Editor's note: This text-based course is a transcript of the webinar, How to Establish a Successful Restorative Aide Program in Long Term Care, presented by Kevin Cezat, PT, DPT, GCS, RAC-CT.
*Please also use the handout with this text course to supplement the material.
Learning Outcomes
- After this course, participants will be able to list three or more program types that qualify for restorative nursing programs on the MDS.
- After this course, participants will be able to list one or more strategies to overcome common barriers when implementing restorative nursing.
- After this course, participants will be able to list at least one measure to audit for efficiency and one measure to audit for effectiveness when evaluating a restorative nursing program.
Introduction
Welcome to this course, and thank you for joining us today. From my personal experience, however, I’ve come to appreciate the significant value of this program and recognize how essential it is for therapy to play both a strong and active role. Depending on the structure of your facility, this program may sometimes seem peripheral to the primary focus of most clinicians. That’s why I’m particularly glad you’re here today. A solid understanding of what this program entails—and what it does not—can be an incredibly valuable addition to your clinical skillset.
Before diving deeper into the content, I’d like to cover some basic definitions. But first, I’ll provide a bit of background about myself. Since I’ve developed this content, there may be inherent biases or perspectives that you might not fully agree with, or that may not align with the regulations or practices in your specific state. Sharing my experience will help you understand the context of where I’m coming from.
Throughout my career, I’ve primarily worked in long-term care, focusing on older adults in skilled nursing facilities, assisted living, independent living, and home health. I spent many years as a rehab director at a large Continuing Care Retirement Community (CCRC) in Central Florida before transitioning into my current role, where I oversee clinical quality and education for multiple long-term care facilities. While I continue to practice about five hours per week, my primary focus now revolves around the broader aspects of clinical care in skilled nursing facilities, particularly improving clinical quality from a systems-level perspective.
I’m based in Florida but also hold licenses in Arizona and Ohio. Given the scope of my career, I acknowledge that I may have blind spots, particularly when it comes to restorative nursing.
I’ve engaged with this area from multiple angles: as a staff clinician, as a rehab director collaborating with other department heads, and now as someone who supports implementing and managing these programs from both the facility and therapist perspectives. However, I’m not a restorative nurse, so there may be areas where I lack the depth of knowledge that someone providing these programs directly would have.
With that in mind, let’s focus on today’s topic: restorative nursing in long-term care and skilled nursing facilities. Restorative nursing involves specialty-trained nurses and aides implementing programs that promote residents' ability to maintain their highest level of function across various domains. I want to address a common point of confusion here, as I’ve seen clinicians grapple with definitions in this area. There is indeed some gray area to consider, which we will clarify as we move forward.
Restorative Definitions
To clarify the key definitions related to restorative nursing plans, home exercise plans, skilled maintenance plans, and functional maintenance plans, it’s important to recognize the distinct purpose each serves, even though there is some overlap.
Restorative nursing plans, which are the focus of today’s discussion, are programs implemented under the oversight of a restorative nurse. These programs are nursing-based and designed to improve or maintain a resident’s functional abilities. The emphasis is on promoting independence and preventing further decline through nursing-driven interventions.
Home exercise plans involve exercises prescribed by a therapist for a patient to perform independently, typically at home after discharge or between therapy sessions. These plans aim to maintain or enhance physical function outside of a clinical setting and are designed for patients who can safely carry out the exercises on their own.
Skilled maintenance plans are ongoing care provided by a skilled therapist, such as a physical or occupational therapist, to maintain a patient’s current level of function. These plans are implemented when a patient still requires the expertise of a therapist to address complex needs, even if there is no expectation of further progress in rehabilitation.
Functional maintenance plans focus on maintaining a patient’s level of function after completing skilled therapy. These programs are typically carried out by trained staff or caregivers and are designed to prevent decline, ensuring the individual can continue performing essential daily activities.
Each of these plans plays a vital role in patient care. However, as you can see, there is often a gray area, particularly between skilled maintenance and functional maintenance plans, which can sometimes lead to confusion about their application and purpose. Understanding these distinctions is essential for ensuring the right plan is used for the right patient at the right time.
RAI Manual Definition
There isn’t always a single, definitive source for the concepts we encounter, but in the context of long-term care settings, I highly recommend the RAI Manual (Resident Assessment Instrument) as a reliable reference for many of the definitions we’re discussing.
The RAI Manual defines restorative nursing as "nursing interventions that promote the resident's ability to adapt and adjust to living as independently and safely as possible." This definition highlights restorative nursing's focus on enhancing independence and safety, making the manual an essential guide for understanding the scope and objectives of restorative nursing programs.
Your familiarity with the RAI Manual may vary depending on your role within the facility. For those who aren’t well-acquainted with it, the manual provides a wealth of detailed information, which can feel overwhelming at first. Therefore, it’s important to break it down and explore how the RAI Manual serves as a practical guide for shaping and supporting effective practices in long-term care settings.
Resident Assessment Instrument (RAI)
The RAI Manual, or Resident Assessment Instrument, is a valuable resource designed to help nursing home staff gather information about a resident's needs and strengths to create an individualized care plan. The RAI process consists of three key components: the Minimum Data Set (MDS), which you may or may not be familiar with, the Care Area Assessment (CAA) process, and the RAI Utilization Guidelines. When I refer to the RAI Manual, I often discuss these utilization guidelines, which provide step-by-step instructions on completing the MDS and other related processes.
It’s worth noting that the RAI Manual is updated annually, so staying current is essential. These updates, along with the most recent version of the MDS assessment and RAI Manual, are available for download on the CMS website. If your role involves big-picture responsibilities, the RAI is an invaluable tool.
The RAI Manual emerged from the IMPACT Act of 2014 (Improving Medicare Post-Acute Care Transformation Act), legislation aimed at standardizing and improving care across post-acute settings. For therapists, while much of the RAI content may seem targeted at the facility’s assessment processes, it also provides critical guidance and definitions relevant to our work.
For example, one of the best references for understanding Section GG, which measures functional abilities and goals, is the RAI Manual. If you find yourself confused about Section GG or unsure of its requirements, this manual serves as an excellent source of clarity, offering precise definitions and detailed guidance on what is—and isn’t—expected.
Minimum Data Set (MDS)
To ensure we’re all on the same page, let’s briefly define the Minimum Data Set (MDS), which I mentioned as part of the RAI process. The MDS is a standardized assessment tool used to evaluate the health status of residents in Medicare- or Medicaid-certified nursing facilities. It’s a federally mandated process, so facilities are required to complete it at specific intervals.
The MDS must be completed at a minimum every three months, but it also includes assessments at key points in a resident’s stay. These include an initial assessment when they enter the facility, quarterly assessments, annual assessments, and discharge assessments. These intervals ensure that the resident’s care plan is regularly updated to reflect their current needs and progress.
If you’ve ever reviewed or completed an MDS, you know it’s broken into a variety of sections, labeled alphabetically from A to Z. For therapists, Section GG is particularly relevant because it focuses on functional abilities and goals, which aligns closely with our scope of practice. However, Section O is also important, as it addresses restorative nursing programs.
Section O, titled “Special Treatments, Procedures, and Programs,” identifies whether a resident received any treatments or programs defined under this category during a specified time period. Restorative nursing falls under this umbrella, and we’ll explore its specific details as we proceed in the discussion.
When to Use Restorative Nursing
Let’s revisit restorative nursing with a focus on its application, timing, and the various components that go along with it. Restorative nursing is typically used in three scenarios. First, it’s implemented when a resident is admitted to a facility with identified restorative nursing needs but isn’t necessarily a candidate for formalized rehab from the therapy team. In these cases, restorative nursing might function as a standalone intervention added to their care plan.
Second, it’s used when restorative needs arise during a long-term stay. If new restorative needs emerge for residents in long-term care, a restorative nursing program can be introduced to address those needs.
Third, restorative nursing can be used in conjunction with formalized rehab. For example, if someone is admitted under a Part A stay and is actively receiving therapy, restorative nursing can run alongside the therapy program. However, it’s important to be mindful of overlap. The focus of restorative nursing and therapy cannot be identical; they must complement rather than duplicate each other. Interestingly, the ability to use these two programs simultaneously hasn’t always been an option, reflecting how restorative nursing has evolved in our current care model.
Today, restorative nursing practices are primarily shaped by CMS guidelines for Medicare and Medicaid, with managed care often following Medicare standards. However, these guidelines don’t necessarily apply to individual payers, and there can be significant differences in how restorative nursing is approached depending on state-specific Medicaid regulations. This variability underscores the need to understand both federal and state-level requirements when implementing restorative nursing programs.
Evolution and Role of Restorative in Long-Term Care
Evolution
The evolution of restorative nursing is an interesting journey, as the concept itself isn’t new. It has been referenced in various forms over the years, with mentions in the literature going back as far as the 1950s, though it doesn’t have a definitive starting point. The real focus on restorative nursing emerged when it became tied to legislation.
One pivotal moment was the Omnibus Budget Reconciliation Act (OBRA) of 1987. This legislation placed responsibility on long-term care facilities to help residents attain and maintain their highest possible level of function and ability to perform activities of daily living (ADLs). OBRA mandated that facilities were accountable for avoiding preventable declines in residents’ functional status. If a decline occurred that could have been avoided, the facility could be held liable. This created a strong incentive for facilities to focus on restorative nursing as a means to meet these legislative requirements, particularly in situations where therapy services were limited or unavailable. Therapy, after all, is not intended to be provided indefinitely, and restorative nursing fills the gap.
