Functional Pathways

Restorative Nursing programs are vital to long term care. These traditional nursing home programs, if not well managed and organized may leave long term care residents with an overall poorer quality of life lower and declines in function that impact quality assurance measures and generate facility deficiencies. The Omnibus Reconciliation Act (OBRA) 87’ requires the facility provide to “each resident the necessary care and services to attain or maintain the highest practical physical, mental, and psychosocial well- being, in accordance with the comprehensive assessment and plan of care.” (483.25) Throughout the OBRA guidelines both restorative and maintenance programs are identified. Specifically, 483.45 (b) states: “specialized rehabilitative services are provided for individuals under a physician’s order by a qualified professional. Once the assessment for specialized rehabilitative services is completed, a care plan must be developed, followed, and monitored by a licensed professional. Once a resident has met his or her care plan goals, a licensed professional can either discontinue treatment or initiate a maintenance program which either nursing or restorative aides will follow to maintain functional and physical status.” The purpose of the restorative nursing program is then described as providing restorative care necessary to meet the needs of residents in order to achieve the standard as described by the Omnibus Reconciliation Act of 1987.

How this mechanism works in your facility is driven by the needs of your resident’s and the capabilities of your staff to consistently implement the program. Developing a clear process for the delivery of the restorative services and assigning role responsibilities is crucial. Although the therapist may refer a resident to the restorative program, nursing must supervise and drive this program. Further clarification on restorative care and requirements for inclusion in the MDS are in Section O: Special Treatments, Procedures, and Programs, in the CMSD RAI Version 3.0 Manual. Restorative programs that can be counted towards the MDS include:
• Range of Motion
• Bed Mobility
• Transfers
• Walking
• Dressing and/or grooming
• Eating and/or swallowing
• Amputation/Prostheses care
• Communication
Additional restorative intervention may include:
• Body alignment/Positioning
• Bowel and Bladder Retraining

The Medicare requirement for inclusion in the MDS to generate the rehab low RUG category is 2 restorative programs for a minimum of 15 minutes daily during the 7 day look back period of the current assessment. The benefit of developing a restorative program is sweeping---

 IMPROVES AND MAITNAINS QUALITY OF LIFE
 It ensures a proactive approach to prevent future functional decline
of the resident
 It creates continuity of care across the continuum and generates
communication with the interdisciplinary team
 Maintains the residents function for a longer period of time,
indicated in quality measurement tools and generates good surveys

The increased scrutiny and focus on quality initiatives by Medicare and other Insurer’s within our industry necessitates the further development of key services being provided in long term care and CCRC communities. With innovative thinking and well developed partnership strategies we can continue to promote and provide effective services for our residents that will positively affect quality of life, improve our admissions, and decrease re-hospitalization.

17 COMMENTS ON THIS POST To “RESTORATIVE NURSING AND QUALITY OF LIFE”

  • Name*

    January 11, 2013 at 7:13 pm

    you only need 6 days of restorative in the look back period is my understanding. Do you consider wheel chair mobility (helping them utilizing their wheel chair) a restorative program. alot of times this is a quality of life issue.

    thank you

    • Cherie Rowell

      February 5, 2013 at 12:41 pm

      Hi Anne,

      I hope you are having a great Friday! You are correct, you only need 6 days of restorative during the 7 day look back period and a minimum of 2 (separately identified restorative interventions). Unfortunately, wheelchair mobility is not one of the restorative programs recognized in the look back period when coding on the MDS for RUG level determination. I do, however, consider this part of the restorative program as it can have a large impact on mobility and quality of life! Thank you for taking the time to comment. Please feel free to contact me regarding your restorative program anytime.

      Sincerely,

      Cherie

  • Sarah Robbins CM

    January 11, 2013 at 8:55 pm

    We do not have a restorative program here at APM. Therapy has been discussing the possibility of starting the program with the thought of handing the program to nursing in 6 months. This way we can “kick it off”, but after reading above I see that nursing has too. Do you have any suggestions? I have approched this issue with administrator, DON and ADON with no luck due to cut backs.

