Are your patients actively i Vinvolved in their own rehabilitation program?
Do your patients make decisions or have the opportunity to concur with other members of the health team regarding their rehabilitation plan of care and treatment?
To what degree do your patients actually participate in their own plan of care?
As health professionals and educators, we accept the premise that patients who participate in their treatment plan will be more motivated to try and reach the goals they have helped to set; however, is this a mere cliche we pretend to live by, or do we actually involve the patient? If the latter is true, what system has your agency developed to monitor this provision? Is it by patient interview, peer review, nursing audit, patient care plan evaluation, postdischarge questionnaire, or other quality control measures?
Whatever patient management system has been devised, the most successful system of health care is the system in which the patient and the health professionals establish a partnership.
If your agency or institution lacks a system for evaluating patient involvement then, perhaps, the following model may be helpful in measuring such activity using a retrospective or concurrent chart audit.
The audit tools presented below provide a method for determining if your patients with rehabilitation potential have been involved, and to what degree, in their own rehabilitation program. Perhaps the results, from applying this tool, will assist the health team in evaluating the degree of effective involvement by the patient. Such results may reveal the team's philosophy of health care, the team approach to care, patient/family expectations versus practitioner expectations, team process skills, communication an documentation skills, and patient care planning skills.
This paper identifies the following nine criteria for monitoring the quality of care in the skilled nursing facility, and to serve as an evaluative tool for analyzing patient participation and documentation of the same:
1. Patient knows reason for admission to the skilled nursing facility (SNF) (on admission).
2. Patient/family have stated own expectations for care and treatment (within 48 hours of admission).
3. Patient was advised by attending physician of medical findings and treatment plan (within 48 hours of admission).
4. Patient/family attended Patient Care Planning Conference (PCPC) (within seven days of admission/prior to discharge).
5. Patient/family have not attended PCPC, but have been provided feedback (within 24 hours of PCPC).
6. Patient/family understand and accept long-term goal(s) and/or discharge plan (within seven days of admission).
7. Self-care skills acquired during course of treatment (identify).
8. A planned teaching program has been implemented for the patient/family (at least two weeks prior to discharge).
9. Patient to be discharged according to plan.
The Patient Knows the Reason for Admission to the SNF
Patients admitted to a skilled nursing facility (SNF) are admitted for care with various health problems. Disruption in self-care and independence, requiring prescribed treatment, medication, retraining, teaching, and/or supervision by a team of health professionals usually necessitates admission.
If a patient is going to be institutionalized in a long-term health care setting for specific treatment objectives, an experience that is costly psychologically, socially, and financially, we can no longer play "games" about admitting a person to the SNF. The attending physician must work with the patient and family as a team in confronting the health problem(s). The patient must know where he/she is going, why he/she is being admitted, and the scope of the health care plan.
Preadmission patient/family contact by the SNF discharge coordinator can be a worthwhile effort for both patient and staff to assess the patient's condition, feelings about admission, knowledge of health problems, and family support system.
Patient/Family has Stated Own Expectations for Care and Treatment
Patient/family expectations of care and treatment in the SNF may have many hidden meanings and cannot be known, dealt with, or reconciled with the health team of care givers until these expectations are expressed.
Therefore, it is critical, upon admission to the SNF, that the data base be systematic and comprehensive, and such information be elicited from the patient/family during the initial assessment. If mutual understanding and planning is not shared openly and early, much time, energy, and money may be wasted due to conflicting goals and plans between the care planners and the care recipients.
Much of the literature speaks to the roles and functions of the health team members of various health care settings, but other than reference to the patient's needs/problems, there appears to be little emphasis on patient expectations and participatory planning of care. In fact, we as professionals fit the patients into our predetermined system of services, rather than assisting the patient in shaping his/her own health care program. The patient's perceptions and input must be considered significant to improving the quality of care delivered.1
Patient Advised by Attending Physician of Medical Findings and Treatment Plan
Only unusual circumstances should prevent the attending physician from informing the patient of the medical findings and the medical plan of care and treatment.
According to the federal regulations pertaining to patient rights in skilled nursing homes, it states that each patient admitted to the facility, "is fully informed, by a physician, of his medical condition unless medically contraindicated (as documented, by a physician, in his medical record), and is afforded the opportunity to participate in the planning of his medical treatment "z
The federal interpretative guidelines explain the patient rights standard in the following way: "The planned regimen of medical care, developed by the physician and based on a medical evaluation at admission 405.1123(a) and (b), is discussed with the patient. Patients are advised of alternative courses of care and treatment and their consequences when such alternatives are available. The patient's preference about alternatives should be elicited and considered in deciding on the plan of care."3
Not only is the patient's informed consent mandated by the federal regulatory agency, but in order to achieve care and treatment results, the patient must understand his/ her medical care and treatment needs as identified by the attending physician. The medical assessment and treatment plan must also be known by the other health team members, who will be directly involved in the patient's care. This allows for coordination of the total rehabilitation program so it can be planned, implemented, and evaluated on a day-to-day basis in the absence of the physician.
