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Adult Learning Principles: Influencing Patient Outcomes through Education

Monday, July 25th, 2011

Understanding the Principles of Adult Learning can assist clinicians to improve patient learning and can result in improved clinical and quality patient outcomes. The brain governs more than memory alone. The brain and mind allow humans to cope with stimuli, creativity, immune responses, language, reasoning, planning, analyzing, and dreaming. It allows the human to feel a myriad of emotions, store experiences, while shaping the capacity to alter behavior and thinking through awareness expansion and critical reflection. The brain is, according to Caine, 2009) biologically designed to learn and learning is a matter of building rich neural networks, but how? Each individual learns a bit differently than their neighbor yet there are 12 strong underlying principles:

  1. All learning is physiological
  2. The brain/mind is social
  3. The search for meaning is innate
  4. The search for meaning occurs through patterning
  5. Emotions are critical to patterning
  6. The brain/mind processes parts and wholes simultaneously
  7. Learning involves both focused attention and peripheral perception
  8. Learning always involves conscious and unconscious processes
  9. There are at least two approaches to memory

10.  Learning is developmental

11.  Complex learning is enhanced by challenge and inhibited by threat associated with helplessness

12.  Each brain is uniquely organized

(Caine, Caine, McClintic, and Klimek, 2009 and Caine and Caine, 1994)

The principles assist us, as clinicians, leaders, managers, to understand that there are several different processes involved. Yet, we all tend to print up some teaching materials and have the nurses leave them with the patient “for reinforcement”. Many people believe, “If I told you, you have had education”.

The best selling education books, Tellin’ ain’t Trainin’ (Stolovitch, 2011) and Sit and Get Won’t Grow Dendrites (Tate, 2004) help us to better understand Brain-Compatible strategies. Some patients may learn well with the written word, while others are spatial and auditory learners.

Future Select Data articles will explore the constructs further but here is one sample activity.

If a patient treatment has changed or is being compared or contrasted, consider using a Venn Diagram. Draw two circles that have an overlapping center like below:

Information that is overlapping in the center is that information that is alike. The information outside that space identifies differences.

A spider chart with the new treatment or new topic in the center of a circle should be drawn. Then draw “spider-like” lines coming out of the circles. These can be goals to be achieved. As the patient articulates each goal they desire to achieve, linking it to the treatment or med in the center of the chart dramatically diagrams the importance of that treatment or medication.

A pie chart can be used to classify the careplan components. Breakdowns can make the plan seem more manageable. Each component or “piece” of the pie can appear to be managed at a setting, much like a tasty lemon pie.

We will look at this topic with more depth in the future. There is a PowerPoint Presentation on the topic of Learning and Brain Compatibility that is based on the Twelve Adult Learning Principles. This presentation was presented at two state association conferences and it could be shared with clinicians.

Having trouble downloading Learning and Brain Compatibility PowerPoint?

right click on the link > Then choose “Save Target As” > “Save”

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Posted in Home Health, Patient Survey, Teaching/Education | No Comments »

Evidence-based practice in Establishing Care Plans for the Home Health Patient: COPD

Wednesday, June 1st, 2011

Evidenced – based practice is considered the best available evidence derived from systematic research, clinical experience, and tested expertise to achieve expected and/or improved patient outcomes (Institute for Healthcare Improvement, 2008 ). The new protocols for surveyors have moved the focus to data – driven and outcome – oriented (CMS, 2011) and the need to establish a well defined plan of care foreshadows the need to follow evidence – based practices for specific diseases to achieve the expected outcomes (even though, at this time, CMS has not yet mandated their use). The following is an evidenced based process for COPD using SmartCues as reminders for clinicians.

A Focus on Chronic Obstructive Pulmonary Disease (COPD)

COPD is a progressive airway disorder associated with abnormal inflammatory response of the lungs to noxious gas and/or particles. It is primarily manifested as two related diseases: chronic bronchitis with the presence of cough and sputum production for at least three months and emphysema.

COPD and exacerbation is the fourth leading cause of death in US and causes about 500,000 hospitalizations annually. It is expected to move up to the third leading cause of death in the US by 2020 (Crawford & Harris, 2008). Anthonisen defines COPD exacerbation as requiring the presence of at least one or more of the following: increased sputum purulence, increased sputum volume, and worsening of dyspnea. COPD decompensation is seen 1-3 times per year when care is not managed. Exacerbation etiology is usually infection driven. Other triggers include heart failure, pulmonary emboli, and non pulmonary infections.

