Webinar: How to Implement a Restorative Nursing Program

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Webinar Transcript

Welcome to how to implement a restorative nursing program. With today’s session, we’re going to be giving you the overall framework to consider when looking at implementing a restorative program, but we’re also going to give you some things to think about.

This webinar and our learning objectives today are how we’re going to define what restorative nursing is.

And we’re going to correlate how the effect of restorative nursing programs can help reduce falls and prevent the decline in function in your residence. We’re going to help you identify team members and the responsibilities we’ll develop a plan or implementation of a restorative program and review what required for the documentation to capture restorative nursing program for our new patients or the payment model.

So for chapter one, is what is restorative nursing?

The century started nursing is interventions that promote the resident’s ability to adapt and adjust to living independently. And that’s a keyword that keyword is trying to get them to be as independent as possible and making sure they’re doing those types of cares as safely as possible. And it doesn’t just focus in on the physical wellbeing of the resident restarted. And our students really wants to look at that holistic approach of achieving and maintaining optimal functioning and physical, mental, and psychosocial. There are regulations around restorative nursing, 676 talks about the activities of daily living and ensuring that when a resident is in your facility, that their activities of daily living do not diminish. And the circumstances of the individual clinical condition demonstrates that such a diminished was unavoidable. And it really looks at those approaches for restorative nursing. So it’s ensuring that you are providing treatment services to maintain not only maintain the, to improve the resident’s ability to carry out activities of daily living.

So your hygiene mobility limited elimination, toileting, dining, et cetera. So your traditional restorative nursing it’s defined as we start in nursing uses all individualized activities to improve or maintain the residents. Self-Performance. So that’s the goal. We’re trying to get them to do their, their cares on their all all-in and it can be provided. And this is also key by any staff member under the supervision of a licensed nurse, as long as a licensed nurse, whether it’s an RN or LPN or LVN, it can be any staff member. And we’ll talk more on that. And what’s key to this is restarted nursing activities include repetition, physical, or verbal queuing and test segment, and why that is so important. As many times, your nursing assistants on a day-to-day basis are most likely, already doing a lot of just physical over verbal queuing with your residents, doing some task segmentation.

You need me to be set up with them, things like that that are a lot of times it is restarted nursing that you’re not necessarily taking credit for. Now under the MDF in order to capture restorative nursing, here are the activities that are coded on the MDF. So your traditional range of motion, whether that’s passive or the active range of motion, the bend mobility, meaning how they turn side and side, how they beat themselves up in bed and how they get themselves from city into mind or line to sitting position, how they transfer from one circle to another. So such as from a bed to a wheelchair or maybe a wheelchair to the toilet, what their walking ability splint or brace assistance. So that’s assisted residents when the donning or removing the brace, cleaning it looking at contracture seems like that dressing and our grooming.

And this was a kind of a key area where a lot of your nursing assistants are probably doing this on a day to day basis. So how do you simply help set up your vendors so that they can perform those tasks as independently as possible? Is it just a matter of setting off their clothes and getting them off the hanger? Is it just getting the toothpaste on the toothbrush and then they’re able to brush your teeth on their own home, et cetera, same with eating and or swallowing. So many times if you’re just setting up the train, maybe cutting a few foods, making sure they have adapted equipment that is all things that’s considered active, restorative nursing amputation or prosthetic care. So again, helping them get it off and care for that actual test static and then their communication skills. So how are you helping them in this?

Again, most of your nursing assistants are probably doing on a daily day day-to-day basis when it comes to communication. If there’s certain ways and cues that your resident communicates with your staff members. So how can we look at restorative nursing for reducing falls and prevent a decline in function. And essentially we need that restorative nursing to keep them function capable. When you look at the asset mobility, it’s a very complicated task that we take for granted. It’s automatic. You know, you’ve probably walked into this room into a chair though. You might be in a room with several people just getting around the table to chair. That’s an obstacle course. You’re, you’re pivoting, you’re turning, you’re stopping, you’re starting and you don’t even think of it. It’s something that’s very automatic to us. And it’s very complicated. It requires neuromuscular function, connection, and requires balance, agility and flexibility to do it.

As we age, we lose that ability over time. And many of us take for granted. I usually ask my participants, how many of you saw your, your child’s first step? Many of you would probably new residents last step and walking is key to proper health. And we’re going to talk about those effects and mobility. Again, looking at regulation S 689 is your accident. And that is where your falls fall under. And a fall is considered unintentionally coming to rest on the ground four or other lower level, but not as a result of the overwhelming external forces. Let’s say another resident pushes another resident that would be considered a fall tenet. The key word to this is unintentional. So they didn’t mean to start the fall, even if the fall was pot midway, if it was unintentional and they are now to a lower surface on what they started, it is considered a fall at that point, like anything we need to get to the root cause.

And if we don’t address the root causes of why people fall, they’re going to continue to fall. And we do a lot of training on how to do a good fall investigation to see what might’ve prompted that person to get up in the first place. We do a lot at looking at the environment to make sure it’s safe for eat grass when they do get out. But at the end of the day, the true reasons why people fall is essentially it comes down to a strength balance or endurance issue. They simply didn’t either have the strength and the balance to get up into an upright position. So those folks who fall right next to the bed or the chair, when they try to stand up from that’s, usually they didn’t have enough strength or the balance to hold themselves in that place. And they tend to fall from trying to get to the bathroom.

