Posts Tagged ‘Patient Teaching’

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Infection Risk Assessment Tool

Thursday, October 28th, 2010

This Infection Risk Assessment Tool offers an easy and quick review of client predisposing factors that aid in preventing infection. The clinician has the opportunity to evaluate education and training needs for patients and family members. It also allows for tracking of signs and symptoms, cultures, and outcomes including unscheduled hospitalizations and secondary infection development.
It is the goal of Select Data to frequently offer tools for home health leaders and clinicians. You should expect to see clinical and operational tools geared toward assisting to identify areas of preventive practice and opportunities for training and education as well .

Expect future tools to focus on Cardiac Status, Dementia, Depression, as well in addition to business and QI tools.

Infection Control Tool (Excel)

Infection Control Tool (PDF)

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Dementia – Part II: Best Practices to Consider

Monday, September 27th, 2010

The Mental Health Foundation (2006) defines dementia as “a decline in mental ability which affects memory, thinking, problem-solving, concentration, and perception. Dementia is almost invariably a disease of aging.”

Building upon the ten warning signs (see Part I Dementia), the following dementia best practices from the Alzheimer’s Association and other valued sources, focus on early recognition of symptoms with suggested best practice interventions.

Assess the person to determine level of difficulty with activities listed below. A positive finding may be considered an indication for further screening and history identified. A Home Health Agency protocol will no doubt include a directive to report results to the physician.

The Assessment should include:

Learning of new information

  • Does the person exhibit repetitive stating?
  • Does the person have difficulty remembering recent conversations, events, or
  • placement of personal objects?
  • Does the person utilize memory aids?

Reasoning ability

  • Is the individual able to respond with a reasonable plan for problems at home,
  • such as knowing what to do if there were a kitchen fire?
  • Do they know how to handle telephone calls from family, from telemarketers?

Language recall

  • Does the individual have increasing difficulty finding the correct words to express what he or she wants to say?
  • Do they struggle finding the right work for a sentence or call something by the incorrect name and not correct it?

Handling complex tasks

  • Does the individual have difficulty following a complex train of thought or
  • performing tasks  that require many steps such as following a recipe?
  • When out walking with a family member, can the patient retrace their path home?

Spatial ability and orientation

  • Does the individual have trouble driving, organizing objects around the house, and finding his or her way around familiar places?

Behaviors

  • Does the individual appear silent more frequently?
  • Does the individual appear more passive and less responsive?
  • Is the individual more irritable than usual; is suspicious of others, or misinterprets visual or auditory stimuli?
  • Do certain events trigger behavioral responses?
  • Is there difficulty discussing current event in an area of interest?

The Home Health clinician understands that a thorough assessment of the patient, support services, and environment is necessary so that an appropriate plan of home health care can be implemented. The National Care Forum (2007) supports the need for an overall assessment. They identify that this is crucial to the development of a useful care plan.  The Forum states additional indicators of best practice include:

  • Evaluation and re-evaluation (Specific services are provided based on the patient’s health care, physiotherapy, and nutritional needs)
  • Involve the patient and family with the careplan. Life stories are used to ensure understanding of the individual.
  • Consider cultural needs and their implementation into the plan of care.
  • Promote the well being for the individual. (Develop measurements of well being and satisfaction for the individual)
  • Care Plans will be used as communication tools, so they must be clear and concise but house depth so the team can individualize care.
  • Match personnel with patients. (Suggest to the family that caregivers must match the well being needs of the individual).
  • Actively involve family and friends, not only for the patient’s needs, but also for the respite of primary family caregivers
  • Technology and telecare telemonitoring may be used to complement care to promote safety and maximize independence (Monitoring bracelets may be needed for individuals who attempt to leave the home).

The Alzheimer’s Association of Australia(2007) state that patterns, convenient schedules and consistent personnel are essential for care. Consistency aids to promote calm. A schedule is necessary.  Focus on retained abilities. What are and have been interests of the individual? Incorporate these interests into the careplan and plan of care. Use the familiar environment as a therapeutic psychosocial tool; i.e. continue favorite activities such as have tea in the afternoon using their familiar china so a sense of comfort is encouraged. Have behavioral management guidelines for the patient and family in place and understood.