Though COPD is progressive, literature states, COPD can be managed better to produce improved outcomes. The Home Health Nurse should follow agency protocol, physician orders, and professional nurse evidence-based practice when assessing and planning care with the patient diagnoses with COPD. Consider the following when establishing care:

  • Symptom: Assess for signs and symptoms of infection (especially pneumonia)

Instruct patient to note change in sputum quantity, volume, and consistency. Patients should also note temperature with any other sign of infection and not increased temperature > than 100 degrees lasting longer than 72 hours (unless different physician guidelines)

Clinician should reassess each visit.

  • Symptom: Assess for hypoxia and dyspnea

Instruct patient to utilize airway tolerance techniques (cough and deep breathing exercises that may include incentive spirometry. Instruct patient when to call home health agency, physician, or to seek emergency care (severe SOB, severe wheezing, or uncontrollable coughing). If Oxygen is used, instruct in importance, in safety and appropriate use of flow rates.

Clinician should assess VS (TPR and B/P), pulse oximetry, and evidence of accessory muscle use.

Clinician should assess for jugular vein distension, peripheral edema, and peripheral edema.

Clinician should assess for anxiety and restlessness

  • Symptom: Smoking

Instruct patient and family in need to cease smoking. First hand and second hand smoke is contraindicated with the patient with COPD.

Clinician must assess each visit.

  • Symptom: Assess for signs of orthopnea

Instruct patient to identify any change in number of propped pillows needed to breathe comfortably when lying down.

Clinician should note baseline and changes each visit.

  • Symptom: Increased wheezing (prolonged expiration)

Instruct patient to identify and eliminate triggers.

Instruct patient on stress reduction and stress management techniques such as guided imagery with simple exercises that can be utilized quickly.

Instruct patient in use of music therapy and choose a piece of music that is associated with calm and piece.

Instruct on airway clearance techniques that may include coughing and deep breathing exercises. Coughing is a general manifestation of COPD and may be worse in the morning. Patient should pace activities.

Instruct patient when to contact home health agency, contact physician, or to seek emergency care especially if there is severe SOB that is uncontrollable.

Clinician should assess incidences upon each visit and effect of instruction.

Clinician should inquire if “tripod” position has been necessary (patient leans forward with head tilted and arms resting on legs or table). Note visible use of accessory muscles in neck, abdomen, and chest. Teach patient to take slow deep breaths through pursed lips. (“This will help him relax and inhale oxygen and exhale carbon dioxide at a slower pace, decreasing the respiratory rate and preventing alveolar collapse” Crawford & Harris, 2008).

Clinician should assess lung sounds and listen for not only wheezes but crackles and may also note diminished breath sounds.

  • Symptom: Assess activity tolerance

Instruct patient to identify activity daily and/or number of feet walked before dyspnea occurs. Wheezing can worsen with activity so a strong assessment and measured activity schedule is necessary.

Consider Physical Therapy referral for muscle strengthening exercises for legs and upper arms. Teach exercise safety. Teach energy conservation when appropriate. Conditioning exercises aid to strengthen the muscles used in breathing.

Clinician should note baseline and assess activity levels and evidence of dyspnea changes each visit.

  • Symptom: Assess for increased weakness and fatigue
  • Instruct patient in energy conservation to achieve ADLs life quality. Patient should note when the symptoms occur.
  • Clinician should note baseline and progress each visit.
  • Symptom: Assess nutrition and hydration status (may have low levels of serum protein)

Instruct in high protein foods that do not require significant energy for preparation. Maintenance of adequate caloric intake should be taught. Nutritional supplements should be considered.

Clinician should assess nutritional status at each visit.

  • Symptom: Medication compliance

Instruct patient as to medication actions, side effects, contraindications, when and how to take, and how to store meds. Likely medications may include bronchodilators, steroids, antibiotics, mucolytics, antivirals, and antipyretics.

Clinician to assess medication changes as well as  patient use of meds such as metered-dose inhaler; exhale completely, take a slow deep breath when inhaling, and holding breath for 5-10 seconds. Verify directions re use on each med.

Patients should have pneumonia and flu vaccine if agreed to by physician.

  • Symptom: Assess for depression or lack of interest in surroundings and difficulty with focus.

Instruct patient as to psychosocial coping skills to maintain optimum self care-management.

Clinician should assess for symptoms of depression on each visit as well as assess family and support systems.

Caring for COPD can present a challenge for home health nurses, but proper patient education, using a variety of techniques, while gaining family and friends’ support can assist to motivate patients to strive for optimal outcomes.