So maybe five or 10 feet out. So you had that resident that gets up from the bed and tends to fall halfway between the bathroom. That’s usually a balance issue. They have the strength to get up, but they didn’t have the balance to maintain that walking stamps from there. If they get out to your hallway and start walking and they tend to just drop or fall in the hallway, that’s usually more of an endurance issue and that’s very key and pivotal, cause those are the things that we need to address so that if they do try to get up any grass and to walk and move, we need to make sure we’re addressing those. So where they fall kind of integral of what issue you’re going to want to actually look at. We do have a new regulation around mobility as well. It’s F 688 and basically it states, and again, this is pivotal for restorative nursing.

We talk about range of motion and mobility. Is it basically states that want to run when it comes in without limited range of motion doesn’t experience reduction in that range of motion again, unless the clinical condition demonstrates that it’s unavoidable. So you really have to prove that that clinical condition and, or it States that the resident has limited range of motion to receives the appropriate treatment services either to increase that or maintain it and prevent further decline. It goes on to state that residents with limited mobility receive appropriate equipment and assistance to maintain or improve that mobility with maximum practical independence. Unless again, that the reduction mobility is demonstrated to be unavoidable. So overall you know, with restorative nursing, we’re trying to maintain that function for that resident improve quality of life. But we also do have regulations surrounding it, as we all know coming up, we’re going to have a patient driven payment model.

So PDPM and your section GG, which looks at those functional abilities that near with that and started nursing Calvin major impact. Cause it’s used to calculate the functional splits for PT, OT and the nursing components of PDPM. And what’s interesting about it is there’s more points for the more independence the resident is thus really working with those caregivers to ensure that the resident is doing the task as independently as possible versus us doing it for them, because you’ll actually get more points if the resident is more independent. And again, if you look at section GG is basically looking at all of those things that restorative nursing can be working on to promote that independence by that verbal queuing, you know, setting up the residents and working with them to strengthen them, to be able to do the walk, the transfers that, that mobility of sitting to lying on how to do their toileting, hygiene, oral hygiene, eating, et cetera.

One of the things that it looks at is your range of motion. And many of us have goals of walking in a new section, GG side, you know, can they walk at least 150 feet per day with that being said, if that’s your revenue goal that we would just do maybe range of motion once a day, walk them 150 feet a day to keep that, that level. Do you think, or how many of you think that once a day range of motion or propelling walking 150 feet is enough to prevent a fall or decline in function? Just going to give you a little minute here to be able to answer that question, can you think about that and will it prevent falls or someone declining or just doing that range of motion and walking at least 150 feet a day.

Well, it looks like 71% of you thought that was false and 28% of you thought that was true. And unfortunately, focusing here to tell you that that is, it definitely is a false statement. And unfortunately that’s many times the only goal we have is walking 150 feet or doing some active range of motion while that might help a little with preventing some contractures blocking 150 feet, isn’t it enough to have a physical impact to help prevent a decline in overall function and muscle mass with that. And I’m sure many of you on this webinar probably know the goals of 10,000 steps per day, that it’s proven that the more that’s per day and the more actively you walk, the healthier you are and the better health outcomes that you have, and the less likely you will have to crime and health. So really kind of looking at moving at task, just kind of that traditional restorative nursing.

Why do we want to ensure that our residents aren’t immobile? And unfortunately, it’s kind of the nature of our business. As our residents, their day tends to be they’re in the wheelchair, you know, they’re in bed, they get in the wheelchair and go to breakfast, maybe some activities in the wheelchair, and then they might pivot transfer back to bed, take a little nap, have a transfer, again, back to the wheelchair and really all their activity in throughout the days, maybe a couple pivot transfers. At the end of the day, there is research showing the effects of, and mobility and the overall health and function of individuals. And one of the research that I’ve got this information from, show us how they actually took college students. So they took 19 20 and 21 year-olds and they rendered them in mobile and study defects fit.

And what I’m about to review with you is what happened with young college students. So now imagine we’re 65, 75 or even 85 year old. Now how quickly even a day of sending around in a wheelchair could have an overall effect their mobility. Yeah. So within one week there was a 12% loss in muscle strength and the whole atrophy. So very quickly on that young adult and then as a little three weeks, almost half their normal muscle strength as well. So again, imagine you’re 85 now, and you’re not moving. Unfortunately, the first muscles to become weak are your lower limbs. And those are the most important muscles in order for you to get into an upright standing position safely and be able to pivot transfer or to walk. And unfortunately this use of the left that will also affect that neuromuscular function. So it’s going to affect their coordination and balance.

So the less they move, the less balance and coordination they’ll have, and it will make it even difficult to do simple things, even something as simple as a transfer with moving their feet or pivoting their feet. And then again, leading to those falls because of balance issues. It also had a tremendous impact on these States as participants and as little as 10 hours became insulin resistance leading to type two diabetes. And we wonder why our residents in the nursing home, why we can have good control of blood sugars, even though they do have pretty much a captive diet that we’re serving them. It’s due to that immobility making it more hard to control those blood sugars. The participants also developed a postural hypotension and that developed under 24 hours. So it was a little 20 hours. They were developing that, that hypotensive response when they would try to stand up and many times they know that those residents that they tolerate and that’s for the egress, you might be seeing that drop in blood pressure.

