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.

Tips for reducing bathing stress in residents

Below is a link to an article on Daily Caring.com that has useful tips to remember when helping to bathe a resident who has Alzheimer’s disease. We encourage you to take a quick look and share with staff, as bathing can be a stressful activity for residents and staff alike.

http://dailycaring.com/7-tips-to-get-someone-with-Alzheimers-to-take-a-bath/

We are announcing a fun contest this week for all of you…please email us (vigne1@verizon.net) a brief “tidbit” of your own that describes how you or a staff member at you facility has been creative in getting residents to shower or bathe without a battle.

The facilities that email us the winning tidbit entries will each receive a gift card towards treating staff to lunch! We will also share your idea in a future weekly tidbit so your experience can help others too. We look forward to reading your great ideas….we know you have them to share!

All hands on deck-Working with champions to reduce BPSD

To change how everyone in your settings manages behavioral and psychological symptoms associated with dementia, we need all hands on deck!  Your identified champions are your leaders and role models.  These individuals play a vital role in implementing the strategies we want all staff to use when working with residents with behavior and psychological symptoms of dementia.

Champions (along with other stakeholders such as administrators, nurses and social workers) not only act as role models, but also cheerleaders, teachers and observers. Encourage your champions to take a few minutes and watch the ways in which their co-workers interact with residents to make sure they are following the resident’s care plan and using person centered approaches during care interactions (e.g., having the individual participate in his or her bathing and dressing; walking the individuals to the bathroom regularly to avoid agitation; or singing the resident’s favorite song during an unpleasant care interaction).  Acknowledge, praise and reward the individual when an effective behavioral intervention is implemented.  Examples of such acknowledgments include:

  • A simple “Great job, keep up the good work!”
  • A write up in a newsletter recognizing their exemplary work
  • A Starbucks gift certificate (or an alternative treat!)

Conversely, when champions witness missteps by staff during resident interactions, they should turn these into opportunities to teach their colleagues a better way to handle those situations.  Role modeling a better way is one of the best ways to make new learning happen.  For example, when a caregiver tells a resident who is repeatedly getting up and down in an unsafe fashion to sit down they might fall…. And the resident persists and gets more agitated….it may be helpful to step in and show that taking the resident for a walk or having him or her stand and sing and dance for a minute or two may decrease the agitation.

Staying positive, encouraging and persistent is key to changing the habits of staff and building a strong team of caregivers who help one another.

Aiding staff in making care more person-centered

When we consider integrating changes to a philosophy of care it is important to remember that small, gradual changes can lead to more lasting success. A good analogy for this that many of us can relate to is dieting. We are more likely to change our eating habits for the long run if we make simple, practical changes to our diet instead of trying an extreme diet that is unrealistic and won’t last.  Attempting to take on too much, too quickly can result in frustration, feeling overwhelmed, and giving up on making any changes at all.

The same is true when it comes to managing behavioral symptoms related to dementia. Consider having nursing staff choose a few residents with less challenging behavioral symptoms to begin. We bet you can already think of a few residents to start with as you read this! Staff can hold weekly “huddles” to discuss ideas, challenges and successes they have had with these individual residents. This can help them build confidence in their abilities, foster teamwork, and create trust in the approach to care that we are encouraging.