Missouri Long-Term Care Information Update

Entire Series Now Available for Download!

The Health Quality Innovation Network’s free 9-week education series is now available for download on our Resource Center. Download the topic(s) that you want to focus on in your facility or download the entire series and work through all nine weeks.

The five short, concentrated evidence-based talking points in each week can easily be included in daily stand-up meetings to increase staff knowledge on relevant topics. The program is designed to empower nursing home staff with practical knowledge to foster a safer environment and decrease preventable emergency room visits and hospital readmissions.

We’d appreciate your feedback on this education series. Please share your experience in using the content and materials offered in the Nursing Home Stand-Up Series.

HQIN is presenting an educational series tailored for nursing home stand-up meetings, aimed at decreasing preventable emergency room (ED) visits and hospital readmissions. HQIN is sending out talking points that can be included in daily stand-up meetings to increase staff knowledge on relevant topics like effective communication, adverse drug events and infection prevention. The program is designed to empower nursing home staff with practical knowledge to foster a safer environment.

This week is the final week of the series. This week’s strategies include Purposeful Conversations. Below is an overview of information and resources.

• Purposeful conversation refers to intentional and meaningful communication that serves specific objectives or goals. It goes beyond casual chitchat and aims to achieve specific outcomes.
  Print and discuss with the team the following resource, Go to the Hospital or Stay Here. Social services staff or nurses can use this decision guide to facilitate clear and informative conversations of a resident’s choice to “Go to the Hospital or Stay Here.”
• Do all of your residents have a documented advanced directive? Review which residents are a full code, and which are a Do Not Resuscitate (DNR). Discuss how staff know which residents are DNR and what the current process is to communicate this to all staff.

Print and discuss Education on CPR for Residents/Patients and their Representatives with the clinical team to guide conversations when providing education for residents and their family.

Advanced directives should be reviewed upon admission, quarterly, and if a change in condition would warrant it. Use this Advance Care Planning Tracking Form to assist with tracking these reviews.

• It is often helpful to involve the physician or healthcare provider, in addition to the resident and their family, in purposeful conversations during care plan meetings. You may want to have an ad hoc care plan meeting if a decline in condition is noted.  Discuss with the team the importance of being proactive with change in condition. Consider inviting the physician or nurse practitioner to participate in a care plan meeting to participate in difficult conversations.

Print and discuss A Patient’s Guide to Serious Illness Conversations from the Institute for Healthcare Improvement to guide these conversations.

• Advanced care planning for vaccinations is a best practice. The Planning for COVID-19 Care Conversation Tool can assist with having purposeful conversations centered around vaccinations upon admission and at quarterly care plan meetings. Print and share the same resource with the admissions and clinical care plan team and discuss how it can be incorporated into current practice.

HQIN is presenting an educational series tailored for nursing home stand-up meetings, aimed at decreasing preventable emergency room (ED) visits and hospital readmissions. HQIN is sending out talking points that can be included in daily stand-up meetings to increase staff knowledge on relevant topics like effective communication, adverse drug events and infection prevention. The program is designed to empower nursing home staff with practical knowledge to foster a safer environment.

This week’s strategies include Falls. Below is an overview of information and resources.

• Talk about environmental hazards that may contribute to a resident falling.
  How many can your staff name (wet floors, poor lighting, incorrect bed height, improperly fitting wheelchair, poor shoes, or resident needs such as the need to use bathroom, items not in reach, call bell not in reach)?
  Print the Environmental Safety resource and review with your team, then post it for other staff members to have for reference. Create a Falls bulletin board to display educational resources to reduce falls for your team.

• How many times have you seen a resident try to stand, transfer or walk unassisted? It takes a team, working together, to reduce falls.
  If you see a resident that looks unsafe, let someone know. Purposeful rounding can be conducted by anyone (housekeeping, dietary, maintenance, nursing, social services, activities and volunteers) who is “walking” in the facility.
  Print the Falls Prevention resource and share with team members, then post it for others to reference.

• What are the 4 P’s to reduce fall risk? Pain. Potty. Positioning. Possessions. Implementing purposeful rounding for all staff can significantly reduce fall risk.
  Print and post the following resource on The 4 P’s of Reducing the Risk of Falls and discuss them in depth with your staff. Also, download these 4 P’s Cards that can be cut out and shared with staff.