The Alzheimer’s Association Campaign for Quality Care (2007) states that a developed checklist can assist to identify certain behavioral symptoms. The list includes observing for:

  • Changes in ability to focus
  • Changes in emotional and physical agitation
  • Changes in mood, suspicion of others
  • Hallucinations, illusions, withdrawal from others
  • Wandering, pacing, rocking

Any symptoms from the above list should not routinely be attributed to Alzheimer’s Disease. A health care professional needs to rule out other causes such as environment, medication, or another health condition (infection, pain, depression, or boredom).

Families can provide information regarding the individual’s prior and present life, customary routines, preferences, behavior triggers, and results of attempted interventions. They can help interpret language, nonverbal interactions and the meaning behind the behaviors affected by major life events and traditions. Include caregivers in the assessment process, as they are an integral part as they notice subtle, individual cues they’ve come to understand.

Ask questions in a systematic way, write down the answers, incorporate these interests into the careplan, observe and intervene.

Include in the Plan:

  • Many home health assessments for Dementia include the CLOCK Drawing Test (CDT).

This exam includes the patient being asked to:

  1. Draw a clock
  2. Draw in all of the numbers
  3. Set the hands at ten minutes past eleven

The Alzheimer’s Disease cooperative scoring system for the Clock Drawing Test is based on a score of five points.

1 point for the clock circle

1 point for all the numbers being in the correct order

1 point for the numbers being in the proper special order

1 point for the two hands of the clock

1 point for the correct time

A normal score is four of five points

The test assists in identifying general cognitive and adaptive functioning such as memory, information processing, and vision issues. Research supports a normal drawing of a clock almost always predicts cognitive abilities within normal limits. Remember, the Clock Drawing Test does not aid in differentiating between vascular dementia and Alzheimer’s Disease and is not sensitive for mild cognitive impairments.

Best Practices from Alzheimer’s Association (2006) Alzheimer’s Association Australia (2007):

  • Have a well established philosophy of care that is shared with all of the team
  • Establish timelines for ongoing formal assessments
  • Identify the care will be person-centered with flexible scheduling of care
  • Identify there will be interdisciplinary care supported with a consistent approach to care
  • Consistency with personnel and other caregivers.
  • Medication optimization
  • All personnel need to be well trained in dementia care
  • Acknowledgement of previous skills
  • Work closely with the family and caregivers
  • Use the environment as a psychosocial tool
  • Have behavioral management guidelines taught to entire team

Implementing the Practices:

  • Have the baseline Clock Drawing Test available
  • Communication should be open and supportive to patients, family, and caregivers
  • Provide Person-Centered Care Philosophy which honors an individual’s personhood (Kirkwood, 1997)
  • Medication Optimization teaching
  • Optimize functioning to include walks and exercise movement as tolerated
  • Institute a Falls Risk Program with special equipment recommendations
  • Assess environment and institute safety and care suggestions
  • Have extended meal times to allow for conversation and a calming environment
  • Assess and institute a Pain Management Program

Coding Tip: If the physician diagnosis for the patient is dementia, expect the Select Data coding team to code 294.8 (other persistent mental disorders due to conditions classified elsewhere, or dementia). If the physician lists or confirms the clinician’s assessed symptoms, the Select Data team will code them separately such as paranoid state would be coded 297.9 (Unspecified paranoid state) for delusions. Should the physician identify a specific diagnosis, then codes such as 290.3 (Senile dementia with delirium) will be listed. If the dementia is from an underlying condition, the physical condition, such as 331.0 (Alzheimer’s Disease) is listed first then a code from subcategory 294.1 (Dementia in conditions classified elsewhere) will be chosen to capture the related dementia.

Instituting a best practice dementia care practice can be challenging but fulfilling. Momentum can be maintained by frequent case conferences and seeking ongoing feedback from family and caregivers. Ongoing personnel education is needed so competency skill levels remain high.

ADDITIONAL SOURCES:

Alzheimer’s Association Campaign for Quality Care: Dementia Care Practice Recommendations for Professionals Working in a Home Setting, Phase 4, 2009

2010 Alzheimers Facts and Figures
http://www.alz.org/documents_custom/report_alzfactsfigures2010.pdf

Hudson, R. (Ed), (2003). Dementia nursing: a guide to practice. Ausmed Publications, Melbourne Australia

Kirkwood, J. (1997). Dementia reconsidered: The person comes first. Open University Press. Berkshire, UK.

