Quality Improvement Long Term Care - Essay Example

Quality Improvement Long Term Care Paper The following quality of care improvement plan applies to a LongTerm Care (LTC) facility in, Maryland. Located in an urban area this facility has not changed ownership in the past year. It is a health care chain with a 177 bed capacity with the current resident population consisting of 42% males and 58% females. This facility offers a variety of services including an Alzheimer care unit, rehabilitation programs, catheter care and IV therapy, total parenteral nutrition, hospice services, respite care and tracheostomy care. A high percentage of the residents suffer some form of dementia and only 5% are ambulatory. 40% of the residents require assistance with feeding. The high numbers of non-ambulatory patients put this facility put it among only 10% in the state. On May 10, 2004 the facility was investigated for a complaint which resulted in a substandard quality of care under Quality Indicator number 4, a prevalence of depression symptoms that also include two of the following; negative comments from residents, agitation or withdrawal, unpleasant mode upon waking, suicidal, weight loss or recurring thoughts of death. I choose the number 4 Quality Indicator for Emotional/Behavior Patterns due to its effect on quality of life. It may also be the end result of the other deficiencies at the facility, which included a high percentage of indwelling catheters, excessive amounts of medications and lack of assistance with personal care. The Quality Indicators for Emotional/Behavior Patterns of agitation and suicide could be signs of overdose of antidepressant medications. Sadness and withdrawal might be symptoms of depression as well as thoughts of death or weight loss, which needs to be treated. Depression encompasses both physical and mental health and can alter the responsiveness to nutritional and physical therapy as well as medical treatments. This deficiency has a potential for more than minimal harm. As per guidelines of the American Medical Directors Association (AMDA 2003) the first action in the quality improvement plan is a medical workup for the affected patients that include a patient history review, depression screening tests and a medication review. Blood tests should include a chemistry profile, complete blood count, serum levels for anticonvulsant or tricyclic antidepressants, thyroid test or other levels pertaining to the individual in question. Before addressing pharmacogenesis of depression, however, consider another factor: Depression in the older adult if often more difficult to diagnose than in younger people. One reason is a prevailing misconception within general society, and even with the professional community, that older adults are supposed to be depressed, that it a natural part of getting older. In fact, an older adult's functional status, or level of impairment thereof, is often more influential than mere aging in shaping a person's mood. The residents of nursing homes usually have significant levels of debilitation, often arising from numerous chronic conditions. The complex nature of these conditions often frustrates physicians and treatment staff, often leading residents to have a sense of sadness or depression. (Garavaglia, 2006) If psychological testing and laboratory testing demonstrate that the resident is in need of psychiatric services, medical treatment or a medication adjustment and those measures lead to improvement, then the nursing staff needs to monitor the behavior and attitudes of the resident to prevent any digression or reaction to prescribed medications. If the depression does not appear to have a physical cause then assessment of the resident's environment and quality of life is the next step. Nursing should ask a few questions to determine the Quality of Care Improvement Plan. Is the resident capable of doing more personal care for himself, but needs clothes laid out or some other measure to maintain some independence If the resident is incontinent without a toileting program could the resident benefit from a toileting program Are indwelling catheters necessary for all residents to have them All of these issues pertain to the dignity of the resident and quality of life. A good quality of life is necessary for good mental health. The substandard quality of care regarding personal assistance not being afforded the residents can be addressed in several ways. The prevalence of non-ambulatory residents indicates the facility is predominately heavy care, which often leads to high staff turn over and poorly trained staff. A mentoring program is one possible solution as described by the Department of Health and Human Services (Emerging Practices in Nursing Homes, EPNH, March 2005). In LTC facilities that utilized mentoring programs the staff turnover was decreased. In the mentor program the newly hired aide is paired with a mentor who trains the new hire and records the progress to superiors. Ideally the new aide remains with the mentor until demonstrating acceptable skills. In addition to mentoring duties, the