    Thanks

    • Cherie Rowell

      February 5, 2013 at 12:42 pm

      Hi Sarah,

      I did see your comment on the restorative blog. I will be happy to work with Brian in opening a dialogue with Administrator and Don regarding a restorative nursing program. They will need to be the initiators of course, although, we can certainly assist with the formatting and training of the program to kick it off.

      Thanks,

      Cherie

  • Jennifer

    March 24, 2013 at 1:59 am

    I’m new to long term care, and I am attempting to master the basics of the Restorative Nursing Program. Does anyone know of a guideline prohibiting the licensed nurse from discharging a resident from Restorative services? I’m finding that there are some residents who have been in the program for a long time, and they wish to be discharged.

    Thanks in advance for sharing your wisdom!

    • scapitosti

      March 29, 2013 at 9:59 pm

      Hi Jennifer
      Restorative nursing does not require a physician’s order so there is no guideline prohibiting the licensed nurse from discharging a resident from Restorative services. Evidence of periodic evaluation by the licensed nurse must be present in the resident’s medical record and the resident’s desire to not participate any longer should be clearly documented. For further guidelines on resorative nursing you can refer to the RAI Manual v1.09 Chapter 3, Section O, pages 31-38. Thanks for your question and welcome to long term care.

  • Allison

    August 2, 2013 at 5:13 pm

    Can restorative nursing treat a resident while they are on physical therapy caseload? If so, what are the parameters i.e. If physical therapy is providing gait training and lower extremity exercises can restorative walk a patient and do range of motion?

    • crowell

      August 7, 2013 at 8:36 pm

      Hi Allison,

      Restorative can provide a program for the resident while they remain on therapy caseload as long as is not a duplication of the primary therapeutic intervention. Therapy services are “skilled” and therefore denote a level of complexity that is not provided in a restorative program. For instance, if Physical Therapy is treating for gait deficits, restorative can provide a walk to dine program to provide follow through of gait strategies and cueing for safety,as instructed by the PT, this is what often occurs when we apply the rehab low expectations with a Medicare A reimbursement scenario. If therapy is providing specific interventions that address exercise and ROM or any other type of skilled intervention, then restorative should wait until therapy discharges them and provides a plan for the restorative team.

      Sincerely,

      Cherie

      • Sheila Capitosti

        August 7, 2013 at 9:40 pm

        Allison
        Please also remember that a resident can qualify for Medicare Part A Rehab Low Intensity if the following criteria are met:
        Total Therapy Minutes of 45 minutes or more and At least 3 days of any combination of the three disciplines (O0400A4 plus O0400B4 plus O0400C4) and Two or more restorative nursing services received for 6 or more days for at least 15 minutes a day
        Be sure you follow the recommendations provided by Cherie in her response as well
        Sincerely
        Sheila Capitosti

  • Kim

    August 10, 2013 at 6:30 pm

    Is there a specific time frame that a resident should recieve restorative nursing services after the therapy department discharges them? Example 2 weeks 1 month 2 months?

    • crowell

      September 10, 2013 at 9:40 pm

      There is no requirement of a set time, however, it should start as soon as possible for the resident to facilitate continuity of care and prevent decline.

  • amy

    September 6, 2013 at 9:20 am

    I had a question about “Walk to Dine”. I am the ADON at a SNF and the MDS cooridinator and I are not seeing quite eye to eye right now. I dabbled in MDS for a little over a year before I took the assistant director position so I know MDS. Our disagreement is whether or not Walk to Dine is a restorative nursing program or not. You see our state survey window opened recently so we are preparing and trying to get all our ducks in a row. I was going through our Walk to Dine list on Care Tracker(C NA charting system) and I noticed like maybe 6 folks in there that were independent with ambulations or maybe needed reminding to go to the dining room or some cueing, however ambulation is their only means of locomotion. So I questioned therapy about the need to keep them on the Walk to Dine program because there just seemed to be no reason as to why? To me a Walk to Dine program is a restorative nursing program for maintanence. Our MDS cooridinator sees it very differently. She informed me that Walk to Dine is not a restorative nursing program that it is just for the people who need ambulated to the dining room. Her exact words were
    “Walk to dine IS NOT A RA program. Walking ROM for individuals that need CGA for ambulation short distances 3x/wk under the RA staff IS the RA program for walking.