Sources:

CMS Appendix B Guidelines for Surveyors

Crawford, A & Harris, H (2008) COPD Help your patients breathe easier. AHC Media. www.modernmedicine.com/modernmedicine/CE+Library/COPD-Help-your-patients

www.homehealthquality.org

HHQI Best Practice Intervention Practice, 8SOW-PA-HHQ07 467 App, 1/2008

www.qualitynet.org

http://mhcc.maryland.gov/consumerinfo/hospitalguide/hospital_leaders/best_practices/hf..h

www.chronicconditions.org/ClearingHouse/cat/Heart%20Failure,61.aspx

Heart and Ling Sounds by 3M

http://solutions.3M.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds

Decision Support Tool: Heart Failure Publication # 8SOW-PA-HH05.187

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Posted in Best Practice Intervention Practice, COPD, Home Health, Teaching/Education | No Comments »

Psychiatric Nursing in Home Health

Wednesday, May 25th, 2011

During these past few weeks, we have seen an increase in questions regarding psychiatric nursing services. More agencies are considering new programs. One agency has shared that Palmetto is no longer asking to see resumes of psychiatric nurses, but agencies must verify with EVERY MAC before beginning a psych program.


The CMS Publication 100-2, Chapter 7, §40.1.2.14, simply says, “Psychiatrically trained nurses are nurses who have special training and/or experience beyond the standard curriculum required for a registered nurse.”  MACs can establish the special training and experience required.  A home health agency should contact its MAC and look at the MAC website for any special qualifications needed.

Introduction

CMS has recognized psychiatric home care as a reimbursable service since 1979, but nationwide, proportionately fewer home health agencies actually provide this service. The exact number of agencies that include psychiatric home care is unknown. There has been a reluctance of agencies to implement psych programs and there are many reasons for these decisions.

First of all, the skills of a psychiatric nurse are required and this specialist is usually more difficult to find. Second, the psychiatric patient is frequently more disorganized and needy than other patients causing the case management responsibilities to become time consuming and complex. Third, this patient is frequently homebound questionable.

CMS Publication 100-2, Chapter 7, §430.1.1, states that a patient with a psychiatric problem may be considered homebound if “the illness … is of such a nature that it would not be considered safe to leave home unattended, even if he or she does not have any physical limitations.”  The homebound status of patients with psychiatric needs require well written, clearly stated clinical visit notes, because there may not be physical impairments, and homebound status must be clearly delineated. Any patient in a certified home health program may leave their home for specific reasons, as identified in Chapter 7 of the Medicare Provider Benefits Manual. Homebound status for a patient suffering from a mental health issue may be just as painful and debilitating, but may not manifest itself with physical symptoms or behaviors.

Homebound status (for a patient suffering from a mental illness) may need to be evaluated as a clinician would evaluate a patient suffering from dementia or Alzheimer’s diseases That patient may have few or no physical limitations and yet would be deemed unsafe to leave his/her home unattended. The patient, in this example, could be considered homebound.

However, if the patient with a psychiatric condition leaves home regularly for reasons other than to visit the physician, he/she may not be considered homebound; the same as any other home health patient in the certified agency.  An example may be that of patient with a mental health issue attending partial hospitalization.

Partial Hospitalization

In 1999, CMS, then known as HCFA, stated that a patient in a partial psychiatric hospitalization program does not qualify for psychiatric home care services.  The partial hospitalization program should be able to provide necessary psychiatric services. The homecare services must be psych-related. If they are not focused on a psychiatric issue, the home health agency must evaluate the patient’s needs, just as it would normally do with any other patient, and evaluate whether home care services are in keeping with medical necessity and homebound status.

What is Psychiatric Home Health Nursing?

What is unique about psychiatric home care? Although psychiatric home care is bound by the same CMS regulations that define other types of home care, these regulations are largely non-specific for the psychiatric patient. This means the clinician must be specific as to symptoms and document those plans and interventions, as well as work closely with the physician.

On the surface, psychiatric care appears to be very eclectic, but there is much depth of choice for intervention strategy. Although psychiatric nurses may draw upon crisis intervention techniques as noted by Duffy, Miller, and Parlocha (1993) and Beck’s or Montgomery-Asburg Depression Inventories, Young Mania Scale, Sheehan Anxiety Scale along with Cognitive Restructuring therapy, there are a number of other psychiatric intervention models that can be very useful: psycho-education, interpersonal reflective, supportive, individual, and/or brief therapy, as well as behavior therapy, relaxation, contract, and reward provisions.

