MDS Alert

Published on Wed Mar 28, 2007 PDF

Don't be behind the bandwagon ... climb aboard with these key strategies.

Culture change is hot on the Centers for Medicare & Medicaid Services' agenda as a focus on providing person-centered care. And the MDS contains a wealth of information that you can tap to individualize residents' care plans.

Start with Section AC (customary routine): This section asks about resident preferences in a number of areas. "Section AC starts to identify the things that can be important to a person in his or her day-to-day living -- particularly to someone" whose life has been turned upside down "and can no longer live at home," says Rena Shephard, RN, RAC-C, MHA, FACDONA. Shephard is president of RRS Healthcare Consulting in San Diego and founding chair and executive editor for the American Association of Nurse Assessment Coordinators.

"If you can get in tune with the person's natural rhythms, he or she will sleep and eat better and have more regular digestive function," says Barbara Frank, cofounder of B&F Consulting in Warren, RI, and a presenter in a recent CMS Webcast on culture change.

"The person will, as a result, have better balance, more energy, a better mood, and be more alert," she tells Eli.

Reap the positive outcomes: Nursing homes participating in a CMS-sponsored pilot study on culture change found that restoring residents' customary routine, sleep appetite and digestive function paid off in spades. For one, the facilities saw a "documented decrease in use of antipsychotic medications," says Frank. Not only did residents' nutrition improve, but they also had fewer pressure ulcers, less pain and depression -- and less need for suppositories to treat constipation, she adds. A number of nursing homes in the pilot also found that restoring residents' basic customary routines restored their functioning, which brings them to a "true baseline of their clinical well-being," says Frank.

Real-world application: Advent Christian Village's Good Samaritan Center uses the MDS to create a personalized care plan. "The person's routines before coming to the facility are very important, especially in creating that initial care plan," says Keri Hilliard, assistant administrator for the center in Dowling Park, FL. "Our goal is to adapt to the person's lifestyle and needs rather than the other way around. It's not just the person's routines, however," she adds. "We also want the person to experience care in the way he preferred receiving it before coming to the facility."

Section N (activities) also contains some information that you can use to customize a person's routines, says Shephard. For example, Section N focuses on activities and routines in terms of what the resident does with his time when "caregiving isn't a priority," notes Shephard.

Use this as a quality check: Item F3c identifies that a resident perceives his daily routine in the facility (customary routine, activities) as being very different from the prior pattern in the community.


Connect the Dots

Section N and F (psychosocial wellbeing) overlap. Yet often social services does Section F and activities personnel collect information for Section N, says Shephard. But the interdisciplinary team needs to view these sections in tandem.

Section F helps you assess a person's past roles, notes Shephard. "The other items [in that section] are trying to help identify unsettled relationships and ... the resident's sense of comfort or ease interacting with others," Shephard adds. In terms of past roles, staff may look at an 85-year-old resident and "view him as fairly dependent for ADLs and with some behavioral idiosyncrasies," says Shephard. But they "don't often see him as the person he was." The person may have "been a school teacher or successful lawyer or spent 30 years working at a job supporting his five children, etc."

Key point: "The person has a whole life and that life isn't behind him -- it underlies him. We can't really begin to understand the person's individuality and what's important to him until we understand his past roles."

Care plan application: "Reminiscing becomes very important to people who like to focus" on important times in their lives "where they let their feelings go back to those times," says Shephard. "Reminiscing groups are satisfying for some residents but many residents don't want to compete with other people to talk about what's important to them," she says.

"On an individual level, we can care plan to involve the family in understanding how important the reminiscing is to the person," says Shephard. That way, "they can spend x amount of time when they come to visit listening to the person talk about what's important to him." She notes that some family members won't have the patience to do that. "In those cases, the staff can spend more time with the person listening to his reminiscing."

Tip: Work with the resident/family to develop a little bio to place over the resident's bed (with their permission in order to be HIPAA-compliant), suggests Shephard. Then staff can "chat with the resident about these things in the normal course of caregiving."

Editor's note: See the next MDS Alert to find out how to use a person-centered approach to depression and anxiety, expert tips on how restorative nursing can enhance quality of life -- and a case study on the "I" care plan.