McCann-Beranger, J., (2002). A caregiver’s guide for Alzheimer and related disorders. The Acorn Press, Chalottetown, PEI.

National Care Forum Older People and Dementia Care Committee (2007) Statement of best practice: Key principles of person-centred dementia care. Coventry CV1 2DY www.nationalcareforum.org.uk

Robinson, J. (March/April, 2007). Utilizing best practice in dementia care. In Canadian Nursing Home Journal.

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Dementia – Part 1: The Disease Symptomatology

Thursday, September 23rd, 2010

Dementia is a syndrome in which progressive deterioration in intellectual and cognitive abilities is so severe that it interferes with the person’s usual activities of daily living including socialization and occupational functioning. An estimated 5 to 10 percent of the U.S. adult population ages 65 and older is affected by a dementia disorder. In this age group, the dementia incidence doubles every 5 years. Dementia makes it hard for an individual to remember, to learn, and to effectively communicate. The brain disorder may cause lapses in memory and disruptive behavior burdening caregivers. This disorder hurts the person afflicted as well as those around him/her.

The Symptoms

Despite its prevalence, dementia often goes unrecognized in its early stages. Many health care professionals, as well as patients and family members chalk up the symptoms to “old age”.  Dementia is caused by damaged brain cells due to a head injury, stroke, or, a disease like Alzheimer’s. The Ten Warning Signs identified by the Alzheimer’s Association include:

  • 1. Recent memory loss. This is demonstrated in recurrent questions for information already answered.  The Alzheimer’s Association states, in contrast, a typical age-related change would be forgetting a name but remembering it later.
  • 2. Problems with language; speaking and writing. The person with dementia may not understand what they want or how to verbalize the request. They may exhibit difficulty in following a conversation or call familiar items by an incorrect term. In contrast, the Alzheimer’s Association states that an age-related change might be having difficulty finding the correct word in a sentence.
  • 3. Diminished judgment. This person may go outside on a cold day and forget their shoes. They may not pay attention to grooming. In contrast, the Alzheimer’s Association states a typical age-related change might be making a poor decision periodically.
  • 4. Confusion with time and space. This person may become confused regarding dates and seasons. In contrast, the Alzheimer’s Association states that an age-related change may include forgetting what date it is but being able to problem solve to find the correct answer.
  • 5. Misplacing things and losing the ability to retrace steps. The individual may lose items, put the items in unusual places, and have difficulty retracing their steps to locate the items. In contrast, the Alzheimer’s Association states that any individual may misplace items periodically, such as glasses, car keys or the remote.
  • 6. Challenged abstract thinking or solving problems. An individual with dementia may attempt to balance a checkbook but forget the meanings for number categories or they may have trouble following a once familiar recipe. In contrast, the Alzheimer’s Association identifies a typical age- related change might be making an error in the checkbook.
  • 7. Difficulty in completing familiar tasks. Sometimes the person experiencing dementia may not remember rules to a favorite game or driving to a location and forgetting how to return home. In contrast, an age-related change might mean requiring assistance with some technology.
  • 8. Rapid mood shifts and changes in personality. Families frequently report their loved one will be happy one moment and tearful the next and angry within the next moment. They may also report a loving calm friend is now anxious, fearful, and suspicious. In contrast, the Alzheimer’s Association cites an age-related change may include acquiring a specific routine and becoming irritable if it is disrupted.
  • 9. Challenges with initiative and withdrawal from work or social activities. A person suffering from dementia frequently displays lack of initiative and difficulty acquiring new skills or maintaining knowledge of a favorite sport or hobby.
  • 10. Difficulty understanding visual images and spatial relationships. A person with Alzheimer’s Disease may exhibit visual and distance judging difficulty as well as difficulty determining color contrasts. An age-related disease may include visual difficulties due to cataracts.

Dementia displays a non-specific illness syndrome in which affected areas of cognition include memory, language, attention, judgment, and problem solving. In later stages, the affected individual is usually disoriented to time, place, and person.

Careful assessment of history is essential to rule out various diseases and disorders that include organ dysfunction. Certain mental disorders can also produce symptoms.