Patient/Family Attended Patient Care Planning Conference (PCPC)
Elderly patients, admitted to skilled nursing facilities for rehabilitation care, usually have more than one health problem; because of this, it requires more than a single practitioner to provide the care.
The physician maintains authority to admit the patient to a skilled nursing facility. "Patients in need of skilled nursing or rehabilitative care are admitted to the facility only upon the recommendation of, and remain under the care of a physician." The federal regulations further state, "The patient is seen by his attending physician at least once every 30 days for the first 90 days following admission. Subsequent to the 90th day following admission, an alternate schedule for physician visits may be adopted... This alternate schedule does not apply for patients who require specialized rehabilitative services "4
It is a common practice of many physicians to visit their patients every 30 days in order to comply with this law; however, patients are frequently in need of total health care management on an ongoing basis from day to day.
From a holistic frame of reference, patient's needs in long-term care often involve the physical, emotional, social, and spiritual components of the total human condition. It is probably safe to say that medical expertise is more concerned with the physical aspects of the patient. However, keeping all the human elements in balance requires the expertise of other health professionals to maintain the patient between the physician's onçe a month visits, and meet the patient's total needs.
The ideal approach to patient care is the team approach by the interdisciplinary team. The latter has been defined as the interaction of two or more disciplines, or specialists pooling their expertise to work toward common objectives.
The health care practitioners, who commonly comprise the interdisciplinary team in a Hillhaven SNF, include a registered professional nurse, a licensed practical nurse, a nursing assistant, activity director, social worker, dietary supervisor or dietary consultant, physical therapist, occasionally the staff development coordinator, the administrator, the medical director, and others as indicated. The patient is the central focus and motivating force behind this team gathering and, hopefully, attends the meeting whenever appropriate to become a significant member of the planning team. A family member may also be invited to attend the conference, if appropriate, for continuity purposes.
Such team conferences have come to be called Patient Care Planning Conferences (PCPC) by Hillhaven. The team's data base and identified patient problems and needs will guide them in determining which disciplines will be required to maintain membership on the interdisciplinary team for any given patient.
The frequency of the team meetings is usually on a weekly basis. All new admissions require an evaluation within seven days. Patients on intensive rehabilitation programs require biweekly evaluations. Patients whose conditions change are candidates for evaluation when the changes occur. All other patients are evaluated at least every 90 days.
The team leader/coordinator apprises the team members a day o more ahead of the scheduled meeting and informs them of the patients to be discussed; this enables them to prepare for and make the best use of the conference time.
At the conference the team members share their obtained data base, including identified patient problems and needs and any new observations. Goals, objectives, care and treatment plans (with target dates), and disciplines responsible for implementing specific aspects of the care plan must be mutually established by the team.
A systematic and uniform data base is obtained on admission by the various team members. It is from these shared assessments and identified problems that an individualized plan of care is designed for problem resolution.
Care planning, implementation, and evaluation will be as effective as the team members involved. If the patient does not become the central focus and does not understand, accept, or participate in the planning and implementing of the care and treatment, the rehabilitation process may remain static or perhaps regress rather than progress.
All patient care planning conferences are documented and become a permanent part of the patient's health record.
Patient/Family Have Not Attended PCPC but Have Been Provided Feedback
When a patient is unable to attend the patient care planning conference, he/she will require feedback from the team.
Due to each professional's orientation, one practitioner may not see the patient's concerns or problems in the same context as what may seem obvious to another discipline, ie, the nurse's experiences with the patient on the ward may differ from the experiences of a therapist in the therapy room. In fact, occasionally a patient may display such inconsistent behavior and manipulative techniques that such discovery may not be revealed until the PCPC and open communication among the team members.
When a patient is not able to attend the PCPC, and sometimes it is not possible or appropriate, one member of the team must accept the responsibility for getting back to the patient to share pertinent information, regarding the team's goals, plans, and approach. The nurse generally assumes this function as the coordinator of patient care. This will give the patient the opportunity to learn of the team plan and begin to develop his/her own plan for participation. The resulting partnership allows for a contract of mutual goals and objectives to be established.
