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Barriers to Implementing a Successful Restorative Program

By Jessica Kunkler, MS, Staff Writer - August 01, 2018

Restorative programs are not required by federal regulation, but what is required is that facilities provide services to help residents maintain or attain their highest practicable level of physical, mental, and psychosocial well-being. Meeting this goal necessitates restorative programming. However, successfully implementing restorative programming has its own challenges. Here are some of the common ones.


Challenge One: Identifying which residents are appropriate for restorative programming

Selecting appropriate residents for restorative programming is a crucial first step. Jessie McGill, RN, RAC-MT, stresses the importance of developing a systematic way to review all residents with potential restorative needs. The first key step is to identify all potential candidates, which can be done in the following ways:

·         Identify common restorative referral sources. These include staff caring for the resident who will be able to observe and report small changes in the resident’s functional ability, such as nursing assistants, nurses, activities, the resident, and the resident’s family.

·         Review QM reports and incident reports. Specifically look for recent triggers, such as falls, choking, or new pressure ulcers.

·         Work with therapy to identify maintenance needs following a skilled therapy treatment. Not only can therapy help you to identify appropriate residents, it can also help you to determine the most appropriate restorative programming needs and exercises. Jeri Lundgren, RN, BSN, PHN, CWS, CWCN, CPT, stresses the importance of working with therapy as a resource. According to her, “If therapy can be a resource and explain the best modifications for residents to do planned exercises safely as they come off of therapy and start the program, that’s the ideal.”


Next, once you have identified residents with potential needs, you must determine whether the needs of each of these residents can be met using standard-practice nursing interventions—that is, using services or tasks that are provided during normal everyday care and that would not require a restorative program. If a resident’s needs can be met only by implementing a resident-specific intervention, then a restorative program may be appropriate. You can use AANAC's Potential Candidates for Restorative Program Tool to help you make this determination.


Challenge Two: An all-or-nothing approach

Jennifer LaBay, RN, RAC-MT, an independent consultant for JLB MDS Consulting in Pawtucket, Rhode Island, stresses the importance of approaching restorative as a case-by-case, per-resident program: “A lot of times facility staff think there needs to be a huge training or a rollout. It can be best to start small.”


1.       Look at resident care that’s already happening. She suggests looking at the care for each resident. Start with the shift that you are on. For example, who cares for Mr. Jones? Are any specific interventions already happening for him? If not, does Mr. Jones need any specific interventions? Establish what these are and review item O0500 of the RAI User’s Manual to understand whether they fit the requirements for restorative nursing and if so, how. Often, specific resident-centered care plans already have resident-specific interventions.

2.       Establish reasonable goals as part of the restorative program.If you look at the resident-specific interventions that are already happening and you realize that you are walking Mr. Jones to the privacy of the bathroom to get dressed anyway, set a related goal as part of the restorative program and then work that into your daily routine with Mr. Jones,” says LaBay. “The goal might require Mr. Jones and his helper to start a little farther away from the bathroom, which would only be a minor adjustment to the existing intervention.”

3.       Document the interventions. Once the goal is established—for example, getting Mr. Jones to walk five feet—document the intervention required and the time it takes. “If you were going to walk Mr. Jones to get to the bathroom to void or to get dressed anyway, document it,” stresses LaBay.

4.       Train all staff members who care for residents in need of restorative interventions. The training must include the specifics required by the resident—for example, how Mr. Jones is to be moved. “It may take a bit of training, but just start with the people that are working with Mr. Jones and train them on the specific intervention,” suggests LaBay.

5.       Put resident care first and the RUG score last. Especially when it comes to state case mix, people are daunted by the requirements for a RUG score, which requires an intervention six days per week in at least two disciplines for at least 15 minutes a day. “Facility staff should start the program regardless of whether they are going to get the RUG score. If Mr. Jones only needs 10 minutes, then that’s all you can do. The clinical need comes first,” LaBay stresses. Gradually, you can add interventions and the actual minutes over a 24-hour period to get the RUG score. Even though you don’t get a RUG score immediately, you will prevent avoidable decline and improve outcomes, and that will pay off financially. “Don’t overwhelm yourself with lofty program goals. Instead, creatively think, Where can we fit this in?” says LaBay.



Challenge Three: Scheduling restorative programs with staffing challenges

McGill acknowledges that despite the best of intentions for a robust restorative program, staffing challenges can be among the most difficult barriers to the program’s success. Typically, when fully staffed, the nursing facility may have one or more restorative aides who are responsible for completing all restorative tasks; however, this approach does not work when there are staffing shortages. She offers the following three recommendations for creating a new culture of restorative programming:

1.       Transition from dedicated restorative aide to shared responsibility

The restorative nurse manager and nursing leadership will need to review the restorative programs and work toward a transition from a dedicated restorative aide to nurse aides performing programs. To be successful, the programs must be integrated into the nurse aides’ work flow—for example, scheduling the passive range-of-motion (ROM) program to be performed in the morning prior to assisting the resident out of bed, or scheduling the walking program to coincide with the resident’s routine of attending morning coffee group. Using a shared-responsibility restorative model requires the entire interdisciplinary team to be involved: train activity staff to offer fun restorative group-exercise programs, which allow up to four residents per staff member. 

2.       Adjust and realign restorative programs

Restorative programs that were successful with a dedicated restorative aide may not be successful with a shared-responsibility program model. Programs that use therapy gym equipment are difficult to fit into the nurse aides’ schedules and need to be eliminated or reduced. For example, a resident who was on an upper-extremity ROM program with strengthening using the gym equipment may be transitioned into an upper ROM group program using resistant bands or weighted dowels.

3.       Graduate residents from programs to a large non-restorative exercise group

The restorative nurse manager will need to identify residents on maintenance programs who may be able to maintain current goals with a large non-restorative exercise group led by the activities department. This is a great way to graduate residents out of restorative and continue to work toward maintaining their highest level of function.


To learn more about establishing an effective restorative nursing program, check out AANAC's new podcast the LTC NAC Chat Podcast! Listen to the first episode of the Restorative Nursing Series now and check out AANAC’s Guide to a Successful Restorative Program.

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