And ironically, it could be secondary to this mobility, also cardiac diseases. Your muscle, your heart is a muscle, and it’s going to atrophy the further atrophy and of the heart. It can lead to respiratory infections and all that. When you’re not mobile, you don’t toilet your lungs. And many times that’s why they end up with that secondary, you know, respiratory infections, bronchitis, or pneumonia. And that’s due to lack of calf muscle pump action in your lower legs. They end up with that lower leg edema, which can lead to alterations and people get pressure injuries when they’re in normal people who are actively moving around and will not develop pressure injuries. So that’s one pivotal way to try and prevent pressure injuries is keeping them moving. And then certainly if you don’t have any impact, meaning we need to be weight bearing in order for our bones to regenerate.

And if we don’t do that, the less active we are, we’ll end up with this youth, ask your process. And that can be further component if you’re already probably tasked your process. So if they do fall more likely to break those bones from there can lead to functional incontinence. And many times in the nursing home, the reason why people become incontinent is that inability to get themselves to the toilet. So again, restorative very imperative on trying to help them be able to get to the toilet and to the toilet timely. And the more incontinence they have, the more increase risk of those urinary tract infections. And then certainly the online, the effects of not moving around will lead to that constipation. It also has a tremendous effect on our neurological system, all of these participants. And it was very interesting there, they would have all some hypoxia and it would fluctuate throughout the day.

And one of the times during the day where they would see them become hypoxic was about 4:00 PM into early evening. And it led to delirium confusion, agitation. And what was interesting about that as many times in the nursing home, we call that sundowners and they could be sundowning just because they’ve been sitting around or laying around all day. It was well noted. All of them developed some type of depression. It also led to insomnia. The less you move, the less likely you’re gonna be able to get into a deep sleep. So many of them, even though they might’ve been laying in bed for long periods of time, they had very poor sleep quality and research has shown and it’s well studied that or lack of sleep and lack of exercise leads to those amyloid plaques, which leads to Alzheimer’s and dementia. And right now we’re seeing a large amount of research on the importance of exercise in order to prevent any of brain deterioration, very important to get blood supply and oxygenation to the brain.

So how do we try to combat those effects and mobility for our residents in a pivotal doing that restorative nursing program to try and keep them moving by adding in strength training. So talk a little bit about fall and walking program and strength training is kind of an advanced piece of restorative nursing. So instead of just doing range of motion, we’re actually going to try and keep that muscle mass. And what’s important to note, it’s never too late. Research has shown that somebody we’ve even seen her at 99 years old, that they may have never done strength training or any type of exercises. Once they start their body will respond to it and their muscles will respond. So a lot of people on the adjuncts, but it’s just too late for me. What’s also key about what you do with your program as the model, how you train is how you gain.

If you’re trying to make a resident, get their leg stronger. So they’re able to get up into an upright position or even pay the transfer. If you put them on a piece of equipment to strengthen their implants, it will strengthen, but it doesn’t necessarily equate to being able to get into that upright position from a city position, you do better serve as doing sentence Dan’s name, have them go from the city to a standing position back to the city 10 times. So really looking at your program, that the type of movements and exercises you’re doing to strengthen those muscles equate to movements that they might need to do such as maybe reaching for something or even a twist, things like that. And also very important, repetition, repetition, repetition. If you don’t use it, you lose it. And that neural test is Nate and respond to repetitive.

So if they’re having unsteady gait or balance problems, the more you practice it over and over again, the more conditions they’re going to get with that. And the better balance that they’ll have strength training by adding that into your restorative nursing program is going to add muscle, which will help them lose fat, but very important. It’s going to help all that joint health movement health is going to help strengthen and support all those joints and muscles. So it’s going to maintain an improve that function and movement. Thus, it’s going to reduce that fall risk by doing strength training. It will put stress on the bones, which is a good thing, and it will help increase bone density. If you have people’s arthritic pain, the more they move, the less pain that they actually have, the more muscle mass you have, the better that you will metabolize glucose.

So getting that diabetes under control. So hopefully getting rid of that constipation is known to lower resting blood pressure and Paul, and it’s also very effective, intriguing, and decreasing depression. So how do you set up that restorative program for and foremost management absolutely has to be supportive of the program. And basically your role as administration is to ensure that your staff has all the support and resources they need. I don’t necessarily recommend that you’re the one in charge of the program. You really need to empower your staff and your frontline staff to do this. Your role is just making sure that it is it is being done and supported that it’s being done. Or you might want to start is look at where your, your, you know, the mindset of the staff is, is your staff thinking, especially when it comes to your resident, is it not sufficient for me to just do the cares for them?

Is it more efficient for me to pop them in the wheelchair and wheel him down the hall? And that’s something we really need to look at that is not restorative nursing and your residents will have that decline. Your section GG will decline. And they’re going to have that over to all the client in their ADL with that. So kind of latter life clients will look at, you know, how many residents are depending on wheelchairs and do they actually need the wheelchairs or should they be walking? So who really, truly needs a wheelchair versus who does it, who are your big fathers? That might be another good way to start. Who do you want to kind of look at another key to starting it as what did you relationship between their same therapy and activities? It’s imperative that you work as a group, because there are a lot of these activities that you can do in conjunction with each other.

