Long-Term Care Report on Quality Indicators

On November 30, 2018, the Canadian Institute for Health Information (CIHI) released new data on their public website that shows how long-term care homes are performing on nine indicators, including pressure ulcers, use of restraints, incidents of falls, use of antipsychotics, symptoms of worsening depression, improved physical functioning, worsened physical functioning, residents with pain, and residents with worsening pain.

Since 2012, the Ministry of Health and Long-Term Care has been reporting on four of these areas, referred to as “health quality indicators,” on the Health Quality Ontario website, highlighting those that are being managed well and those that need improvement.  These areas included the treatment of pressure ulcers, use of restraints, incidents of falls and treatment of incontinence.

We encourage you to view McCormick Home’s results for both Health Quality Ontario and CIHI reports.  We are pleased to share this information with you, along with some information on how these measures contribute to our efforts to continually enhance the quality of care we provide.

At McCormick Home, the care and safety of our residents is our first priority. We are committed to quality improvement that leads to better resident health and safety and better care performance, and we value these public reporting efforts as important tools that can be used to inform our quality improvement activities.

Since 1985, McCormick Home has been voluntarily participating in rigorous reviews conducted by Accreditation Canada to ensure compliance with quality care practices.  In 2015, McCormick Home received an Exemplary Standing, the highest possible rating from Accreditation Canada, which conducts these reviews every four years.

If you have any comments or questions, please contact the McCormick Home Administrator, Tanya Pol at tpol@mccormickcare.ca or 519-432-2648 ext. 2321.

Background

People are living longer, which means that there is an overall increase in residents who are admitted to long-term care homes with pre-existing conditions, such as pressure ulcers or depression. An October 2012 report from the Ontario Association of Non-Profit Homes and Services for Seniors states that of the current residents in long-term care, 99% cannot eat alone, 99% cannot dress alone, 97% need help toileting and 95% are incontinent.  Latest results for McCormick Home show that 71.1% of its residents have some form of dementia. Given the particular needs of the home’s population, we continually strive to offer an enhanced quality of life for our residents while adhering to the important regulations established by the Long-Term Care Homes Act (2007).

Restraint Use in Long-Term Care

According to the CIHI report, McCormick Home employed restraints in 3.2% of resident cases, compared to the SWLHIN average of 6.3%, the provincial average of 4.5% and the national average of 5.7%.

McCormick Home is committed to complying with Long-Term Care Homes Act (2007) legislation, aimed at minimizing the restraining of residents and specifying when and how physical devices are to be used in the home.

It is important to know that restraints are not used on any resident unless they have been recommended by a licensed physician and agreed to by the resident’s family/substitute decision maker.  In addition, our restraint policy is reviewed annually with all staff as part of the annual education/training review.  Training is provided to staff on the application, use and associated risks of using restraints.

It is also worth noting that although we use the term restraint, we mean to convey an attitude of least restraint; that is, affording the resident the most freedom possible, yet offering the safety they require.  For example, seatbelts in wheelchairs and lap trays (for meals or activities) are considered “restraints” unless they can be removed by the resident themselves. It is important to note that these types of devices enable a resident to have more independence and participate more fully in their self care (e.g. eating a meal) and in recreational activities or other activities of daily living.  As such, some assistive devices, which are defined as restraints, are important to promoting resident independence.

We acknowledge that there are rare occasions when residents may need to be restrained for their own protection if they are experiencing impaired judgment and/or loss of self control.

The following restraints are prohibited by provincial regulation and are not used in the home:

• Pelvic restraints
• Vest or jacket restraints
• Wrist restraints or any four-point extremity restraints
• Any device that restrains a resident to a toilet/commode
• Any device that requires a special tool to be released (e.g. pinlock restraint)
• Roller bars on wheelchairs, commodes or toilets
• Any device that cannot immediately be released by staff
• Sheets, wraps, tensors or any other type of strips or bandages used other than for a therapeutic purpose

Worsened Pressure Ulcer in Long-Term Care

According to the CIHI report, 3.4% of residents at McCormick Home experienced a pressure ulcer that recently got worse, compared to the SWLHIN average of 3.1%, the provincial average of 2.7% and the national average of 2.8%.

Pressure ulcers are wounds that are caused by constant pressure or friction on an area of skin.  This includes any kind of blister experienced by a resident.

We acknowledge that more can be done to reduce the number of pressure ulcers experienced by our residents, and our senior medical staff are dedicated to finding solutions. For example, we have been increasing the use of specialty mattresses that help alleviate pressure on existing wounds and prevent new ones from forming.

We also recognize that there are situations where individual choices by either the resident or family may not support the physical healing of pressure ulcers.  In such instances, these same choices often promote a resident’s emotional, spiritual or cognitive health and wellbeing.

McCormick Home recognizes the importance of preventing pressure ulcers from starting as well as employing methods to heal them quickly. We follow best practice guidelines in wound treatment as established by the Registered Nurses Association of Ontario.

McCormick Home employs a skin care expert on site as well as a nurse practitioner who is certified in skin and wound care.  The home also works with an outside consultant who specializes in skin care.

