Resident-Centered Care
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Resident-Centered Care: What does it mean?
Resident- or patient-centered care is a concept that is widely embraced across all health care settings, including long-term care. The concept encompasses a wide range of options, but the theme that defines most efforts in this area centers on determining consumer preferences and encouraging choice. In long-term-care settings, where residents both live and receive medical care, there is consensus that it is important to offer residents choice about all aspects of their lives, including those aspects that affect daily life quality. Expert consensus methodology has been used to validate quality indicators related to residential life in NHs. Many of these indicators are related to identifying resident preferences and offering residents choices (1-3). It is difficult to believe or argue that choice is unrelated to the quality of life of NH residents, who often require assistance with activities of daily living (ADL) and hence, are dependent on staff for such basic life functions as movement and toileting. In fact, there is a significant risk among NH residents of becoming “institutionalized” and accepting or being forced to adhere to staff schedules as opposed to a life schedule consistent with one’s individual preferences.
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National Initiatives to Implement Resident-Centered Care Principles in Nursing Homes
There is widespread and growing interest in resident-centered care provision in NHs. This interest is reflected on the national level by a recent report from the Institute of Medicine that endorses resident-centered care and a coalition of providers and advocates who have given rise to what is popularly known as the NH culture change movement (4-7). This movement encompasses a broad range of interests, from transforming physical settings to redefining staff roles, but at its core it emphasizes resident autonomy and the importance of offering residents choices about their care and life (5-7). In 2005, the Center for Medicare services (CMS) recognized the culture change movement as a force for improving quality of life when it directed state Quality Improvement Organizations in their 8th scope of work to work with NHs to improve organizational culture (8). In September 2006, CMS launched a nursing home quality campaign whose eight goals include creating a culture of person- centered care and an empowered work force in NHs.
The federal NH regulatory industry also is placing increased emphasis on resident-centered care and choice in federal surveys of NH quality. The interpretive guidelines for conducting federal quality assessments include instructions throughout that residents’ preferences for care be identified. Survey deficiencies (or F tags) for quality of life have been designated, with language that specifically addresses resident preferences and choice (1). Consider, for example, F tag 242: “The resident has the right to choose activities, schedules and health care consistent with his or her interests, assessments and plans of care.” Surveyors are instructed to ask residents whether they are offered choices about daily life activities such as bedtimes and to observe whether resident choice and individuality is honored during daily care. F tags or care deficiencies can be cited if the surveyors find evidence that resident choice is not being honored.
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Who can be interviewed and what types of questions should be asked?
The high prevalence of depression and cognitive impairment among NH residents raises questions about which and how many residents can express meaningful preferences when interviewed. A series of studies led by Dr. Sandra Simmons has demonstrated that between 50 and 90% of residents could answer questions in a stable fashion across two interviews about their pain status and their preferences for care in the following areas: pain medication, walking assistance, incontinence care, out of bed times and dining location for meals (9-12). A study by another research team that measured resident perceptions of quality of life in a nationwide sample of NHs found that a similar percentage of residents could be interviewed about their preferences and life quality (13). When considered together, these studies lead to the conclusion that most NH residents can express their preferences for care; thus, it follows that NH medical records (MDS assessments, care plans) should include documentation of residents’ preferences for daily care. Unfortunately, documentation of residents’ daily care preferences is often absent or erroneous when compared to independent assessments by research staff using standardized resident interview protocols.
We provide in this Quality-of-Life assessment module criteria to select residents appropriate for interview because staff have a tendency to erroneously assume that most residents are incapable of answering questions about their daily care preferences due to cognitive impairment (Refer / Provide links to other appropriate sections for MDS CPS and Recall Scale selection criteria. Note: add instructions and scoring algorithm to calculate CPS earlier in QOL section when CPS is mentioned as selection criteria). We also provide guidelines for how to structure interview questions to allow residents with mild to moderate cognitive impairment to reliably answer such questions. In addition, we developed a resident interview protocol specifically for the purpose of assessing resident’s daily care preferences in three activities of daily living: getting out of bed, toileting and dressing. You can start by asking residents about just one of the three care activities, although we focused on these three because the care is typically provided at the same time (during morning ADL care delivery). Remember that residents often report preferences that reflect reduced expectations for care and the established staff routine because they believe that they really don’t have alternative choices available to them. Thus, the person conducting the interview should be different from the person who typically provides the care (nurse aides); and, the interviewer should be sensitive to residents’ expression of reduced expectations in response to the interview questions (e.g., comments such as, “it’s okay, the way it is”; “the staff do what they can”; “I’m not the only person who lives here, you know”).
We also developed a corollary observational protocol that supervisory-level staff can use to determine if direct care staff are offering resident’s choice during daily care provision – providing “resident-centered” care – in these three care areas (observation protocol). The advantage of the observation protocol is that a supervisory-level staff person can observe a small group of residents who reside on the same hallway during morning care provision to document the following aspects of resident-centered care provision:
Related to staff offers of choice, our research shows it is important to differentiate between “active” versus “passive” choice during care provision. For example, we noticed that a typical style of communication between residents and direct care staff was a variation of the following: “Hi Ms. Smith, its time to get up now, okay?” Or “Let’s go to the dining room, okay?” This type of communication implied choice but was more in the direction of soliciting assent to care than alternative, direct communications of choice such as “Do you want to get up now?” Or “Where would you like to have your breakfast – in your room or the dining room?” We believe the latter type of communication, which promotes active choice, is preferable and should be the goal of resident-centered care provision.
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- Resident-Centered Care: What does it mean?
- National Initiatives to Implement Resident-Centered Care Principles in Nursing Homes
- Who can be interviewed and what types of questions should be asked?
Resident-Centered Care: What does it mean?