So there’s a lot that activity can do with group exercises and functional type exercising and then therapy and nursing. Definitely that handout. We, we can’t have therapy forever, so we don’t want, as soon as the relevance DC from therapy to decline, and that’s where nursing can take over to help continue and maintain the program. Once they come off of therapy, you know, what is your restorative nursing program look like? Now, do you have one, or you’re starting from square one, or is it reliant on one person which we don’t recommend? Which I’ll talk about in a minute, because obviously if it’s one person, if they’re not there, it’s not going to happen. And if you’re short staffed, they’re the first ones to get polled. And then, you know, again, looking at those activities, how can you pull them and what kind of activities can they be doing that will help with that range of motion and even group exercise type program.

So the key is to get all your staff on board. One thing you might want to do is just some initial training on the effects and mobility. And I did a really high level fly by of effects and mobility, but your staff needs to understand that this is not only about keeping them their range of motion, where they’re at they’re walking and billing, whatever the case may be, but you just saw how the effects and mobility can not only lead to fall, but their overall decline in health with diabetes. And as you say, the muscles and hypotension, and you know, all those kinds of things can happen. Respiratory infections, your team needs to be interdisciplinary. You definitely therapy and nursing have to at a minimum be talking on this, that it really shouldn’t be that interdisciplinary team approach. You do want to pick some lead nurses and some need nursing assistants.

But my recommendation is you’re going to involve all your nursing assistants, but you’re going to have those key lead ones that will help coordinate the program, be the resource to the rest of your nursing assistants. And you have to have that oversight of your nurses. And again, all your nurses should be ensuring that the restorative is being done, even though you have a lead. And then from there that lead again is that resource. You want to make sure through all shifts, because there’ll be things that they can do. Even Vic range of motion in that turning, repositioning, nice coming in, instead of turning the person for them, if they actually can assist with it, things like that. Making sure physicians and nurse practitioners are supportive of it. And again, having that activities being involved with it and maybe even helping take over and being a part of some of these exercises, you definitely want dietary involved to help with making sure they’re getting enough fluids and enough calories.

If they’re on an exercise program and maintenance and health keeping is pivotal to make sure that your environment is safe for mobility, gram rails are in place that you have raised toilet seats and equipment to make sure right egress Heights, especially in the bathroom, do they need adaptive equipment in there? Things like that, and then making sure that your hallway, that there’s smooth transition. So there’s not trip hazards. Going down the hall where I recommend you start is competency. All your nursing assistants, going back to square one. We all those of you. I started out as a nursing assistant, but all under Siebel systems are trained on traditional restorative nursing. And not sure it happened, but we stopped doing it. And I can assure you during your scene, assistants are doing restorative on a day to day basis. And you’re just such weight, just not capturing it.

I bet if you sit down with a group of your nursing assistants, say, how do you help your resident get dressed in the morning? What is it you do for them? Do you totally dress them? Are you setting them up and then letting them do as much as they can same with how do you, how are they grooming at a brushing their own hair, brushing their teeth after a set-up, et cetera. You just really need to sit down and talk with them and let them know your duty to start a nursing at that point. So a making sure they know what we’re starting nursing is, and that they know those activities and can do things safely, especially things like your range of motion. How did you transfers appropriately and walking, and then also reiterating the importance of them. You know, we all love to document, but you need to start taking credit for what you do, and they need to be documenting on a daily basis.

You know, you might have it set up. Yep. We’re gonna cue and do this. You know, we’re going to actually set the, get the toothpaste, I’ll get it on the toothbrush, put it in their hand. But then from there allow them to brush their own teeth. And you would document that that was actually done. So first I would just get to go back to baseline. It is a responsibility of all your nursing assistants, not one person or two people or three people can do it for all of your residents. And again, guaranteed that they’re probably doing it. I do recommend you start small at might seem all around the AE. I do some baseline competency for all of them, but then you might target a unit. Maybe let’s start with 10 residents where we really focus in with them and all those nursing assistants that are involved with those residents to get the program going, and then slowly add residents until you get so whole health. It’s just day-to-day practice to really help promote your residents to be as independent as possible
From there, with the advanced program. So adding in that strength training or true exercises to ensure that they don’t lose that muscle mass, that they don’t lose their strength that help improve their balance and endurance that’s where you might want to have your targeted staff. So really ensuring that we’re picking up with therapy games off now, traditional therapy can’t do head to toe straight forward exercises and has to be very skilled and has to be targeted as well to have a hip fracture targeted to that hip fracture that has, it has to be at a skill level of a therapist nursing. However, can do your traditional head to toe strength training of all those imbecile groups. And so really picking up many of the buildings I had worked with we’ll do it in tandem, especially just the therapy’s about to DC them off of therapy and the nursing continues the program on, and then it’s re-evaluated.