    Walk to dine is NSG/CNA staff encouraging, supervision and providing SBA for residents that Primarily ambulate with walkers that are at risk for falling and require staff to be watching / SBA in order to go the distance 3 x a day to meals, to provide exercise, stretching / mobility, improve appetites and fluid intakes. WE have VERY FEW residents that are Independent for ambulation in the facility, that have not had falls or other risk events.

    Walk to dine is a nursing intervention program to address / improve outcomes in the areas of concern: weight loss, UTI’s and falls.
    I mean I agree with the nursing intervention program part…however that nursing intervention would fall under restorative nursing. Or at least thats what I think/feel.
    Can you shed an inch of light on this situation for me?

    • crowell

      September 11, 2013 at 2:19 pm

      I have always considered Walk to Dine a restorative nursing program. The parameters for using it as such is up to the individual facility, however, I would not use it for independent ambulators. A walk to dine program should be used for those residents that require assistance to ambulate and would not be able to get to the dining room independently. Conversely, if the resident needs maximum assistance and can only walk a few feet (or less), then a more specific and guided restorative program for walking may be needed and Walk to Dine would not be optimal for that resident (they would require more time and one on one cueing). It may be helpful to get the care plan team together and discuss the parameters of “when” a resident would qualify for Walk to Dine program so there are specific guidelines that everyone can agree on. Ultimately, our goal is to promote quality of life and prevent functional decline. So, how we get there is open for discussion with the team. Please let me know if you would like more specific information and I will be happy to share.

      Cherie

  • Rhonda

    January 16, 2014 at 1:18 pm

    Questions On about nursing restorative programs:
    1) Is the communication restorative program limited to just expressive impairments? Can communication programs be expanded to hearing deficits and cognitive deficits? Having difficulty finding any guidelines or examples on the communication restorative program.
    2) Our facility provides a physical rehab service (PR) 5 days per week after residents have been discharged from skilled therapy. A nurse does review the physical rehab service program along with a therapist and authorizes the programs implemented. This department has therapy equipment and approximately 160 residents attend this physical rehab services which could include ambulation, saratoga exercise, tread mill exercise, and the list goes on. Our physical rehab service (PR) is not provided by therapist but trained rehab therapy assistant. This program is not counted on the MDS section O for therapies. We also have rehab nursing aides that perform nursing restorative to all house residents; sometimes the physical rehab service (PR) and nursing restorative programs overlap with programs. According to the RAI manual the our physical rehab services (PR) could be counted as our nursing restorative progams…….Could you offer your advice on this?
    Thank you for your time.

    • Cherie Rowell

      February 4, 2014 at 4:54 pm

      A restorative communication program can and should include all components of communication, including compensatory strategies and training/instruction for hearing loss and cognitive deficits. The Speech-Language Pathologist and nursing staff should collaborate as part of the care plan team to determine the best interventions to address the resident’s deficits in order to promote quality of life and maximize appropriate and meaningful communication. Many restorative nursing program manuals generalize interventions and it is up to care givers to make them more meaningful to the individual resident based on their history and clinical needs.

      Your physical rehab service program would indeed be considered a restorative program and would fall under the state guidelines of “restorative” intervention for purposes of documentation and care planning. I would reconsider the program name as it may be perceived as “skilled” intervention since the name suggests that skilled physical therapy is being provided. A policy and process for this program would be beneficial as well. I think the program is a good idea and proactively addresses maintaining function!

  • misha

    January 17, 2014 at 3:11 am

    I would like to start a walk to dine program at the facility I work at. How do I go about getting it starting? What paper work do I need? Really I am clueless where to begin

    • Cherie Rowell

      February 3, 2014 at 8:53 pm

      Most facility restorative program manuals have an outline of what is required for documentation of a walk and dine program. It is also very easy to research on line. You may want to review the RAI manual, section 0 for specific guidelines on restorative components for Medicare part A. A walk to dine program can be set up similar to an restorative ambulation program and would follow the same documentation guidelines. Usually this entails setting the individual resident goal, including care plan, daily documentation of participation by the CNA and a monthly note indicating supervision of the program by a licensed nurse.

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