The QM, Functional Outcome & Reimbursement Perks of Restorative Nursing Restorative & PDPM
As we began discussing in part 1 of this blog last week, there are many benefits to considering Restorative Nursing programs. In part 2 of this blog, let’s review some of the key operational considerations to address for an effective program.
Restorative techniques can be taught by therapy staff or nursing staff that have been trained. If utilizing contract rehab, consider including therapy education of restorative staff as part of the contract terms. Nursing assistants who are providing restorative interventions should receive ongoing, routine (at least annually) competency evaluations to ensure they are properly trained. Documentation of this competency evaluation should be noted in the employee file.
Performance & Documentation
At least 2 restorative programs (outlined in the table below) must be provided 6 out of 7 days for a minimum of 15 minutes per day.
|MDS Section O0500|
|Range of motion (Passive)*|
|Range of Motion (Active)*|
|Splint or Brace Assistance|
|Dressing and/or Grooming|
|Eating and/or Swallowing|
|MDS Sections H0200 & H0400|
*These programs, when used together, will be counted as one program.
Restorative can be performed in a group as long as there are no more than four residents in the group. Participants should be cognitively able to follow along in a group setting without need for one-one-one help. Group restorative is an effective way to manage scheduling. Instead of spending 15 minutes each for 4 residents for a total of 60 minutes, 4 residents are given restorative for a total of 15 minutes. This promotes efficiency while providing quality care. Also, group restorative programs can be fun and promote socialization. Be creative with restorative programming so that it is not just exercise moving an extremity a certain amount of repetitions. For example, two restorative groups could play against each other in chair volleyball. Grooming programs, including programs to help residents learn to apply make-up, may be considered restorative nursing programs when conducted by a member of the activity staff as long as they meet the restorative requirements referenced previously.
Who needs restorative?
The first step in implementing a program is to determine which residents are appropriate and would benefit from restorative services. The following sources can be reviewed for potential candidates:
- ADL reports/tracking
- Screening assessments (i.e. Functional ADL, ROM, Bowel and Bladder, Pain)
- Weight Variance Report
- BIMS report
- Fall Report
- Nurse’s notes (i.e. Clinical, 24-hour report)
- Quality measures report
- Staff referral (ALL staff)
- Current therapy load (upcoming discharges and those who would benefit from a combination of skilled therapy and restorative nursing services)
The second step of program implementation is to analyze the staffing needs for the identified restorative caseload. A Restorative Nurse Manager should be appointed who is familiar with restorative requirements and concepts and should be an effective team leader. Restorative Nurse Assistants (RNAs) chosen should encourage residents’ optimal well-being and be an advocate for resident-centered care. The RNAs should not be selected by seniority or who wants to work day shift Monday-Friday. Actually, the restorative staffing schedules need to cover at least 6 days a week with flexible, extended hours to cover all three meals and allow for providing programs before and in between meals, bathing activities, visitors, rest periods, etc. The biggest pitfalls with restorative staffing are call-outs and pulling RNAs to work as CNAs on the floor and assigning nonrestorative duties (i.e. weights, transportation aide, stocking supplies). These practices make restorative nursing programs appear optional and not of importance. Also, it negatively impacts the residents on restorative case load because they do not receive their beneficial restorative programs. Furthermore, a survey deficiency can be cited for not following the restorative plan of care and, again, quality of care. If there is a staffing crunch, consider training all CNAs in restorative techniques and/or consider cross training staff to be CNAs with training in restorative. Also, keep in mind the use of group restorative, Walk to Dine to help attain efficiency.
Restorative and the Admission Process
With the increase in Accountable Care Organizations and bundled payment initiatives, the trend and goal with facilities has been to provide higher functional levels more efficiently within a shorter length of stay. With PDPM, it is important for the nursing team to have a process and clinical pathway in place for assessing restorative needs and starting those programs upon admission. In order to capture restorative on the initial 5-day admission assessment, programs will need to be started on days 1-3 to provide the required minimum 6 days of restorative by day 8. Moreover, therapy and nursing would need to collaborate in this timeframe because restorative cannot perform the same activities and functions that therapy is providing. If therapy and restorative services are being provided in conjunction (performing different activities), this should be with the intent of benefiting the resident. CMS is monitoring therapy utilization before and after PDPM and utilization is reported on the PPS Discharge so minimizing therapy and relying on restorative could place an organization at risk. Four SNF QRP Measures consisting of change and discharge mobility and self-care scores compare section GG coding from the 5 day to the End of PPS stay Discharge assessment. Worsening quality measures may be a compliance risk and trigger medical review under PDPM. Restorative nursing can assist therapy to enhance section GG self-performance and obtain discharge goals which would improve these measures.
A successful restorative program embraces the resident as the most important member of the team. There should be a facility wide commitment to the program to make a difference in resident outcomes. Additional best practices are included below.
|Best Practices for a Successful Restorative Program|
|Updated Policies and Procedures|
|Strong Nurse Leader/Manager|
|Assessment process for identification of need(s)|
|Daily documentation monitoring|
|Consistent meeting discussion (i.e. PPS)|
|Quarterly screens/ongoing clinical evaluation|
|Staff/Therapy referral system|
|Staff awareness of ARD/reference period|
|Resource Management (i.e. staffing, supplies)|
|Daily & periodic evaluation documentation monitoring|
|Addressing refusals in a timely manner|
|Making changes to the plan of care timely|
|Ongoing monitoring, auditing and re-evaluation|
|Functional outcomes and program review – QAPI|
Do you need assistance starting an effective restorative nursing program or would benefit from an evaluation of your current program? Please contact Proactive Medical Review @ firstname.lastname@example.org or (812) 471-7777.
Center for Medicare and Medicaid Services. (2019). MDS 3.0 RAI Manual. Retrieved from: https://downloads.cms.gov/files/mds-3.0-rai-manual-v1.17.1_october_2019.pdf
Centers for Medicare and Medicaid Services. (2019). Patient-Driven Payment Model. Retrieved from: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM
Center for Medicare and Medicaid Services. State Operations Manual. Transmittal. Rev. 11-22-17. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
Center for Medicare and Medicaid Services. SNF PPS Payment Model Research. Retrieved from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch
Contact Proactive for assistance in implementing a successful restorative program and check out these resources in our web shop:
Restorative Nursing Competency Tool-Kit.
MDS Proficiency Series: Rehabilitative & Restorative Services (MDS Sections H and O)