Growing pains on the front line.

IMPLEMENTING PPS 

CNAs are vital to helping facilities provide quality care - and seeing that they get paid for it - in the new PPS climate

Even before the full implementation of PPS last July, facilities that were using some version of MDS to quantify clinical data realized that the key player in the system is the CNA. Without the CNA's firsthand knowledge, it's difficult to document residents' abilities, condition and actual care received. It is perhaps not an exaggeration to say that this realization turned the industry upside down; instead of most of the important information flowing from top to bottom, seemingly overnight the opposite became plainly necessary to both care planning and payment.

Even before the big picture became entirely clear, the outline of that picture was clearly a triangle - with the MDS coordinator at the top and the nursing assistants, in possession of much of the raw data, especially regarding activities of daily living (ADLs), forming the base. The unwritten mandate was clear: to capture the necessary data and create a system that would move that information from the realm of daily caregiving to both the care-planning team and the business office via the MDS coordinator.

There were, and still are, obstacles aplenty, among them the widespread feeling among CNAs that they're simply being asked to do more work - and "paperwork" at that - on top of what already seems to be an enormous load. In some facilities, communication is complicated by the fact that many CNAs have only a limited command of English. In others, years of "top-down" management have created a culture in which CNAs are the infantry, doing only what they're told and volunteering for nothing. Providers have devised a variety of approaches to address these obstacles. In essence, the challenge of PPS is to get CNAs to become trained observers and skillful communicators.

The focus of CNAs' work - daily care of residents - will not change, but they will have to shift from a task-oriented to an outcomes-oriented approach. While it is not necessary for CNAs to comprehend the specifics of PPS, it is vital that they understand the scope of the transformation going on around them and understand their role in the new system. Like anyone else faced with change, CNAs require both information and reassurance.

Integrated Health Services (IHS), long considered an innovator in the industry, produced a video for CNAs that went through several versions before release to their facilities. According to Marcie Snyder, vice-president of clinical services, "Everyone needs to understand that we are no longer responsible only for the quality of care we provide, but for the quality of communication on which our planning rests."

The IHS video briefly introduces CNAs to the MDS form, pointing out that it can only be completed with the input of all members of the interdisciplinary caregiving team, including CNAs. It explains how the data entered on this form will determine the RUG to which a resident is assigned. Further explaining that there are different daily payment rates for each RUG, the video makes clear how Medicare pays the facility. Some providers have deemed this kind of overview too complex for most of their CNAs, but most believe that providing it helps their CNAs to feel a part of the changes going on in the industry and makes it easier for them to offer the important input that they alone can offer the team.

Other providers have used printed material or conducted in-services to outline the new system for CNAs. Whatever the method, CNAs must know that they are helping to ensure that residents get all the care they need and that the facility receives payment for all the care it provides.

The next phase in bringing CNAs on board involves focusing on the key caregiving areas that affect the MDS. Along with Frontline Publishing, IHS devised the acronym BETTER to provide CNAs with a handy way to remember those observations of a resident's needs and abilities that will be useful in filling out the MDS (see sidebar). The MDS requires that significant changes in bed mobility, eating, transfer, toileting, emotional/behavioral status or restorative care be recorded.

There are various ways to set up effective communication with CNAs to elicit the necessary data for the MDS. Some facilities interview CNAs at frequent intervals about residents' ADLs, mood, behaviors and response to treatment. This method might not provide accurate data, however, given the sometimes rapidly changing needs of residents. Additional factors are the difficulty nursing assistants might have in accurately remembering the care several different residents have received and the extra layer of interpretation involved when a supervisor or the MDS coordinator must make documentation decisions based on how they understand what the CNA is telling them.

IHS developed a reporting tool for CNAs to use to provide information to the MDS coordinator using the BETTER acronym, a "checkbook" CNAs keep in their pockets and fill out for each resident, tearing off each resident's "check" at the end of the shift. "We tried to make it easy to use because the last thing our CNAs need is to get bogged down in paperwork," says Snyder.