A Planned Teaching Program has Been Implemented for the Patient/Family
The need for patient/family teaching may be the significant element of the SNF patient's restorative program in determining the length of stay/discharge from the facility. Persons who experience injury or illness often need to learn new skills in order to return to selfcare and independence. In order to help these patients bridge the gap, the health care practitioners will be needed to teach new skills in order for the patient to progress through the rehabilitation process.
The nurse may be called upon to provide such teaching. First, she must assess her patient for readiness, learning capacity, and motivation to learn. Once these learning principles reflect a green light, the nurse and other members will determine what new skills the patient will need, share them with the patient, and then design a sequential plan for teaching them, which is noted on the patient care plan. The nurse (or other health professionals) will demonstrate the needed rehabilitation procedure(s) to the patient until he/she understands and can comfortably return the demonstration with skill and confidence. The latter (satisfactory return demonstration) is necessary feedback in order to assure the teacher that learning has taken place.
Educating adults toward prevention, health maintenance, or rehabilitation places the patient/family in the learner role and is seen as being analogous to continuing nursing education. Bille states that . .the educator has an obligation to involve the learner in the process of program planning, not only to increase motivation but also to promote learning and the ultimate use of the knowledge and skills gained." This author goes on to say that "adults tend to feel committed to a decision or activity in direct proportion to their participation in (or influence on) its planning and related decision making."5 A positive attitude on the part of the learner is one of the benefits of mutual planning. The mechanism for involving the adult patient in participatory planning and the rehabilitation process is the Patient Care Planning Conference.
The teaching plan and patientlearning progress must be docuAl merited in the patient's health record. Many times, patient teaching may require family education. Family members, in order to function as an integrated unit, must all understand the problems, needs, goals, and methods of dealing appropriately with the patient to maintain continuity of care.
Self-Care Skills Acquired During Course of Treatment
Patient admitted to the SNF with rehabilitation potential may need to learn new self-care skills because of acquired losses resulting from the injury/illness that brought them to the institution.
During their care and treatment regimens within the health care setting, the nurse or other team members will identify learning needs exhibited by the patient. However, before learning can take place and teaching plans are established, the health professional must determine the patient's readiness and capacity to learn.
Educators have said that the process of learning involves three steps: (1) cognitive, (2) behavioral, and (3) attitudinal. For a patient who must change his approach to fit with some facets of living, it will not be accomplished unless all three steps or changes take place.6
A patient who is given a new concept to learn must first be able to understand what is actually being presented to him. Next he must be able to integrate this new idea into his own functional set of values and practices. For example, a person who had had a cerebral vascular accident resulting in right-sided hemiplegia, may have to perfrom activities of daily living with the left extremities or facilitate return of the dominate side by the help of assistive devices. The behavioral changes that the patient must develop occur when he starts to translate the material he has learned into appropriate actions. The attitudinal changes occur when the patient accepts the reason for change by displaying new or changed behavior.
In addition to considering these three steps in the learning process, the nurse (or other) educator must formulate teaching objectives (learning outcomes) for the identified learning needs, establish appropriate teaching methods, and develop an evaluation tool to measure the patient's progress toward objectives.
It is of prime importance for both the patient and staff that all aspects of the teaching-learning effort be documented in the patient's health record as well as on the patient care plan.
Patient/Family Understand and Accept Long-Term Goal or Discharge Plan
Goal setting in gerontological nursing has some special challenges. Few people want to give the elderly person the benefit oí the ability to make his own decisions and set his own goals. Family goals are sometimes in direct conflict with the patient's goals for himself, which places the nurse in an advocacy/teaching/counseling role. Probably the most difficult situation is that in which the patient's goals for himself are in truth, unrealistic or impossible, and he cannot accept that that is so, Certainly there must be exquisite skill and empathy involved in assisting the patient to come to the conclusion that he is, in fact, unrealistic. The fine line between protecting the patient and interfering with his human rights is a very difficult one to discern.7
Frequently, the SNF patient is so eager to return home that insight and self-evaluation become distorted or colored by this desire. In addition, many times the family member(s) feels inadequate, incapable, fearful, or lacks resources and the necessary emotional support from others to encourage the patient's return home.
In other instances, the patient may be restored to a higher level of care, but realistically may never be able to return to functional living at home. The patient may not have the capacity or willingness to understand the reason for supervised living in an institution. In such cases, the patient may display hostile, aggressive behavior and become unmanageable at times. Family members may also have a hard time accepting such a discharge plan and may develop varying degrees of guilt feelings, requiring professional counseling and guidance in order to work them through.
