time/staff for ambulation Staff encourage self care & movementRole of therapy Frontline staff monitor resident mobilityLimited areas for walking Exercise activities W/C seating all day Environment for mobilityExcess safety Walking and dining programs

Medical model Person Centered Model

QAPI Five Elements

• Element 1: Design and Scope• Element 2: Governance and Leadership• Element 3: Feedback, Data Systems and Monitoring• Element 4: Performance Improvement Projects • Element 5: Systematic Analysis and Systemic Action

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What the workgroup developed or identified

Use the Mobility Goal “package” of resources to improve care and become QAPI compliant

•AE’s Circle of Success – PDSA change framework for systematic performance analysis leading to systemic action (QAPI Element 5)•Data measurement & tracking tools (QAPI Elements 3, 4 and 5)•Root cause analysis tools – called “Probing Questions” (QAPI Element 5)•Consumer, staff, and leadership fact sheets (QAPI Element 2)

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Mobility Resource Package

Evidence-based or field tested educational materials and clinical practice tools (QAPI Element 1)

• Walking programs• Dining programs• Exercise programs• Environmental design• Bed mobility• Transfer• Wheelchair seating & mobility• Balance, endurance, strength

• Restraint reduction• Falls management

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AE INCREASE RESIDENT MOBILITY WEBSITE RESOURCES & TRACKING TOOL

Adrienne Mihelic, Ph.D.

PPlanlanDoStudyAct

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Explore the Goalwww.nhqualitycampaign.org

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www.nhqualitycampaign.org

Why choose mobility?

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www.nhqualitycampaign.org

PlanDDooStudyAct

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Where am I?www.nhqualitycampaign.org

PlanDoSStudytudyAct

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Studywww.nhqualitycampaign.org

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www.nhqualitycampaign.org

Examine Processes

Probing Questions

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Examine Processeswww.nhqualitycampaign.org

PlanDoStudyAActct

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Improvewww.nhqualitycampaign.org

http://www.nhqualitycampaign.org/star_index.aspx?controls=MobilityImprove

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Engagewww.nhqualitycampaign.org

Data and the Quality Improvement Process

How do I know where I am?

Where do I want to be?

What processes are associated with my outcome?

When I change a process, how do I know it had the effect I wanted?

How am I doing compared to other nursing homes working on this goal?

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QA and PI

Quality Assurance Performance Improvement

Reactive Proactive

Episode or event-based Aggregate data & patterns

Prevent recurrence Optimize process

Sometime anecdotal Always measurable

Retrospective Concurrent

Audit-based monitoring Continuous monitoring

What went wrong? How can we be excellent?

• Easy view of individual records allows resident-level view

• Matrix of individual data allows scanning for patterns

• Summary information helps identify opportunities to improve at the system level

Tracking Tools Support both QA and PI

The Tracking Tool

AE_MobilityTrackingTool.xls

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www.NHQualityCampaign.org

Thank you pilot testers!

Step 1: Monthly mobility assessment on every resident you are tracking. 8 items.

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Thank You For making our nursing homes better places to live, work, and

visit!