Falls in the Last 30 Days in Long-Term Care

According to the CIHI report, 20.0% of McCormick Home residents recently had a fall, compared to the SWLHIN average of 17.7%, the provincial average of 16.4% and the national average of 16.3%.

A fall is defined by the CIHI as “any unintentional change in position where the resident ends up on the ground or other lower level.” McCormick Home holds itself to a high standard and strictly applies the CIHI’s definition of a fall. This includes reporting all occurrences of this nature, such as a resident’s sudden shift in position while remaining seated.  A resident does not have to land on the floor in order to be considered as having fallen.

We recognize that more can be done to reduce the number of falls experienced at the home. In order to improve our results in this area, we are undertaking a number of proactive measures, including:

• Identifying the fall risk level of each resident using a Fall Risk Assessment Tool on an ongoing basis
• Holding regular Fall and Injury Prevention Committee meetings to review incidents and to research new ways to prevent falls and their related injuries
• Incorporating fall prevention strategies into the home’s mandatory staff education program
• Developing a customized care plan for residents identified at a medium to high risk of falls, including appropriate recommendations regarding hip protectors, safety floor mats, restorative walking programs, physiotherapy, bed rails, non-skid footwear, alarm systems and/or staff monitoring

At McCormick Home, keeping residents safe from falls and fall-related injuries is a priority.  We are committed to ensuring that all falls are reported accurately and promptly, and according to CIHI guidelines. In addition, a person’s ability to make choices when it comes to safety is carefully balanced with the need to keep them from harm.

McCormick Home proactively manages the prevention of falls by assessing each resident for their fall risk level and identifying a customized care plan that outlines ways to prevent falls. Families are notified about the care plan and are asked to consider supporting suggested strategies that are not covered by OHIP, such as hip protectors and non-skid footwear.

McCormick Home places a high priority on keeping residents active and independent for as long as possible, while maintaining a safe environment. A key aspect of this effort involves our Nursing Restorative Care Program, a customized care plan designed to maintain or restore a person’s ability to participate fully in daily living activities. Participation in this program exposes participants to a higher risk of falls, but enables them to experience the benefits of exercise and enhanced independence.

Potentially Inappropriate Use of Anti-psychotics in Long-Term Care

According to the CIHI report, 15.9% of McCormick Home residents were prescribed anti-psychotic medication without a diagnosis of psychosis, compared to the SWLHIN average of 19.3%, the provincial average of 19.6% and the national average of 21.2%.

McCormick Home is committed to working with our licensed medical practitioners to reduce the use of anti-psychotic drugs.  The home does not administer any medications, including anti-psychotic drugs, unless they have been prescribed by a licensed physician and agreed to by the resident’s family/substitute decision maker.

McCormick Home has established the Antipsychotic Drug Rounds Team — a working group consisting of the home’s pharmacist, a registered nurse, our statistics coordinator and members of the home’s behavioural support staff to review the use of antipsychotic medications in the home on a bi-monthly basis. The team reviews each resident’s medications and makes recommendations to reduce or discontinue antipsychotic drug use based upon their findings. In addition, the medical director has requested that the home’s team of physicians document the specific reason for every prescription on each resident’s quarterly medication review so that antipsychotic drug use can be monitored more closely for its intended purpose.

There are times when anti-psychotic medications are prescribed by physicians to manage responsive behaviours as a result of symptoms related to dementia (e.g., hallucinations, delusions, aggression) or to manage depression or anxiety disorders should anti-depressants prove ineffective.

McCormick Home’s first approach to managing responsive behaviours is through non-pharmacological interventions, such as those supported by the Ontario Behavioural Supports Program. This program involves caring for seniors with cognitive impairments who exhibit responsive behaviours and is based on understanding a person’s history, interests and physical needs.  A care program that meets these needs is then developed to either prevent responsive behaviours from occurring or to lessen their severity. McCormick Home employs a team of in-house specialists in behavioural support approaches and provides related comprehensive training and education for its staff.

Worsened Depressive Mood in Long-Term Care

According to the CIHI report, 34.5% of McCormick Home residents experienced signs of depression, compared to the SWLHIN average of 30.0%, the provincial average of 23.4% and the national average of 21.7%.

At McCormick Home, we recognize that depression is a serious issue.  We also understand that depression can at times be a symptom of dementia. In addition, as physical ability declines, a person’s ability to express or communicate emotions can be impacted.  This lack of response can often result in a person being labelled as “depressed.”

In order to reduce the number of our residents who have displayed symptoms of depression (e.g. uttering negative statements; displaying persistent anger; expressing unrealistic fears; uttering repetitive health and anxiety complaints; displaying sad, pained, worried or flat facial expressions; crying or exhibiting tearfulness), we have implemented a well-received one-on-one visiting program to provide residents with an opportunity for individual attention and to express their emotions and thoughts.  In addition, we have conducted a quality improvement study to enable us to better understand and identify residents who are at risk of developing depression before it sets in.