The spotlight on restorative nursing intensified when financial implications were tied to it. The introduction of the Prospective Payment System (PPS) in 1998, and specifically the RUG-IV (Resource Utilization Groups) model, made restorative nursing programs a direct factor in Medicare reimbursement. Under certain RUG models, restorative nursing became a driver of payment, ensuring it gained more attention and integration into facility practices. For those practicing before the shift to the Patient-Driven Payment Model (PDPM) in 2019, this connection to reimbursement would be a familiar story.
We’ll delve further into these historical reimbursement models and their implications for restorative nursing in upcoming slides, but understanding the link between legislation, financial incentives, and the development of restorative nursing practices is key to understanding how they have evolved over time.
Recent Changes
In 2019, when the Patient-Driven Payment Model (PDPM) became the primary payment structure, this shift brought some notable changes to how restorative nursing could be utilized, especially in conjunction with therapy.
Under PDPM, providers gained the ability to capture reimbursement for restorative nursing more directly than they could under the previous system. To break this down further, the transition from the Prospective Payment System (PPS) to PDPM introduced significant differences. Under PPS, therapy and restorative nursing could only be combined for skilled patients in the Rehab Low category, which was associated with minimal reimbursement. As a result, there was little incentive to incorporate restorative nursing on the Part A side for subacute patients, as its application was limited to a narrow category.
PDPM, however, allows for a more integrated approach, enabling restorative nursing to be combined with skilled therapy for subacute patients in a way that enhances their care plan. While there are still some limitations and reimbursement remains somewhat constrained, PDPM provides a clearer method for combining these interventions. This represents a shift from the restrictions that previously existed, opening up more opportunities to use restorative nursing in conjunction with therapy for subacute patients.
One important caveat here is that this discussion pertains specifically to subacute stays, such as those covered under Medicare Part A. These restrictions and reimbursement considerations do not apply to long-term care residents. The distinction between subacute care and long-term care can sometimes cause confusion, so it’s crucial to keep this in mind as we discuss the evolving role of restorative nursing.
Skilled Nursing Benefits
Restorative nursing programs clearly have the potential to impact all stakeholders—the facility, therapy, and, of course, the residents. Let’s discuss what we typically see in more detail. We’ll break this out further, but there are really three main benefits that I typically observe for facilities.
One benefit is meeting resident-specific care needs. Numerous requirements and F-tags are tied to ensuring that we actively prevent avoidable declines in residents' conditions. Restorative nursing serves as a critical tool to help meet these regulatory mandates.
Another benefit is the potential to improve overall outcomes. Providing more focused care often leads to better results, whether that involves supplementing therapy during short-term rehab or enhancing the quality of life for long-term residents. These efforts can directly impact quality measures, such as reducing falls, hospital readmissions, or other adverse events.
Finally, there is the potential for reimbursement impact. Not only can restorative nursing improve clinical outcomes, but it can also influence financial performance. Under PDPM, for subacute residents, restorative nursing can be integrated to enhance reimbursement opportunities. Similarly, for long-term residents, it can play a role in Medicaid reimbursement or other care formats, aligning financial incentives with improved resident care.
Skilled Nursing Facility Responsibilities/Benefits
In more detail, for our long-term residents, restorative nursing can significantly impact outcome measures and quality indicators, such as those tracked on CASPER Reports. By implementing restorative nursing programs, we can reduce the risk of functional decline in multiple areas, lower the likelihood of hospitalizations, and, in some states, even qualify for increased state funding based on improved care metrics.
For short-term residents, restorative nursing can play a complementary role in improving outcomes. When used to supplement therapy programs, it helps bridge gaps in care, supports continuity, and enhances overall recovery, contributing to better functional and clinical results.
Under PDPM, restorative nursing can influence the daily reimbursement rate for Part A rehab stays or managed care rehab stays. However, while it can have a financial impact, it’s typically not a significant one. As we’ll discuss, the requirements to qualify for reimbursement under restorative nursing often create a cost-versus-benefit scenario that doesn’t always favor widespread use. This consideration often affects decisions about when and where restorative nursing is implemented.
PDPM Reimbursement
When looking at the PDPM categories, restorative nursing impacts only the last two elements of the reimbursement formula, where it begins to influence the daily rate. Breaking down the specific PDPM reimbursement formula is beyond the scope of today’s discussion. However, we are planning a PDPM-specific webinar later in the year, potentially in the fall, where we’ll delve deeper into the calculations and how restorative nursing fits into the overall financial framework.
Therapy Benefits
The shift from the RUGS and PPS systems to PDPM has significantly altered the financial incentives for therapy. Under RUGS, therapy teams were encouraged to maximize therapy minutes and extend plans of care, as these were directly tied to reimbursement. This allowed for more time to incorporate a variety of interventions, including restorative approaches, into the therapy framework.
Under PDPM, however, the focus has shifted to achieving the best outcomes with the least amount of skilled therapy necessary. This new model incentivizes efficiency and prioritizes outcomes over volume, fundamentally changing how therapy teams allocate their time and how restorative nursing integrates into the broader care model.
One key benefit of restorative nursing for therapy teams is the ability to hand off components of a plan of care that do not require skilled intervention. Tasks such as basic functional skills and range-of-motion exercises, while beneficial to the patient, don’t necessitate the expertise of a therapist. Delegating these to restorative nursing allows therapists to focus on more complex, high-level interventions, thereby maximizing their impact in the reduced time available under PDPM.
Restorative nursing provides a practical way to "do more with less." By shifting appropriate tasks to restorative nursing teams—if available in the facility—therapists can be more judicious with their time. Additionally, restorative nursing supports enhanced PDPM outcomes, particularly regarding GG score improvements. With the new quality measure, the Discharge Function Score, coming in October, therapy outcomes will be scrutinized even further. As therapists work to move patients’ functional levels forward through the plan of care, having restorative nursing as an adjunct can positively influence outcomes.
The challenge of reduced therapy time is real. CMS data from a 2022 post-PDPM study showed a significant drop in skilled therapy minutes. The average daily therapy time on the five-day assessment fell from 91 minutes pre-PDPM to 62 minutes in 2022. In some settings, this number has likely declined even further, requiring therapists to carefully prioritize how and where minutes are spent.
Another significant area where restorative nursing shines is in preventing functional declines among long-term care residents who are not currently on skilled therapy. These residents often experience a frustrating "yo-yo effect," where they improve during skilled care, decline after discharge, and then require re-admission to skilled therapy every six months to a year. This cycle is challenging for residents and therapists alike.
Restorative nursing can break this cycle by acting as a transitional tool for rehab. It helps maintain the gains achieved during skilled therapy and provides residents with ongoing support to sustain their functional abilities. As a staff clinician, I found this incredibly valuable. Knowing that residents wouldn’t immediately lose the progress we worked so hard to achieve gave me confidence in transitioning them off skilled therapy. While it’s inevitable that some residents may eventually require skilled care again, restorative nursing helps extend the benefits of therapy and supports a more gradual and sustainable approach to long-term care.
Patient Benefits
The patient benefits of restorative nursing are likely the most apparent. In long-term care settings, unless residents are receiving regular therapy or can justify prolonged skilled maintenance therapy, they often experience significant gaps in care between rehab sessions. Many long-term care residents struggle to maintain their functional abilities without some level of assistance, and these gaps can lead to avoidable declines.
Additionally, financial barriers can make regular therapy unattainable for some residents. Copays for skilled care may be prohibitively expensive, leaving individuals without the support they need. Restorative nursing offers an alternative for these residents, providing ongoing assistance to help maintain function without the financial burden associated with skilled therapy.
Research has consistently demonstrated the positive impact of restorative nursing on various aspects of residents’ quality of life. Long-term care settings often face challenges with functional and cognitive declines, and restorative nursing programs provide an effective way to mitigate these issues. By focusing on maintaining and enhancing residents’ abilities, these programs can significantly improve overall well-being.
Ultimately, the primary goal of restorative nursing is to enhance the quality of life for residents. That’s what truly matters at the end of the day—ensuring that individuals in long-term care can live with as much independence, dignity, and enjoyment as possible.
What Programs Qualify?
When it comes to restorative nursing programs that qualify for capture on the MDS for reimbursement purposes, there are specific rules and criteria that need to be followed. While some facilities focus heavily on capturing these programs for reimbursement, others prioritize providing resident-centered care without necessarily considering the financial aspect. For those aiming to capture these programs on the MDS, there are specific ones that qualify.
Walking and bed mobility are grouped together on the MDS, meaning that even if separate programs are created for walking and bed mobility, they will count as one program for reimbursement purposes. There isn’t a clear explanation for why these two are grouped this way, but it is an established rule. Similarly, range of motion programs, whether active or passive, are also captured as a single program on the MDS. Each program must be written and managed separately to meet requirements, but they are treated as one for documentation purposes.
Toilet training, which includes bowel and bladder programs, is another qualifying category, along with eating and swallowing programs, dressing and grooming programs, transfer training, communication programs, amputation and prosthetic care, and splinting and bracing programs. These programs are all effective in addressing specific resident needs, though their use may vary depending on the facility and resident population.
As a clinician, the programs I found myself using most often were the functional ones, such as walking, activities of daily living, transfers, range of motion, toileting, and splinting. In my experience, amputation and prosthetic care programs were less common due to the lower acuity levels in the settings I worked in, although I can certainly see their value in facilities with different populations. Communication programs are effective but tend to be managed more frequently by speech-language pathologists or occupational therapy practitioners, depending on the staffing and structure of the facility. While all these programs have their place in improving resident care, certain ones naturally see more frequent use depending on the specific needs of the residents and the goals of the facility.
Program Types
The RAI manual offers additional clarification by breaking down restorative nursing programs into two general types: technique or maintenance programs and skill or progress programs. While there are no specific RAI requirements for facilities to choose one type over the other for reimbursement purposes, the definitions help provide clarity on how these programs are structured.
