Achieving Real Improvement Through Communication, Education

Many recent studies have highlighted the importance of establishing effective communication between long-term care (LTC) staff, clinicians, and residents in order to provide the type of care that is most responsive to residents’ needs, values, and preferences, and enables them to make informed decisions about their care. Additionally, empowering staff through education to look for opportunities to improve communication in their daily practice can have a greater impact on quality of care. 

Insufficient monitoring of residents’ oral self-care, staff confusion concerning oral assessment responsibilities, and overall resident resistance to oral care assessments all contribute to the decline of oral health in the nursing home (NH) setting. Several studies have reported a desire by staff for more leadership and education in meeting the challenges of implementing oral health protocols for their residents. However, implementing oral health protocols in NHs is challenging.

Katie Williams, RDH, MSDH, and coauthors investigated the way oral health protocols are approached in NHs and sought to facilitate the implementation of oral health protocols in this setting using a routine assessment tool. The researchers conducted a cross-sectional comparison retrospective chart review regarding dental referrals, and they conducted a pre- and post-survey of nursing staff to assess outcomes of the implementation of an oral assessment educational module based on the Minimum Data Set (MDS). The education module designed for NH staff outlined how daily oral assessments and oral care are performed and when referrals for subsequent dental treatment are necessary. The results suggest that education on identifying oral health conditions and completing the MDS 3.0 dental section helped NH staff to increase their knowledge and perceptions of providing oral care and assessments as well as to make referrals to oral health care providers.

Constipation has a negative impact on quality of life as well as overall wellbeing. The prevalence of constipation among NH residents is high, ranging from 44% to 80%. It is important for nursing staff to recognize the signs and symptoms of constipation and to quickly initiate treatment, as chronic constipation can lead to fecal impaction, fecal incontinence, hemorrhoids, anal fissures, and rectal prolapse.

The Bristol stool scale (BSS) is a medical aid designed to classify stool forms into seven categories. At a US Department of Veterans Affairs (VA) nursing facility located in the southwestern region of the United States, Jagruti R Patel, RPh, et al explored the feasibility of using the BSS to improve communication about constipation with LTC residents in order to decrease the prevalence of constipation in NHs. After an in-service about the BSS, residents at a VA nursing facility self-reported stool types to nurses. A nursing note template was changed in order for nurses to document BSS scores and interventions for constipation. In the month after the practice change, the proportion of constipated patients decreased from baseline. Among nurses completing a satisfaction survey, most agreed that the BSS improved communication and helped to assess constipation.

When nursing facility residents transition to and from hospitals, these transitions present opportunities for communication breakdown and for poor outcomes such as medication errors, inadequate follow-up care, family dissatisfaction with care, untreated pain, and hospitalizations. 

In 2012, the Centers for Medicare & Medicaid Services (CMS) Center for Innovation funded seven 4-year demonstration projects targeted to improve care for long-stay nursing facility residents in order to reduce potentially avoidable hospital transfers. In one of these projects, the OPTIMISTIC (Optimizing Patient Transfers, Impacting Medical Quality, and Improving Symptoms: Transforming Institutional Care) project, a registered nurse in each of 19 partnering facilities orchestrates data collection, INTERACT implementation, and quality improvement initiatives, and provides urgent care in collaboration with the facility staff. Additionally, six nurse practitioners assist in improving care on multiple fronts. Arif Nazir, MD, FACP, CMD, AGSF and coauthors provide an overview of the transition visit model and a preliminary analysis of the outcomes of their interventions. They also highlight key areas of potential quality improvement around transitions, which could be addressed by proactive systems.

The articles in this issue of Annals of Long-Term Care: Clinical Care and Aging^® provide examples of such opportunities and demonstrate how improved communication and education can lead to improved outcomes for LTC residents.