Restorative care: When doing less can help more. (Caregiving).

A NURSING FACILITY S RESTORATIVE-CARE PROGRAM CAN Provide a powerful clinical and OBRA-compliance tool and "sell" the facility to prospective residents and their families and certified nursing assistants (CNAs). Providers can take several steps to make sure they are providing a state-of-the-art restorative-care program that helps residents achieve realistic goals toward reclaiming their independence.

Choose a model

First, the interdisciplinary staff should agree on a model for restorative services and then make sure everyone understands how the model works and follows that mode of delivery. Cheryl Field, RN, MSN, CRRN, director of clinical and reimbursement services at LTCQ Inc. in Bedford, Mass., notes that some nursing facilities use a "designated model" where a single restorative aide completes all of the facility's restorative-care programs. "While this is certainly a good start, most successful programs follow an integrated model where everyone is trained in the philosophy and concepts of restorative care, she says.

In Field's view, integrating the restorative-care program throughout the facility promotes a philosophy of "you are going to do less for people so that in the end they will do more for themselves, and that's good care," she explains. "You think: How can I set this person up so that he or she can complete some aspects of his or her needs more independently? Every CNA needs to have that in mind so they seize every chance to implement restorative approaches and activities in daily care."

By contrast, Field notes, one or two officially designated restorative aides may not have time to get to all the residents, or they arrive in the resident's room and he or she is doing something else so the resident won't get restorative care that day. "Also, if the staff caring for the residents every day don't know what to look for, they are going to miss referring people who could benefit from a restorative-care program. So nursing homes have moved toward an integrated model."

As a hybrid of the designated model and integrated model, a restorative-care team--usually consisting of a therapist, the nurse who oversees the program, and trained CNAs or restorative aides--acts as consultants to the CNAs who then include restorative care as part of the residents' daily care. "That way, if the restorative aide is out, the resident will still receive the services," says Pat Boyer, clinical operations consultant with the Milwaukee office of BDO Seidman LLP. "Using this model, the restorative care team can serve several floors of residents. Team members act as coach, role model, and consultant, as well as deliver some of the services."

Overcoming family resistance

Nursing facilities must anticipate family members' response to restorative care, which has a different focus than many people expect. Families may resist or misinterpret the staffs philosophy of doing less as being best for the resident.

"Without appropriate instruction and involvement, families can misperceive some of the facility's actions as being due to short staffing," Field cautions. "You have to take an approach where everyone involved, including the resident, is going to promote the resident's independence in areas that are important to the resident and their family. You have to get the resident's input on where they want to improve their functioning and independence."

A resident with heart disease who becomes very compromised with activity may not find it worthwhile to dress himself because he's too exhausted afterward to do the things he enjoys doing. "Sometimes what the facility staff values, such as the patient getting dressed by himself, isn't a top goal for the resident," Field cautions. "The family and resident should thus be involved in setting the goals and designing the plan of care. It's their plan of care and their goals. They will be more motivated to work toward what they value."

Meet resident and staff needs

The program should meet the needs of the residents and the facility staff. "The most successful programs are creative or innovative ones that also use staff efficiently," says Field. "The best-practice approach will be one that meets the needs of the staff and the institution. For example, shift change is notorious for an increased incidence of resident falls and incontinence episodes, because staff are busy doing reports, charting, etc.," she notes.

By providing a restorative activity at that time, the residents are engaged in a productive way during shift change, diminishing the risks of falls, accidents, and incontinent episodes. "You can stagger staffing to have someone do the activities--you should have a 4:1 ratio of residents to caregivers for all group activities," Field suggests.

As long as the restorative care program is driven by nursing, the persons carrying out the program can be properly-trained, non-nursing staff. This allows facilities to use volunteers to conduct the activities programs at shift change.

Offer popular, productive programs

You want your restorative-care programs to be popular and productive. The CNAs and activities program staff may be your best resources for ideas and programs that will motivate residents to improve or maintain their ability to perform basic tasks. "Many of the most inventive programs I've seen are the ones that CNAs have come up with themselves," comments Annette Fleishell, RN, BSN, VP for clinical services at Joann Wilson's Gerontological Nursing Ventures in Laurel, Md.

Restorative-care programs that combine ambulation and eating skills are very popular; the ones that work best normalize the mealtime as an enjoyable experience while also working on restorative goals. In "park-and-dine" programs, residents park their wheelchairs and work on ambulating to the dining room.

"Makeover" programs are also popular. Residents focus on personal hygiene and grooming, such as hair and nail care, thereby enhancing their self-esteem and sense of being a "well" person. Boyer has encountered an innovative "Let's Vent" program that focuses on communication skills among ventilator-dependent residents.

Staff-development benefits

The facility can also use restorative care training as a recruitment and retention tool. "CNAs definitely view restorative training as a career-development step," Boyer confirms. "Restorative training makes CNAs more marketable and gives them additional skills."

There are established programs that certify a CNA in restorative care, Boyer notes. She recommends nursing facilities make a big deal out of such programs: "Have a graduation, give a certificate of completion."

Residents and their families also enjoy showing off a resident's newly reclaimed skill, such as walking down the aisle to receive a hard-earned diploma. Those are also the occasions that motivate caregivers to keep encouraging reluctant residents to take that first step toward having the highest practicable level of functioning and well-being.

Karen Lusky, RN, MSN, is a Brentwood, Tenn.-based freelance health care journalist specializing in post acute care.