A technique or maintenance program involves the nursing staff completing the activity primarily for the resident. While the resident may participate to some degree, the staff generally takes the lead in performing the task. Examples include splint or passive range of motion programs, where the focus is on maintaining the resident’s current level of function or preventing further decline.
In contrast, a skill or progress program is designed to encourage the resident to actively perform the activity with assistance. In these programs, the resident works on tasks with support, such as cues or supervision provided by the restorative aide. This type of program includes functional tasks like toileting, eating, walking, and transfers, where the aim is often to develop or maintain the resident’s skills through active participation.
Understanding these distinctions helps clarify how restorative nursing programs can be tailored to meet the specific needs and abilities of each resident, whether the goal is maintenance, progress, or a combination of both.
Who Provides the Programs?
The question of who provides restorative nursing programs can vary somewhat depending on the facility and the state's regulations. In most cases, these programs can be provided by anyone who is trained and supervised by the restorative nurse. However, in practice, the majority of facilities assign these responsibilities to licensed CNAs who receive additional training to serve as restorative aides.
While some states have specific requirements regarding who can provide and oversee restorative programs, many do not define these roles in detail. The general expectation is that individuals providing the programs must have the appropriate training and operate under proper oversight to ensure the programs are implemented safely and effectively.
If you are ever uncertain about the requirements in your state, the best resource is your state’s RAI coordinator. Every state has an RAI coordinator whose contact information is available through CMS. A quick online search for "state RAI coordinator" will usually provide email addresses and phone numbers for these contacts. Their role is to assist facilities, providers, consultants, and associates with questions related to MDS and restorative nursing.
RAI coordinators are typically very responsive and helpful. If they cannot answer your question directly, they will escalate it to an RAI panel for further guidance. For any regulatory questions or uncertainties, reaching out to your state’s RAI coordinator is an excellent approach to getting accurate and timely information.
Restorative Oversight
Oversight for restorative nursing programs must be provided by either an RN or an LPN, depending on the state. Some states mandate that oversight be provided by an RN, while others allow an LPN to fulfill this role. There are some basic requirements for oversight that we’ll discuss in more detail later, but because there’s so much to cover, we’ll likely revisit this information more than once to reinforce key points. Even if you retain just 10 to 20% of it at first, reviewing it will help solidify your understanding.
Restorative nurses play a crucial role in these programs. They are responsible for documenting an initial note for each resident when a program begins and providing monthly documentation thereafter. This documentation must include details about the resident’s progress within the program, any continuing deficits, and whether they should remain in the program.
While physician orders are not required by regulation for restorative nursing programs, they are often recommended and used by many facilities. Having a physician’s order can provide a clear, formalized directive, which often helps ensure that the program is consistently implemented and that there’s a straightforward paper trail for accountability. However, this approach does carry some risks. Once a physician’s order is in place, failure to follow it could lead to noncompliance issues during a state survey or other regulatory reviews. This double-edged sword is something facilities need to carefully consider when deciding how to manage their restorative nursing programs.
Restorative Requirements
Several key criteria must be met for restorative nursing programs to count toward reimbursement on the MDS. First, the program must be one of the nine qualifying programs we discussed earlier. Additionally, there need to be at least two qualifying programs in place for a resident to meet the criteria.
Each program must be performed for at least 15 minutes within a 24-hour period. This time doesn’t need to be continuous—it can be broken up throughout the day. Furthermore, each program must be carried out at least six days a week. So, to summarize: two programs, each for 15 minutes, six days a week.
To make the process more manageable, facilities are allowed to group residents during restorative programming. Up to four residents can participate in a group at the same time. Unlike therapy, restorative nursing does not have the same restrictions regarding group activities. For example, restorative minutes are not subject to the 25% group limit seen in therapy. Additionally, residents in a group can be working on entirely different programs, which is another distinction from therapy group rules.
Despite this flexibility, meeting these requirements can be quite demanding. Capturing two programs, 15 minutes each, six days a week, and documenting everything properly can quickly add up in terms of workload. When considering the financial aspect, the potential reimbursement impact is typically only a few dollars per day per resident. To make restorative programming a financial advantage—or even cost-neutral—facilities must implement it consistently and at scale, which can be challenging. For many facilities, the administrative and operational effort required to meet these standards may outweigh the modest financial returns, making it a complex decision in terms of resource allocation.
PDPM Reimbursement
For many facilities, the approach to restorative nursing programs reflects a balance between financial considerations and resident care priorities. While they aim to capture as much reimbursement as possible, the focus often leans more toward long-term care residents rather than short-term rehab stays. This shift makes sense given the practical and financial realities of restorative nursing.
Facilities often prioritize how restorative nursing can improve care for long-term residents, particularly by addressing publicly reported quality measures through CASPER and other reporting systems. These measures, which include metrics like fall rates, mobility levels, and continence, are critical for demonstrating quality care and maintaining a strong reputation. Moreover, in some states, long-term residents can also provide a financial incentive if their care qualifies for a daily rate boost under Medicaid-specific guidelines.
As a result, in the facilities I’ve worked with, the primary focus tends to be on long-term residents. By improving outcomes for this population, facilities not only enhance the residents' quality of life but also position themselves more favorably in terms of quality ratings and financial sustainability. While short-term rehab remains a priority for maximizing PDPM rates, the consistency and longer-term benefits of focusing on the long-term care population often yield a greater impact overall.
Restorative Usage Rates
Let’s look at how restorative nursing programs are actually utilized in the field, including their prevalence and patterns of use. In one study conducted pre-PDPM, it was found that approximately two-thirds of facilities provided some level of restorative nursing care to their residents. This means about two out of every three facilities had restorative programs in place.
On average, around 25% of residents were placed on restorative programming at the time of admission. This percentage increased slightly over the course of a resident's stay, reaching about 37% as residents transitioned into long-term care. Interestingly, for residents who remained in long-term care for extended periods, the likelihood of being on a restorative program didn’t increase beyond 37%.
The study also highlighted the most commonly used restorative programs, which included passive and active range-of-motion exercises, walking programs, and dressing and grooming tasks. These three categories topped the list of the nine qualifying programs, reflecting the focus on basic functional maintenance and mobility for many residents. These trends give us a clearer picture of how restorative nursing is typically implemented and the priorities facilities tend to emphasize.
Impact of Restorative Nursing
As discussed, both anecdotally and in the data, long-term care residents tend to be the primary focus of restorative nursing programs. This makes sense given that they typically represent a larger proportion of the average census in most facilities. Nationally, about 70% of nursing home residents have been in their facility for at least six months, placing them firmly in the long-term care group.
This population is also the most likely to benefit from restorative care, as they are at the highest risk for declines, even in the best facilities. It’s well recognized that long-term care residents often face faster rates of decline compared to individuals of the same age living in the community. This heightened vulnerability makes them a key focus for restorative interventions aimed at maintaining function and preventing avoidable deterioration.
Interestingly, Medicare data analyzed on a larger scale has not shown significant differences in decline rates between long-term care residents on restorative nursing programs and those who are not. While this might seem concerning at first, there’s an argument to be made that this data may reflect the success of targeting higher-risk individuals. If those identified as high-risk and placed on restorative programs are declining at the same rate as lower-risk individuals, not on programs, that could indicate the program is effectively mitigating what would otherwise be a more rapid decline.
However, this data also underscores an important point: simply having a restorative nursing program in place does not guarantee results. To achieve meaningful outcomes, the program must be well-run and implemented with clear intent and strong oversight. This is true for nearly any initiative—results come from quality execution, not merely the presence of a program.
Smaller-scale studies have consistently shown that restorative nursing, when properly executed, can positively impact physical, cognitive, and psychosocial function. While I’ve only referenced two studies here, there is a wealth of evidence supporting the potential of restorative nursing to drive improvements across multiple domains. Many of these studies are older than five years, which is why I avoid citing them in presentations, but they remain valid in demonstrating the positive impact of restorative programs.
Ultimately, the key takeaway is that the success of restorative nursing depends on intentional design and execution. A well-run program can have a substantial positive effect, but simply stating that a program exists will not drive the outcomes we aim to achieve. This principle applies broadly across all areas of care: quality and intention matter most.
Restorative During the Public Health Emergency
The public health emergency during the COVID-19 pandemic had a profound impact on restorative nursing and the long-term care setting as a whole. While every sector faced challenges, the intensity felt in nursing homes and skilled nursing facilities was unparalleled. Let’s go back to the winter of 2019 when we thought the biggest challenge on the horizon was the transition from PPS to PDPM.
At the time, I was a rehab director, and that shift brought a lot of uncertainty. PDPM changed the financial dynamics of therapy entirely—therapy was no longer the primary driver of reimbursement. We all braced for reduced hours and grappled with the new emphasis on group and concurrent therapy, something many of us had minimal experience with. It was a daunting transition, and just as we were starting to adjust, the world shifted dramatically in March of 2020.
When COVID-19 hit, nursing homes became a focal point of national concern. If long-term care hadn’t already been under heavy regulation and scrutiny, the pandemic amplified that tenfold. The initial challenge was keeping the virus out, but once it entered, the reality became even more overwhelming.
I vividly remember the first case in our facility. At the time, we had managed to keep COVID out, but when it arrived, everything changed. We dedicated an entire unit to isolating the infected individual, blocking off a full hallway with hazmat-style negative pressure containment. Only dedicated staff were allowed in—a single nurse, one CNA, and me as the designated therapist.
