What does a Physiotherapy programme look like in Aged Care?

Prior to contracting a Physiotherapist, or as part of your Physiotherapy service review process, you should consider what your goal is in having physiotherapy input.  These should include key values such as Meaningful Outcomes for residents.

We asked Jessie Snowden of On The Go Physio what should felt was important for a Physiotherapy programme to which she offered the following:

For us this means we carry out thorough assessments, find out what is important or meaningful to the resident, their whānau and how this impacts their functioning in the aged care environment. Our input with people can range from rehabilitation to a previous level of function.  This may be intensive physio input for a few weeks, to ensuring someone is safe and comfortable with appropriate seating and pressure care at the end of life (which could be one visit only).

This level of assessment means that you need to ‘budget’ for 40-60 minutes (sometimes longer for complicated admissions) of physiotherapy time for a new assessment and possibly longer if they are needing to make referrals, liaise with other services and family. Follow up visits will be shorter. It is recommended that if you have a set number of hours per week that your staff and the physiotherapist are clear on expectations and priorities. If you only contract 2 hours per week it is not fair to have 10 new assessments on your ‘urgent’ list!

Some facilities have a set standard of 6 monthly reviews of all their residents. Although we do undertake these if asked, it is often more meaningful to use physiotherapy skills for those residents who may improve with input, or who your staff need assistance with due to functional decline. We suggest  if a 6 monthly review is wanted, then the RN is able to carry this out by considering if there have been changes in mobility, falls rates or other physical changes affecting function. If not then your physiotherapy dollar could be better spent on residents with clear rehabilitation needs or declining function.  The key goal here being to optimise mobility and maintain as much independence as possible.

Once the Physiotherapy service is up and running you can expect your physiotherapist to provide a clearly written assessment and a clear treatment plan, including either a discharge comment or a review date. Ideally you will maintain data related to Physiotherapy input and be able to see clearly if your allocated time is meeting the needs of your staff and residents.

Finally consider which residents will be eligible for physiotherapy assessments. If you are funding a Physiotherapy service you may choose to extend this to your hospital level and rest home level of care residents but not to independent studio units/apartments as these residents will usually be eligible for DHB funded services. Some DHBs will happily provide physiotherapy to rest home level of care residents and some put guidelines around who they will see. Depending on your DHB and care philosophy you may choose only to fund Physiotherapy services to hospital level of care residents or to extend this to rest home. In our company we work with aged care facilities who operate under both of these models and the key is to have it clear to both your Physiotherapist and staff who are completing referrals.

Spend your dollar wisely!

A final note here. Physiotherapists are highly skilled healthcare professionals who will be an asset to your team. The days of Physiotherapists spending all their time on walking programmes are long gone and you should set your expectations high for a physiotherapist who will add quality of life to your residents and cost benefit to your organisation. To use your physiotherapist wisely I strongly recommend you have the expectation that your care staff will have time to walk with people who are safe to do so.  We also encourage you to employ or allocate a Physiotherapy assistant hours into your roster to implement Physiotherapy plans. For information on using Physiotherapy assistants please look at an earlier article here .

This article was kindly contributed by Jessie Snowdon – Director of On the Go Physio. On the Go Physio provide physiotherapy services to over 20 facilities in Christchurch and Moving and Handling training to many more facilities and the CDHB.

Disaster Management should include security measures

This is a good time to be reminded that disaster management or your security policy may need to be extended to include management of threats, both internal and external to your organisation.  During the past years I’ve been personally involved with facilities where a resident entered the facility with a fire-arm, an intruder break-in during the night with a fire-arm, and another where intruders who entered the facility went into an occupied residents room. This last case related to intruders who had allegedly held-up the local bottle store earlier that same day.

Things happen which we don’t expect and we must be prepared as best we can.  It’s impossible to cover every possible eventuality but when events such as the shootings in Christchurch occur, it’s a reminder to ask are we doing enough?  For example, staff security rounds should be strictly enforced and documented to verify these were carried out. If you have surveillance cameras, where are your blind spots? If it’s the staff car park for staff going off duty late at night, improvements are desirable for staff safety. What about your processes for visitor verification? 