The psychiatric nursing home care plan must be intermittent. This short term program frequently focuses on improved problem-solving, stronger ego boundaries, and enhanced self-concept. This is important with patients of all ages, but the need is seen often with elder patients who are suffering significant losses in life.

With patients suffering from depression, the psych nurse frequently seeks ways to displace internalized anger outwardly. Activities designed by an occupational therapist can augment the skills of the psych nurse. An increasing number of home health agency psych programs are adding this discipline because of the physical activities that can be beneficial.

Stress management and education of stress strategies are commonly taught. Many patients have weak or fragile coping mechanisms that require reinforcement or a new approach.

Forming linkages between the patient and needed community services is a vital component of the role of the psychiatric home care nurse. This type of nursing brings an existential/spiritual concern and dimension to patient care. The clinician frequently provides support to a patient with low self esteem and a belief that the community has prejudged them. The clinician can assist the patient to cope with behaviors and approaches patients with an attitude of respect, reinforcing or assisting to rebuild worth and dignity.

Demoralized individuals are frequently seen in this program. Patients may lack energy, frequently because of losses; losses of friends, of family, of job, of status, of money, of respect, and others. This patient frequently requires a nurse whose plan with the patient requires assessment of the patient, their role within the family, the family support system, teaching use of psychotherapeutic techniques to facilitate change, medication management, and supervising their care in a supportive fashion that sustains physical, emotional, and spiritual life,

Relationship Building and Trust

The clinician will build relationships established on trust, caring, compassion, empathy, education, and hopefulness. The RN will use verbal and non-verbal communication techniques to convey interest in the patient, to assess what the patient wants to accomplish, to assist with care planning and goal achievement, and to clarify the boundaries of the relationship, and lastly to affirm the patient has value and worth.

Medication Management

Medication management is frequently a need for patients and is one of the main reasons for hospitalization. CMS identifies a significant portion of hospitalizations are due to poor medication management. Some patients do not understand the reasons they has been prescribed certain medication. Sometimes, patients do not like the side effects and feel those effects are nearly as bad as the psychiatric condition. Some patients cannot afford their meds and still others do not wish to take their meds as they provide a constant reminder of a condition many wish could be forgotten. One patient once shared, “I look in the mirror, put the pill in my mouth, bring the glass to my lips, and know I am ill.” Unless this issue is addressed, the chance that this patient will become medication non compliant is great.

Medication management intervention must be individual. Certain patients may require a contract by which they contractually agree to take their medications as prescribed. It is this tangible “document” that assists with compliance reinforcement. Teaching about major effects of the medications can be an empowering experience. For those patients whose cognitive impairment is apparent, modified pictorial teaching tools may be necessary. Role-playing, coaching, and teaching can be a part of  an empowering strategy.

Summary

Patients with stressors, depression, and cognitive impairments can frequently benefit by a psychiatric nurse. The program must be comprehensive aiding the patient through stabilization, caring, and reinforcement of strengths. A therapeutic relationship built upon trust can provide acceptance to teaching and compliance with medication. Leaving the patient more calm, organized, stronger, and knowledgeable can assist the individual to improve links with family, friends, and the community and be more compliant with their medication regime.

The psychiatric program can be a strong support to total quality care and improved outcomes.

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Posted in CY2011, Home Health, Psychiatric, Teaching/Education | No Comments »

Educational Video: Medicare Rehab Therapy V Codes

Thursday, May 19th, 2011

Medicare Rehab Therapy V Codes

There are v-codes (meaning the ICD-9 code begins with the letter “V” followed by 2-4 digits) that designate care involving use of rehabilitation procedures. These are used when the purpose of the admission or encounter is rehabilitation. Coding guidelines only allow these encounters for rehabilitation V codes to be used as a primary diagnosis, in M1020a. They cannot be used in M1022b or beyond or in M1010 or M1016. If skilled nursing is seeing the patient for the billable visits then these encounters for rehabilitation V codes cannot be used.

There is encounter for rehabilitation V codes for physical therapy of PT is the only rehab services ordered. This is code V57.1. There is an encounter for rehabilitation V code for speech therapy if ST is the only rehab service ordered. This is code V57.3. There is also an encounter for rehabilitation V code for occupational therapy if OT is the only rehab service ordered at recertification time, this is code V57.2. Because OT cannot open a home care case under Medicare, this code will be used at recertification when OT is the only skilled discipline remaining, and going forward into the next 60 day episode.

