SLIDE 1
Nothing is Traditional about Nothing is Traditional about Environments in a Traditional Environments in a Traditional Nursing Home Nursing Home
Lois J. Cutler, PhD Lois J. Cutler, PhD Creating Home in the Nursing Home Creating Home in the Nursing Home Symposium by CMS & Pioneer Network Symposium by CMS & Pioneer Network April, 3, 2008 April, 3, 2008
SLIDE 2 Session Plan Session Plan
- Focus: Physical environments in typical
Focus: Physical environments in typical nursing homes based on 10 years of research nursing homes based on 10 years of research
Findings from research
– – Quality of Life Study & other studies Quality of Life Study & other studies
- Introduction to NHRegsPlus Website
Introduction to NHRegsPlus Website
- Recommendations at 4 levels:
Recommendations at 4 levels:
– – Federal regulators & policymakers Federal regulators & policymakers – – State regulators & policymakers State regulators & policymakers – – Builders & owners Builders & owners – – Administrators & staff leaders Administrators & staff leaders
SLIDE 3 QOL in Nursing Homes QOL in Nursing Homes
Funded by CMS, 1998-2003 Funded by CMS, 1998-2003
5 states – – 8 NH/ state 8 NH/ state – – 131 units 131 units – – 21 SCU 21 SCU – – 1988 resident rooms & baths 1988 resident rooms & baths
- Environmental checklists focus on QOL
Environmental checklists focus on QOL domains (not dementia specific) domains (not dementia specific)
3 levels of assessments
– – Resident room & bath (112 items) Resident room & bath (112 items) – – Nursing unit (140 items) Nursing unit (140 items) – – Facility wide (134 items) Facility wide (134 items)
- Captured specific objective environment of each
Captured specific objective environment of each individual & linked environment to QOL & functional individual & linked environment to QOL & functional data data
SLIDE 4
Definition of Physical Environment Definition of Physical Environment
Fixed, semi-fixed, & unfixed Fixed, semi-fixed, & unfixed components of physical structure & components of physical structure & furnishings, fixtures, decor, and furnishings, fixtures, decor, and equipment (excluding backstage). equipment (excluding backstage).
SLIDE 5 Quality of Life Domains Quality of Life Domains
Autonomy
Dignity
Privacy
Meaningful activity activity
Enjoyment
Relationships
Comfort
Security
Functional competence competence
Spiritual well- being being
Individuality
SLIDE 6 Sharing Space Sharing Space
Bedroom Bedroom
580 (29%) private
1152 (58%) 2 bed
178 (9%) 3 bed
78 (4%) 4-6 bed Bathroom Bathroom
25% private
42% 2 people
5% 3 people
18% 4 people
10% 5-20 people
13% outside room traveled up to 82ft traveled up to 82ft
SLIDE 7 Storage Storage
(Regulations require: accessible, (Regulations require: accessible, individual, private closet space) individual, private closet space)
- 7% clothes rods accessible (36
7% clothes rods accessible (36” ”-48
”) ) yet 65% used wheelchairs yet 65% used wheelchairs
37% lockable storage
- 41% counter space around bathroom
41% counter space around bathroom sink sink
9 bathrooms had space 2’ ’X2 X2’ ’X2 X2’ ’
- 14% of rooms incontinence products
14% of rooms incontinence products visible visible
SLIDE 8
Sharing Space: Sharing Space: One Counter and One Chair One Counter and One Chair
SLIDE 9 Barriers to Autonomy Barriers to Autonomy
(65 % wheelchair usage) (65 % wheelchair usage)
Long undistinguishable corridors corridors
State req. distance to nursing station seldom nursing station seldom achieved achieved
Limited automatic door
– – Main door: 19 yes, 21 no Main door: 19 yes, 21 no – – Unit: 2 yes, 129 no Unit: 2 yes, 129 no
Bathroom key needed
- r for visitors only
- r for visitors only
SLIDE 10 Distance as a Barrier Distance as a Barrier
Distance measured from Distance measured from farthest bedroom to: farthest bedroom to: Min Min Max Max Mean Mean Unit entrance Unit entrance .05 mile
.05 mile
58 58’ ’ 288 288’ ’ 135 135’ ’ Dining/social area on unit Dining/social area on unit .04
.04 30
30’ ’ 230 230’ ’ 115 115’ ’ Primary toilet Primary toilet .02 mile (2-20
.02 mile (2-20 residents shared bathroom) residents shared bathroom)
Bathing area Bathing area .05 mile
.05 mile
03 03’ ’ 20 20’ ’ 82 82’ ’ 270 270’ ’ 10 10’ ’ 107 107’ ’ Facility dining room Facility dining room .07 mile
.07 mile
08 08’ ’ 348 348’ ’ 102 102’ ’ Main front entrance Main front entrance .07 mile
.07 mile
14 14’ ’ 387 387’ ’ 110 110’ ’
SLIDE 11
Inadequate Light Levels Inadequate Light Levels
( (3053 Total Light Meter Readings)
3053 Total Light Meter Readings) Nurses Nurses’ ’ station station Range Range 10 - 410 FC 10 - 410 FC Mean Mean 91 FC 91 FC Head of bed Head of bed 4-95 FC 4-95 FC 37 FC 37 FC Bathroom sink Bathroom sink 1-75 FC 1-75 FC 25 FC 25 FC Primary toilet Primary toilet 1-48 FC 1-48 FC 13 FC 13 FC Shower/tub Shower/tub room room 4-152 FC 4-152 FC 46 FC 46 FC
SLIDE 12 Corridor Clutter as a Barrier Corridor Clutter as a Barrier to to
Functional Competence
Functional Competence