My role during that time shifted dramatically. I wasn’t allowed to treat any other patients. My day began with my usual rehab director duties, but once I suited up in a full hazmat suit, I worked solely with that one individual. Afterward, I left directly, going home to essentially "delouse" and change before returning the next day. It was an exhausting and surreal experience, but it was the only way we could manage in those early days.
Those initial months were chaos as we all learned how to navigate an unprecedented crisis. Staffing was stretched, residents were isolated, and the already fragile systems in long-term care faced unimaginable strain. It felt like a constant uphill battle, but it was also a time when we saw the incredible resilience of our teams. Everyone found themselves doing things they never expected, and I’m sure many of you on this call have similar stories of those early days. It truly was a wild and unforgettable time.
Impact on Staffing
The impact of the pandemic on the long-term care setting was nothing short of staggering. Over 100,000 registered nurses left the workforce during this time, and that figure doesn’t even account for the loss of other essential staff, including CNAs, restorative aides, and therapists. By March of 2022, nearly 30% of nursing homes reported staffing shortages, a crisis driven by burnout, illness, and the emotional toll of working in such a heavily impacted environment.
Medicare data from 2020 reflect the sheer scale of COVID-19’s effect on nursing homes. That year alone, two in five nursing home residents contracted or previously had COVID-19. During surge periods, more than 1,300 nursing homes reported infection rates of 75% or higher among their residents, underscoring how devastating the virus was in these congregate care settings.
The consequences extended far beyond infection rates. Mortality in nursing homes rose dramatically, with an increase of about one-third from 2019 to 2020. This spike in mortality, combined with the challenges of staffing shortages, burnout, and regulatory pressure, created a perfect storm that fundamentally reshaped the landscape of long-term care. The pandemic’s impact was massive, not just in terms of numbers but in the lived experiences of staff and residents who endured the brunt of this crisis.
Impact on Programs and Residents
Before the pandemic, about two-thirds of facilities provided some level of restorative nursing care, and the implementation of PDPM had primed the industry for growth in both the number of facilities providing restorative care and the amount of programming being offered. With PDPM shifting therapy away from being the main driver of reimbursement, facilities began looking for ways to reallocate costs and duties. Restorative nursing became a key focus, as it seemed like a logical area to absorb some of the responsibilities and time that might otherwise have been handled by therapy teams.
However, when the public health emergency (PHE) hit, restorative nursing programs—whether they were thriving before or not—were significantly impacted. Staffing shortages forced facilities to triage their priorities, and restorative nursing often ended up on the chopping block. Facilities with dedicated restorative nurses or aides often reassigned those staff members to floor duties, prioritizing basic care and essential staffing needs over restorative programs. This shift resulted in a sharp decline in the availability and consistency of restorative care.
The consequences were stark. Functional declines among residents skyrocketed during this period, and while multiple factors contributed to this, the loss of restorative nursing programs played a significant role. Quarantine protocols, limited staff resources, and the direct impact of COVID-19 itself all compounded the issue.
In March 2020, CMS issued emergency guidance for nursing homes, which only heightened these challenges. The restrictions included barring all visitors except for compassionate care situations like end-of-life cases, suspending volunteers and non-essential healthcare personnel, canceling group activities and communal dining, and implementing active screening for all individuals entering the facility. These measures, while necessary to control the spread of the virus, had profound secondary effects.
Residents were left isolated, with no resident-to-resident interaction, minimal communication with staff, and limited contact with their loved ones. The absence of group activities and restorative programs stripped away much of the structure and support that residents relied on for maintaining their physical and emotional well-being. This loss of interaction and engagement, coupled with the reduced availability of restorative care, exacerbated the decline in function and quality of life for many residents.
The pandemic didn’t just disrupt restorative nursing—it redefined priorities in ways that made programs like these feel like luxuries when, in fact, they are vital to maintaining the health and dignity of long-term care residents.
Impact on Restorative Nursing
We’ve all seen, both anecdotally and through studies, just how significant the impact of the pandemic was on the emotional and physical well-being of nursing home residents. The effects of social isolation during quarantines were devastating. Studies, including one from CMS, showed that 85% of nursing home residents experienced a decline in physical abilities, 87% of family members noticed physical decline in their loved ones, and 91% reported a negative change in demeanor due to the effects of quarantine. Depression, anxiety, worsening dementia, and even failure to thrive became all too common in these settings.
These outcomes weren’t solely the result of social isolation. The combination of staffing shortages, the direct effects of COVID-19 infections, and the suspension of programs like restorative nursing all contributed significantly. During the public health emergency, residents declined in functional categories at rates much faster than before. The absence of consistent programming, including restorative interventions, removed an essential component of care that might have otherwise mitigated some of these declines.
Fast forward to 2024, and while COVID-19 hasn’t completely disappeared, we’ve moved beyond the worst of the crisis. Many facilities are now shifting their focus back to improving the quality of care. Although staffing shortages remain a challenge, there’s a renewed interest in reviving, revamping, or even starting restorative nursing programs from scratch. Facility leaders are recognizing the critical role these programs play in maintaining residents’ physical and emotional well-being.
If you’re participating in this course, it’s a great time to deepen your understanding of restorative nursing. With more facilities looking to ramp up these programs, there’s a growing need for professionals who are well-prepared to implement and manage them successfully. Restorative nursing has always been an essential component of care, and as we move forward, it’s poised to become an even more prominent tool in ensuring the best outcomes for residents.
Role of the Therapy Team
The therapy team’s role in restorative nursing programs can vary widely depending on the facility’s approach. In some facilities, therapists are deeply involved, overseeing restorative staff, monitoring efficiency, writing programs, auditing documentation, and providing extensive training. In others, the involvement might be more peripheral, with therapy serving as an occasional resource. Ultimately, your role will depend on whether you’re working in a contracted model or in-house and how the facility chooses to structure its programs.
Regardless of the level of involvement, the key to success lies in adopting a partnership mindset. While restorative nursing is technically a nursing-driven program, viewing it through an interdisciplinary team (IDT) lens is essential. IDT is a term often used but not always fully implemented. True interdisciplinary collaboration, as supported by CMS and required in many aspects of care planning, is what yields the greatest benefit for residents. For example, CMS audits care planning processes, including F-tags related to interdisciplinary teamwork, to ensure that professional disciplines are effectively collaborating for the best outcomes.
Interdisciplinary thinking can be challenging and requires a structured approach to foster genuine collaboration. In restorative nursing, this means resisting the temptation to shift full responsibility onto nursing staff. Therapy teams are a critical resource in identifying restorative needs, triaging which should be addressed by therapy versus nursing, and helping design programs that address residents' functional goals. This involvement ensures the program runs effectively and benefits both residents and staff.
Communication is a cornerstone of effective restorative programming. Whether you’re starting from scratch or evaluating an existing program, it’s vital to assess how information is relayed among team members. Good communication relies on structured processes, including clear forms, scheduled meetings, and efficient methods for sharing updates. If you’re building a program, consulting reputable resources such as nursing organizations or professional bodies can provide templates and guidance for setting up effective communication systems.
Training is another essential component. Restorative aides must be trained in general competencies such as safety, identifying red flags, and implementing care plans, as well as in specific program techniques. Your role in this training will depend on the facility’s expectations. Some facilities may ask therapy staff to provide general competency training, while others may limit your role to training on specific program recommendations. The RAI manual outlines training requirements for aides, including understanding techniques that promote resident involvement, implementing interventions from the care plan, and recognizing and reporting changes in condition. Determining who will handle these training components is a critical step in starting or refining a program.
Caseload management is another area where facilities often struggle. While identifying residents who could benefit from restorative programming is straightforward, determining when someone should be removed from the caseload is less so. Without a clear process, caseloads can swell to unmanageable levels, reducing the quality of care and preventing timely access for new residents who need support. A prioritized system for adding and removing residents is essential, ensuring that restorative care remains effective and targeted.
Finally, refining the program is an ongoing process. No program is perfect from the outset, and continuous evaluation and adjustment are necessary to ensure it meets residents’ needs and operates efficiently. Whether your role involves direct auditing or supporting the refining process, being part of this ongoing improvement is critical. Later, we’ll dive into specific auditing techniques in case this is part of your responsibility.
Ultimately, the therapy team has a significant role to play in restorative nursing, from identifying needs and triaging care to training staff and refining processes. By embracing this collaborative approach, you can help ensure that restorative programs deliver meaningful results and support residents in maintaining their independence and quality of life.
Remember: It Is a Nursing Program
It’s crucial to remember that restorative nursing is, by definition, a nursing program. While therapy teams can play a significant role in supporting and enhancing these programs, they should not take over to the extent that the program becomes therapy-driven. The oversight and leadership must come from the restorative nurse.
Restorative nurses are capable of writing the programs and should be encouraged to take the lead in doing so. Their involvement ensures that the program remains aligned with nursing goals and maintains the proper oversight required by regulations. Therapy can and should provide input, help with program development, and train staff on specific techniques, but the nursing leader identified as the restorative nurse must oversee the program to ensure it adheres to its intended purpose and structure.
Facilities must strike a balance, leveraging therapy's expertise while respecting that this is a nursing-led initiative. Effective collaboration between nursing and therapy is key to achieving the best outcomes, but keeping the program’s identity and oversight firmly within nursing’s domain is vital.
Steps in Developing a Successful Program
There’s no definitive blueprint for building a successful restorative nursing program, but I’ll share some anecdotal advice from my experience about what tends to work well and what can undermine a program. Over the years, I’ve observed key elements that drive success and the pitfalls that can derail even the best intentions. While we often only have partial control over some aspects, it’s important to acknowledge that certain steps are necessary for success. Even if these steps feel out of reach in your current role, understanding their importance can help you advocate for them with leadership.
Start to Build a Program
Step one is the hardest step, and that’s gaining commitment from the top down. If facility leadership is still in a triage mentality, constantly deciding what’s on the chopping block, it will be nearly impossible to build a successful restorative nursing program. This mindset is particularly challenging to shift coming out of the COVID era, when facilities were forced to prioritize immediate needs over long-term goals. Even now, with some barriers like staffing shortages still present, it’s important to recognize that no facility will ever reach a point where it’s entirely barrier-free. That was never the case in the past and likely never will be in the future.
To make restorative nursing successful, leadership must adopt a mindset of commitment. They need to determine the resources they are willing to dedicate to the program and stick to that commitment, regardless of shifting priorities. Restorative nursing can’t become something that is constantly paused or reprioritized. Without consistent dedication, the program will not succeed. This can be especially tough to secure because restorative nursing’s benefits are often long-term and not immediately visible. For example, improving quality measures for long-term care residents may take months or even years to reflect in the data, whereas reimbursement benefits from therapy programs are often more immediate. Despite this, leadership buy-in is key and must be the first step.
Step two is appointing a strong restorative leader, and that leader must be a nurse. Restorative nursing is a nursing program by definition, and it requires a nurse leader who can drive the program forward. If therapy is left dragging the restorative nurse along, the program is unlikely to succeed. While therapy can champion and support the program, the nurse leader must take ownership.
For the nurse leader to succeed, they need the right tools, appropriate training, and the authority to make decisions and hold staff accountable. Additionally, they must have enough time dedicated to managing the program effectively. Lack of time is often one of the biggest barriers to success. If I asked the audience how many facilities provide their restorative nurse with adequate time to oversee the program, I imagine very few hands would go up. Unfortunately, this is a common challenge, but it is the reality we face.
In the long-term care therapy world, we are accustomed to metrics of accountability, and this same structure applies to restorative programs. These programs must have clear responsibilities, and there must be oversight to ensure those responsibilities are met. For the restorative nurse, defining specific tasks and expectations can be more challenging. While the RAI manual outlines key components that must be completed, many successful programs incorporate additional expectations to maintain high quality. Facilities often define regular tasks and responsibilities beyond the minimum requirements to ensure the program thrives. Establishing these expectations will require discussion and collaboration with facility leadership.
Ultimately, creating a successful restorative nursing program requires leadership commitment, a strong restorative nurse leader, and a clear understanding of responsibilities. While some aspects are more straightforward, success depends on a thoughtful approach and consistent follow-through.
Staffing Model Types
When considering a staffing model for restorative nursing, it’s one of the most significant decisions a facility must make, and it’s critical to commit to one approach. I’ve seen many facilities struggle because they flip back and forth between models when challenges arise, which only serves to sabotage the program. Whether you choose a shared responsibility model or an independent model, both have pros and cons, but success hinges on sticking to the chosen approach despite occasional hurdles.
The independent model is often the preferred choice when resources allow. This model involves having a full-time, dedicated restorative aide or nurse who is solely responsible for providing restorative programming without being pulled into traditional CNA or nursing duties. This setup is more common in larger facilities where the caseload can justify a full-time role.
The benefits of this model are straightforward. It’s easier to measure the effectiveness of the programming because the responsibilities and hours of the dedicated staff are clearly defined. Accountability is higher since the restorative aide or nurse focuses exclusively on these tasks. Additionally, training and care delivery can be more specific, as fewer individuals are involved in carrying out the programs.
However, the barriers to this model are significant. It is the most costly option, requiring a separate staff position with potentially limited direct ROI. While the overall benefits to resident care and quality measures are valuable, the upfront investment may not immediately pay off in terms of reimbursement. Efficiency can also be an issue; without specific volume expectations, dedicated staff may not feel driven to maximize their time. Finally, having a dedicated restorative aide or nurse creates the temptation to reassign them to floor duties when staffing shortages arise, disrupting the restorative program.
The shared responsibility model, by contrast, distributes restorative programming among the floor staff, such as CNAs and nurses, who integrate these duties into their regular workflow. While this model is less costly and avoids the issue of losing all restorative programming if a single staff member is unavailable, it comes with its own challenges.
This approach requires a significant upfront effort to establish. It involves training a large number of staff members, providing consistent oversight, and writing programs that fit within the existing workflow. The shared responsibility model can be effective once stabilized, but it demands careful coordination. Staff already have a heavy workload, and restorative programming can easily become a lower priority, both in execution and documentation, especially during busy shifts.
Ultimately, the choice between these models depends on the facility’s resources, size, and goals. Each model has distinct strengths and weaknesses, and the key to success lies in committing to one approach and addressing its challenges with consistency and intention. Flipping between models when difficulties arise will only disrupt the program and hinder its effectiveness.
Training on Documentation
Another key component to success in restorative nursing is proper documentation, which differs significantly from traditional nursing documentation. It closely resembles therapy-style documentation, focusing on clear, goal-oriented approaches such as SMART goals. For those unfamiliar, SMART is an acronym representing five critical benchmarks for effective goal-setting: specific, measurable, achievable, relevant, and time-bound.
Goals should be specific to ensure clarity for all team members, measurable so there’s an objective way to track progress, achievable to ensure they are realistic within the given timeframe, relevant to align with the resident’s broader long-term objectives, and time-bound to provide a clear timeline for evaluation and accomplishment.
If federal reimbursement is part of your facility’s restorative nursing program, proper documentation is even more critical. In these cases, documentation will likely be closely scrutinized during audits. Even if the program isn’t tied directly to reimbursement, poor documentation can still expose facilities to issues during surveys. There are approximately eleven potential F-tags that could relate to restorative programming. While I don’t have them listed here, they include general quality-of-care requirements and specific areas such as ADLs, care planning, assessments, professional standards, prevention of accidents and hazards, sufficient nursing staff, and targeted care concerns like pressure sores, incontinence, and range-of-motion decline.
To ensure compliance, facilities must determine who is best equipped to train staff on the documentation requirements. Staff need to understand what is required for reimbursement and MDS reporting and how to document in a way that supports the program’s objectives and protects the facility during audits or surveys.
Ideally, the restorative nurse takes the lead in writing goals, ensuring they align with the SMART framework. Staff must also be trained on the importance of proper documentation and the consequences of inadequate or incomplete records. Clear processes, ongoing training, and regular audits can help ensure that documentation remains consistent and supports the program's success.
Caseload Management
Caseload management in restorative nursing is so critical that it warrants further discussion, even after being touched on earlier when addressing therapy’s role. Having a consistent process to determine when restorative programming should end is essential, yet it can be one of the most challenging aspects to navigate. The gray areas often make this decision less straightforward.
When a resident shifts back to skilled care, the transition is usually clearer—there’s typically a well-defined need or decline that justifies the move. However, deciding when a resident should come off restorative programming entirely without transitioning to another level of care is far less concrete. Even with well-crafted SMART goals that provide clear benchmarks, there’s often a sense that residents could continue to benefit from restorative care indefinitely. This is especially true for those whose needs don’t necessarily stop at achieving a single goal but who seem to thrive with ongoing support.
While it’s possible to keep some residents on restorative programming for extended periods, clear goals, timelines, and regular reassessments must still be in place to ensure the programming remains meaningful and effective. There’s no strict regulatory standard limiting how long a resident can stay on restorative care, but leaving residents on programming indefinitely without reassessment or progress can dilute the program’s overall purpose and effectiveness.
The real gray area emerges when deciding whether a resident should leave restorative programming and transition to nothing at all. This situation requires careful judgment to avoid inadvertently contributing to a functional decline due to a lack of continued support. The decision should always involve a thorough reassessment of the resident’s current status, goals, and needs.
Having a structured caseload management process, with periodic evaluations and team discussions, can help ensure these decisions are made thoughtfully. Establishing clear criteria for transitions and involving the interdisciplinary team can provide additional clarity and support in these gray areas, balancing the resident’s ongoing needs with the program’s overall efficiency.
Auditing
Auditing is a massively important process for any programming, and I urge you to consider auditing processes for really any of your programming. Not just restorative nursing, but any therapy programming should have an auditing component that you use to move your program forward and make sure you're accomplishing what you want. So in general, what we're looking at for auditing, of course, you need to decide who will do it, how often they do it, and what process, what forms you use, things like that.
For restorative nursing, specifically, I recommend auditing not only the documentation but also the programming itself in terms of efficiency and effectiveness.
Auditing
Especially in healthcare, quality and safety issues have become increasingly important, and auditing is the key to shaping practices effectively. Auditing provides tangible data points to identify concerns, and those data points are invaluable when trying to implement change. Having concrete data allows you to relay concerns up the chain of command more effectively, making it easier to advocate for additional resources, more time, or adjustments to programming.
In my experience, audits are incredibly useful. However, simply conducting one audit and suggesting improvements usually falls short. There is often a quality gap that requires continuous effort to address. Auditing needs to be an ongoing process, not a one-time event. It’s something that has to happen regularly to maintain and improve program effectiveness.
A significant portion of my time is spent auditing various elements like G scoring and intervention selections, and it’s clear to me that auditing is absolutely essential for program success. If you’re in a leadership role, such as a TCN, rehab director, or another higher-level position in therapy, you may find yourself involved in auditing restorative nursing programming to some extent. There are a few key aspects to focus on when auditing these programs.
Documentation Audits
When auditing a restorative nursing program, several key components must be reviewed to ensure compliance and effectiveness. First, it’s essential to verify that measurable objectives and interventions are clearly documented and that periodic evaluations, ideally monthly, are being completed. Change of condition charting is another critical area to address, as it ensures that the program is responsive to residents' evolving needs. For programs tied to reimbursement, treatment grids and flow sheets are required, and these need to be consistently maintained.