The Alzheimer’s Association has compiled a detailed 64 page compendium of practice recommendations. The recommendations include a strong person and family – centered approach to dementia care. Individualizing care to the abilities and needs of individuals affected by the disease are stressed. This type of approach respects cultural and family values focusing on maintaining the traditions of the family and encouraging personalized care. Relationship building with family members is a cornerstone to care of an individual with dementia. In part two of this series, care and best practices will be discussed further.

Dementia Care Practice Recommendations for Professionals Working in a Home Setting

http://www.alz.org/national/documents/Phase_4_Home_Care_Recs.pdf

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Evidenced Based Practice

Monday, April 19th, 2010

CMS, through OASIS C, is guiding the home health industry toward evidenced-based practices. These practices require the identification of a solid literature review with established clinical integrated expertise that includes the patient’s cultural, socioeconomic, and educational background.

An organized plan with expected outcomes is being mandated in this contemporary health industry. There is a need for information directed toward diagnosis, prognosis and disease prevention. Traditional sources; such as textbooks no longer meet the fast paced knowledge accumulation of today. Time treating patients has become expensive and limited. Current up to date, tested knowledge is vital to maintain diagnostic/practitioner skills and quality outcomes.

There are specific steps recommended to achieve evidenced-based practices:
1. Select a topic or a clinical question is asked:
Problem-focused such as identified through Quality improvement, benchmarking, and recurrent data
Knowledge-focused, based on research from conferences or journals
2. Form a Team
3. Have a well defined process for evidence retrieval . A common paradigm used today is PICO; a) who is the Population, b) what is the intended Intervention, c) is there a Comparison intervention or Control group, d) what is the desired outcome.
4. Classify the literature as either conceptual (theory and clinical articles) or data driven (systemic research reviews). The data is derived from clinical trials, meta analysis, and national rated articles.
5. The information should then be interpreted and critically evaluated as to application, validity, and expected outcome. Apply the evidence.
6. The decision to change practice considers the relevance of the evidence and the consistency in research findings, looking for ways to improve or modify the application. Qualitative research is being used more frequently in this regard.

To further encourage evidence based practice in home health care, CMS is seeking standardized tools to be used in the OASIS C Integrated Assessment. These tools, such as the Braden and Norton used for skin integrity assessment are readily recognizable, not only in home health but, in other levels of care in health care. Thus, if the patient is transferred to another care level, a reliability of skin assessment can be maintained because the tool is a recognizable standardized instrument.

Evidenced-based processes are also being encouraged because the patient population is requiring more from their health care practitioners, having increased knowledge, empowerment, and access to information, and expecting predictable outcomes from care.

Evidenced – based practice is not a new concept. It is documented in Daniel 1:6 in the Bible where “controlled trials” were used in comparing dietary benefits for families. In the 1700s, James Lind used randomized trials to show that scurvy could be prevented by citrus fruit. In the 1800s, Semmelweis studied the transmittal of puerperal fever, an infection occurring in females post partum. Semmelweis was able to document that physicians and medical students would perform aurtopsies, and in the same clothing (dirty aprons and all), frequently, merely wiping their bloody hands on their aprons, then perform gynecologic examinations on the new mothers. By instituting hand washing with chloride of lime prior to examining the females, the infection rate dropped over 80%. Evidence-based practice is soundly grounded in research.

The Agency for Healthcare Research and Quality, the National Guideline Clearinghouse, and the Evidence-based Medicine Resource Center are just a few organizations involved with the practices of EBP. Discipline specific associations impacting medicine, nursing, and the rehabilitation oriented therapies are also actively involved in research.

Evidence-based practice in nursing is seen with a new model called Guided Care Nursing (GON) being researched in Maryland, to examine seven chronic care interventions, including disease management, patient self management, case management, lifestyle modification and geriatric management. The nurses involved in the program have completed a specific educational program that looked to enhance their skills in these areas. Predictive modeling software was used to identify patients for the study. The study has been so positive further clinical trials have been funded..

Researchers at the University of California San Francisco Medical Center have undertaken a prospective study to look at incongruencies in practice standards across specific disease lines.

Evidence Based Practice is now being applied in the health care education and training setting. Data has been evaluated on over 109 medical schools in the country.