In fact, in order to make reporting as painless (and therefore reliable) as possible, even for those CNAs who struggle with English, IHS devised a graphic approach in which the CNA chooses icons representing degrees of assistance needed, equipment used, range of motion, continency and other bits of raw data.

Facilities have evolved any number of ways to capture CNA input, from checklists, to stickers, to photocopied forms. The aim of most of these approaches is immediacy, simplicity and ease of integration with other systems. Beyond the nuts and bolts, successful programs for capturing these crucial data share a number of other characteristics:

They engage nursing assistants by meeting them where they are. A growing number of facilities are seeking to provide educational and career ladders to CNAs that will help them contribute more fully as team members. Recently, AGE Institute developed a text for long-term care facilities called English at Work, an ESL (English as Second Language) course specifically designed for eldercare workers.

They are part of an integrated, larger program that seeks to empower CNAs. The good news is that PPS implicitly requires that CNAs be full-fledged members of the care-planning team. It is not, perhaps, bad news that their hard work, dedication and hands-on expertise are at last being acknowledged.

They address crucial communication issues across departments and specialties with whom the CNA must cooperate. The dissolution of a pecking order based on salaries and degrees, in favor of mutual respect and coordination of function, reinforces the quality of everyone's caregiving.

They involve experienced CNAs in the process of devising and modifying reporting tools. Any systems analyst will agree that you cannot facilitate the flow of information from bottom to top by mandating it from the top down. Recently, in its in-house newsletter, The IHS Caregiver, Editor Paul Wray, RN, solicited cost-saving tips from CNAs throughout the organization and even offered a prize for the best tip.

"We're still in our growing pains stage," says Snyder. "We're looking again at which things make sense for the CNAs to document and which things, maybe nutritional intake and output, should be recorded by the nurses. It's all still new. We need to work with it a while longer. It will take some fine-tuning to get the system working efficiently, but for the most part everybody's on the same page."

BETTER Caregiving

BETTER care represents the following ADLs: Bed Mobility, Eating, Transfer and Toileting, along with the resident's Emotional/Behavioral Status and any Restorative Care provided.

Bed Mobility. How does the resident move to and from a lying position? Turn from side to side? Position his body while in bed? How much assistance, if any, does the resident require? (This is also a good time to observe the condition of the resident's skin and note any signs of pain.)

Eating. How much help does the resident need to get adequate nutrition? Does the resident require set-up help? Do you have to assist in actual feeding? Does the resident require your undivided attention for the course of the meal? Remember that manners don't count here: If a resident eats with her hands and gets food all over her face, she is still eating independently. (This is also a good time to observe and record any changes in the resident's appetite.)

Transfer. How does the resident move from one surface to another - from wheelchair to bed, for example? How much assistance does the resident require? (Do not include transfers to and from the toilet or bath, since these will be recorded in a different category on the MDS form.)

Toileting. Does the resident use a toilet or bedpan? Does the resident require assistance during this transfer? Can the resident manage her own ostomy or catheter? Is there a scheduled toileting plan, such as prompted voiding or habit training?

Emotional/Behavioral Status. Has the resident lost interest in activities? Does he seem anxious, depressed or angry? Afraid? Is the resident having trouble sleeping? Does the resident wander? Exhibit socially inappropriate behaviors such as public nudity, smearing food or feces, hitting, biting or other inappropriate touching? (On the other hand, be sure to note positive changes, too. These may be signs that a resident's care plan is working well or that his medication is helping.)

Restorative Care. In many facilities, CNAs perform certain kinds of restorative care under the guidance of the PT/OT department. Restorative care can be range of motion or any other program of exercise or therapeutic activity, such as walking, weight training or massage.

Richard Hoffman is editor of Nursing Assistant Monthly, a continuing education program for CNAs. For more information, phone [phone].