Aligning patient-centered activities with CMS guidelines

Most have you have probably been paying attention to the new CMS guidelines for 2017. One of the new guidelines (f-tag F679) relates to activities: “The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.”

This is a challenge for most staff working with nursing home residents, and is far more challenging when those residents are experiencing BPSD.  It can seem an overwhelming task when dealing with so many different people with a variety of needs, so we hope this week’s tidbit will help guide you and provide ideas for ways create activities and practical plans for your residents that will meet the CMS guideline.

When choosing an activity for a resident with BPSD, keep in mind that the intervention should match the functional skills of the person to promote movement and an opportunity for success. In Neurodevelopmental Sequencing Program (NDSP), individuals are placed in a program level based on an assessment of their level of functioning. You can read the full paper by Linda Buettner, CTRS, PhD and Ann Kolanowski, PhD, RN, about this at:  http://www.gnjournal.com/article/S0197-4572(02)09019-5/abstract

See the table below from the paper to help determine functional levels and appropriate activities for each:

Level I: Strengths: Ambulatory but with overhead movements more difficult; decreased endurance level; able to change positions independently; usually continent; assists with personal hygiene

Challenges: At risk for falls; slower gross motor movements; balance problem; needs reminders to maintain posture; strength and endurance may be decreasing; may have muscle tension or loss of hand control (weaker grasp)

Interventions:

  • Active sports and games of choice
  • Fall prevention
  • Cognitive stimulation programs with motor component
  • Geriatric exercise
  • Walking group
  • Air mat therapy (balance and strength or relaxation)
  • Kitchen activities
  • Assisting with special events: decorating, food preparation, pushing wheelchairs, greeting and assisting
  • Leisure lounge and leisure education

Level II: Strengths: May have trunk control and head-neck control; able to use upper extremities; fair range of motion and strength; may be able to independently move wheelchair; can roll over segmentally

Challenges: Unable to ambulate without maximal assistance; may have poor posture habits; decreasing visual acuity; may use palmar grasp; reduced fine motor control; incontinence; needs assistance for bathing, dressing, toileting

Interventions:

  • Geriatric exercise to music
  • Adapted sports/games
  • Food preparation activities
  • Air mat therapy (balance and strength or relaxation)
  • Prepare for special sensory events
  • Stimulation box and simple pleasures activities

Level III: Strengths: Conscious; able to respond to familiar stimulation; may be able to make eye contact

Challenges: Non-ambulatory; poor trunk control; poor head and neck control; poor range of motion; poor strength, e.g. head lag; head or knee contracture; poor vision and hearing; may be able to roll (or may log roll); incontinent

Interventions:

  • Passive and active range of motion
  • Massage
  • Positioning (e.g. air mat, bean bag chair)
  • Reaching activities
  • Air mat therapy
  • Sensory integration, special sensory events, and tactile simple pleasure items

In another paper, Recreational Activities to Reduce Behavioral Symptoms in Dementia,   (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2780321/) the authors emphasize that activity interventions are most effective in the prevention of behavioral symptoms and less so during a behavioral crisis. Second, they need to be provided on a routine basis to prevent the behavioral symptoms from recurring. Third, interventions are most successful when they are matched to a person’s interests (remember that family members are a rich source of information about the activity preferences their loved ones) and functional abilities and balance throughout the day with periods of rest. Finally, these interventions require a partnership between nurses, nursing assistants, activity directors, recreational therapists and physicians to be successful.

If you are looking for some new ideas for activities to do with your residents, Table 2 from the paper lists recreational activities commonly enjoyed by people with early and moderate dementia. A few from the list include:

  • Table games
  • Chair volleyball
  • Horse shoes
  • Music lessons
  • Cooking
  • Construction crafts
  • Dancing
  • Gardening
  • Putting green/adapted golf
  • Relaxation session

We hope this helps you think about the activities that are most appropriate for each individual resident at your facility, and starts a dialogue between your staff members about ways to address BPSD through activity interventions. Please share your thoughts and ideas with us on this important topic.

Care plan snapshots: Making care plans useful

Developing and updating care plans to ensure they include the required information takes a lot of staff time and attention. Unfortunately, they don’t usually live up to their potential for day to day usefulness and practicality.

To help address this, we’ve developed a Care Plan Snapshot…a “Readers Digest” version of a care plan that highlights the key information that a GNA or other caregiver would find most helpful day to day. It includes short and long terms goal(s), guidance on ADL care that helps residents maintain or improve function, behavioral issues with suggested approaches to care, and motivational ideas based on a resident’s interests. All in just a few pages!

Below is an example of a Care Plan Snapshot for “Mr. WXYZ”, along with an example of a completed capability test for him, which guided the development of the care plan’s goals and ADL care approaches. We invite you to take a look, share with staff, and discuss how this might be beneficial. Feel free to use and adapt as you’d like for your facility. For example, if family members are involved with a resident’s care, you may want to add a section on what family members can do during visits to help their loved one meet his/her goals.