Competency forms for all staff involved in restorative programming should also be on file. During audits, one area that is often overlooked is tracking the four-to-one ratio for group programming. Different facilities use various methods to document participation on treatment grids or in the EMR, but it’s crucial to have a clear system in place that records who was in a group and how many participants were present. This documentation is a potential audit focus and needs to be accurate to avoid compliance issues.
Common issues that arise during audits often involve incomplete evaluations or the lack of SMART-style goals, which can lead to case mix review adjustments. Ensuring thorough documentation and goal-setting processes is vital to maintaining program integrity.
As for the slides, I know some of the upcoming ones are dense with information. While this isn’t ideal for live presentations, you’ll receive a PDF version of this presentation at the end. Given the depth of the material, I anticipate that many of you will want to revisit and reference these slides as you implement restorative programming in your facilities. The detailed content is included intentionally to serve as a comprehensive resource. While you might not absorb everything during today’s session, it’s there to guide you moving forward.
Problem Statement
A problem statement in restorative nursing documentation serves to clearly outline the issue at hand and justify the need for restorative care. It identifies the problem itself, the root cause, and the effect the problem has on the resident’s functional abilities. Together, these components create the justification for the restorative intervention, following a logic similar to that used in therapy.
For example, a problem statement might address decreased range of motion as the primary issue. The root cause could be a recent stroke or prolonged immobility, while the effect might be difficulty performing self-care tasks such as dressing. When combined, the problem, cause, and effect form a cohesive justification for why restorative programming is necessary.
Here’s a sample problem statement to illustrate the concept:
"Resident exhibits decreased range of motion in the right shoulder (problem) secondary to a prior stroke (cause), which impacts their ability to complete dressing tasks independently (effect), necessitating restorative intervention to improve or maintain functional independence."
While this example might not represent the most refined or ideal problem statement, it provides a basic framework to understand how to construct one effectively. The key is ensuring that each component is clearly identified and tied to the resident’s functional outcomes. This structure not only guides the care plan but also supports the documentation required for audits or reimbursement processes.
Measurable Goal
As discussed earlier, we have that SMART goal. These are some examples of ones that I've seen. They can be relatively simple. They don't have to be as complicated as some therapy goals, but all those have at least some level of component of a SMART goal.
- Specific, Measurable, Attainable, Relevant, and Time-Bound
- Will not develop contractures to the right arm, wrist, or hand x 90 days
- Will maintain the ability to fully extend right leg so that the back of the knee lays flat on the bed x 90 days
- Will open fingers of right hand far enough to hold a spoon x 90 days
Intervention
And then, with the intervention specifically, often, this is a component we're much more involved in. This is a pretty good example of a straightforward range-of-motion intervention.
- Passive range of motion (PROM) to right arm, wrist, and hand for five to seven minutes, three times daily per instructions, seven days per week for three months.
For instance, something like "five to seven minutes, three times daily" is a great concept, but I think it’s often difficult to put into practice. It’s probably easier to capture the 15 minutes straight through in one session.
That said, you can spread the 15 minutes across a 24-hour period, which is particularly useful when it's integrated into routine nursing care. For example, it’s often easier to meet this requirement when interventions involve tasks like toileting multiple times a day, dressing, or undressing. Ultimately, how you choose to structure it—whether in one block of time or broken into smaller sessions—will depend on the specific intervention and what works best for your facility.
You don’t necessarily have to specify in the intervention description whether it’s completed in one block or across breaks, though you can if you feel it adds value. That level of detail isn’t a strict requirement but may help clarify expectations based on your facility’s workflow.
The RN Evaluation
Now, I know there are likely fewer RNs on this course, but I still wanted to provide some behind-the-scenes information about the documentation requirements. As part of the process, they need to include progress toward the goal, though that would fall under the periodic evaluation, not the initial evaluation. Another important component is identifying what barriers are in place, which is a big focus and something we’ll discuss more.
Refusals
Assessment of refusals is a critical component of restorative nursing documentation and one that warrants close attention. Residents refusing care is a common issue in long-term care, often due to cognitive challenges, pain, fatigue, or other factors. However, these refusals must always be documented thoroughly to avoid potential issues, such as a tag during a survey.
Every periodic evaluation must include a clear decision on whether to continue the program, modify it, or discharge it. This decision must be informed by the resident’s progress, barriers, and participation, including any refusals.
Refusals themselves require careful management. It’s essential to document the reasons for the resident’s refusal and make every effort to accommodate their preferences to increase the likelihood of participation. If the resident continues to refuse, alternative options should be explored, and their right to refuse care must always be respected.
Crucially, documentation must show that the resident was educated on the risks and benefits of declining the care. Even more challenging, this refusal and educational process must be revisited periodically. This adds another layer of tracking and documentation, which can be difficult to manage in an already heavily regulated environment.
Long-term care operates under some of the most stringent regulations in healthcare for good reason—the patients are among the most vulnerable. However, the sheer volume of requirements can be overwhelming, and keeping everything organized, including refusals, is one of the many challenges faced by care teams.
Common Barriers
want to take a moment to address common barriers and pushback that often come up when discussing the implementation of restorative nursing with clinicians. This is an important topic, so I’ve slotted it here to ensure it gets attention.
One significant barrier is staff buy-in, especially in a shared responsibility model. From my experience and a survey I recall—possibly a CMS survey, though it focused on CNAs rather than therapists—the challenges outlined align closely with what I’ve seen in practice. Staff buy-in can be particularly difficult to achieve when aides feel overburdened, believe the programming won’t make a difference, or feel inadequately trained. Many aides also express frustration about not being recognized for the additional work being added to their already heavy responsibilities.
The survey recommended several strategies to address this. First, it’s critical to demonstrate support from the top level, ensuring that staff understand the program’s importance and see it as a priority within the facility. The interdisciplinary team (IDT) process should be visible and active, creating a sense of collaboration between those who design and train on the programs—often therapists—and those who carry them out.
When introducing programming to CNAs, it’s crucial to recognize that their workloads are already substantial. Developing relationships with them and soliciting their feedback can make a big difference. Ask whether the training provided meets their needs or if they require more support. Avoid the common pitfall of conducting a quick training, checking it off the list, and moving on without verifying confidence levels. Mentorship within nursing, including identifying nursing leaders or lead CNAs, can also help guide and support the implementation of restorative programs.
Positive reinforcement and incentives are also effective. These can take many forms, such as recognition for improved quality measures or other program outcomes. However, tying incentives to meaningful results is typically more impactful than basing them solely on the volume of programs provided.
Another significant barrier is ongoing staffing challenges, which remain a major issue. Many staff report feeling unsupported and overburdened, especially in facilities relying on shared responsibility models rather than independent restorative aides. High staff turnover and inadequate staffing levels exacerbate these concerns. Facilities may also view restorative programs as an added cost, making it harder to prioritize them.
There’s no perfect solution to staffing challenges, but keeping a long-term perspective is crucial. Facilities must understand that deprioritizing restorative programming today can lead to declines in quality measures tomorrow. Emphasizing this long-term vision can help garner support even when short-term pressures make it difficult.
For shared responsibility models, it’s vital for the therapy team to work closely with restorative nursing staff to adapt programming to fit seamlessly into the workflow. For example, range of motion programs can be built into routines like dressing, or walk-to-dine programs can be written to combine functional goals with daily activities. Similarly, transfers can be integrated into toileting or other regular care tasks to make the programming less disruptive to the staff’s workflow.
Auditing for Efficiency
Auditing for efficiency is also an essential part of this process, ensuring that programming is both effective and manageable within the facility’s constraints. By addressing these barriers thoughtfully, facilities can better position themselves to implement restorative nursing programs successfully.
In long-term care, the need to focus on efficiency is nothing new. We’re constantly evaluated on how effectively we utilize our time and resources, and the same applies to restorative nursing. Whether working within a shared responsibility model or with standalone restorative aides, it’s crucial to establish clear efficiency expectations to ensure time is being used effectively.
Efficiency standards will vary by facility, but in my anecdotal experience, I’ve seen many settings successfully aim for an efficiency rate where restorative aides provide around 60 to 75 minutes of programming per hour. This is achievable when group programming is utilized effectively, and downtime is minimized. The lack of restrictions on the percentage of group program minutes within restorative nursing offers an advantage in reaching these goals.
Some facilities, however, choose to measure efficiency differently—focusing not on the minutes of programming provided per hour but instead on how many programs or residents are seen in a day. Setting clear, realistic goals based on your facility’s specific workflow and barriers is essential. These key performance metrics not only help ensure the program runs smoothly but also provide justification for the program’s existence by demonstrating its value and impact.
Auditing for Effectiveness
Effectiveness is the real measure of success in restorative programming. Efficiency is important, but it ultimately doesn’t matter if the programming itself isn’t effective. It’s similar to therapy—being efficient means little if the outcomes, such as GG scores, are poor. In restorative programming, we need to evaluate whether the interventions are truly making a difference.
Effectiveness can be assessed in various ways. One way is to look directly at the programs: How often are the goals within the restorative programming being met? Are residents being discharged from programs because they’ve achieved their goals? This is a straightforward metric, but it doesn’t always tell the full story.
A more meaningful measure, especially for facilities focused on long-term care, is the impact on quality measures (QMs). If restorative programming is aligned with the facility’s priorities, its effectiveness can often be judged by improvements in these QMs. For example, are the restorative programs addressing the areas where the facility struggles most in quality measures? Are residents on restorative programming triggering on related QMs, and if so, is there improvement over time?
Since not everyone may be familiar with how quality measures are broken down or where that information is housed, we’ll use the next few slides to discuss QMs in detail—what they are, how they’re measured, and how restorative programming can influence them.