We recognize that through the practices established by the ministry’s Behavioural Support Ontario program, which is designed to help decipher and address responsive behaviours such as aggression and withdrawal with redirecting techniques, some depressive symptoms can sometimes be used to communicate that a resident is in physical rather than psychological pain.  As such, we employ the BSO approach to discern how to best respond to a resident’s expression, be it verbal, physical or emotional, and have experienced considerable success in this area.

Improved Physical Functioning in Long-Term Care

According to the CIHI report, 32.4% of McCormick Home residents experienced improved physical functioning, compared to the SWLHIN average of 32.9%, the provincial average of 29.6% and the national average of 31.4%.

This measurement reflects the general decrease in physical activity levels that a person experiences as they age and is defined by CIHI as “residents who improved or remained independent in transferring and locomotion (mid-loss activities of daily living or ADLs) since the previous assessment.” It is important to also recognize that a resident’s improvement in physical functioning declines as dementia progresses.  Essentially, people can forget how to perform their daily activities.

In general, the “early loss” stage is determined when a resident loses the ability to manage their own personal hygiene activities, including the ability to brush their hair or teeth, shave, or wash themselves. “Mid-loss” activities include the ability to use the toilet on their own, manage their own care, or move themselves from one place to another. The “late-loss” level is reached when a resident can no longer feed themselves.

McCormick Home has had an increase in the percentage of residents improving or remaining independent in their mid-loss activities of daily living, and as a result we are higher than the provincial average in this area. We attribute our positive results to our strong physiotherapy and restorative care programs.

Worsened Physical Functioning in Long-Term Care

According to the CIHI report, 45.5% of McCormick Home residents experienced worsened physical functioning, compared to the SWLHIN average of 39.1%, the provincial average of 34.5% and the national average of 33.1%.

This measurement reflects “the percentage of residents who worsened or remained completely dependent in transferring and locomotion (mid-loss activities of daily living or ADLs) since the prior assessment.”  In general, the “early loss” stage is determined when a resident loses the ability to manage their own personal hygiene activities, including the ability to brush their hair or teeth, shave, or wash themselves. “Mid-loss” activities include the ability to use the toilet on their own, manage their own care, or move themselves from one place to another. The “late-loss” level is reached when a resident can no longer feed themselves.

McCormick Home experienced a larger percentage of residents who had worsened in their physical functioning. This result reflects that the home has a higher number of residents with severe cognitive impairment at 36.9% than the provincial average of 30.4%. Typically, ADL losses occur when an individual is diagnosed with severely impaired cognitive functioning.

Experiencing Pain in Long-Term Care

According to the CIHI report, 2.2% of McCormick Home residents experienced pain, compared to the SWLHIN average of 6.5%, the provincial average of 5.3% and the national average of 7.2%.

For reporting purposes, pain is measured by frequency and intensity. It refers to any type of physical pain or discomfort in any part of the body that may occur when the resident is at rest or with movement. Pain may be localized in one area or may be more generalized; it may also be acute or chronic, intermittent or constant.  Because the pain experience is personal and subjective, pain is whatever the resident says it is.

In the long-term care reporting model, pain is recorded over a seven day look-back period. If the resident states that he or she has pain, the indicator for pain is marked yes. If the resident is non-verbal, indications that pain may be present include moaning, crying, wincing, frowning, guarding or protecting an area of the body, lying very still, or decreasing or changing their usual activities.

In order to ensure a comprehensive approach to reporting pain at McCormick Home, all nursing staff as well as direct care providers, including physiotherapists, foot care specialists, physicians and life enrichment staff, are asked about a resident’s pain status.

Pain is coded using two approaches:  First, it is determined as being present, not present, present daily or less than daily.  Second, it is defined as being mild (the resident is able to carry on with daily routines, socialization and sleep), moderate (some disruption to daily routines is indicated) or strong (pain is at its extreme, interfering with daily routines, socialization and sleep).

All residents who are coded for pain receive a full pain assessment to determine the cause of the pain as well as a treatment plan. In many cases, medications are reviewed and necessary adjustments are made in order to reduce the pain and enhance the resident’s quality of life.

Experiencing Worsened Pain in Long-Term Care

According to the CIHI report, 6.5% of McCormick Home residents experienced worsening pain, compared to the SWLHIN average of 12.7%, the provincial average of 9.9% and the national average of 10.2%.

At McCormick Home, we are committed to finding better ways to ensure that pain is managed effectively. We have made great progress in pain management through early detection and intervention.

For reporting purposes, pain is measured by frequency and intensity. In addition to the criteria used to record a resident’s experience of pain, this category focuses particularly on worsening pain levels.  This assessment measures when a resident moves from a mild to moderate or a moderate to strong level of pain.

All residents who are coded for pain receive a full pain assessment to determine the cause of the pain as well as a treatment plan. In the case of worsening pain, residents are reassessed every 72 hours, and if necessary, the treatment plan is changed accordingly.

In many cases, medications are reviewed and required adjustments are made in order to reduce the pain and enhance the resident’s quality of life.