Sharing Successful Strategies

from Maine’s LANE/Culture Change Coalition

From Direct Care Worker to Bottom Line
By Connie McDonald, Administrative Director for Glenridge and Gray Birch Rehabilitation and Nursing Care Centers, Augusta, Maine

The most prominent definition of culture change in nursing homes focuses on "resident-centered care" and all the things that includes such as choices and lifestyle preferences. And it is pretty much universally accepted that in order to have resident-centered care, there must be consistent assignments of direct care staff. The value of consistent assignments is that a relationship develops between the caregiver and the resident and through this the residents' preferences and choices are known and met.

This article is to share one strategy that takes advantage of the well informed dedicated CNA 24-hour team to improve the documentation that eventually supports a higher RUG and reimbursement.  

Reorganize the shift hand-off process

Dedicate a minimum of 15 minutes for the whole going-off team to communicate with the whole coming-on team. Never record the report and leave for the next shift to listen to.  So much important information sharing is lost when a dialogue can't take place.  For example, one person on one shift may be successful in getting a person to take a bath or eat well and can share what their technique is.

Let the dedicated CNA report on their shift plus pertinent info from the last shift for all their dedicated residents. The nurse can add any pertinent medical changes and reminders.

Reports should focus on only what is out of the norm such as lethargic today, refused lunch or struck another resident.  Do not report on things that are routine or unremarkable such as normal bowel movements or "slept well". On the other hand if the person did not sleep well that should be reported as it may explain behaviors or alert the team to monitor for pain.
Make sure each dedicated CNA has the strengths and risks noted on their assignment sheet for each resident.  For example likes to socialize, enjoys music, risk for falls, pressure ulcers, hydration, mood or behavior concerns. Informed CNAs have a much more comprehensive approach to care.
 
"Spotlight" all the residents that are in the ARD window each week.  By having more emphasis on these residents it will make sure that there is less "copy cat" documentation and higher accuracy during the time when it will be captured for the MDS. 

Post the care plan and have staff identify what the progress on goals is and what isn't working or has changed.  For example Mrs. Smith now requires limited assist with transferring and Mr. Jones now requires 2 assist to get out of bed or chair.

Make sure that the Social Worker joins the shift hand-off discussion at least once per week to share her/his insight and to ask questions about the indicators of depression and mood. The Dietitian and Activities Coordinator should also contribute to the discussion each week on the "Spot light" residents for the quality of life discussions. It's a wonderful teaching moment and creates a cohesive team. The MDS interview questions and the QIS survey focus can be used for guidance.

Engaging the whole care team in the flow of pertinent resident information will ensure a higher RUG score. Missing documentation about the occasional 2 assist can cost a facility from $34.00 - $150.00 a day and depression indicators can yield another $15 per day according to Post Acute Consulting, LLC.  The result of this transformation of the shift hand-off will be better care and better reimbursement.  A win-win!

For more information, contact Connie McDonald

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