Patient to be Discharged According to Plan
Discharge planning is considered at the time of the patient's admission. Discharge planning is the vehicle that moves the patient to another level of care and/or environment for more independent functioning. It is also a patient management process, necessary to identify and resolve complex health problems. The patient should be the primary benefactor of the systematic approach to the health care delivery system. The various components of the system should gain optimal effectiveness by centering attention on the patient.
Discharge planning, which inherently cloaks patient care planning, is a process that should maintain a holistic health planning approach for preventive, therapeutic, rehabilitative, and activities of daily living concerns. This patientcentered approach-and partnership-will include short- and longterm goals and mobilize facility and community resources for specific patient needs.
Success of a discharge planning program rests on assessing needs and matching those needs with available resources. Discharge planning has been said to be dependent upon the following six variables:
1. Degree of illness and health;
2. Expected outcome of care;
3. Duration or length of care needed;
4. Types of services required;
5. Addition of complications; and
6. Resources available.
Summary and Conclusions
The primary task of quality assurance programs is to identify problems and deficiencies in the utilization of health services; they are further characterized by their attempt to remedy deficiencies as they are discovered.
The function of a quality assurance model is to provide a mechanism into which one may feed specific data. A model can accommodate practice situations such as individual practitioner's performance, an institutional or organizational setting, or a patient and his care.
There are three major approaches considered significant in quality assurance programs and the evaluation process. They are as follows:
1. Structure-assessment based on the evaluation of the settings used in providing care, the qualifications of personnel, and facilities and equipment available;
2. Process-assessment of the activities of health care providers; and
3. Outcome-assessment based on the end result of patient care.9
The main purpose of this paper is to share an evaluation tool with a set of criteria that requires specific data regarding two variables: (1) a patient's participation in his own rehabilitation program, and (2) the provider's activities. This model accommodates the process approach. The philosophy of this approach is based on the assumption that a PARTNERSHIP in health care (between the patient and the caregiver) results in an optimum level of patient outcome. Thus, it provides a mechanism for specific feedback data which discloses process activities.
Given et al in their study, "Relationships of Processes of Care to Patient Outcomes," stated that their findings indicated the importance and interrelationships of the patient component of process (compliance) and outcome (knowledge and perception). Of the independent variables, patients and provider, they found the patient compliance level was the most significant. Also, their study findings clearly documented that compliance is closely associated with patient's knowledge and perceptions of their disease and its therapy. As a result of their study, they suggest evaluation studies should include the patient contribution components, such as compliance, knowledge, and perception. They further recommend that more emphasis should be placed on study of the patient as an active participant in his care.10
It is hoped that this tool will be tested in many other skilled nursing facilities in order to determine its usefulness in the process approach to quality assurance either through retrospective or concurrent chart audits. (Perhaps the findings of such audit studies may lead to hypotheses for formal research studies, exploring patient and provider process activities and their relationship to patient outcomes.) Also, it is hoped that through the application of this evaluation tool in conjunction with the multidisciplinary chart audit, recommendations for improvement will lead to more patient involvement, the provider's concern for more patient involvement, and increased achievement of patients reaching mutually established rehabilitation goals.
- 1. Kirchoff KT: Let's ask the patient: Consumer input can improve patient care. J Nurs Admin 6(10):36-40, 1976.
- 2. Federal Conditions of Participation for Skilled Nursing Facilities, Federal Register: Condition 405.1121, standard (k) (3) 1974.
- 3. Federal Conditions of Participation for Skilled Nursing Facilities With Interpretive Guidelines and Survey Procedures. Condition 405.1121, (k) (3) 4, 1974.
- 4. Federal Conditions of Participation for Skilled Nursing Facilities, Federal Register: Condition 405.1123, 405.1123(b), 1974.
- 5. Bille DA: Successful educational programming: Increasing learner motivation through involvement. J Nurs Admin 9(5):37-42, 1979.
- 6. Gaines HP: Why patients learn..-Why patients fail. J Prac Nurs 29(9):22-24, 1979.
- 7. Schab M: Implementation of standards of practice in gerontological nursing. Am Health Care Assoc J 3(5):60-64, 1977.
- 8. Bristow O, Sticknéy C, Thompson S: Discharge Planning for Continuity of Care. New York, National League for Nursing, 1976, p 13.
- 9. Stergachis AS: Administration of Long Term Care Organization. University of Minnesota, 1977 (unpublished).
- 10. Given B, Given CW, Simoni LE: Relationships of processes of care to patient outcomes. Nurs Res 28(2):85-92, 1979.
- 11. Quality Assurance in Long Term Care: Commission on Professional and Hospital Activities. (The Interdisciplinary Audit Tool, adapated from CPHA.)