Security isn’t just about the people and environment but also about assets and information.  These should all be detailed in your policy documents.

HCSL are currently updating the security policies we provide ARC services to include reduction of risk from internal and external threats. This includes a procedure for lock-down. Let’s hope we never need to use it! 

For those of you wondering about how to debrief with your staff as a means to support them, there are some great resources available here.  For more resources on supporting others in relation to disaster type events, go here

Culture Change in Long Term Care

Culture is a word we hear a lot and goes hand in hand with the concept of culture change.  In this article I’d like to touch on how to facilitate culture change and why it is beneficial to your long term care setting.  Let’s face it, aged residential care in New Zealand is changing rapidly and this impacts the experience of residents, staff and visitors to long term care settings. It impacts their desire to be in your care facility or to move somewhere else. This applies to be both residents and staff.  Families often choose the care provider for their elderly relatives.  What do they perceive when they visit you?

There are also barriers and challenges to creating and sustaining a definable and deliberate culture. The experience of the residents and staff is a result of the culture (behaviours) which should be aligned to your organisation values, mission and goals.  There are well publicised workforce shortages and high turnover of staff. Long term care is also in the middle of change from paper-based systems to electronic storage and management of information. The environment in which care is being provided is also changing through new construction of buildings from a institution to non-institutional. The atmosphere being created by those within the long term aged care residential setting is changing to a more relaxed feel.

Nursing care  and direct support is now also being provided within retirement village studios, apartments, villas, homes.  This means a change of not only the context of care.  Ensuring person centred care where each individual feels seen, heard and respected takes consistent focus and strong leadership.  Not always easy in a industry that is changing in so many ways. I wrote in a previous article on workplace culture that behaviours could be a better point of focus rather than simply focusing conversation on culture as a concept.

The behaviours which support a culture you can be proud of and one that sets you as an industry leader, require a long term focus and not just a one time exercise.  The strong leadership needed along with education and ongoing communication is key to setting a desirable culture.  Have you aligned your staff, management and Governance behaviours with your organisation vision and mission statements?  Behaviours reflect actions and they can be optimal actions, good actions, poor actions or non-action.  All will have an outcome which impacts the residents experience and determine how they feel about residing in your long term aged residential care setting.

For change to occur there needs to be a focus on improvement, a reason to change which residents and their families see as beneficial.  We tend to stick to doing what we’ve always done unless we can see a personal gain or something which provides a sense of satisfaction on a personal level.  What’s in it for me?  Culture change is not something that’s going to be achieved from a top-down approach. It’s going to take engagement from all levels of the organisation and create wins for those involved. Without perceived gains or wins, people stay stuck in old habits which don’t fit the new expectations of those seeking care and support.

If you’re the manager or CEO and delegate a ‘change management’ process to someone else, then expect to check in later to find wonderful results without your direct involvement and engagement, you may be disappointed.  Culture change is a team effort. To achieve change, everyone needs to participate.  They need to believe in the outcomes you’re trying to achieve with whatever strategies or initiatives you put in place.

Who is going to lead change?  There is an old saying that everything flows from the top down and this is also true of culture.  If the Board are dysfunctional then there should be no surprise when staff working at all levels of the organisation are dysfunctional. How is communication about strategies of change being done to gain buy-in? How are you going to measure your change initiatives to find out if you’ve been successful?  How are you going to ensure the desired culture is maintained?  There are a number of tools (mostly overseas based) which can be used to start this process. Here is a free online culture change assessment tool you could use.

What is the experience of your resident and your staff on a daily basis?  Would they recommend you to others in a way to reflects loyalty to your care facility as a preferred place to live or work? If not, what are you going to do about it?

Mattresses – are your mattresses causing harm?