• It is time to talk about engagement and sleep hygiene. Improving mobility, psychosocial well-being and sleep hygiene has been shown to reduce fall risk.
  Print and post Simple Strategies to Prevent Falls: Engagement and Sleep Hygiene for your team. Discuss ways your team can improve sleep for your residents.

• Who is tracking falls in your facility and are they including it as part of QAPI? Is there a system of sharing information on falls and letting all members of the team know the facility’s fall data?
  Designate a “falls champion” today and continue to find great information on fall reduction to share with your team. Charts and graphs can be great to share! Download the Health Quality Innovation Network (HQIN) Nursing Home Falls Tracking Tool and implement it into your team processes.

HQIN is presenting an educational series tailored for nursing home stand-up meetings, aimed at decreasing preventable emergency room (ED) visits and hospital readmissions. HQIN is sending out talking points that can be included in daily stand-up meetings to increase staff knowledge on relevant topics like effective communication, adverse drug events and infection prevention. The program is designed to empower nursing home staff with practical knowledge to foster a safer environment.

This week’s strategies include Discharge Analysis. Below is an overview of information and resources.

• Any time an emergency department (ED) visit, unplanned discharge or adverse event occurs, we can identify areas where improvement is possible.
• Do you have a process in place to review ED visits and unplanned discharges?
• Does an interdisciplinary team conduct these reviews?
• Are they done after each transfer or adverse event?

Discuss current strategies for improvement.

If not already established, consider assembling an interdisciplinary team consisting of leadership, the medical director and direct care staff to review these events.

• A resident may discharge unexpectantly for a number of different reasons. It might seem like there was nothing that would have prevented an ED visit or hospitalization but often processes could have identified a problem before it resulted in discharge. Facilities must have processes in place for early identification of changes in condition and to communicate those changes to ensure timely interventions.

Assess your facilities communication processes. Do you have a huddle meeting with frontline staff to share and discuss important information? If not, consider using the HQIN Huddle Toolkit to implement huddles at start of shift and end of shift, quality improvement huddles, new resident huddles or “Everyone Stands Up Together” huddles where the daily standup meeting is conducted on the unit(s) with frontline staff.

Also, INTERACT® (Interventions to Reduce Acute Care Transfers) offers communication tools at no cost including Stop and Watch Early Warning Tool, SBAR (Situation, Background, Appearance and Review and Notify) and the Medication Reconciliation Worksheet.

• Other adverse events should trigger the same evaluation as unplanned discharges. Reviewing adverse events helps to find opportunities for improvement that can prevent future ED visits or hospitalizations.
  • When issues are identified or communicated, how are these issues reviewed?
  • Are they reviewed at risk management meetings?

Discuss how possible opportunities are communicated to the risk management team. Use the EMR to help identify factors like changes in condition, falls, medication errors, etc. to include in risk management meetings.

• Residents and families play an important role in preventing ED visits and hospitalizations. Care planning and advanced care planning should be discussed with patients and families regularly. Review CMS’ Go to the Hospital or Stay Here Decision Guide for patients and families. Make use of the resource to assist patients and families to plan for future care.

INTERACT® (Interventions to Reduce Acute Care Transfers) also offers care planning tools at no cost including the Advance Care Planning Communication Guide and Identifying Residents who may be Appropriate for Hospice or Palliative/Comfort Care Order. Choose your favorite resources as a team and make sure they are available to assist with care planning.

• Sometimes the root cause of an adverse event is not immediately clear. Root cause analysis can help uncover the cause, and a fishbone diagram can assist with finding it. Fill out the problem (adverse event) at the head of the fish. As you brainstorm possible causes, group them into categories. Use these categories to identify areas where improvement would be beneficial.

When you have identified a problem and root cause, you will want to implement quality improvement interventions. Consider the problems and root causes you have noted this week. Use the QAPI Sustainability Decision Guide to assist with choosing effective interventions.

INTERACT® Version 4.5 Tools For SNFs/Nursing Homes also offers quality improvement resources including an Acute Care Transfer Log, Calculating Hospitalization Rates, Hospitalization Rate Tracking Tool, Quality Improvement Tool for Review of Acute Care Transfers and Quality Improvement Summary Worksheet.

