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Glenburn Home: Using The MDS To Target Clinical Risk Management Efforts

Published on Thu Sep 11, 2003 Print Friendly and PDF PDF

The MDS provides the keys to quality improvement, which Glenburn Home in Linton, IN has used to open the door to some new risk management approaches.
 
When administrator Norma Lesher and DON Tammy Alley took over the skilled nursing facility in February of 2003, they immediately began looking at the MDS-driven quality measures and using the software to pull frequent quality indicator reports. Based on that analysis, they formulated special risk management programs in the areas of nutrition and fall prevention and management.
 
"The facility's quality measures still don't look really nice on the Nursing Home Compare Web site" because the data is old, Lesher says, "but its QIs have shown dramatic improvements." For example, the facility's falls have fallen from the 40th percentile to the low 20s in the last four months. And the new management and clinical team has whittled down the list of residents with five or more triggers for QIs from an initial figure of 45 over a six-month lookback to 19 at the last count.
 
To produce the new quality profile, the facility takes these steps:
 

  •  Validates areas on the MDS that trigger QIs. To make sure they were looking at a valid snapshot of care and outcomes, Glenburn's interdisciplinary team revamped the MDS process and spent a lot of time validating the areas on the MDS that trigger the QIs, Alley reports. The MDS audit process, in fact, revealed "quite a few wounds coded as pressure ulcers that were probably really stasis or diabetic ulcers or excoriation due to loose stools," she says. To ensure accurate wound classification and staging, the wound care nurse and Alley now look at each wound when it's reported.
     
  •  Targets care and resources to residents triggering QIs. The facility has implemented weekly quality of life and care review meetings to stay on top of residents' clinical and quality of life issues. At the first meeting, the team made a list of every resident who had five or more QI triggers over the preceding six months. Then each department involved in the area of care related to the trigger addressed the issue. For example, if a resident triggered the QI flagging little or no activities, the activities staff figured out what was going on. If a resident triggered being bedfast, staff looked at why she was bedfast and whether that could change. As a result, the facility has had some residents get out of bed so they aren't triggering that QI any more. "If an antipsychotic drug with no diagnosis triggers that QI, then we have someone verify that there is a diagnosis and that it's being care planned," Alley reports.
     
  •  Performs intensive fall risk assessments and care planning. Every resident has a fall risk assessment for MDS purposes. Staff then updates the assessment when a resident has a fall or a significant change in his activities of daily living status. When Alley finds out that a resident has fallen, she looks at the resident's lab results, diagnoses and chemical and physical restraints, as well as nutritional intake and hydration. "Adequate nutrition and hydration decrease confusion and increase muscle strength," she explains. The staff also looks at whether to obtain physician orders for physical therapy or occupational therapy. They then pull all of the assessment data together to produce a new plan to keep the resident from falling again.
     
    That care plan then goes in an ADL flowchart for CNAs, who sign their initials on an in-service page each shift to indicate they have read the updated care plan. "We implemented that requirement because the CNAs are the ones providing the hands-on care," says Alley, noting that the state surveyors really like the approach.
     
  •  Screens residents for a new program called "Nutritionally at Risk." The interdisciplinary team refers residents to the newly launched nutrition program if they are assessed as having weight loss, skin issues, a new diagnosis of renal failure, multiple comorbidities and/or low body weight (even without weight loss). The facility also made changes to its dining program and reduced by 30 percent the number of residents who choose to eat in their rooms. To help prevent choking incidents, "the speech therapist monitors meals as a risk management strategy to see who is having problems eating/swallowing and might need some therapy or other interventions," Lesher reports. 
     
  •  Constantly monitors QIs, with a goal of learning from what's gone right. The team routinely targets any QI at the 75th percentile or higher - or even one that's suddenly jumped from the 25th to 35th percentile to figure out why. "In the latter case, we might find that the increase is due to residents recently admitted who came in with a certain condition," Lesher explains. But the facility is also looking at scores that have dropped to figure out what's gone right. "We are still in the mode of putting out some fires," Lescher says, "but plan to begin focusing more on positive trends and what we can learn from them to improve care."

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