Mattresses aren’t just something to lie on but if not maintained and cared for appropriately, also have the potential for causing harm.

As I travel a lot for work, I have the opportunity to test many different mattresses, all with varying degrees of comfort.  This reminds me how difficult it must be for those who may be suffering painful joints to get a good night’s sleep.  Appropriate mattresses are not only required to reduce pain from positioning discomfort but also reducing risk to residents. This include ensuring the mattresses are of a suitable standard and fit for purpose.

I’ve seen a number of mattresses which had hardened and torn linings and were well past being able to provide much comfort or an appropriate degree of pressure support. Some had masking tape used in an attempt to cover splits in the mattress cover.  Others had holes in and were badly stained from exposure to body substances.  As the residents in care are becoming frailer, with increasing acuity, the need for ensuring appropriate pressure support is crucial to preventing pressure injuries, maintaining comfort and maximizing the opportunity for good sleep.

There is the potential for old and in poor condition mattresses to be a potential source for infection transmission.  For those of you operating newer facilities, this may not yet be an issue. For older facilities, part of stock and resource control should include mattress stock checks to verify they are in fact still fit for use.  When conducting checks, determine the mix of mattress types you have and speak with your supplier about a replacement programme should this be necessary.  As mattresses differ, so do beds and it’s important to make sure the mattress you use is appropriate for the particular bed type and size.

When reviewing your mattress stocks and purchasing new mattresses you might like to think about the following factors:

  • Only purchase from reputable suppliers. Review the manufacturer’s instructions for use to ensure they include verification of cleaning instructions and ask about preventative maintenance. This may include staffing training e.g. via the use of online training videos or instruction booklets.
  • Make sure you record the date of purchase and do your best to track each mattress and pillow to maximize warranties and make plans for replacement. Add the item to the facility cleaning schedules for regular cleaning and drying of exterior surfaces which should be durable, water-repellent and quick drying. They should also be seamless, if possible. When there are seams or edges, much sure these are situated away from resident skin contact to prevent absorption of liquid into interior and increased friction.
  • All seams must be tightly closed and sealed. Masking or packaging tape is not appropriate for sealing. When mattresses become worn and tear, you might like to have a supplier representative review to see what options are available for repair or replacement.
  • When reviewing the condition of mattresses, inspect all mattress surfaces, covers, seams and zippers for proper function and damage including wear, tears, splits, cracks, punctures, permanent odours and stains. If visible contamination from body substances are present, determine appropriate steps (eg. replacement or repair).
  • To support longevity of mattresses, remind staff not to place any furniture or sharp objects on mattresses. Protect the mattress with mattress protectors only if advised by the supplier this is appropriate. A number of pressure support functions in mattresses may be adversely impacted by the use of additional mattress coverings to do check.
  • Cleaning and disinfection must be considered in relation to mattresses, covers, wedges, cushions and pillows which are all classified as non-critical medical devices. Clean and low-level disinfect according to the manufacturer’s instructions between different resident use and when visibly soiled. Some mattress covers are removable for laundering so remember to verify which ones can be cleaned separately.
  • Remove damaged or stained items from service and report these in your maintenance book or to the Manager. Follow manufacturer’s instructions for use and disposal of damaged mattresses, covers, and pillows, and in accordance with infection prevention and control guidelines.
  • Ensure when using alternating therapy type mattresses that there is a process in place for a shift by shift verification that the pressure is maintained at the current level for the individual resident utilizing that mattress. If you plan to use an air alternating topper pad on a mattress, ensure it’s suitable for the mattress as depending on heights and size, it may not be appropriate.

Harm prevention can also be supported with advances in technology such as Pressure Monitoring sensing devices to ensure appropriate pressure distribution.  I’m not aware of anyone who can rent or lease out Pressure Mappers in NZ. However Cubro have one that they can bring onsite to facilities for training and education. Make contact with your supplier to see if they can assist if this could be useful for you.