mentor also may by responsible for; Conducting in-service training for other staff Orienting new employees from non-nursing staff, such as dietary and housekeeping Participating in the hiring process, such as touring the facility with prospective employees (EPNH March 2005 pg 3). The drawbacks to the mentor program are that it raises costs due to additional staff required as the experienced mentor will be spending time away from aide duties. However, long term care administrators have indicated that mentoring has decreased aide turnover by fifty percent. "Managers felt that improvements in retention can lead to an increase in quality and continuity of care." (EPNH March 2005 pg 3) Other suggestions made by the Department of Health and Humans Services to reduce staff turnover include involving all staff in the decision making process and providing flexible work schedules. By allowing nontraditional work schedules personnel who might otherwise have had to resign could continue employment. This program helps those with child care problems and those returning to school remain at the facility. The quality of care can also be improved by involving the family in resident care beginning at admission to the facility. A lack of understanding contributes to the expectations of family members as to what sort of services their relative will receive. "Families had expected nursing home care to be similar to hospital care, with daily involvement of physicians and with licensed nursing staff handling most aspects of care." (EPNH 2005 pg 5) This inclusion of family members could reduce the frequency of complaints due to high expectations rather than substandard care. If staffing deficiencies were corrected resulting in a better trained and consistent staff, the day to life of residents could see improvement. Nursing home residents are people, individuals who once owned homes, worked and made their decisions. Entering a LTC facility has to be a drastic experience where a person finds themselves with little to say about their own lives. The adjustment could be eased by providing a more home like environment where the resident can make a few choices such as room decorations, outside recreation and meal choices. The quality improvements discussed in this paper require cooperation between staff, physicians, social workers, residents and family members, however, nursing staff are on the front lines from day to day and can apply and monitor needed changes. The State of Maryland was one of the five states that participated in a Department of Health and Human Services (DHHS) pilot project in 2001 to improve nursing home quality of care as reported by the Department of Health and Mental Hygiene (DHMH). The project was initiated by the DHHS Centers for Medicare and Medicaid Services (CMS). The object of the project was to make LTC facilities more accountable for services rendered and to collect data regarding the various facilities and make it available to the public. Previously, the public had little information regarding the regulations and services offered by nursing homes and did not have the education to make the best placement decisions for family members. The data could also serve as a tool for administrators to improve quality of care. While the quality indicators have been used internally by nursing homes for several years to identify potential problems in health care delivery, Maryland is one of a few states to adapt this information into a tool for consumers to compare a specific nursing home's performance to other nursing homes. (DHMH news release 2001) In the study by the DHHS, Emerging Practices in Nursing Homes, moves to prevent adverse events were also considered. In the example provided a resident had several falls because she kept getting out of bed. When discussing this behavior with family members it was discovered that the resident liked to pray every night. Involving family members in care plans can provide answers that staff might not be able to address. A detailed resident history with input from family members could be an invaluable tool for monitoring resident mental and physical health. Depression that appears to have no cause might easily be treated if resident's personality and past habits were understood. For example, a resident who loved to decorate her own home could find the nursing home environment too institutional and become depressed that this activity could not continue. One nursing home held a bathroom decorating contest of staff and residents. (EPNH 2005 pg 7) Making a long term care facility more like home is a reasonable goal and not necessarily costly. Common areas could have plants, magazine racks, curtains, couches and perhaps even a dog or cat. A pet has been shown to increase quality of life and longevity in the elderly and creates a friendly atmosphere where relatives and friends would want to visit. Depression in a long term care facility can originate from a feeling of isolation as well as a lack of independence. For residents who have no family or the family is not able to visit regularly due to distance, this feeling of