Government has a strong belief that evidence based practice will positively impact both on the quality and financial outcomes in health care. It is an exciting time in health care. It is truly the time for strong data driven practice.

Susan Carmichael
MS, RN, CHCQM, COS-C
Fellow of the American Institute for Healthcare Quality

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Evidenced Based Outcome Improvement

Wednesday, March 24th, 2010

Outcome improvement and safety in Home Care is a focus of CMS. All levels of health care are being encouraged to find evidenced- based ways to improve patient safety, prevent adverse events, and achieve optimal outcomes. OASIS C has been designed to measure improvement in processes. Data collected from the OASIS C assessment, plan of treatment, and evidenced practices will be utilized in publicly reported measures, OBQI/OBQM quality reports regarding care improvement guidance, and development of a Pay for Performance system.

In 1999, the Institute of Medicine (IOM) recommended adverse event reporting, first in the acute care setting and then to other health care delivery systems. An adverse event is defined as “an injury caused by medical management rather than by the underlying disease or condition of the patient” (IOM, November, 1999).  Systems failure remains the number one reason for medical error. Types of errors include medication, accidents/falls, and pressure wounds. Causes of error and adverse events include complex patients with complex problems (multiple diagnoses and co-morbidities, multiple medications), complex information management, and the complexities of being human (emotions, support systems, and resistance to change). The IOM encouraged improved data collection and analysis and improved systems.

By 2005, various studies reflected that the IOM goals had not been met (Leape and Berwick, JAMA, 2005). This fact encouraged various organizations, including the Joint Commission to revise and update performance standards including National Patient Safety Goals to more aggressively encourage safety and prevent adverse events. CHAP encouraged improved infection control processes by clinicians in the home. In 2010, CMS, through OASIS C, is driving evidenced-based processes. Home Health Agencies are charged to screen patients for risk in skin condition, depression, pain, falls. SOB, depression, and anxiety are considered very strong risk predictors for outcomes. In the near future, outcomes are expected to be tied to referral potential and payment reality.

Evidenced-based processes are advanced by standardized assessment tools. These measureable assessment tools are enhanced when used in conjunction with well captured patient data. That means completing an OASIS data set thoroughly and accurately. Changes in OASIS coupled with impending RAC audits should be an impetus to agency leadership to effect powerful change and/or review in their organization. Clinical accountability for timely documentation, attending educational sessions, and case conferences are essential to maintaining skill sets and excelling to achieve improved patient outcomes. Streamlining processes becomes vital.

Clinicians require a thorough knowledge of how to answer each of the OASIS M question. As adult learners, they will naturally want a better understanding of the big picture conceptual changes and how the new evidence tools will drive care quality. They may ask for more education as to how to assign risk. This is where algorithms and protocols play a part in quality care. Agencies need to establish “next steps” in care; a falls risk score of 10 may trigger a physical therapy referral or weekend hospital discharges may mean an admission to home care is completed that same day instead of the agency routine policy of “within 24 hours”.

OASIS C has the potential to measurably improve clinical excellence and increase consumer value but, assisting clinicians to embrace the change can still be challenging. One facet to review regarding clinician efficiency and accuracy is having the right tools. Having a tool designed by home care clinicians that flows through a head to toe assessment, that triggers clinician care planning, that allows for additional screening tools to be available is essential. Also, consider providing coding support for the clinician.  We all know that for the average home health agency, the home health nurse is an excellent clinical generalist, not having the luxury to specialize in one diagnostic area. (And many nurses state that is one reason they enjoy homehealth). But in the area of coding, providing coding expertise is an essential part of risk management.

OASIS C may be the impetus for transformational change for the industry. It has morphed from a mere data collection tool to a process oriented tool that requires the clinician to create a highly comprehensive client/patient-centered plan of care with a diagnosis code table of contents and evidenced –based care with expected outcomes. In the very near future, those outcomes are expected to be linked to patient/client satisfaction ratings and agency reimbursement. CMS is well on its way to expanding processes that have publicly reported measures solidly supported with evidenced – based practices. Those practices begin with tools to aid the clinician in gathering accurate data…efficiently.

Susan Carmichael
MS, RN, CHCQM, COS-C
Fellow of the American Institute for Healthcare Quality

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