Also remember that other devices used in beds should be checked  as well to ensure they are still safe and appropriate for use eg; wedges, rolls, pillows, seat cushions, mattress covers (where these are appropriate for use), bed sensor monitoring pads.  For reading on how to choose the best mattress option for your needs go here.

For more related information view here.

Article compiled by Gillian Robinson (RN, BN, Lead Auditor) for Healthcare Compliance Solutions Ltd.

Spiritual care and Pastoral Care

As we age, the need for spiritual care and pastoral care often come to the fore.  This is particularly so as people near the end of their life.  The need for comfort and peace of mind on a holistic basis.  Let’s firstly lets define the difference between these two concepts.

Pastoral care is an ancient model of emotional and spiritual support that can be found in all cultures and traditions. It has been described in our modern context as individual and corporate patience in which trained pastoral carers support people in their pain, loss and anxiety, and their triumphs, joys and victories. Spiritual care attends to a person’s spiritual or religious needs as he or she copes with illness, loss, grief or pain and can help him or her heal emotionally as well as physically, rebuild relationships and regain a sense of spiritual wellbeing.

For most of human history, in all major religions, an ultimate goal of spiritual practice was accomplishing a good death. When this goal was held in common by the whole society, spiritual care could focus on the interaction between a dying person and his or her caregivers.

A number of clergy have commented to me that spiritual care is not recognised by many aged care facility staff as important. They have frequently commented on services being interrupted by staff activity, or being asked to hold services or provide pastoral care in areas of the facility that are very close to the main entrance or actually in main thoroughfare areas. This is not respectful of the needs of the residents who choose to attend, or the need to peace and calm to receive spiritual care. In learning more about the importance of these concepts, it may support good holistic care for residents if you were to discuss with the clergy and pastoral care workers whether the circumstances being provided for them to support residents are appropriate.

To read more on this topic go here.

 

How friendly are nurses?

How friendly are nurses? I would generally say nurses are very friendly however we frequently see articles in nursing journals of bullying in the workplace.

I pondered this while attending the Global Speakers Summit in Auckland recently.  I was over-whelmed by the friendliness of the speakers there, many of whom are very well known internationally. It was a level of friendliness I haven’t observed at the many nursing conferences I’ve attended and certainly gives an opportunity to reflect and see how this can be improved.

I asked a nursing colleague about this and asked her for her opinion. Her response was ‘that’s why speakers are successful and nurses struggle. The lack of genuine connection and sharing.’  She went on to say ‘nurses have been eating their young for years‘. She added that nurses would do well to build each other up and celebrate success not labour struggles.

At the Speakers Summit, I don’t recall a single time when a person walked in my direction without a smile and stopping to exchange pleasantries. Some of these people I knew or had met previously but many were first time encounters. Their responses went beyond pleasantries and extended to engage in a conversation that created connection and sharing and a sense of belonging. A pleasant change and one I hope we can do more to foster in nursing. Surely our patients and their families would benefit hugely if we can all be a little more compassionate and patient, and show genuine interest in each other.

A colleague offered the following explanation as to why nurses rush and lack apparent friendliness at times. ‘Nurses jobs have become about the task and the paperwork , with fewer nurses looking after more patients. And whilst there are still some who manage to make time to connect with those in their care, there are many more who are on a treadmill running from task to task.  Many of these nurses are then given students to look after and they do their best to make it a great experience in difficult circumstances. That rushing and being task focused doesn’t do the best job of mentoring and teaching and doesn’t support the best possible care which otherwise might be achieved. Perhaps if the health care system had more nurses and less management you would see a lot more friendly nurses.’

How do we as a collective ponder and plan for change to improve not only the outcomes of what we’re trying to achieve as nurses, but provide a much more enjoyable workplace for all those in it? Remembering that in residential care, the workplace of nurses and care-giving staff is also the home of residents needing support.