HQIN is presenting an educational series tailored for nursing home stand-up meetings, aimed at decreasing preventable emergency room (ED) visits and hospital readmissions. HQIN is sending out talking points that can be included in daily stand-up meetings to increase staff knowledge on relevant topics like effective communication, adverse drug events and infection prevention. The program is designed to empower nursing home staff with practical knowledge to foster a safer environment.

This week’s strategies include Medication Reconciliation. Below is an overview of information and resources.

• If a resident’s medication orders reflect the wrong medication, the wrong dose, the wrong time, or the wrong route, adverse drug events are likely. Review which staff reconciles medication on admission. Discuss with the team the policy for admission medication reconciliation.
  • How many times are admission orders reviewed?
  • Is the contacted pharmacy made aware when orders are for a new admission?
  • How are diagnoses, indications and allergies identified?

Are medications reviewed with the previous facility during report?
Review the Interact Medication Reconciliation Worksheet. How does this compare to the facility’s medication reconciliation processes?

• After admission, every nurse that gives medication is responsible for giving medication correctly. Along with the Five Rights of medication administration (right patient, right drug, right dose, right route, right time), nurses will need to be aware of the indications for medications, any needed lab work or monitoring and possible adverse reactions.
  Discuss the systems in place at your facility to ensure medications are given properly. Review the Five Rights with staff.

• Doctors, nurse practitioners and pharmacists should be involved in medication reconciliation.
  Ask your team these questions:

• • When is this review triggered in your facility?
  • If there has been a behavior change, is medication reviewed for possible side effects?
  • Who can you reach out to internally and at the contracted pharmacy if you are unsure if orders or administration are appropriate or with any other questions?
• Medication reconciliation should not stop at admission. Changes in condition or changes in locations should trigger a medication review.
  Are physicians or pharmacists notified when a resident’s condition changes?
  Are they notified when a resident becomes more or less compliant with medication or diet?
  These changes could result in the need for closer monitoring or changes to medications. Residents with over eight scheduled medications are at higher risk for drug-to-drug interactions. Do you have a process to handle those higher risks?
• Medication needs to be administered according to company policy. Using a computer system to assist with medication administration helps prevent medication errors. Discuss the drawbacks staff see in using the computer system.
  Do you experience fatigue due to repeated drug interaction alerts? How can those drawbacks be eliminated? Review some lessons learned about implementing and using technology in a clinical setting.

HQIN is presenting an educational series tailored for nursing home stand-up meetings, aimed at decreasing preventable emergency room (ED) visits and hospital readmissions. HQIN is sending out talking points that can be included in daily stand-up meetings to increase staff knowledge on relevant topics like effective communication, adverse drug events and infection prevention. The program is designed to empower nursing home staff with practical knowledge to foster a safer environment.

This week’s strategies include Adverse Drug Events – Opioids. Below is an overview of information and resources.

• Adverse drug events are commonly experienced by people taking opioids as well as anticoagulants. Like anticoagulants, you will want to ensure staff caring for residents know which residents are at risk and what risk factors and sign/symptoms of adverse events may be. Discuss opioid risk factors, adverse event signs/symptoms and interventions using the Opioid Tip Sheet for Frontline Nursing and CMT Staff.
• Using non-medication pain relief methods can decrease the need for opioids. Communicating with residents and families will help find the most effective pain relief methods for each patient. Sometimes facilities use methods like applying heat/cold, massage, ultrasound, or stretching exercises to help ease pain. Remember to evaluate things like positioning, bed choice and seating choice when you are working to reduce pain.
• Knowledge of risk factors, signs and symptoms of adverse drug events, and the best ways to stay safe can prevent them and assist with early identification. Review your policy for medication education and explore Opioid Resources for Patients and Caregivers.
• Opioids can be useful for controlling pain, but it is important to remember they carry a high risk for adverse events. Review the Opioid Adverse Drug Events Self-Assessment with your team. Use the Plan-Do-Study-Act Worksheet to work toward improvements.
• Narcan (Naloxone) is a medication used to reverse the effects of opioids. It is often discussed for treatment of overdose with illicit drugs but is often needed for people who are prescribed opioids. Every nursing home should have a policy for Narcan use. Review your facility’s policy with staff. Can staff identify where Narcan is kept and when it should be given? Post the Opioid Information Card to educate residents and caregivers.