So if nursing sees are having to decline, or maybe an exercise is not working for the resident, he time to refer back to therapy or maybe they they’ve maxed out and they really need to go to that next level, that referral back to therapy to see if there, you know, can modify that program to advance it. So having some dedicated staff for more of those advanced or intense residents and, or your new residents, so maybe you have that new prosthetic care or a new splint device. So anything that’s new before it’s rolled up the house, that that is where your team can really look at it. So having therapy, those dedicated, and it doesn’t have to be nursing assistants that can be activity coordinators, whomever guidance, States that as long as the person’s trained on it and competency tested on it, they will be safe to, to do the program for you.
So really kind of looking at key staff and, you know, again, keep in mind that it doesn’t necessarily have to be a nursing assistant. You definitely do have to have dedicated nurses that are going to be the lead to that. Once you decide to do the advanced program who those folks are going to be, make sure they are competency tested on proper strength training techniques. So how to do a proper warmup to make sure they’re doing the exercise techniques safely through the full range of motions what’s done to safely at a safe speed reading, et cetera, what they need to watch for, for warning signs. And many times, if you’re doing straight forward, traditional strength training, it should not be too taxing for your relevance, but they need to be taught what warning signs to watch for, and then how to cool the resident down and very important how to stretch them.

So how to stretch those muscle groups to help prevent any soreness, but very important. The more flexible the muscle is the less likely they’ll get injured as they do have a fall. So how do you document that you’re seeing restorative program basically under PDPM the nursing component, we’ll use the depressive systems and the restorative nursing services that are coded on your MDs to further adjust your case mix. So in order to meet that, and it’s going to bump up that nursing component for you and give you a higher rate first and foremost, this is why you need it. And I recommend you start now, again, start with section of your facility. You might want to start where your admissions come in and see how your staff just so they get used to it, but it must start on day one of admission, having that restorative nursing look at that resident, look at their capabilities and start that program from there to capture it.

And half the total, that task has to be 15 minutes and a 24 hour period, six to seven days a week. And that 15 minutes can be broken up. So let’s say you’re practicing, transferring. Well, it could be five minutes in the morning, five in the afternoon and five minutes in the evening. It probably is going to be more than that. At least it has to equal 15 minutes on that same task. You know, maybe it’s turning and rolling in bed. Justin and grooming, it might take you, you know, 10 minutes in the morning and 10 minutes at night for them to fully do their dressing and grooming type things. So what you’d want to do is have the nursing habit set up to how they’re supposed to help to, or perform those tasks. And the negligence indicate that they’ve done it and how many minutes that it actually took.

And then hopefully it’ll add to at least 15 minutes or more with that. Now, if you do any restorative nursing, it will help under that nursing component. But if you do at least two restorative nursing components to two minutes a day, it’ll get you into that higher adjustment. And in particular, if you add in the strength training program, it’s very easy to get to. In fact, a lot of the clients that I work with, a lot of the residents, when they really start looking at how they truly do care for the residents usually end up with more than two very easily, especially when it looks, when you look at things like dressing and grooming, how you’re assisting with their eating function and then just their overall movement. How are you doing that? Many times it’s going to be very easily for you to hit that higher adjustment.

You can also provide it in groups but it can’t be more than a wonderful ratio. So many times we’d recommend any started out on to, and then as a resident progressions, you can maybe do some of the strength training as groups. So that one to four. So this is where once they get proficient, you can maybe turn them over to activities. You need to make sure that care plan and medical record has measurable objectives and interventions. And that’s where a lot of folks kind of struggle. And if you do, especially the strength training piece of it, it will, it’s very easy to get measurable. So how many reps did they do? Did they go off and weight with it, you know, increasing that. So is there contracture maintaining it? Are they able to put on their splints and clean it?

So very metal that they very segmented she’s past that you can actually do and continue with. You need to have periodic evaluation. And it really kind of depends on how larger units are. A lot of the clients I work with on a weekly basis as a team, we’ll go through who their higher with started nursing people are, and then just kind of review the overall residents or they might have set number of residents to, to review each week. So by the end of the month, all your residents on that unit have been reviewed as far as our restorative nursing goals. So again, you have to show the nursing systems have been trained and competency tested. And then making sure again, that, that oversight with some supportive and licensed nurse. So again, it can be an RN or an LPN can oversight and program.

And we usually recommend that the nursing assistant check in with the licensures before obviously starting their day to make sure that the residents there’s no concerns with them. Maybe they’re ill whatnot and what you might be doing restorative wise. Now, if you add in that strengthening component and you’re strengthening exercises and you really what’s going to have our tremendous impact we do see most falls and reducing that decline in function where you would call this as under the range of motion. And when we read the range of motion, it says, exercise performed by the residents of queuing supervision or physical scissors by staff that are individualized, that residents needs planned, monitored and evaluated. So this is where you can capture that strength training and really help kind of bump up that PDPM and help really promote that strengthening of your resident and preventing that decline overall, when it comes to the strength training, many of the facilities as far as the groups go, we’ll offer it to two minutes.

And what you might want to do is if your person is new to the strength training and you guys to start this program out, you might want to start with flat work up to two, three, just kind of, and again, you might want to look at who’s your biggest followers right now who is using a wheelchair that, you know, there’s no physical reason why they shouldn’t be able to walk or maybe chin short distances. So maybe starting with one with your more advanced restorative nursing work, your way up to, you know, more residents. And over time you can turn them over to groups. So that’s where you’re at might want to be trained in to maybe your restorative aid is actually targeting the individual. And once they feel they’re safe to do that, they can send them on and advance them to that group type setting.

