Early Recognition of Resident Change in Condition

Mary Madison, RN, RAC-CT, CDP
Clinical Consultant – Briggs Healthcare

The TMF QIN-QIO developed this change package to assist LTC providers working directly with TMF QIN-QIO experts in improving resident care through early recognition of changes in condition.  Early Recognition of Resident Change in Condition Change Package … Version 1 was released in July.  If you do not have a TMFNetworking.org account, you will need to create a new account (free).  [TIP: Please do create a new account then bookmark this website as it has some great resources available for several networks: NHs/SNFs, Community Coalitions as well as Patients, Families and Caregivers.  It is also part of the Quality Improvement Initiative network (QIN).  TMF works to help providers navigate the rules and requirements of various federal quality improvement programs. There are more than 8000 registered users on the TMF Networks website.]  This package is a 12-page resource document.

“Recognition of physiological, mental and behavioral changes in a nursing home resident early in the trajectory of a new or worsening condition is important in treatment. Compared to younger counterparts, geriatric patients may demonstrate only mild symptoms or minor changes indicating illness. Unreported changes can lead to serious complications and outcomes; therefore, early identification of changes in a resident’s condition can help avoid rapid decline leading to an ED visit or hospitalization.

Medicare beneficiaries with three or more chronic conditions and four or more ED visits per year are defined by CMS as super-utilizers. According to AHRQ’s HCUP Statistical Brief #221, congestive heart failure and sepsis are among the top 10 reasons that super-utilizers are hospitalized. Residents with a history of frequent ED visits and hospitalizations should be monitored more closely for minor changes in condition that could lead to hospitalization. In the long-term care setting in particular, staff care for residents on a regular basis and know a resident’s normal condition. Staff are key in recognizing and reporting changes to provide early intervention and treatment. Having the tools in place to effectively identify and communicate changes are crucial to early intervention.

This change package is a resource to assist LTC providers working directly with TMF QIN-QIO experts to improve resident quality of care. It serves as a guide or menu of strategies, change concepts and actionable items that LTC facilities can choose from for assessment, disease management, advance care planning, communication and staffing, as they relate to a resident’s acute change of condition.

The TMF QIN-QIO advises against implementing all interventions at once, nor is it likely that all interventions will be applicable to your clinical setting. The included tools are best practices for LTC facilities. Some clinical details may reflect treatment and management decisions that do not apply to, or differ from, your setting. However, these tools can be adapted by filtering in the evidence, practices and characteristics that are unique to your resident population.”

This is the Table of Contents for the resource document:

Below is a sample of one of the Change Concepts and the Ideas, Tools, Tips and Resources corresponding to that concept: