With ongoing nurse shortages and the increasing pressure put on long-term care professionals, restorative nursing programs are often overlooked. However, implementing successful restorative programs in care communities is not only invaluable to your residents' quality of life but they can also be essential sources of reimbursement. So how can restorative programming be effectively implemented despite all the challenges long-term care facilities now face? You're in precisely the right place to find out.
The holy book of restorative nursing programs (or RNPs for short) is the RAI Manual and the definition of restorative nursing programs according to this is as follows:
An RNP "refers to nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning" - MDS 3.0, RAI manual
What does that mean in practice, though? Well, an RNP is a formal, planned and organized program of care which is intended to restore a lost ability or maintain a potentially deteriorating function for a particular resident. Restorative expert, Nicole Watson says "This type of programming is a vital component to individualizing one's care. They're more than just normal nursing or custodial care, it's person-centered Vs traditional care."
From a regulatory perspective, no you don't have to implement RNPs in your care facility, but the benefits of them both for residents and the facility, make them a no-brainer in our opinion. Some people may see RNPs as "extra" to care requirements and so don't take advantage of them. We've heard it said that there aren't enough staff to carry out essential care, let alone additional care plans but there are ways you can incorporate them into the daily care tasks your nursing team is already carrying out. It's often a case of documenting what you already do to help encourage independence, taking credit for it and being reimbursed for it.
Whether RNPs are truly necessary is all a case of perspective. Nicole says "If you can get your staff to think of restorative programs as the foundation of your individualized resident care, it actually becomes part of your culture and your mission to help people live the best quality that they can at this stage in their lives, which is truly why most of us are in this industry; because we want to enhance the lives of our elders. So, making [RNPs] part of your culture and ingraining it in your foundation and in your nursing practice makes it easier."
Therefore restorative programming shouldn't be perceived as an optional add-on to care but should be seen as intrinsic to the practice and success of that care.
Placing yourself in a resident's shoes for a second, it's plain to see that most of them upon entry to a SNF or other sub-acute care community, are experiencing an overwhelming amount of loss; both materially and emotionally. They might have come from a spacious house with all their favorite things and are now in a nursing facility without the items and freedom they were previously used to. They might have lost the right to drive, they might have lost the constant presence of their partner, family and support network. They might have lost their ability to communicate effectively and many will also be experiencing loss or distortion of the most precious thing humans have: their memories. With all this loss at one time, it's no wonder we often see a decline in mental wellness and enthusiasm for life in residents.
RNPs are one way we can actively help residents restore or maintain some of their independence. Compared to the size of the grief they may be experiencing, getting back the ability to walk independently, dress themselves or whatever other goals your RNP aims to reach may seem like a very small victory, but it can be priceless for their inner and outer well being. Additionally, there's also potential reimbursement for your facility and documented proof of your delivering quality care.
All restorative programs seek to see either maintenance or improvement in function for residents, but there are two main categories of RNPs you should be aware of: Technique programs and training and skill practice programs.
These are programs that aim to maintain flexibility and joint motion. In this type of RNP, the nursing staff are completing the activity with or for the resident. Examples of this type of program might be splint assistance or range of motion improvement programs.
These are restorative care delivery systems in which the resident is performing the activity with cues, supervision or task segmentation from the staff. Examples of these RNPs could include, toileting, communication, eating, walking, transfer, or dressing/grooming programs. Many facilities have a walk-to-dine program in which residents are encouraged to walk from their rooms to the dining room for all or some of their meals.
How do RNPs impact regulatory requirements?
When RNPs successfully impact the quality of life for residents, this also has a knock-on effect as to how the facility's quality measures are perceived by surveyors.
According to Nicole Watson, "surveyors are going to do a record review of section GG to see their prior functioning which captures the resident's usual ability to perform self-care, indoor mobility, how they manage stairs and their cognitive state prior to their illness, exacerbation or injury. Then they can compare our evaluation and the resident's progress towards their goals.
So, when your team are educated and consistent with RNP programs, not only do the residents benefit from better quality of life, but the programs impact the bottom line financially with reimbursement which we receive from CMS."
In order to qualify for reimbursement for restorative nursing, you need to ensure there are two or more RNPs in place for at least six days a week. To count a day of RNP there needs to be fifteen minutes documented during a 24-hour period. The fifteen minutes don't all need to be at once so make sure day and night shifts communicate expectations clearly. Only the time staff spend with the resident can be counted and RNPs should not overlap in terms of activities or goals with that resident's therapy program.
It's good to note at this point that you can have group RNPs in which four residents to one staff is the minimum ratio, but remember that whoever is leading the session, must be aware of the goals of each of the individual's RNPs so their activities support their specific goals.
In addition to this, your documentation must support progress towards the goals and a licensed nurse must document regular supervision and re-evaluation or adjustments of the programs, at least quarterly. Common reasons why reimbursement may not be granted for restorative nursing are:
As with all things in LTC nursing, documentation is key so if you can document the correct execution of your RNPs and prove your ongoing improvement through periodic evaluations then it will result in a higher CMI and subsequently higher reimbursement for your facility.
As for which members of the team are responsible for implementing and executing restorative nursing programs, there are a number of parties who should be collaborating on RNPs. Some of the key players in terms of supervision and execution would be Nurse Aides, LPNs, RNs and Recreational Therapists. If you're fortunate enough to have Restorative Aides then they should obviously be utilized. But you should also include all three therapy departments in planning the activities, tools and equipment in the program. You might also find it useful to consult with the social work department for their input on the resident's psychosocial function and areas of potential improvement.
While you need an LP or RN to supervise and review results, documentation and sign off on results, your CNAs or restorative aides will be the ones doing a lot of the actual execution of the program and clocking up those minutes with the residents. Finally, you also want to involve the RNACs to ensure that documentation and coding on the MDS are correct.
This was a question we were asked in our recent webinar on restorative nursing and RNP oracle, Nicole Watson answered: "Absolutely! That’s what I’ve always done because this staffing crisis didn’t just happen with Covid; it started prior.
So, for dressing and grooming, for example, we need to set things up for Mary. We get all of her supplies ready and she’s getting herself dressed and she’s doing active range of motion. As long as the licensed nurse is outlining that dressing can be part of active range of motion, then we can incorporate that into the RNP and capture those minutes.
Sometimes we don’t take credit for the things that we’re doing and we just have to be smarter about how we’re doing it and have the documentation to support that."
You can get creative with the RNPs in terms of activities. You're probably already doing a lot of what is required for a successful restorative program, it's a matter of documenting it properly and creating a more intentional outline of goals and time expectations to make them SMART.
While restorative nursing often has to take a backseat to more pressing issues in long-term care communities, it's important to understand the value of RNPs to both the resident's quality of life, both now and in the future and also to the bottom line of the business. Even if restorative nursing is already a priority in your nursing practices, you can still face challenges to successful implementation and reimbursement.
The success of an RNP could hinge on resident involvement. If they do not wish to participate in a program from the beginning then the success of it is likely to be very limited. Some residents will not be appropriate for a restorative program at all, let alone the two that are needed to qualify for reimbursement and sometimes the program requirements and documentation requirements can prove to be difficult to divide between the staff that you have on their varying schedules. But even considering all of this, we still owe it to our elders to do our level best to provide a quality outcome of care for residents and to improve their quality of life. With this in mind, RNPs are vital for ensuring optimal care delivery and also for the longevity and viability of long-term care organizations themselves.
If you found this article useful, then you'll love the full webinar presented by Nicole which you can access at any time on the Accora website. You can also find a copy of the Q&A transcript after the webinar here.