Aged Care Managers and Nurses Study Days

April 12th and 13th, 2018 – Christchurch

Presenters: 

 

Gillian Robinson – Bachelor of Nursing, Registered Nurse, Lead Auditor, Management Consultant, Author
Liz Beaglehole – New Zealand Registered Dietitian, with a Post-graduate Diploma in Dietetics (with distinction), Canterbury Dietitians.
Ben HarrisMedical Laboratory Scientist, Honorary Lecturer for the University of Otago

Incorporating clinical and management topics, these study days are designed to provide the opportunity to learn together and gain a greater understanding of each others roles and aged care industry expectations. Gain your professional development hours by joining your colleagues for two fun days of learning.

Topics include:

Day One – Thursday 12th April – 9.00am to 4.30pm

  • Age-related Residential Care (ARRC) – understanding the DHB funding service specifications
  • Quality and Risk Management – striving and achieving excellence
  • Clinical Leadership – how to lead the clinical team effectively
  • Clinical Documentation – What, when, how and why to document
  • Clinical Assessment and Care Planning – bringing it all together for better resident outcomes
  • Microbiome – why understanding this is so important
  • Multi-Drug Resistant Organisms (MDROs) – the current and pending impact

Day two – Friday 13th April (9.00am start, finish approximately 1.00pm) 

  • Urinary Tract Infections – to dip or not?!
  • Norovirus and Influenza – latest updates
  • Food Safety – Food Safety and Nutrition
  • Question and Answer session

Attendees will supply their own lunch.  Morning and afternoon tea will be provided.

Venue: Chapel Street Centre, Cnr Harewood Road and Chapel Street, Papanui, Christchurch.   (Easy access from the airport)

Numbers will be limited so register today.

To register – email gill@agedcarecompliance.com and supply the names and designations of each staff member attending, and confirmation if they will be attending day one or day two or both days?

 

The attendance fee for this content filled education is $155 (plus GST per attendee to cover both days), $85.00 plus GST per attendee to cover either day one or day  two.

We will respond with confirmation of registrations. Certificates of attendance will be provided.

Moving  and Handling People – Good Practice Guidelines – December 2017

The Draft Moving and Handling guidelines are currently being finalised with the view to be implemented from December 2017.  Developed by Worksafe, they cover Health and Safety at Work Act 2015 (HSWA) duties and risk management for PCBUs in the health care industry and supersede the 2012 guidelines.  There are a range of factors noted in these which need to be taken into consideration for those building new facilities or doing refurbishment of existing facilities. There is also a raft of information on Bariatric Care which is an increasing part of the services being provided in residential care.

The draft guidelines include the following:

Please note that there is not a complete consensus on the criteria for classifying a person as bariatric based on weight or Body Mass Index (BMI). However some examples include those people:

– with a body weight greater than 140 kilograms.

– with a BMI greater than 40 (severely obese), or a BMI greater than 35 (obese) with co‑morbidities.

– with restricted mobility, or is immobile, owing to their size in terms of height and girth.

– whose weight exceeds, or appears to exceed, the identified safe working loads (SWLs).

Health risks for bariatric clients

People who have been bariatric for a considerable time face chronic and serious health conditions, many of which should be considered before moving or handling them. Health conditions to take into account include:

– skin excoriation

– rashes or ulcers in the deep tissue folds of the perineum, breast, legs and abdominal areas

– fungal infection

– bodily congestion, including causing the leaking of fluid from pores throughout the body, a state called diaphoresis, which makes the skin even more vulnerable to infections and tearing

– diabetes

– respiratory problems

– added stress to the joints, which may result in osteoarthritis.

Planning for bariatric clients:

The planning process for bariatric clients in order to reduce moving and handling risks should include:

– admission planning

– client assessment

– communication

– room preparation

– mobilisation plan

– equipment needs

– space and facility design considerations

– planning for discharge.

