The 'gift' of restorative nursing: focusing on restorative care benefits both residents and staff at Cove's Edge Comprehensive Care Center.

Restorative nursing dates back to the 1950s--so why the recent flurry of interest by nursing homes in restorative nursing programs? In 1998, the onset of the Prospective Payment System (PPS) for skilled nursing facilities raised awareness of the reimbursement benefits of restorative programs. PPS guidelines created an incentive to provide restorative programs to achieve higher reimbursement in Medicare populations and Medicaid case-mix states. In short, PPS converted a fundamental philosophy of providing care into a spreadsheet line item.

Providers who fall short of meeting the MDS coding guidelines can miss out of this reimbursement benefit. A new program established by a facility in Maine found a way to avoid this, and is the subject of this article.

First, though, let's be clear on what restorative nursing is. A broad definition can be found in the MDS 2.0 User's Manual (2003 edition). It highlights the goal of maintaining optimal physical, mental, and psychosocial functioning, and acknowledges that any resident at any time may benefit from restorative nursing. Based on this approach, one might expect to see a high percentage of residents in LTC settings receiving restorative nursing care. Is this the case?

A recent study conducted by LTCQ, Inc., examined the need for and provision of restorative care in a random sample of 15,000 MDS assessments. "Need" was defined as having both an MDS Section G1a value greater than 1 and the presence of intact short-term memory. In the chronic care population, while 8% were found to be in need of bed mobility training, 0.10% of residents actually received such restorative care. In the post-acute population, 14% of residents were in need of such care, and 0.2% received it. These findings support the hypothesis that there is a tremendous disparity between those who have a need for this type of rehabilitation and those who receive it.

Unfortunately, in contrast to the financial incentive created by PPS, MDS documentation guidelines create a disincentive for providing restorative nursing. Documentation of restorative care provided on flow sheets and the required periodic review add paperwork to a system already overburdened with paperwork. Therefore, while the definition of restorative nursing includes most aspects of care, the documentation required to take credit for this care serves to exclude providers from providing it. Providers might find it helpful to consider using "The Vulnerable Transition Model"--as did the Maine facility discussed below--for identifying clinically meaningful opportunities for providing restorative care.

The Vulnerable Transition Model

The Vulnerable Transition Model considers the resident's "vulnerability and/ or transitional status" as a determinant of candidacy a restorative program. It operates on three assumptions: (1) that all care is restorative in nature, and this care can be seen as a "gift"; (2) that documentation of the unique needs of a resident in vulnerable transition, of the interventions received, and of the progress attained can meet the requirements for actually checking "P3--restorative nursing" on the MDS; and (3) that residents who are in a state of vulnerable transition need their care (their "gift") wrapped in special packaging so every member of the interdisciplinary team perceives that residents are receiving uniquely restorative care.

Residents who qualify and are placed in restorative nursing programs are provided with the "gift wrapping" of MDS documentation, a written plan of care, and a flow sheet for the complete program. Once the residents' restorative goals are attained and they are no long-considered to be in a vulnerable/ transition status, the program is "unwrapped," i.e., the wrapping paper of special documentation is removed (while the gift of care goes on). One facility took this metaphor to the extent that it used the symbol of a "gift" over the resident's room number to indicate that the resident was receiving restorative care.

Achieving integration. Integrating restorative programs into daily resident care requires that the facility as a whole adopt the philosophy of restorative nursing care, not merely a focus on the tasks often associated with it. Thus, although restorative programs are coordinated by nursing, they include nonlicensed staff who meet the requirements for competency and documentation skills; support from the interdisciplinary team--everyone from administrator to dietary aide--is crucial to successful integration.

Measuring outcomes. A simple return-on-investment model looking at meeting clinical, financial, and regulatory measures can assist in evaluating and supporting the benefits of restorative nursing. Clinical improvement can be measured by a review of MDS data to evaluate changes in key items related to the goals of the program (e.g., mobility, self-care, feeding, toileting, and range of motion). The MDS is not the only resource for measuring improvement. In fact, the MDS isn't sensitive enough to capture many degrees of clinical improvement. Consider the variations in weight-bearing support all coded as 3. Regard less if one bears 75% of a resident's weight during a transfer or 5%, the MDS transfer code is 3. However, a difference between these two functional levels can be noted and measured as clinical improvement in alternate documentation systems. For this reason, a review of the medical record for outcomes of functional improvement is suggested.

Financial impact is measured by a review of the facility's case mix qualified for Medicaid and PPS/RUG reimbursement dollars directly generated by restorative programs.

Regulatory outcomes may be noted at the time of the annual survey; for example, integrated restorative nursing programs aimed at stabilizing or improving the functional abilities of a resident in vulnerable transition can impact such F-tags as F-309 (highest practical quality of life) and F-297 (development of comprehensive care plan).