(Range 0-10 Items, M= 3.5) (Range 0-10 Items, M= 3.5)
9% no clutter
3 units had all 10 items
58% medical equipment
48% laundry carts
48% housekeeping carts
- 47% other (cages, dishes,
47% other (cages, dishes, podiatrist, prosthesis) podiatrist, prosthesis)
41% clean linen
32% medicine carts
- 22% incontinence disposal
22% incontinence disposal
18% trash containers
15% weight scales
SLIDE 13 Personalization Personalization
(7 item scale) (7 item scale)
85% personal photos
39% door personalization personalization
30% brought chair
29% individualized bedspread bedspread
18% lamps
18% own bureau
8% individualized drapes drapes
SLIDE 14
Resident Resident’ ’s Space s Space
SLIDE 15 Mean Scores of Resident Items Mean Scores of Resident Items by Number of Beds by Number of Beds
Chair (s) in sleeping Chair (s) in sleeping area area Private (580) Private (580) 2 Bed (1152) 2 Bed (1152) 3+ bed (256) 3+ bed (256) .95* .95* .78* .78* .31* .31* Resident controls TV Resident controls TV Private Private 2 Bed 2 Bed 3+ bed 3+ bed .78* .78* .55* .55* .37* .37* Lockable storage in Lockable storage in room room Private Private 2 Bed 2 Bed 3+ bed 3+ bed .48* .48* .34* .34* .26* .26* Primary toilet Primary toilet * Sig. 000 * Sig. 000 Private Private 2 Bed 2 Bed 3+ bed 3+ bed .46* .46* .23* .23* .14* .14*
SLIDE 16 Checklists on CMS Website Checklists on CMS Website
- http://www.cms.hhs.gov/NursingHom
http://www.cms.hhs.gov/NursingHom eQualityInits/05_NHQIHighlights.asp# eQualityInits/05_NHQIHighlights.asp# TopOfPage TopOfPage
- Click: Quality of Life Volume 2
Click: Quality of Life Volume 2
Appendices
– – Appendix G Appendix G – – Room & Bath Checklist Room & Bath Checklist – – Appendix H Appendix H – – Nursing Unit Checklist Nursing Unit Checklist – – Appendix I Appendix I – – Facility Checklist Facility Checklist
Published papers on MN website: Published papers on MN website:
http://www.hpm.umn.edu/ltcresourcecenter/ http://www.hpm.umn.edu/ltcresourcecenter/
SLIDE 17 Practical Strategies to Improve Nursing Home Practical Strategies to Improve Nursing Home Environments for Better QOL Environments for Better QOL
Funded by Funded by
Retirement Research Foundation
Retirement Research Foundation
- NH personnel get used to their environments:
NH personnel get used to their environments: need to assess with fresh eyes need to assess with fresh eyes
- Tendency to rely on convenient suppliers
Tendency to rely on convenient suppliers
- Practical solutions can help within ordinary
Practical solutions can help within ordinary maintenance budgets maintenance budgets
- Materials included self-assessment protocol
Materials included self-assessment protocol and manual for low-cost strategies and manual for low-cost strategies
SLIDE 18 NHRegsPlus Website NHRegsPlus Website http://www.hpm.umn.edu/nhregsPlus/ http://www.hpm.umn.edu/nhregsPlus/
Funded by Hulda B. & Maurice L. Rothschild Foundation Funded by Hulda B. & Maurice L. Rothschild Foundation
Searchable website of federal & state NH Searchable website of federal & state NH Regulations Regulations— —regs updated as of August 2007 regs updated as of August 2007
- Comparative tables and text by topics
Comparative tables and text by topics
- 4 categories existing facilities
4 categories existing facilities
– – Resident room & bath; nursing unit; facility wide; dining & Resident room & bath; nursing unit; facility wide; dining & lounge space lounge space – – 17 topics 17 topics
- 4 categories new construction
4 categories new construction
– – Application process; bedroom area; nursing unit; facility Application process; bedroom area; nursing unit; facility wide wide – – 19 topics 19 topics
- Analysis links regulations to resident autonomy and
Analysis links regulations to resident autonomy and quality of life both positively and negatively quality of life both positively and negatively
SLIDE 19 Ten Examples of State Regulations Ten Examples of State Regulations
1. 1. Body holding room required for dignified holding Body holding room required for dignified holding
- f body where it will not be exposed to the view
- f body where it will not be exposed to the view
- f patients or visitors. Room may be used for
- f patients or visitors. Room may be used for
- ther purposes when not holding a body. (CT)
- ther purposes when not holding a body. (CT)
2. 2. Rags from patient bedding or clothing shall not Rags from patient bedding or clothing shall not be used in dietetic services for any purpose. (AR) be used in dietetic services for any purpose. (AR) 3. 3. In resident bathrooms, all sinks shall have hot In resident bathrooms, all sinks shall have hot and cold running water (NM) & toilet paper in a and cold running water (NM) & toilet paper in a suitable dispenser must be provided within reach suitable dispenser must be provided within reach
- f each toilet. (TX)
- f each toilet. (TX)
4. 4. Alternative to public address system for non- Alternative to public address system for non- emergency messages required in new emergency messages required in new