being cut off the world can be severe. Some nursing homes have began programs that involve the facility in community activities such as holding meetings in the common rooms, participating in Foster Grandparent programs or as in the case of one facility, holding baby showers for women in local shelters. (EPNH 2005 pg 8) Another method of reducing the helpless feeling of residents is to involve them in decisions made that will directly affect them. Holding meetings to solicit resident opinions regarding changes to be made can serve to avoid future problems and allow the residents some power over their lives. Indiscriminately repainting without consulting residents on color, switching food suppliers or buying furniture without their input is not necessary and leaves residents no choices. While doing what is possible to make the LTC environment for hospitable, it is still an institution. "..caring for those who are usually quite ill and severely compromised with the paramount response being medical intervention. This is a sad and somber setting at best, making it all the more difficult to identify true depression in a resident. Think of how difficult it is for many on your staff to accurately code the section of the MDS differentiating depression from a sad or somber affect." (Garavaglia, 2006) Depression is found in one third of nursing home residents with new admits needing more staff time and are 1.5 times more likely to die within 12 months of admission. (Wagner et al 2003) The quality indicator of Behavior/Emotional Pattern was substandard in the state inspection preceded by a complaint filed. The solutions and outcomes are feasible and the deficiency could be removed at the next survey by educating staff on the signs of depression and reassessing care plans in incontinent residents. While many of the residents have significant chronic health disorders and may be on several medications that could cause clinical depression, it is not normal for the elderly to be depressed and measures can be taken to improve quality of life. Nursing staff will work together to report any changes in residents behavior or demeanor. Nurses, CMAs and aides will monitor residents for altered mental states and report findings daily. Outcome measures include; Medical treatment if needed Risk of relapse or recurrence of depression Safety of medications use to treat depression (National Guidelines Clearinghouse 2005) An obvious improvement in mood, social participation, appetite and activity level Family member's observation of mental improvement Reduced aggression, preoccupation with death or suicide talk Extra observation of new residents for the first few months In-service hours about Depression and its symptoms A new plan of care for incontinent residents who exhibit depression signs and do not have a toileting program will be written if no medical reason for the incontinence is found. Outcomes will be; Resident will be on a toileting schedule An evaluation of needed assistance will be performed Resident will be allowed as much independence as ability allows Incontinence is reduced or stops Resident self image improves With staff turnover reduced, in-services provided regarding depression and the elderly, and with residents being included in decision making, there should be some improvement in the resident quality of care and in their quality of life issues. Some sadness is expected due to the drastic change in resident lives after placement, but it should not be a chronic condition. In a facility with most of the residents being non-ambulatory there is a greater challenge to improve and maintain resident quality of care due to overworked staff or understaffing. Resident quality of life depends on those who care for them directly from day to day. It takes experienced, consistent staff to know the residents well enough to notice small changes in behavior and thus enable a diagnosis of depression in the early stages. Works Cited American Medical Directors Association (AMDA). (1996)Guideline Title: Depression. Retrieved April 13, 2006, from AMDA http://www.amda.com Department of Health and Human Services (DHHS). (March 2005). Emerging Practices in Nursing Homes (OEI-01-04-00070). Retrieved April 13, 2006, from the Office of the Inspector General (OIG) http://www.oig.hhs.org Department of Health and Human Services (DHHS). (November 2001). Maryland to Pilot Nursing Home Quality of Care Project. Retried April 13, 2006, from the Department of Health and Human Services, http://www.dhmh.state.md.us/publ-rel/html/pr112001.htm Garavaglia, Brian PhD. (n.d.) Avoiding Drug-induced Depression in Nursing Home Residents: Depression is Not Inevitable-But It Can Be Caused By Our Treatments. Retrieved April 13, 2006, from http://www.findarticles.com/p/articles/mi_m2820/is_10_53/ai_n6359044/print Works Cited Wagenaar, Deborah DO. Colenda, Christopher, MD. Kreft, Michelle, BS. Sawade, Julie BS., Gardiner, Joseph PhD., Poverejan, Elena PhD. (October 2003). Treating Depression in Nursing Homes: Practice Guidelines in the Real World. [Electronic Version] JAOA 103 (10) 465-469 Read More