The Cove's Edge Experience

In November 2002, Cove's Edge in Damariscotta, Maine, embarked upon a journey to fully integrate restorative nursing into its philosophy of care. This comprehensive care center is a member of the Miles Health Care organization, and has 54 LTC beds and 22 SNF beds. Motivated by the observation that residents transitioning from SNF to LTC frequently lost newly acquired skills, Cove's Edge sought to enhance its restorative nursing program, focusing first on the LTC unit. Taking a unified approach, management worked with the quality assurance committee, provided education and competency training for all start; and devised a documentation system that integrated restorative programs into their standard documentation tools. A formal communication system was designed using green copies of existing documentation tools, and a colored "gift box" placed outside each involved resident's door, to indicate active restorative programs in progress. These efforts were continuously reinforced by the dedicated CNAs who worked daily to implement new programs, learn new documentation tools, and provide resident and staff program feedback.

After three months, Cove's Edge evaluated the program's outcomes. At that time there were eight residents on active programs; two residents had received restorative services but experienced a change in condition that resulted in their withdrawal from the program. Of the remaining six residents, four met all of their rehabilitation goals, with an overall goal-obtainment average of 90% for all participating residents. While the staff were enthusiastic and continued to push the program forward, it was determined that the program needed a coordinator. Beckie Lovell, RN, accepted the role of restorative nurse coordinator for 8 hours a week while working 24 hours a week on the floor.

Six months after the program's inception, an on-site program assessment was conducted. This included an evaluation of MDS assessment accuracy, overall resident change from prior level of function, staff morale, and compliance with program components and documentation requirements. These outcomes are illustrated by the following case studies:

   Mrs. F, who was in her mid-eighties,
   and having experienced a change in her
   condition because of respiratory illness,
   was selected as a restorative candidate in
   January 2003. She required extensive to
   total assistance with her ADLs, was transferred
   by a mechanical lift, and was
   nonambulatory. Restorative nursing
   goals focused on her bathing skills while
   seated in a wheelchair. The staff provided
   set up assistance and verbal cues--and
   a lot of patience. Mrs. F progressed,
   and in April had advanced to a set-up
   only with upper body bathing and
   dressing, with occasional assistance to
   straighten her blouse. She now transferred
   using a stand-pivot technique and
   a walker, and ambulated 15 to 25 feet.
   The key to this resident's success was the
   CNA staff noting her ability to progress
   in function if she was allowed more time
   to complete the tasks. Remember, what
   is valued in restorative nursing programs
   is functional gain, not efficient task
   completion. Comments from staff interviews
   reinforced this approach to success;
   as one experienced CNA stated,
   "Giving them the time they need has
   given us a lot more time back."

   Mr. C, who was in his early seventies,
   had experienced his second stroke two
   years prior to admission to Cove's Edge.
   Driven by a desire for independence, he
   expressed his frustration with his illness
   and being dependent on others with verbal
   outbursts and other behavioral challenges.
   The interdisciplinary team felt he
   could take a greater role in his care and, in
   late November 2002, he began a restorative
   program. At the onset, he required
   extensive assistance with all upper-body
   ADLs and mouth care. He did not walk
   and was transferred via mechanical lift.
   Initial goals were limited assistance with
   upper-body ADLs and limited assistance
   to transfer with slide board. Six months
   later, a one point positive change in five
   ADL areas was noted on his MDS assess
   merits as having occurred from Novena
   her to February. Mr. C and the staff set
   new goals that included ambulating 300
   feet with an assistive device and single
   assist, donning shoes and socks with long-handled
   equipment, and independently
   completing a bed-level exercise program
   that focused on abdominal strength.
   While his ultimate desire to go home
   remained unrealistic, few would have
   believed the changes that were measured
   over the six-month program. As one
   CNA stated, "Mr. C was amazing--he
   started with a slide board, then he was
   standing, then we were walking him!"
   All of the negative behaviors that were
   noted at the initiation of the program
   were gone; his progress was felt to have
   been "life changing."

Following Up

Staff shared their experiences with the program at a lunchtime meeting for those working in rehabilitation, nursing, administration, social services, and staff development. Along with sharing success stories, keys to success were identified, systems for measuring outcomes were discussed, and the program's future was outlined. Consistent staff performance and dedication to the project were noted as a critical foundation for the program's survival and success. Initial team training, which occurred over three days, and the sharing of information on resident benefits, based on measurements at the beginning and throughout the program, were also important ingredients for success. Indeed, there are many success stories published on the Restorative Nursing Bulletin Board at Cove's Edge, with pictures of residents and caregivers working together to foster independence.

It all verifies what Staff Development Coordinator Ruth Veitze says she has known for some time: "Restorative nursing changes the whole focus on the part of the staff," resulting in measurable outcomes that are both clinically significant and personally meaningful. NH

Cheryl Field is the director of clinical and reimbursement services at LTCQ, Inc. For further information, phone [phone], visit www.ltcq.com, or e-mail clinicians@ ltcq.com. To comment on this article, please e-mail [e-mail].