We usually recommend just offer the strength training that usually takes her full body, had to tell straight training, 15 minutes a day, stay green muscle groups. You always want to ask 48 hours in between that muscle groups. So many of the civilians I work with they’ll do Monday, Wednesday, Friday, upper body exercises. And Tuesday, Thursday, Saturday are always the lower body. That way. If the residents coming in on a certain day, we just know every Wednesday it’s going to be upper body, or you might have a more advanced section in your facility. So you might have your rehab unit or short-term stay where you might have people that are more capable and want more of a 30 minute exercise. Only two to three times a week. You can offer a full body, more intense exercise program two to three times a week. So maybe Monday, Wednesday, Friday, you do the strength training.

And then Tuesday, Thursday, Saturday for that resident, you just have them do range of motion without the weight. So that way you’re still able to capture it. Again, as I stated initially, if you’re doing the strength training, offer one-on-one or any of the restorative, if you need to learn techniques, offer at London, and then from there, once they get proficient and safe to do so, going to that more advanced group type setting. So in summary, keeping your residents mobile and as independent as possible, and their activities of daily living will enhance your quality of life and overall health outcomes and the higher functioning physically and mentally your residents are the less likely to fall or have that decline in those activities of daily living. So it’s something to really think about. I know many times I stated, you know, we do a, we have regulations around it.

So the regulations essentially state that somebody who comes into your facility should not have a decline in their ADL, their range of motion or their mobility levels. Again, unless you can show that maybe, you know, they’re having to advance the ML. So that clinical condition truly was preventing that. And we also do have the payment system. So it will behoove you with that restorative nursing program. That’s under that party, stay in that if you do have that restorative program going up and running you will actually be able to capture that and really looking at that section GG. So not only, you know, just capturing, we started nursing in those first five days, but section GG again, the more independent that relevant can be within five days with your restorative program, it will your PMPM payment system at the end of the day, though, with that being said with regulatory. And with that, that financial aside, hopefully this quick overview really gave you some insight that the more mobile your residents are, the stronger they are, the less likely they’re going to decline. They’re going to have better overall health and quality of life. And they’re definitely going to be less likely to actually fall the better strengthened they are and the more that you work with them. But that being said, I am going to go ahead and open this up to any questions that might be out there.

So the first question is what is PDPM, that’s the patient driven payment model for those of you that are in long-term cares starting on October 1st, that is going to be how long term care is going to be reimbursed for their residents stay. So essentially how the facility is going to be paid for that overall residents care. And it’s not just the nursing care. It is also PT, OT, and speech as well. See here looking at some of these other questions.

It, is it possible that the program or for staff is part of the program and then have a person who can focus on specific programs or advanced RA? Absolutely. Yes. And the only way you’re going to be successful is if you do it this way. So again, I can’t stress enough when looking at that restorative programs all your age should be doing restorative nursing. And trust me, I think they already are on a day to day basis. Again, unless they’re completely doing all the care for the residents, that’s not restorative, but if they’re only assisting chewing, setting them up with those daily tasks that is restorative nursing and allowing them to be independent. So very important yes. On a day to day basis, have your floor staff do that. And again, you might need to start slow methodically to help capture that. So you might want to start with, let’s start with a section of the building.

What are we doing with these residents? How can we be capturing that? And then from there use your more advanced RA again for strength training. So having them do more of that advanced strength training, or getting them that they’re not quite able to walk it more on that walking program, or if it’s a brand new prosthetic or splint device, having them focus in on those more advanced type issues and getting them going before they might turn them over to the floor or to those group activities, she was at quite a team question.

Have you started, or does it need to be charted in multiple locations? No. In fact only chart it in one location, as long as its act is documented. So basically what I would maybe set up, you know, maybe to simplify it. So let’s say it’s drafting and grew me, I’d have one form and have, you know, am and PM and stayed on there for, and make it individualized for this resident, for them to brush your teeth. Your role is to just put the toothpaste on and put the brush in their hand and allow them to brush your teeth. And they can then initial it and say how long that actually took and that’s what they can be using for that ADL coding. So just be, make sure it’s individualized on what that cue, what that set up is or what they’re doing to assist the resident to be as independent, pass them to each nursing assistant knows what those cues are. Again, like if it’s, if it’s 18 having them set you know, if it’s setting up the adaptive equipment, maybe cutting an opening containers and then from there, the resident is capable of feeding themselves. So then again, they can initial it and how long it took for them to be able to be independent and feed. And that would be, what’s used to actually code that repeat here.

I try as much as possible at admission to kind of do a little restorative assessment as soon as possible. Cause it it’ll affect you the sooner you do it the better. So maybe having that, you know, assessment that training and really focusing in where your admissions come in and working with those nursing assistants, because they should be part of building that care plan. Anyway, they need to figure out how does this resident dress themselves or how do they need assistance? How do they need to brush their teeth? How are they eating? So really having them be very cognizant, especially in that first 48 hours and documenting. So you might have more of a blank form under there where they fill in for dressing and grooming, and this is what they’re capable of.

