TIP OF THE WEEK
Ideas for improving chronic care pain management
- Understand the Quality Measure calculation
- Identify which residents flag according to the Quality Measure definition
- For each resident who flagged, consider the following:
- Determine if the resident still has pain. Preferably, this can be determined by conducting resident interviews; alternatively, you can review Medication Administration Records (MARs) and nursing documentation. If the resident is still having pain, a new comprehensive pain assessment should be completed; location, intensity, duration, alleviating and aggravating factors should all be re-evaluated.
- If the resident has any new pain or change in pain: Notify the resident’s physician of the changes. The presence of pain may be an indication of an undiagnosed or under-treated disease process; left untreated, it can also lead to negative outcomes, including ADL decline, mobility decline, depression, etc.
- Musculoskeletal factors such as gait/balance disorders, osteoarthritis, rheumatoid arthritis, osteoporosis, muscle imbalance and atrophy, fractures, soft tissue injury and pain
- If the level of and type of pain is unchanged from the prior assessment: Consider requesting a change in medication, dose, frequency, etc. Or, consider adding some non-pharmacologic interventions to the care plan. Some additional issues to consider:
- Are routine pain medications given, or does the resident rely on PRN pain medications? Around-the-clock dosing is preferred for those with chronic pain. Request a routine order from the physician.
- If PRN medications are used, how frequently are they actually given? Are some staff members more proactive in medicating for pain than others?
- Review MDS coding. Remember to code for the presence or absence of pain, regardless of any efforts at pain management that are used (as instructed in RAI User’s Manual).
- Review the resident’s care plan. Is pain on the list of nursing problems? If not, add pain to the list and review pain management with other issues during future plan of care meetings.
- When all residents have had proper evaluation and care plan modifications, consider some facility-wide changes.
- Conduct a staff attitudinal survey on pain. Determine your staff’s opinions, biases, or underlying assumptions about symptoms of pain, treatment options, etc. If staff members’ individual beliefs are that pain is to be expected or tolerated, they will not be effective advocates for their residents. Provide training for your staff based on the results of the attitudinal surveys.
- Develop a culture of pain management. Teach your staff that pain is everyone’s responsibility; teach them to identify symptoms of pain and who to notify when they notice signs. Be sure that this healthcare priority is communicated to new staff members early and often during their orientation; the use of peer mentors can be especially helpful in emphasizing those priorities.
- Review contingency box medications. Are frequently used emergency pain medications kept stocked in the box? Ask the floor nurses if they ever have difficulty receiving replacement pain meds from the pharmacy for the contingency box. What is the process for replacing them when they are used?
- Eliminate or reduce the use of physical restraints. The use of physical restraints can lead to many possible adverse physiological and psychological outcomes, and can cause pain due to lack of movement and muscle deterioration.
- Initiate a program to educate residents and family members on pain. Consider utilizing the Ohio KePRO tri-fold educational brochures; assure your residents that they don’t have to live with pain. Explain your facility’s policy for pain assessments.
- Involve your Medical Director. With the assistance of your Medical Director, develop a plan to educate attending physicians regarding effective pain management for nursing home residents. Several clinical guidelines are available as resources.
- Modify activities. Consider individualized activities that can help alleviate the resident’s pain; activities that use humor, reminiscence, soothing sounds etc., are often effective in temporarily relieving pain
- Utilize the restorative nursing program or refer to Physical Therapy. Restorative nursing and/or therapy programs can help residents maintain their physical functioning, prevent falls, and alleviate pain through non-pharmacologic modalities.
- Ensure accurate documentation. Be sure to educate your staff regarding accurate and thorough documentation of pain. Help them realize that their documentation can affect MDS coding, which in turn, affects your facility’s Quality Measure scores.
- Initiate dialogue on pain management with other providers in your area. Many hospitals, home health agencies, hospices and other provider settings also have concerns about effective pain management. Offer to host a meeting where discussions focus on the patient experience across the continuum of care.
This measure is calculated from residents who either had daily pain with at least one episode of moderate pain (J2a=2 AND J2b=2) OR excruciating pain at any frequency (J2b=3) during the seven-day look-back period of the Minimum Data Set (MDS) assessment.
A 2001 report from Brown University indicates that more than 41 percent of Ohio’s nursing home residents experience persistent pain. Use the Resident Level Quality Indicator/Measure reports to determine which residents flag for this measure each quarter, and which of those residents also flagged during the prior quarter.
In addition to an inter-disciplinary team approach, some nursing homes have found these strategies helpful in reducing pain for their residents:
RESOURCE SPOTLIGHT
Facility Assessment Checklists for Pain
(Microsoft Word document) Assess your facility process for screening for pain, assessing/reassessing for pain, developing pain care plans, and monitoring pain.
