MDS Alert

Published on Tue Nov 07, 2017 PDF

Find out which implications this little phrase for care, as well as facility organization.

"Patient-centered care" seems easy enough to understand: Include the resident or her representative in your planning and delivery of care. But are facility leaders and team members doing enough to reframe how to really put readers at the center of their own homes and care?

"Person-centered are is about the person, not your systems or organization," says Kris Mastranagelo, president and CEO of Harmony Healthcare International, in Topsfield, Massachuesetts.

Try new staffing patterns

Your facility may need to shuffle staffing patterns anyway to meet the upcoming Phase 2 regulations, but it's easy to see how staffing flexibility will make person-centered care easier to actually implement.

Resident-centered care means residents will need care and other services when it's convenient to them -  within reason - which means some of the more shift-immune jobs in skilled nursing facilities may deviate from the traditional 9 to 5 schedule.

This will especially affect RNs, who need to be on hand to do assessments and establish care plans according to other new requirements. But social services, staff who work with dietary needs, and therapists can probably expect to work different hours, too. Treatments will not be relegated to the typical workday schedule anymore.

It's all about the residents, and the fact that what is our workplace is their homes, says Maureen Kelly, RN, Don-Ct, senior clinical consultant at LW Consulting Inc. in Harrisburg, Pennsylvania. Facilities will need to adjust staffing and resources to better align with residents and their needs, she says.

But person-centered care isn't limited to those who provide the physical or medical care to residents. Your facility's administration should interact with residents and know your staff well. Fully immersing in person-centered care involves every layer of your workforce; leaders need to be a part as well.

Shuffling staffing patterns around could have other outsize benefits, like allowing all team members to engage more fully in collaborative, decentralized decision-making. The typical "nursing home hierarchy" no longer has to exist; facilities can maintain rules and procedures while encouraging all team members to participate more fully.

For example, make sure the CNAs who work most closely with an individual resident is part of the interdisciplinary team who develops the comprehensive care plan, Mastrangelo says. Include representatives from other departments, too, like a member of the food and nutrition services staff and a social worker, to cover as many aspects of the resident's everyday life and care as possible.

Think of residents as whole people

Those who choose long-term care as a career often have more appreciation for the elderly than society at large, but it's easy to get lost in how to most effectively provide care to as many people as possible instead of focusing on how to provide the type of care individuals need.

You know to incorporate language and cultural preferences and concerns into individual residents' care, but consider specifics.

For example: Does Mrs. Johnson seem especially refreshed by her weekly shower? Ask her if she would prefer to bathe more regularly; what is preventing staff from assisting her in more frequent showers? The long-term care industry has perhaps overlooked the simple pleasures that the independent, able-bodied take for granted in order to provide care as efficiently as possible.

Consider the residents' convenience

Right now, most facilities have dining rooms where staff bring residents for meals at a set time. While this is convenient for managing the meals of however many residents your facility needs to feed, it may be especially jarring for Mr. García to eat dinner at 4:30 p.m. when he always ate dinner around 10 p.m. in his native Spain.

Though it could be a logistical challenge, at least at first, imagine how much less "institutional" your facility would feel if skilled nursing facilities treated dining rooms like universities do. The dining room could be open for a set amount of time, and residents could choose when they wanted a meal and could decide between items upon arrival. Some assisted-living facilities already take this approach; don't let staffing and other logistics limit how skilled nursing facilities could operate with residents as their true focus.

Incorporate behavioral health services

Another new aspect to Phase 2 regulations is the addition of behavioral health services, which aim to provide another layer of consideration and care for residents.

CMS's most recent Appendix PP grounds these new requirements in providing person-centered care:

"Providing behavioral health care and services is an integral part of the person-centered environment. This involves an interdisciplinary approach to care, with qualified staff that demonstrate the competencies and skills necessary to provide appropriate services to the resident. Individualized approaches to care (including direct care and activities) are provided as part of a supportive physical, mental, and psychosocial environment, and are directed toward understanding, preventing, relieving, and/or accommodating a resident's distress or loss of abilities."

This new section encompasses whole emotional and mental well-being but also includes prevention and treatment of mental and substance abuse disorders, Kelly says. This may mean that facilities need to hire or schedule more team members for the direct-care roles. Management needs to make sure that all staff -  especially those who fulfill the hands-on, frontline roles - have the necessary competencies and skillsets to provide care appropriate for residents who have illnesses that result in behavioral symptoms, like dementia.

Your facility and staff know your residents best - and therefore their diagnoses - which would help determine what kind of training your current staff needs and what skillsets you should look out for. Make sure your therapy department knows how to provide the services your residents require (and if they're not equipped, the facility must obtain these services).

Think about providing behavioral health services as a means of safeguarding your residents - to attain or maintain the highest practicable physical, mental, and psychosocial well-being, Kelly says.

Surveyors will be on the lookout for concerns about a facility's behavioral health services and will judge noncompliance by severity level. "The facility is responsible for providing behavioral health care and services that create an environment that promotes emotional and psychosocial well-being, meet each resident's needs, and include individualized approaches to care," Appendix PP says.

Take trauma seriously

Though trauma-informed care is not officially implemented until Phase 3, acknowledging and planning around individual residents' trauma is crucial for their own well-being, as well as your facility's compliance. Appendix PP lists, as an example of noncompliance, a scenario where a resident is known to have war-related post-traumatic stress disorder and becomes visibly upset when triggered by loud sounds and other startling moments. In the scenario, the surveyor watches staff trying to get the resident's attention when approaching from behind by touching his shoulder. The surveyor quotes the hypothetical director of nursing hoping that the resident will get used to living in a skilled nursing facility, along with the door alarms and other noises.

Surveyors are instructed to evaluate the resident's MDS and other documentation (including care plans) to assess whether residents are getting the care they need. Surveyors are also instructed to interview residents and residents' families or representatives they feel they need more information. In this scenario, the surveyor would cite this facility with F740 and severity level 3 of noncompliance, because the resident suffered actual harm but whose health and safety was not immediately jeopardized.