And this is what we did and continue to modify that because as the resident rehab, the might, you know, be able to advance, but very important, really focusing in, and that might be another place to start. Maybe you’re going to focus on where you get your ad mitts and start that now, who are the AIDS involved? Who are the nurses involved and how are we currently figuring out how to care for them? You know, and ensuring that they’re just not doing things for the resident and how are we coordinating that too with therapy? So how are we talking, especially in that first 40, you know, 24, 48 hours to be able to capture that you’re going to find two the better, you know, the residents and assisting with mobility and activities of daily living, less likely they’re going to be falling. And the safety of their residents is going to be,
Can you put a person on a walking starter program, even a therapy has multiple ambulation goals, is that duplicate of service. It kind of depends the how advanced therapy is with it and what they’re doing with the Joaquin. So maybe nursing is only doing maybe a shorter distance than therapy is, or maybe therapy having them do more obstacles and you can do a tandem. You should do a tandem just for the effects that immobility, the more the person exercises or walks the better it’s going to be for that person. So again, really looking at how therapies lacking them. Is there more advanced things that they’re actually doing with the person versus what nursing can do? There’s a question to basically, you know, with the larger groups, what other things can be done other than straight training in that larger group. And this is where walking, I have a lot of facilities actually have Congo lines or walks throughout the day.

In fact, all staff get involved and, and are trained on it. And again, the safe residents for their walking mobilities, you see a lot more in the short term rehab assisted living tends to do this a lot, but you can do have a little condo lines where you have more of a one to four ratio for all the staff, walking, monitoring the residents and going through a walk through the building can be counted as that even feeding if you’re at a table for, and the nursing assistant is setting up each of those residents making sure you watch your infection control of that, that can be considered a group activity as well. Let’s see, what else do we have here?

What is a good goal for a person in a walking program? The majority of our residents have distance. I would basically do distance and step a lot of our at the facilities I work with distance. Definitely because with coding with the MDs are kind of looking at that 150 feet under section GG. And many of my buildings have hadn’t beaten. It’s kind of mapped out for them. How many seats this hallway is from this point to this point to kind of help you out. So I have little triggers and your residents like that too. Some of them even have, you know, very visible things saying that from here to here, it says many feet cause it gives your residents goals as they’re going down the hall, some with that, but you can also, I recommend steps per day. That’s been a big incentive. In fact, I have clients that they couldn’t take any steps per day to had such balance problems, but once we get them going strength training, I have a resident that was wheelchair bound.

Nobody really knew why she had to have herself around. But once we got her strain trainer like strong enough, we got her walking, she went from zero steps a day. And the last time I checked in was at 8,200 steps a day. So another good goal steps. So getting predominately letters put on your residents if your pen and Tyrion that, or measure that a lot of I’ve even paid family members or, you know, in residents coming in with their own Fitbit. So that’s something that you can look at with now that you can look at those, those steps for days, not just feet per day. And then really looking at, you know, those distance goals, maybe adding more steps or a couple more feet each time with that. Now another question was, you know, can they do it once they just do it one time a day for four days a week, that’s a great goal.

Will it affect your payment under that party stay for that, that restorative, if they’re only doing it four times a day, no, but if you have them walking, you know, really good distance for camping week, the fact that they’re continuing to walk, they’re not falling and they’re keeping their strength and their mobility level that in and of itself should be incentive enough. So you might have a resident that might famine come strength training twice a week. Don’t want to do range of motion, hopefully by looking at, and I would like to go spend more time on these, that, and mobility to what we’ve done today to having that true understanding, but really you know, the more you can keep them active, the less likely they’re going to have an overall health declined and less likely they’re going to fall again.

Okay. How do you differentiate regular ADL care from a store and as programs? So again, it’s looking at promoting independence. So traditional, I mean, ADL care is if you totally provided, again, it wouldn’t be restorative, but if you’re allowing the resident to participate in it and you’re trying to help promote that independence. So again, just setting them up, laying their clothes out, even putting the shirt on, and maybe they can put their own shirt on, but you’re buttoning it. That’s still restorative and ADL care because you’re allowing the resident to be as independent as possible. And I know that one of them in my certification training, I was told that it had to be different. And this is where it’s really unfortunate restorative as kind of has a mindset that it’s a special, some more advanced care. And when you really look at it again at the beginning under the definition, it just says, as long as you’re setting up even just verbal queuing supervision any kind of assistance, maybe putting their grab morale up, what’s there for them.

And then their independence and standing up and doing their transfer that is truly restorative nursing. So you’re doing some type of assistance and cuing to ensure that they maintain their independence or even continue to improve on it. You’ve got lots of questions here. Let me kind of keep going through. Is there a specific competency training for RAs? And unfortunately you would think in this day and age there would be there isn’t any specific certifications. They first and foremost nursing assistant center certified should have been trained, trained in traditional range of motion, things like that. So really looking within your facility and looking at skill level, and this is for really tapping into your therapy. So there’s even things out there with technology that you can use even and med bridge. And that has things that you can use with technology, or it trains people how to do proper exercises or how to do the range of motion. And then from there you can competency tested. So really looking at your therapy they, they can help look at that competency test, you know, again, looking at some of these online courses, now that restorative tend to being highlighted you might have an ability where they are trained on how to do it and have to do a demonstration back for that and show that they did it appropriately with that. Let’s see, what else do we have here that some of these are kind of repeat, so give me one minute here.

Are there any regulations that address having a patient’s skilled therapy and restorative nursing program site? I’m a chance. So as far as regulation though, there’s, there’s no regulation on that. Basically again, the regulations broad it’s says that, you know, when somebody enters your facility, they should basically shouldn’t have a decline. And that our job is to make sure that we’re providing them the appropriate resources to, you know, maintain or increase their level of function, unless again, that clinical condition demonstrates that they’re not capable of doing that. And maybe that might be rare cases, you know it could be the advancing Ms. Maybe their purposes is at a point where they are assigning, but we still want to try and maintain the level that they’re coming in on. So it doesn’t talk about putting them together or regulation on that.