Quality Measures
Quality measures are metrics used to evaluate how effectively a nursing home is addressing the medical and physical needs of its residents. CMS uses a range of these measures to assess performance, with some focused on long-term residents and others on short-term residents. These measures are constantly evolving, with updates and changes occurring regularly, making it challenging to pin down a definitive list at any given time.
Quality measures are used in various ways, including public reporting. For example, they are featured on the Nursing Home Compare website, which provides a valuable resource for understanding facility performance. If you’ve never explored this, it’s worth checking out your facility or others in your area. The site includes detailed ratings based on the CMS Five-Star Quality Rating System, which evaluates facilities on state survey performance, staffing levels, and multiple quality measures. This tool is helpful for gaining insight into how a facility is performing and where there may be opportunities for improvement.
CASPER
You can review a variety of quality measures on your Casper report, which is a valuable tool for understanding facility performance. Who looks at this report depends on the staff’s role, but all clinicians should have some awareness of its key components. However, it’s usually a bigger focus for rehab directors or clinicians involved in program implementation or quality improvement initiatives.
For those unfamiliar, the Casper report is a resource that rehab directors should incorporate into their evaluation processes. It includes somewhere between 12 and 15 quality measures at any given time, depending on updates. These measures cover both short-stay and long-stay residents, providing insights into how your facility performs in critical care areas.
The report highlights what percentage of your residents are affected by specific issues, compares those percentages to state and national averages, and identifies which residents have triggered in those areas. It breaks down performance data on a large scale while also offering resident-level details. If you’ve never seen a Casper report before, it might not make much sense initially, but it’s a powerful tool for identifying trends, areas for improvement, and opportunities for targeted interventions.
Example Quality Measures
Until I show you some examples, I won’t break down exactly how quality measures are calculated. That’s an entire presentation in itself, covering what’s included in each item, risk-adjusted factors, and how percentages are determined. However, if you’re unfamiliar with the Casper report, it’s worth finding out who in your building has access to it. Both the facility-level and resident-specific Casper Reports are essential tools for evaluating your facility’s performance in these quality areas. This isn’t just important for restorative nursing—it’s also crucial for therapy as a whole.
To give you a sense of what these measures look like, I’ll share a few examples of common quality measures. These include areas like pressure ulcers, falls, bowel and bladder issues, and weight loss. These examples represent just a portion of what’s tracked. They’re not all publicly reported, nor are they the entirety of what appears on Casper, but they give a general idea.
Let’s start with the percentage of residents with pressure ulcers or injuries that are new or worse. This measure evaluates the percentage of residents with a qualifying episode who have a stage 2 to stage 4 pressure ulcer or an unstageable ulcer that is either new or worsened since admission.
Next is falls with a major injury, which tracks the number of residents who experienced a fall resulting in a major injury. CMS defines major injuries as fractures, dislocations, head injuries, altered consciousness, or conditions like a septal hematoma.
This long-stay measure identifies residents who are documented on the MDS as frequently or always incontinent for bowel and bladder issues. There are certain exclusions for this measure, but it generally captures a significant concern in long-term care.
Lastly, weight loss is measured by identifying residents who have lost either 5% or more of their body weight in the past month or 10% or more in the past six months, provided the weight loss wasn’t part of a physician-prescribed regimen.
Each of these measures has a lot of detail, but this overview provides a basic understanding of how they’re approached and calculated. Each measure gives insight into specific care areas that can be addressed through restorative programming and other interventions.
Auditing for Effectiveness, Cont.
Back to the discussion on effectiveness. If you’re evaluating restorative programming from a long-term care perspective, my recommendation is to assess its impact on the quality measures (QMs) we just discussed. Specifically, consider how your facility is performing on QMs related to restorative programming. If your facility is struggling in certain areas compared to state or national averages—or even compared to past performance—it might indicate a need to develop restorative programs focused on those specific issues.
When reviewing these QMs, ask whether residents triggering in certain areas are receiving appropriate interventions. For those triggering but not receiving restorative programming, determine if they require skilled services under rehab. If skilled care isn’t necessary, restorative services might be the appropriate alternative.
Evaluate whether the programs are effective for residents already receiving programming but still triggering. This could involve adjusting the program’s focus, intensity, or approach. Alternatively, it might mean shifting the resident to skilled care if restorative programming isn’t sufficient to address their needs.
The ultimate goal is to ensure you’re doing everything possible to help residents improve or prevent further decline, thereby reducing the likelihood of triggering on QMs. If your facility prioritizes QMs, this approach provides a structured way to audit restorative programming and maximize its effectiveness.
Restorative and the Future of Healthcare
Let's now look at how restorative fits into the future of healthcare.
Evolution of Healthcare
There’s a lot to unpack here. Healthcare, like everything else, is constantly evolving, and while we can’t predict everything, we do have some clear indicators of where things are headed. Some of these changes are exciting, particularly advancements in technology and adjustments to meet shifting demographics and patient needs. On the flip side, there’s also the reality of cost containment, where the focus shifts to maintaining quality while reducing expenses—a challenging balance for everyone involved.
One of the key concepts shaping the future of healthcare, particularly in relation to CMS, is value-based care. This model focuses on linking payment to performance rather than volume, prioritizing health outcomes and patient care while aiming to lower costs. CMS’s ultimate goal is to move entirely to a value-based payment system by 2030, which is less than six years away. This means we’ll see continued growth in programs that emphasize outcomes, quality measures, and cost efficiency.
A foundational aspect of value-based care is its emphasis on treating the whole person rather than isolated illnesses. Programs within this model are incentive-based, with payment tied to performance on quality measures. Any initiative that drives improved outcomes reduces rehospitalizations or improves quality measures at a reasonable cost will align well with this framework.
One specific program clinicians should familiarize themselves with is Institutional Special Needs Plans (I-SNPs). These are managed care models designed for long-term care residents. There are other similar plans, like D-SNPs, but I-SNPs specifically address the needs of those in institutional settings. They operate using various payment structures, including capitated models, where a fixed amount of money is allocated to cover all the resident’s needs. This approach often leaves limited funds for functional care, which can shift focus to programs like restorative nursing or other non-clinician-led initiatives.
This shift is challenging for therapists to navigate. It raises concerns about whether these models allow us to provide the best care possible. Still, this is the direction the industry is moving in, and as clinicians, we need to adapt and find ways to demonstrate our value within these constraints. The focus must remain on providing effective, efficient care and showcasing outcomes that reflect our impact.
Historically, the transition from the PPS and RUGS days taught us what didn’t work—long, inefficient sessions of low-value exercises that didn’t provide the best outcomes for patients. That approach didn’t allow us to work at the top of our license, and we know we need to avoid repeating those mistakes. At the same time, we must avoid going too far the other way, where we lose sight of the individualized, skilled care patients need.
Our challenge now is to maximize outcomes, operate efficiently, and prove our value in this shifting landscape. The better we are at delivering meaningful, measurable results, the stronger our place will be in the future healthcare model.
Next, I’ll discuss in more detail some of the components of the SNF value-based care model, including the Quality Reporting Program (QRP), Value-Based Purchasing (VBP), and the Five-Star Rating System.
Quality Reporting Program (QRP)
The Quality Reporting Program (QRP) was mandated as part of the Medicare Post-Acute Care Transformation Act (IMPACT Act) of 2014. This program requires facilities to report on a set of quality measures (QMs) each year—currently, about 15. Failure to report on these measures results in a 2% reduction in the annual payment update, emphasizing the importance of complete and accurate data submission.
For 2024, some notable updates to QRP include tracking vaccination coverage among healthcare providers and incorporating a significant new quality measure: the Discharge Function Score. This measure is particularly relevant for therapists, and if you’re not familiar with it yet, it’s time to get up to speed.
The Discharge Function Score quality measure assesses a resident's functional improvement during their stay. CMS evaluates a resident's functional status upon admission using ten core GG items, applies a complex calculation to predict where the resident should be at discharge based on prior level of function and other factors, and then measures what percentage of Part A skilled residents meet or exceed these expectations at discharge. This quality measure directly ties therapy performance to facility outcomes, making it a critical metric for therapists to understand.
While this isn’t the primary focus of this presentation, therapists are strongly encouraged to delve deeper into this measure and its implications. Understanding it is essential for aligning therapy practices with CMS expectations and ensuring success under QRP.
Value-Based Purchasing
The Value-Based Purchasing (VBP) program is structured to redistribute Medicare payments based on performance. Medicare withholds 2% of all its payments and then redistributes 60% of that pool to facilities that perform well on specific metrics. Currently, the only measure determining VBP performance is all-cause rehospitalization, but additional measures, such as the Discharge Function Score, are expected to be included in the future.
Rehospitalization is a key focus because of its significant impact on patient outcomes and costs. Approximately 25% of SNF residents are rehospitalized within 30 days of admission, a rate that underscores the need for improvement. Rehospitalizations are linked to a fourfold increase in mortality within six months, making them a critical issue for patient care. They also carry a substantial financial burden, with the average cost per rehospitalization estimated at $11,000, resulting in an annual cost to CMS of approximately $4.34 billion.
CMS considers about 75% of these rehospitalizations avoidable, attributing $3.39 billion of the annual cost to preventable factors. Common causes include pneumonia, CHF exacerbations, falls, sepsis, and kidney issues. While addressing rehospitalization in detail is a topic in itself, the takeaway is clear: reducing these events is not only beneficial for patient outcomes but also for facilities aiming to succeed under the VBP program.
The financial implications of VBP are significant. The 2% withhold from Medicare payments equates to approximately $470 million annually, which is redistributed to facilities based on their performance. As CMS introduces new metrics, such as the Discharge Function Score, facilities that excel in key quality measures will have opportunities to capture more of this funding.