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Capability Test for: Mr. WXYZ                                                     Date: July 19, 2017

Ask and encourage the resident to do each of the following:

  1. Range of Motion (ROM)
  • Full ROM to 180 degrees of abduction (hands over head) __1__ (1 point if yes, 0 if no.)
  • Full external rotation (hands behind head) _1____ (1 point if yes, 0 if no)
  • Full internal rotation and adduction (hands in small of back) __0__ (1 point if yes, 0 if no)
  1. Either lying or sitting, point and flex your toes, bend and straighten your knees, and/or if sitting, ask to march.
  • Able to flex ankle__1__ (1 point if yes, 0 if no)
  • Able to point toe__1___ (1 point if yes, 0 if no)
  • Able to bend and straighten knees ___1___ (1 point if yes, 0 if no)
  • Able to march ___1_(weak)_ (1 point if yes, 0 if no)
  1. Chair rise – observe to do this independently or how much help is needed (give up to 10 minutes to complete the task)
  • How many tries does it take? __0_ (Scoring: 1-3 tries= 1 point; > 3 tries = 0 points)
  • Do they use their arms? ___0___ (0 point if yes, 1 if no)
  • Can they make it to a full stand and stand independently for 1 minute? ___0__

(1 point if yes, 0 if no)

  1. Follow a one, two, or three step commands doing a functional task:

Ask the participant to take a towel, fold it in half, and put it on the table (bedside table or bed or whatever is available).

  • Follows a one-step verbal command __0____ (1point if yes, 0 if no)
  • Follows a two-step verbal command ___0____(1point if yes, 0 if no)
  • Follows a three-step verbal command ___0___ (1point if yes, 0 if no)
  • Follows a one-step visual/cueing command ___1___ (1 point if yes, 0 if no)
  • Follows a two-step visual/cueing command ___0___ (1point if yes, 0 if no)
  • Follows a three-step visual/cueing command ___0___ (1 point if yes, 0 if no)

Total Score:  7 (max = 16)

HIGHER SCORES ARE BETTER CAPABILITY

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Care Plan Snapshot

Resident Name: Mr. WXYZ
Room number:  0A

 

Care Goals

Short term goal #1: Resident will attend at least one preferred activity each day to decrease boredom and restlessness
Short term goal #2: Resident will perform sit-to-stand exercises at least once daily with assistance from staff to increase strength, maintain ability to transfer, and decrease risk of falls
Short term goal #3: Resident will go outside at least once per day, weather permitting, with assistance from staff
Long-term goal: Resident will show an increase in expressions of wellbeing (smiling, laughing, engaging in activities) and a decrease in expressions of distress (agitation, restlessness, wandering and apathy).
Care Area Resident Responsibilities Staff Responsibilities
Physical

Activity/

Ambulation

Resident will self-propel in WC, perform sit-to-stand exercises with assistance daily, participate in at least one scheduled activity daily, visit outdoor courtyard once daily, and transfer out of WC and into chair for all meals with assistance

 

 

Staff will encourage resident to self-propel in WC, assist with sit-to-stand exercises after lunch daily, encourage and assist resident to attend at least one daily activity with staff; visit outdoor patio with assistance from staff once daily, and assist with transfer out of WC for all meals
Bathing/Grooming Resident will wash/dry face and upper body with visual cuing from staff

 

 

Staff will provide 1-step visual cuing and encouragement for resident to wash/dry face and upper body
Dressing Resident will dress upper body with visual cuing from staff and engage in AROM while getting dressed

e.g., wave to friend in the hallway, march knees up to hit GNA’s hands, swim strokes

 

Staff will provide 1-step visual cuing to assist resident in dressing upper body; assist resident to perform AROM while dressing using 1-step visual cuing; ask resident to lift legs to help dress lower body
Eating Resident will eat finger foods and use utensils as needed with visual cuing from staff

 

 

Staff will place one food on plate/in bowl at a time, cut foods as needed and provide finger foods to encourage independence; use visual cuing with utensils
Oral Care Resident will brush teeth twice each day with 1-step visual cuing from staff as needed

 

Staff will have supplies ready and provide 1-step visual cueing and encouragement
Toileting

 

Resident will assist with transfer to toilet

 

Staff will encourage toileting after meals or at designated intervals; use 1-step cues during transfers; monitor for skin breakdown
Behavioral Issues:  Restlessness, agitation; occasionally engages in disruptive vocalizations, apathetic
Related to: Schizophrenia; Alzheimer’s disease; difficulty adjusting to new surroundings
Approaches by staff:

  • Assess for boredom, pain or other behavioral and psychological symptoms of dementia
  • Engage resident in sit-to-stand exercises, visits outside and other physical activities regularly
  • Provide consistency in care using same caregivers when possible; communicate successful strategies with other caregivers
  • When resident shows signs of boredom or agitation, attempt to engage him in one of his favorite activities, e.g., a game of horseshoes, going outside to courtyard, visit with receptionist
  • Respond calmly to resident during times of agitation, allow resident to vent feelings, and provide ample time for resident to respond to simple questions and direction from staff
  • Model behavior for resident
  • Offer choices to resident when available
 

Motivational ideas/Rewards:

 

(What are his interests, likes/dislikes, strengths? Who are his favorite caregivers?)

Mr. WXYZ loves to go outside and visit with his buddies. They like to talk about their time in the war. He also enjoys listening to jazz music, and it calms him down when he is agitated. His favorite GNA is Mary. He does not like eating in bed or playing games like BINGO, because they are for “old” people.