restore your restorative nursing program · o0500i, amputation/prosthesis care: activities to...

Harmony Healthcare International, Inc.

Copyright © 2012 All Rights Reserved 1

Restore Your Restorative Nursing Program

Harmony University

The Provider Unit of

Harmony Healthcare International, Inc. (HHI) Presented by:

Beckie Dow, RN, RAC-MT

Denise Bird, PT Regional Consultants

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Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 2

Today’s Objectives

To explain what is meant by Restorative Nursing

To explain the criteria for the Restorative Nursing program

To demonstrate an understanding of the basic documentation requirements for the Restorative Nursing program

Copyright © 2012 All Rights Reserved 3 Harmony Healthcare International, Inc.



Restorative Nursing Program

Restorative Nursing Program (RNP) refers to nursing interventions that promote the resident’s ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning.


5

Why Consider a RNP?

Maintaining independence in activities of daily living and mobility is critically important to most people

Physical benefits of maintaining mobility are proven through many studies

Increased independence in even a few areas of personal care can have significant mood benefits

Potential financial benefits for the facility


The Dangers of Functional Decline

Functional decline can lead to:

Depression or decreased mood

Withdrawal from activities of interest

Social isolation

Immobility and increased muscle weakness

Incontinence

Pressure ulcers

Respiratory insufficiency

And ultimately, death!




The Positive Impact of RNP

Increased independence

Promote safety

Preserve function

Increase self-esteem

Promote improvement in function

Minimize deterioration

Encourages the patient to focus on areas of potential or actual strength and improvement, not just weaknesses


When is a RNP appropriate?

A resident may be considered for a RNP when:

Admitted to the facility with restorative needs, but is not a candidate for formalized rehabilitation therapy

Restorative needs arise during the course of a longer-term stay, or in conjunction with formalized rehabilitation therapy

Discharged from formalized Physical, Occupational, or Speech rehabilitation therapy, but could continue to benefit from rehabilitative or maintenance services


Who Will Benefit from a RNP?

Residents who experience a gradual decline in functional status

Residents who are assessed with a potential to benefit from restorative intervention

Residents coming off skilled therapy with continuing needs for restorative intervention

Residents who are assessed with the potential to benefit from a combination of skilled therapy and restorative nursing services




Restorative Nursing: Key Concepts

Goals are resident driven—ask your resident what they would like to do!

Goals are individualized to each residents particular strengths or weaknesses.

Interventions and activities are also individualized to each residents unique characteristics



Activities of the program may be carried out by a nursing aide, but the program is overseen by a licensed nurse

Activities may be carried out during the course of the patients ADLs

Daily programming must be planned and deliberate



Can be integrated into the culture of the unit/facility or it can be created into a specific department (RNP aide)

Primarily a nursing program, but the RNP works best with input from all disciplines

TEAMWORK!





Restorative Nursing Programs provide a

gift for your patient, enabling them to

regain lost function and independence!


RNP – Required Components

As defined by the RAI User’s Manual

Assessment of the resident’s current functional level

Individual resident - specific Care Plan based on current assessment

Measurable resident specific goals for RNP

Periodic documentation of resident’s response to their individualized care plan



As defined by the RAI User’s Manual

Program must be supervised by a licensed nurse

Can be an LPN unless state practice act requires an RN

A Restorative Nursing Aide (RNA) may document and the licensed nurse can cosign (if allowed by state practice act)





Evidence of a periodic evaluation is a required element

Reevaluation:

Know your state requirements; for instance, in some cases the progress note should be during assessment reference period when one is due during a given month



Reevaluation:

Consider the following: reevaluation quarterly unless the licensed nurse determines (based on the clinical status of the resident) that a more frequent evaluation is required.

If RNP is the reason for Medicare coverage, biweekly evaluation would be an absolute minimum; the more frequent the licensed nurse involvement, the better



Persons providing interventions must be trained in the skills/techniques identified in the RNP

Program can be either individual or group

Group is defined – 1 staff to a maximum of 4 residents

Program may be 100 percent group, if appropriate for the resident




O0500 Restorative Nursing Program

O0500A, Range of Motion (ROM)*: Passive

Resident joints are moved by another person

O0500B, Range of Motion (ROM)*: Active

Resident moves joints independently with or without verbal cues

*For RUG impact, count as one program even if both are provided



O0500C, Splint or Brace Assistance:

Teaching and training, verbal or physical guidance to resident to apply splint/brace

A splinting or brace scheduled program



Training and Skill Practice

O0500D, Bed Mobility Number:

Improve or maintain the resident’s self-performance in moving to and from a lying position and turning side to side in bed

O0500F, Walking Number:

Activities to improve or maintain the resident’s self performance in walking

#For RUG impact, count as one program even if both are provided





O0500E, Transfer Number:

Activities provided to improve or maintain the resident’s self-performance in moving between surfaces or planes either with or without assistive devices



O0500G, Dressing and Grooming:

Activities provided to improve or maintain residents self-performance in dressing and undressing, bathing and washing and performing other personal hygiene tasks

O0500H, Eating and/or Swallowing:

Activities provided to improve or maintain resident’s self-performance in feeding self or to improve ability to ingest nutrition/hydration



O0500I, Amputation/Prosthesis Care:

Activities to improve or maintain resident’s self-performance in putting on and removing a prosthesis, caring for the prosthesis, and providing appropriate hygiene

O0500J, Communication:

Activities provided to improve or maintain the resident’s self-performance in functional communication skills or assisting the resident in using residual communication skills and adaptive devices





H0200C, H0500** Urinary toileting program and/or bowel toileting program

**count as one program for RUG grouper

Resident specific assessment (usually done by a voiding and/or BM diary)

Documentation in the medical record must support that certain criteria were met to be considered a “program”



Requirements for H0200 (Urinary Toileting Program):

Implementation of an individualized, resident-specific toileting program based on assessment of the resident’s unique voiding pattern;

Evidence that the individualized program was communicated to staff and the resident (as appropriate) verbally and through a care plan, flow records, and a written report; and



Urinary Toileting Program (Cont.)

Notations of the resident’s response to the toileting program and subsequent evaluations, as needed





A systematically implemented bowel toileting program (H0500) may decrease or prevent bowel incontinence, minimizing or avoiding the negative consequences of incontinence

Many incontinent residents respond to a bowel training program, especially during the daytime hours



A bowel training program that leads to a decrease or resolution of incontinence should be maintained

Unresolved bowel incontinence may be an indicator of other medical problems

Medical reasons for incontinence should be considered by the team, including the physician



When developing a toileting program the provider may want to consider assessing the resident for adequate fluid intake, adequate fiber in the diet, exercise, and scheduled times to dedicate to attempting to evacuate the bowels





The following are NOT considered a toileting program:

Check-and-Change

Simple tracking of continence status

Changing pads or wet garments

Random assistance with toileting or hygiene


Restorative Nursing Program Financial Impact

RNP has impact on four RUG-IV groups:

Rehab Low plus Extensive

Rehab Low

Behavioral Symptoms and Cognitive Performance

Reduced Physical Function

Additionally, it effects RUGs in many case mix systems (for state Medicaid)


Restorative Nursing Program Financial Impact

Must have 2 or more programs to effect RUG

6 days a week (15 minutes per day (i.e., in a 24 hour time frame)

RNP is considered a skilled service for Medicare Part A as long as resident is progressing toward goals




Restorative Nursing-Medicare

May defer the need for an EOT OMRA with continued reimbursement at the Restorative Low rate

Rehab must continue to be provided without a 3 day break in services

RNP alone may qualify as a skilled level of care to appropriately manage length of stay


Restorative Nursing-Medicare

Address in daily skilled nursing notes

Weekly Restorative progress note recommended

Address at Medicare Meeting

Should be considered as part of a short term “bridge to home” program


Making It Work: An Interdisciplinary Approach

Screening process – starts on admission and then ongoing

Rehab treatments not required for non-skilled level of RNP

IDT assessment to include:

Current and past functional level

Assessing for decline

Resident or staff feel the resident can do more




Making It Work: An Interdisciplinary Approach

Some situations in which to consider RNP:

Weight loss

Pain

Positioning concerns

Eating or swallowing difficulties

Decrease in ADL function (i.e., ROM, eating, ambulation, transfer ability, etc.)

Teaching and training needs

Communication limitations


Nursing Restorative Program

Determine resident’s need for a restorative program after assessment

Assess resources needed, adaptive equipment, and training needs for both the resident and staff

Referrals to therapy when indicated

Obtain therapy orders

Develop an individualized program


Restorative Nursing Program Example:

Assessed need: Decreased upper and lower body ROM

Goal: Maintain current ability to use arms and legs for dressing and mobility as evidenced by donning blouses with verbal cues and propelling wheelchair 40 feet for 90 days

Interventions:

1. Encourage to propel self independently to dining room in wheelchair for each meal

2. Resident to attend group activities as follows:

Volleyball Tues., Thur., and Fri.

Kickball on Wed. and Sat.

“Wii” bowling Mon. evening





Assessed need: Does not ambulate independently

Goal: Will maintain current ambulation ability – Ambulate one way to D/R (a distance of 50 feet) with walker and contact guard for 90 days

Interventions:

1. Ambulate with walker to D/R with walker for each meal (a distance of 50 feet)

2. Praise during ambulation

3. Remind to hold head up when ambulating

4. Stand by assist when appears tired or unsteady



Assessed need: 100% incontinent of urine, no structural problem identified

Goal: Will be continent while out of bed for 90days

Interventions:

1.Will be toileted between 6:30am – 7:30am, 11:00 – 12:00, 2:30 – 3:30, 6:30pm – 7:30pm and at hs

2. Incontinence product at night, do not awaken at night to ensure a good night sleep

3. Praise for accomplishment


Final Thoughts…

Determine education needs

Licensed nurse must oversee the restorative nursing program

Nurse assistant - both for referrals to therapy and specialized programming

Other staff training such as activities, volunteers, etc.




Final Thoughts…

Determine How your going to Implementation programs

Determine When your going to Start program

Determine Who is going to do what and when

Then Start your road to Success!!


Questions/Answers

Harmony Healthcare International

1 (800) 530 – 4413

[email protected]

[email protected]

Reference: RAI User’s Manual

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Copyright © 2012 All Rights Reserved Harmony Healthcare International, Inc. 45

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