5-Star Rating Program
The Five-Star Quality Rating System, developed by CMS, is designed to help consumers, families, and caregivers compare nursing homes more easily and identify areas for further inquiry. This system assigns each nursing home a rating between one and five stars, with five stars indicating much above-average quality and one star indicating much below-average quality.
The overall star rating is based on three key components: health inspections, staffing levels, and quality measures. The health inspection rating is derived from the three most recent annual inspections and any complaint investigations over the past three years. Staffing levels are assessed based on the average number of care hours provided per resident per day by nursing staff. Quality measures evaluate performance on various metrics, such as the prevalence of pressure ulcers, use of restraints, and incidence of falls.
The calculation of the overall star rating begins with the health inspection score. Adjustments are then made based on staffing levels and quality measures. If the staffing rating is four or five stars and exceeds the health inspection rating, an additional star is added. Conversely, a one-star staffing rating results in a subtraction of one star. Similarly, a five-star quality measure rating adds a star, while a one-star rating subtracts one. However, if the health inspection rating is only one star, the overall rating cannot be increased by more than one star, regardless of the other components.
For facilities designated as Special Focus Facilities (SFF), which are under close monitoring due to performance concerns, the maximum overall rating is capped at three stars until they graduate from the program.
The Five-Star Rating System is publicly available on the Nursing Home Compare website, providing a valuable tool for individuals to assess and compare facilities. However, while the ratings are informative, they should be used alongside other resources, such as facility visits, consultations with local advocacy groups, and discussions with state ombudsman programs, to make well-informed decisions about care options.
Case Study
This example highlights the practical application and impact of restorative nursing programs, particularly in transitioning care for long-term care residents post-rehabilitation. Let’s break it down:
Imagine a resident with a history of CHF exacerbation admitted to the hospital for IV Lasix treatment. Upon their return, they exhibit significant deficits in mobility and functional independence. Skilled therapy under Medicare Part A addresses these deficits, bringing the resident close to their prior functional level. However, as progress plateaus and the need for skilled therapy diminishes, the question becomes: how do we maintain these gains and prevent decline?
Transitioning to a restorative nursing program is often the answer. For this resident, a walk-to-dine program could be initiated. This type of program focuses on maintaining functional ambulation by incorporating walking into daily activities, like walking to meals. The restorative aide is provided with detailed guidance on technique, verbal safety cues, and strategies for reinforcement. For example, they might be instructed to ensure proper gait belt use, accommodate specific balance concerns, and adhere to fall prevention protocols. Competency is established through training and documented with sign-offs, ensuring the aide is equipped to implement the program safely and effectively.
In practice, well-executed restorative programs frequently not only maintain but sometimes improve functional levels, reducing the likelihood of future skilled therapy needs. When goals are met, discharge from a restorative program signals a success. However, regular screening becomes vital post-discharge to monitor the resident's status and prevent regression. Without such programs, facilities often face the frustrating cycle of progress during skilled therapy, decline post-therapy, and eventual readmission to skilled care—sometimes precipitated by preventable events like falls.
The value of restorative nursing is further reflected in the perspective of those on the frontlines. A restorative nursing assistant shared their personal satisfaction in helping residents regain mobility and independence. They emphasized the importance of patience, encouragement, and collaboration between therapists, nurses, and aides to create a supportive environment for residents. They also highlighted the importance of adapting to each resident’s condition—whether through managing pain, fostering engagement, or simply offering compassionate attention when participation in exercises isn’t feasible.
This testimonial encapsulates the heart of restorative nursing: providing consistent, meaningful care that aligns with residents' needs, preserves their dignity, and fosters their best possible outcomes. It also underscores the importance of teamwork, communication, and adaptability in making restorative programs a practical and impactful part of long-term care.
Wrap-Up
Looking back on everything we've discussed, the foundation of a successful restorative nursing program really begins with a commitment from leadership. This top-down commitment is absolutely crucial. Without it, the necessary resources, support, and prioritization simply won’t exist, and the program will struggle to succeed. While we may not have direct control over this aspect, it’s a key factor that must be in place.
Equally important is having clear expectations and accountability. Everyone involved in the program needs to understand their role. The restorative nurse must know their responsibilities, the restorative aides must be clear on theirs, and there must be someone ensuring accountability. Without these well-defined expectations, it’s easy for the program to lose focus or falter.
Another essential element is training and support, which is where we, as therapists, play a pivotal role. Training should be thorough and targeted, ensuring that everyone delivering restorative care feels confident and capable. As part of the interdisciplinary team, we’re well positioned to guide this process, ensuring that the training is not only effective but also aligns with the program's overall goals.
A successful program also requires a commitment to ongoing improvement. Whether the program is being built from the ground up or is already established, there must be a structured way to review its effectiveness and adapt as needed. Continuous improvement ensures that the program remains relevant and impactful over time.
Lastly, a robust auditing process is critical. Audits provide the data needed to evaluate how well the program is functioning, whether it’s achieving its goals, and where adjustments are needed. They also help ensure compliance with regulatory standards and support ongoing refinement of the program.
These elements—leadership commitment, clear roles, effective training, a focus on improvement, and regular audits—create the backbone of a restorative nursing program that truly improves resident care. By focusing on these priorities, we can build programs that are not only sustainable but also impactful in improving residents' quality of life.
Questions and Answers
What is the Minimum Data Set (MDS)? Is the MDS essentially Medicare?
Not quite. The MDS is an assessment tool used in long-term care facilities that are CMS providers. It’s a requirement for assessing residents at least every three months and during specific events: initial admission, annual reviews, quarterly updates, and discharge. It’s not a substitute term for Medicare but rather a critical part of the assessment and care planning process tied to CMS requirements.
Where would you typically document a resident’s refusal?
This is highly facility-specific. If you’re a contract provider, you may have a separate electronic medical record (EMR) system for therapy documentation. In-house providers might document in the same system used for nursing documentation, such as PointClickCare, which is commonly used for nursing-specific documentation. Refusals should be noted in treatment grids or nursing notes, wherever your facility tracks this type of information.
Are restorative nursing programs a reality?
Yes, restorative nursing programs are very real. While not every facility implements them fully, many do, and the level of implementation varies. In my experience, about one-third of facilities actively run restorative programs with proper documentation, reimbursement capture, and measurable impact on quality metrics. Training and documentation can be challenging, especially in facilities with limited staffing or resources, but successful programs exist even in resource-constrained settings.
Is the PDPM model related to restorative aide staffing?
No, the Patient-Driven Payment Model (PDPM) is a payment framework used by CMS to reimburse long-term care facilities. It is not directly tied to restorative aide staffing, though facilities often consider restorative programs as part of their overall care strategy under PDPM.
Are social service evaluations relevant when auditing restorative nursing documentation?
While not directly audited as part of restorative programming, social service evaluations often influence care planning, which ties into restorative nursing indirectly. They can be a valuable component in identifying resident needs and ensuring a comprehensive approach to care.
Can the Casper Report be used to audit restorative programming efficiency?
Not exactly. The Casper Report is better suited for evaluating the effectiveness of restorative programs through quality measures (QMs), such as those related to falls or pressure ulcers. Efficiency audits typically focus on the program's operational aspects, such as minutes of care provided or the number of residents served.
What is the vaccination coverage metric for healthcare workers?
CMS tracks vaccination rates for both staff and residents in long-term care facilities. This is primarily a monitoring effort rather than a direct mandate, though exemptions and specific requirements may apply depending on facility policies and state regulations.
Do you use screening forms to determine skilled care versus restorative programming?
Yes, screening forms can help, but there’s often a gray area. Determining whether care falls under skilled therapy or restorative nursing requires clinical judgment, especially for cases that don’t clearly meet the thresholds for skilled intervention.
How do you bill and document staff training on restorative programs?
When the resident is present and participating during the training, it may be billable under certain therapy CPT codes. However, time spent solely training staff without resident participation is not billable and is considered a non-reimbursable administrative duty.
Is the MDS shared with residents or families?
While the MDS is part of a resident’s medical record and could be requested, it’s not typically shared proactively. Portions of the data, such as quality measures, are publicly available through tools like Nursing Home Compare.
How can restorative nursing programming be integrated into an EMR system like Epic?
Epic and similar systems often have customizable modules that can include restorative programming. Facilities can work with their IT teams or Epic representatives to ensure documentation needs are met, including tracking refusals and program details.
What are common barriers to implementing restorative nursing programs, and how can they be addressed?
Some common challenges include staff buy-in, lack of training, and staffing shortages. To overcome these, facilities should focus on leadership support, thorough training, mentorship, clear communication, and incentives tied to outcomes like quality measures.
How can efficiency in restorative programming be measured?
Efficiency can be tracked by evaluating programming minutes provided per hour or the number of residents served within a set timeframe. Clear performance metrics should be established based on facility needs.
How do you evaluate the effectiveness of restorative programs?
Effectiveness is often gauged through outcomes, such as meeting program goals or improvements in quality measures. Facilities should regularly audit their programs to ensure they align with quality improvement initiatives and resident needs.
What is the role of the Casper Report in restorative nursing?
The Casper Report provides data on quality measures and resident outcomes. While it doesn’t audit efficiency, it can indicate areas where restorative programs may improve resident care and impact quality metrics like falls or weight loss.
Addressing these questions and effectively implementing restorative nursing can significantly improve resident outcomes and overall quality of care.
Resources
Please refer to the additional handout.
Citation
Cezat, K. (2024). How to establish a successful restorative aide program in long term care. PhysicalTherapy.com, Article 4929. Available at www.physicaltherapy.com
