Focusing on restorative care benefits both residents and staff at Cove's Edge Comprehensive Care Center
BY CHERYL FIELD 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 for 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 these 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 longer 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. Regardless 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.