IN THE NEWS
April 9, 2007 -- Alliance for Aging Research -- More than 85 disease groups, patient advocacy organizations, and foundations urge Congress and the president to chart a better course for medical research on behalf of America's aging population. In a report released today, the 2007 Task Force on Aging Research Funding calls for a 6.7percent increase in funding for the National Institutes of Health (NIH) in fiscal year (FY) 2008 to halt the erosion of the nation's research base and facilitate medical discoveries to fight diseases and disabilities that disproportionately affect older Americans. Read more >>
STUDY: ETHICAL CHALLENGES RELATED TO ELDER CARE. HIGH LEVEL DECISION-MAKERS' EXPERIENCES
BMC Medical Ethics, 2007 -- This paper provides further insight into the ethical dilemmas and ethical challenges met by high level decision-makers, which is important since the overall responsibility for elder care that is also ethically defensible rests with them.
U.S. SUPREME COURT HEARS ARGUMENTS IN HOME HEALTH CARE WORKERS WAGE CASE
April 17, 2007 -- Kaiser Network -- The Supreme Court on Monday heard oral arguments in a case that could determine whether federal minimum wage and overtime laws apply to home care workers, the AP/Winston-Salem Journal reports. In the case, Evelyn Coke, a 73-year-old immigrant from Jamaica, filed a lawsuit against New York-based Long Island Care at Home to challenge Department of Labor regulations that exempt agency home care workers from the laws.
Read more >>
HOSPICE CARE DOES NOT HASTEN DEATH, STUDY SHOWS
April 12, 2007 -- Reuters Health -- Researchers hope a new study will help dispel the myth that medications used in a hospice to relieve pain and other symptoms hasten death. On the contrary, hospice care may actually prolong life, they've found. Read more >>
OHIO KEPRO EVENTS
THE GOOD APPLES: TIPS FOR ATTRACTING AND RETAINING THE RIGHT EMPLOYEES
In this half-day workshop, we will delve into key strategies for improving workforce retention in the nursing home, including:
- The impact of turnover and absenteeism on an organization and what you can do about it.
- Strategies to improve the hiring and orientation process.
- Motivating employees and improving staff satisfaction.
- Setting goals and measure improvement in workforce retention.
Who should attend: Directors of Operations, Directors of Nursing, Nursing Home Administrators, Staff Development, and Human Resources.
Save these dates and register today!
7/11 – Cincinnati | 7/24 – Wooster | |
7/12 – Springfield | 8/7 – Boardman | |
7/17 – Cambridge | 8/15 – Columbus | |
7/19 – Sylvania | 8/21 – Wellston |
CANCELLED: COMMUNITY OF PRACTICE CONFERENCE CALLS
The remaining community of practice conference calls have been cancelled. This includes further discussions about pressure ulcers (April 17+19, 2007), pain (April 24+26, 2007), and restraints (May 1+3, 2007).
For more information, please contact the Nursing Home Team at 1-800-385-5080
INDUSTRY EVENTS
PRESSURE ULCERS: THE POWER OF PREVENTION AND EARLY DETECTION
A workshop series presented by American Medical Technologies in support of the Advancing Excellence in America’s Nursing Homes Campaign. April 18-26, 2007 in locations throughout Ohio. Registration one week in advance is required. Register now
2007 DQA QUALITY FORUMS FOR NURSING HOMES
In April and May, the Ohio Division of Quality Assurance (DQA) is presenting one-half day quality forums to discuss current issues with Nursing Home Administrators, Directors of Nursing and Maintenance Supervisors (limited to two participants per facility, advanced registration is required). The quality forums will include the following topics: GPRA goals/restraint use guidelines, MRSA in LTC, LTC updates, enforcement updates, and life safety code updates.
30th Annual Nursing Assistant Convention and Recognition Program
June 20, 2007, Akron, OH
Dementia: The Emerging Epidemic, A support group meeting for family, friends, and caregivers
May 10, 2007, 7:00pm to 8:30pm, Courtyard by Marriott, Springfield, OH.
Call OMH, Rita Brown at 937-525-3000 to register before May 3, 2007.
Dementia: The Emerging Epidemic Training for Professionals
May 11, 2007, 8:30 p.m. to 4:30 p.m., The Ohio Masonic Home, Springfield, OH.
Call OMH, Rita Brown at 937.525.3000 to register before May 4, 2007.
Navigating the MDS Through the Ohio Medicaid Reimbursement System
Ohio Department of Job and Family Services
June 11, 2007 or August 23, 2007
Call Cheryl Robertson at (614) 466-9088 for more information.
Medicare Learning Network: Learning resources and products for the healthcare professional.
Alzheimer’s Association Training Events
Case Western Reserve University School of Medicine Courses
Ohio Department of Health, Technical Assistance Program – New Programs
Ohio Health Care Association Events
An archive of The Nursing Home Weekly Update is available on our Web site. Click here >>