- construction. (WA)
- construction. (WA)
SLIDE 20 Ten Examples of State Regulations, Ten Examples of State Regulations, cont cont’ ’d d
5. 5. All unique design solutions shall be described with All unique design solutions shall be described with
- utcome measures. This shall be reviewed in
- utcome measures. This shall be reviewed in
cooperation with the center. (VA) cooperation with the center. (VA) 6. 6. Provisions shall be made to keep clothes dry Provisions shall be made to keep clothes dry while resident is bathing. (PA) while resident is bathing. (PA) 7. 7. Ceramic kiln must be installed in accordance with Ceramic kiln must be installed in accordance with Uniform Mechanical Code. (MN) Uniform Mechanical Code. (MN) 8. 8. If patient is allowed to scrape trays, there must If patient is allowed to scrape trays, there must be a physician be a physician’ ’s order. (AR) s order. (AR) 9. 9. Household straw brooms shall be used only at Household straw brooms shall be used only at entrances and exits of building. (WY) entrances and exits of building. (WY) 10.
- 10. Deodorants can not be used to cover up odors.
Deodorants can not be used to cover up odors. (AR) (AR)
SLIDE 21 Recommendations: Federal Recommendations: Federal
- Create standard for private rooms (unless by
Create standard for private rooms (unless by choice) in new construction choice) in new construction
- Consider expanding minimum room sizes &
Consider expanding minimum room sizes & specifying distances specifying distances
- Take a parsimonious approach to
Take a parsimonious approach to promulgating new federal regulations on promulgating new federal regulations on physical environment: physical environment:
– – Clarify verbiage: unsightliness; cheerful space; Clarify verbiage: unsightliness; cheerful space; satisfactory bed-stand; comfortable interior; satisfactory bed-stand; comfortable interior; adequate light levels and good condition linens adequate light levels and good condition linens – – Consider approach that is geared to functional Consider approach that is geared to functional requirements of space requirements of space
- Amend surveyor instructions to look into all
Amend surveyor instructions to look into all spaces residents routinely spaces residents routinely use use— —e e.g. .g. tub/shower rooms tub/shower rooms
SLIDE 22 Recommendations: State Recommendations: State
- Collaborate to develop a set of model
Collaborate to develop a set of model regulations directed towards underlying regulations directed towards underlying intent to promote innovation & flexibility, intent to promote innovation & flexibility, not to exceed Federal regulatory scope not to exceed Federal regulatory scope
- Develop convenient & transparent way to
Develop convenient & transparent way to grant waivers grant waivers
- Tie waivers to outcome based studies (POE)
Tie waivers to outcome based studies (POE) & share results & share results
- Do not develop double sets of regs for
Do not develop double sets of regs for
- rdinary vs. culture change nursing homes
- rdinary vs. culture change nursing homes
SLIDE 23 Recommendations: Builders & Recommendations: Builders & Owners of New Construction Owners of New Construction
- Move beyond obsolete classic design
Move beyond obsolete classic design (nurses (nurses’ ’ stations, headboards, multi-purpose stations, headboards, multi-purpose rooms) towards innovative function rooms) towards innovative function enhancing spaces enhancing spaces
- Go beyond regulatory minimums (e.g.,
Go beyond regulatory minimums (e.g., ceiling night light, storage, accessibility) ceiling night light, storage, accessibility)
- Team with local researchers to study
Team with local researchers to study environments environments
SLIDE 24 Recommendations: Recommendations: Administrators/Staff Leaders Administrators/Staff Leaders
- Look at facility with new eyes: do nursing
Look at facility with new eyes: do nursing home self-assessment home self-assessment
Get rid of clutter— —off-site storage
- ff-site storage
- Exemplary features not sufficient
Exemplary features not sufficient— —need need plan for broad utilization plan for broad utilization
- Consider buying furnishings, decorative
Consider buying furnishings, decorative items, and equipment from atypical vendors items, and equipment from atypical vendors
SLIDE 25 Thank you for listening & please visit our web site: Thank you for listening & please visit our web site: http://www. http://www.hpm hpm. .umn umn. .edu/nhregsplus/ edu/nhregsplus/ and our departmental website: and our departmental website: http://www. http://www.hpm hpm. .umn umn. .edu/ltcresourcecenter edu/ltcresourcecenter/
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Lois J. Cutler, PhD Lois J. Cutler, PhD Division of Health Policy & Management Division of Health Policy & Management School of Public Health School of Public Health University of Minnesota University of Minnesota cutle001@umn. cutle001@umn.edu edu