There is an encounter for rehabilitation V code that is used when multiple therapies are ordered and provided but no nursing. This code is V57.89. It is used with any combination of PT, OT and ST or if all 3 therapies are involved with no nursing. Again, this code can only be used as the primary diagnosis in M1020a.
There is one more encounter for rehabilitation therapy code we see in home care, V57.81, For Orthopedic training, meaning cat training in the use of artificial limbs. This can only be primary diagnosis as well. The patient’s amputation stump has matured and has been fitted for prosthesis and a physical therapist will train the patient in the use of the prosthesis in the home setting. Documentation must show why the patient remains homebound since this training is usually several months after the original surgery and often done in an outpatient setting.

Remember, use encounter for rehabilitation V code only as a primary diagnosis in therapy only cases when skilled nursing has not been ordered.

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Therapy Requirements For CY2011

Tuesday, May 10th, 2011

The CY 2011Therapy Requirements effective April, 2011 have resulted in many questions after use by therapists.

 

Therapy Requirements:

Questions are rampant about the reassessments required every 30 days and those required on the 13th and 19th visits. In the March 28, 2011 issue of Home Health Line the journal states “the visit count that will trigger the need for a reassessment is based on the total number of visits when multiple therapy disciplines are involved rather than the visit count for each individual discipline, the fact sheet states.”

 

The fact sheet referred to is the CMS Therapy Requirements Fact Sheet that can be found at:

https://www.cms.gov/HomeHealthPPS/Downloads/Therapy_Requirements_Fact_Sheet.pdf.

This fact sheet was meant to provide guidance. However weeks of implementation of the new regulations have caused more questions to arise.

 

The Therapy Requirements Fact Sheet states, “Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must provide the ordered therapy service and functionally reassess, measure, and document the effectiveness of therapy or lack thereof close to or no later than the 13th and 19th therapy visit. The 13th and 19th therapy visit timepoints relate to the sum total of therapy visits from all therapy disciplines. In multi-discipline therapy cases, the qualified therapist would reassess functional items and measure those which correspond to the therapist’s discipline and care plan goals.”

 

HHL, March 21, 2011 edition cites, “Therapy services won’t be covered after the 13th and 19th visits unless a qualified therapist completes a reassessment.”

In addition, the Fact Sheet identifies:

“Therapy services provided after the 13th and 19th visit (sum total of therapy visits from all therapy disciplines), are not covered until:

The qualified therapist(s) completes the assessment/measurement/documentation requirements.

The qualified therapist(s) determines if the goals of the plan of care have been achieved or if the plan of care may require updating. If needed, changes to therapy goals or an updated plan of care is sent to the physician for signature or discharge.

If the measurement results do not reveal progress toward therapy goals and/or do not indicate that therapy is effective, but therapy continues, the qualified therapist(s) must document why the physician and therapist have determined therapy should be continued.” CMS expects these requirements to be followed or expect no payment for the visits.

 

The CMS Therapy Requirements Fact Sheet also identifies that “At least every 30 days, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must provide the ordered therapy service, functionally assess the patient, and compare the resultant measurement to prior assessment measurements.” It notes that “The thirty-day clock begins with the first therapy service (of that discipline) and the clock resets with each therapist’s visit/assessment/measurement/documentation (of that discipline).

 

Per NAHC Regulatory Affairs, ‘the thirty day reassessment count would begin with the initial therapy evaluation through discharge from therapy. The 13th and 19th reassessments are counted per episode since they serve as justification for meeting the therapy threshold.”

 

Remember, the overall mission of the CY 2011 new rules, for therapy, include continuing or discontinuing treatment or having treatment plan revisions with changes in goals made by a qualified therapist. If therapy is to continue, there must be:

  • Clear documentation of objective evidence of patient improvement, or
  • A clinically supportable statement of expectations that the patient’s potential to improve is yet to be attained and is expected in a reasonable and generally predictable period of time

CMS clarified regulations at 42 CFR §409.44(c)(2)(iii) by adding that:

  • There must be significant improvement
  • The clinical record must demonstrate functional improvements that are ongoing and of practical value
  • The improvements are to be measured against the patient’s condition at the start of treatment
  • Covered therapy services are to be rehabilitative therapy or maintenance therapy (New G-codes for both were included in CY2011).

CMS defines “rehabilitative therapy” as requiring the skills of a qualified therapist, with recovery or improvement in function and, when possible, restoration to the previous level of health. Therapy is meant to assist a patient to improve function and assist a patient to a prior level of well being. The new regulations are meant to capture objective reassessment data at least every 30 days, by a qualified therapist, as well as require a reassessment prior to the higher payment thresholds of the 14th and 20th visits.

 

 

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