Facility and equipment needs for bariatric clients

Health care and other facilities providing care for bariatric clients need to provide adequate spaces for these clients. Some considerations could include:

– ramps and handrails at entrances

– bariatric wheelchairs

– that the facility’s main entrance has sufficient clearance

– adequate door clearance and weight capacity in lifts

It must be remembered that the above comes from a draft but as drafts often end up being very close to the finished document, I felt it timely to share this information. To read more on Health and Safety in the Workplace go here

Understanding the Change Process

When undertaking a change management process in care facilities, I’ve identified 5 distinct phases of reaction from managers and staff.  These have often occurred after I’ve been appointed to perform the role of statutory (temporary) manager by a DHB. This is generally after risk to residents has been identified following an audit or a serious complaint.

As a temporary manager, often there is a facility manager in place however for a range of reasons doesn’t have the resources or knowledge to meet the needs of the residents to a standard that satisfies audit outcomes.

Phase 1 is on first arriving and there is relief on the part of the staff and manager (if there is one) on the basis they have the view that I’m there to ‘save the day’, make things right and then they can get on with running things.  Comments such as “you should have been called in a long time ago” are common.

Phase 2 is where the staff and in place management start to realise that I’m not going to do all the work for them and my role is that of mentor and coach. Further to that the role includes assistance with obtaining necessary resources to support clinical and operational practices. This is where push-back and resistance starts to show as people resist change and try to hold stead-fast to those practices that have got them to the point they’re at.  As pressure increases for change to occur, resistance increases and at times sabotage of the new way of doing things starts to appear.  As one provider put it recently “they’re ever so nice to your face and will stab you in the back”. The denial phase plays out and the anger phase starts.

Phase 3 is a time when divisions start between those who want to embrace change knowing it’s intended to improve and make the workplace safer for staff and more so, safer for residents; and those who don’t have insight to recognise the need for change.  The need for people to remain in their comfort circle doing what’s known and predictable is incredibly strong for a large number of people. This slows momentum and the temporary manager starts to get the blame for things being wrong.  Such comments as ‘it was all fine before the DHB stepped in, they just need to back off and let us get on with it’ are also commonplace in this phase. Sometimes senior staff at the facility will contact their DHB and say the temporary manager is unreasonable, not doing anything and needs to be removed. All as an attempt to get rid of the person they see as pushing them outside their comfort circle and affecting maintaining of the status quot. The bargaining phase can continue for quite some time but this often depends on how direct and steadfast the response is to the bargaining strategies.

Phase 4 occurs when there is the start of the depression phase and realising that solid work, participation by all and a willingness to take on new ideas and learn new ways of doing things needs to occur. The real work has started by the willing few in the early phase and continues and now the collective change can start to be evident.

Phase 5 is acceptance that the temporary management or change management process was necessary. Staff start to commend the new way and embrace new ideas recognising that things are actually better now than they’ve been before.  As people always have choice about coming on board with change or leaving, invariably there are some staff and sometimes managers or even members of Governance who continue to resist seeing a new way is needed and those few will leave the organisation or continue to resist.

I’m able to observe which phase an organisation is operating in by the response of those working there and was intrigued to read of exactly this same set of steps in a book titled ‘Expert Secrets’ written by Russell Brunson. Some of you who are familiar with the work of Elisabeth Kübler-Ross will also recognise these phases as reflecting her stages of grief.

Acceptance is hard as people take the need for change as a criticism when in my view, people don’t fail; systems do!!

Clinical online tools for Aged Residential Care

HCSL are pleased to announce that from January 2018, you will be able to access clinical online tools for:

  • Initial assessment and initial care plan.
  • Short term care plans (and evaluations)
  • Long term care planning (and evaluations)
  • Progress notes
  • Restraint/ Enabler restraint management (and evaluations)

All mobile device compatible so you can be with your residents rather than stuck in the office!

HCSL bringing cost effective, specifically designed tools for the New Zealand residential care sector.  The Corporates have their tools, why shouldn’t you have the same advantage?!

 

To find out more and get a no obligation free quote for use contact us here.