Resident- or patient-centered care is a concept that is widely embraced across all health care settings, including long-term care. The concept encompasses a wide range of options, but the theme that defines most efforts in this area centers on determining consumer preferences and encouraging choice. In long-term-care settings, where residents both live and receive medical care, there is consensus that it is important to offer residents choice about all aspects of their lives, including those aspects that affect daily life quality. Expert consensus methodology has been used to validate quality indicators related to residential life in NHs. Many of these indicators are related to identifying resident preferences and offering residents choices (1-3). It is difficult to believe or argue that choice is unrelated to the quality of life of NH residents, who often require assistance with activities of daily living (ADL) and hence, are dependent on staff for such basic life functions as movement and toileting. In fact, there is a significant risk among NH residents of becoming “institutionalized” and accepting or being forced to adhere to staff schedules as opposed to a life schedule consistent with one’s individual preferences.
Back to Top
National Initiatives to Implement Resident-Centered Care Principles in Nursing Homes
There is widespread and growing interest in resident-centered care provision in NHs. This interest is reflected on the national level by a recent report from the Institute of Medicine that endorses resident-centered care and a coalition of providers and advocates who have given rise to what is popularly known as the NH culture change movement (4-7). This movement encompasses a broad range of interests, from transforming physical settings to redefining staff roles, but at its core it emphasizes resident autonomy and the importance of offering residents choices about their care and life (5-7). In 2005, the Center for Medicare services (CMS) recognized the culture change movement as a force for improving quality of life when it directed state Quality Improvement Organizations in their 8th scope of work to work with NHs to improve organizational culture (8). In September 2006, CMS launched a nursing home quality campaign whose eight goals include creating a culture of person- centered care and an empowered work force in NHs.
The federal NH regulatory industry also is placing increased emphasis on resident-centered care and choice in federal surveys of NH quality. The interpretive guidelines for conducting federal quality assessments include instructions throughout that residents’ preferences for care be identified. Survey deficiencies (or F tags) for quality of life have been designated, with language that specifically addresses resident preferences and choice (1). Consider, for example, F tag 242: “The resident has the right to choose activities, schedules and health care consistent with his or her interests, assessments and plans of care.” Surveyors are instructed to ask residents whether they are offered choices about daily life activities such as bedtimes and to observe whether resident choice and individuality is honored during daily care. F tags or care deficiencies can be cited if the surveyors find evidence that resident choice is not being honored.
Back to Top
Who can be interviewed and what types of questions should be asked?
The high prevalence of depression and cognitive impairment among NH residents raises questions about which and how many residents can express meaningful preferences when interviewed. A series of studies led by Dr. Sandra Simmons has demonstrated that between 50 and 90% of residents could answer questions in a stable fashion across two interviews about their pain status and their preferences for care in the following areas: pain medication, walking assistance, incontinence care, out of bed times and dining location for meals (9-12). A study by another research team that measured resident perceptions of quality of life in a nationwide sample of NHs found that a similar percentage of residents could be interviewed about their preferences and life quality (13). When considered together, these studies lead to the conclusion that most NH residents can express their preferences for care; thus, it follows that NH medical records (MDS assessments, care plans) should include documentation of residents’ preferences for daily care. Unfortunately, documentation of residents’ daily care preferences is often absent or erroneous when compared to independent assessments by research staff using standardized resident interview protocols.
We provide in this Quality-of-Life assessment module criteria to select residents appropriate for interview because staff have a tendency to erroneously assume that most residents are incapable of answering questions about their daily care preferences due to cognitive impairment (Refer / Provide links to other appropriate sections for MDS CPS and Recall Scale selection criteria. Note: add instructions and scoring algorithm to calculate CPS earlier in QOL section when CPS is mentioned as selection criteria). We also provide guidelines for how to structure interview questions to allow residents with mild to moderate cognitive impairment to reliably answer such questions. In addition, we developed a resident interview protocol specifically for the purpose of assessing resident’s daily care preferences in three activities of daily living: getting out of bed, toileting and dressing. You can start by asking residents about just one of the three care activities, although we focused on these three because the care is typically provided at the same time (during morning ADL care delivery). Remember that residents often report preferences that reflect reduced expectations for care and the established staff routine because they believe that they really don’t have alternative choices available to them. Thus, the person conducting the interview should be different from the person who typically provides the care (nurse aides); and, the interviewer should be sensitive to residents’ expression of reduced expectations in response to the interview questions (e.g., comments such as, “it’s okay, the way it is”; “the staff do what they can”; “I’m not the only person who lives here, you know”).
We also developed a corollary observational protocol that supervisory-level staff can use to determine if direct care staff are offering resident’s choice during daily care provision – providing “resident-centered” care – in these three care areas (observation protocol). The advantage of the observation protocol is that a supervisory-level staff person can observe a small group of residents who reside on the same hallway during morning care provision to document the following aspects of resident-centered care provision:
- Did staff greet the resident?
- Did the resident state a spontaneous care preference (e.g. “I would like to get up now.”)
- Did staff offer the resident a choice? (e.g., “Would you like to get up now or later?”)
- Did staff honor a resident’s stated preference or choice?
- What was the resident’s reaction to care delivery? (e.g. cooperative, resists care verbally or physically)
Related to staff offers of choice, our research shows it is important to differentiate between “active” versus “passive” choice during care provision. For example, we noticed that a typical style of communication between residents and direct care staff was a variation of the following: “Hi Ms. Smith, its time to get up now, okay?” Or “Let’s go to the dining room, okay?” This type of communication implied choice but was more in the direction of soliciting assent to care than alternative, direct communications of choice such as “Do you want to get up now?” Or “Where would you like to have your breakfast – in your room or the dining room?” We believe the latter type of communication, which promotes active choice, is preferable and should be the goal of resident-centered care provision.
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