It just says, Hey, overall, this should, you know, your building is responsible for this person’s ADL. You know, trying to prevent them from falling and trying to prevent them from having that decrease a range of motion it’s asked of the goals have to be related to different programs. Not necessarily, you know, just again, whatever that make it individualized to whatever that goal is of your resident. My goal is to be able to walk 250 feet instead of 150 feet. So really just kind of looking at that individualized resident, what their needs are kind of what they want to do for goals as well.

On day one of admission, a therapy has to hand off. So basically therapies they’ll be looking at more advanced. So they might be looking at things like transferring the residence maybe bed mobility, but their nursing assistant can still look at the basics. How does this person need to be dressed and groomed, okay, Howard, how are you seeing that they’re feeding themselves right away? So there’s still those basic cares. You know, how are they performing their peri care and their toileting you know, dressing and grooming. So again, looking at those basic cares that are safe and the, and the nursing assistants are already doing on a day to day basis. Versus that more advanced, you know, if they’re coming up that hip fracture therapy might be looking initially at you know, how they’re going to transfer things like that, but there’s still other areas, even being able, you know, they could safely do, you know, range of motion you know, on the unaffected side things like that. So again, kind of thinking big picture and how do you just do your day to day cares and how you’re promoting that independence? So it doesn’t necessarily have to be that skill level.

Yeah, it says can non-CNAs that are supervised by a licensed nurse deliver restorative. Yes, they can. You can call them a restart, an aid. They don’t have to be a CNA certified nursing assistant. And this is where many facilities, this is where I would tap into other peripheral chefs, particularly your activities, because there’s a lot activities can be doing because many times I bet your activities are, are you doing a lot on little release exercises for now? It’s a matter of looking at the ratio and the room at the time. You know, do you have more of a one to four ratio with that and how can help them? We make sure we’re promoting that function. And there might be even things that, you know, activities can, you know, they’re getting snacks, things like that, how are they, you know, feeding them, things like that. So a non-CNA can be supervised by that licensed nurse. So the nurses needs to sign off, you know, that I, you know, watch them definitely competent in doing whatever that task might be. And again, you’re going to be surprised and you go back and start talking with your group, you know, what does activities already doing for exercises and movement type programs, things like that.

One question is how does straight training improve balance? Really good question. So when you’re looking at the fall, so that’s probably one of the number one reasons why residents fall aided on that strength. So we know we need to get that muscle mass is traced back, but how does it affect balance? Well, the stronger your muscles are obviously the more sturdy you’re actually going to be, but again, that how you train is how you gain and what I mean by that, how you do the strength training. So I do recommend set of going out, buying, you know, you see all the big equipment, especially when you walk into a drum, it was, again, might make you strong. It won’t equate to function. So instead of doing bicep curls in a sitting position, so first of all, the equipment I would use dumbbells resistant bands and just body weight.

Those will all help promote and balance and proprioception of your residents. So if they can stand having them stand and doing a bicep curl, now they have to be able to balance. They have to have good posture. The more you can do things in an upright position is going to absolutely help with that balance with it, but even in a sitting position where you might need to start, but having them make sure they hold themselves upright through the right posture is going to actually help with their balance as well. So again, kind of how you’re trained, what kind of movements you’re doing is going to help with their balance and holding stances, things like that.

So since he wants them to be independence, pass on doing passive range of motion, with someone who cannot help at all, can that still be restorative nursing program? Yes. With a path for them, what your measurement might be too, is the flexibility of that, that range of that joint. So the purpose of passive range of motion with that is to prevent contractures. And there is regulations around that too, making sure that people don’t become contracted some book that so it’s still would be considered started if that person continues to maintain or improve that range of motion and that effective limb. And very importantly, if that person can’t move it, that those are the ones you really need to watch because they’re going to be more prone to it contracting. And once it can track and stays contracted on, they can become permanent. So it still would be a restorative showing that you’re maintaining that full range of the limb effected.

So for the higher category, that is two programs. Does that mean it must be two 15 minute programs at least six to seven days a week. Yes. And again, that’s easier than you realize if you’re doing the dressing and grooming twice a day, it usually equals 15 minutes, but you may be helping them move in bed or even the transferring, if you’re cuing and doing that, that’s, you’re going to do that several times a day, transferee moving inside the mental health side to side in bed, quite from sitting in the line. It’s actually quite easy to get, so yes, we’d be two separate restorative things that total, and they have to be within the same chat. So you can’t say they did splint device for five minutes, transferring for five minutes in grooming for five minutes and competence 15 has to be the same task, but usually most of those tasks, when you look at them are broken up throughout the day. If you’re doing range of motion in the morning and then get at night for that.

It looks like we are to the top of the hour. A lot of these kind of repeat in as okay, to strength, train group settings. Yes. As long as it’s, you can do it in a group setting. But to it for payments, it has to be a wonderful ratio. And again, you want to make sure it’s safe with that. But I do have buildings that might not necessarily capturing, but they’re doing some group things just to keep their residents active and happy with activities.