It started with a rhythm band. At the time, I was the nurse assessment coordinator and the restorative nurse, and I watched as the activity director guided a small group of residents shaking tambourines and other noise makers. She led the group in shaking their instruments above their heads, below their waists, to the left, then to the right. As the residents shimmied, I realized that with just a few more added movements, the group was doing upper body active range of motion (ROM).
Activity and restorative programs have many similarities, as well as some key differences, but when they partner, the combination can benefit the entire team.
Where activities and restorative collide
Nursing home federal regulations require that services are “furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.” Restorative programs are most often considered an intervention to maintain or improve physical functioning; however, when combined with a group activity, this also meets additional psychosocial needs. When developing a combined program and establishing individual goals for each resident, facilities should consider both physical and psychosocial aspects.
The activity and restorative partnership begins with a common goal: to keep the residents in motion. There are ten restorative program categories: passive ROM, active ROM, splint or brace assistance, bed mobility, transfer, walking, dressing and/or grooming, eating and/or swallowing, amputation/protheses care, and communication. Active ROM programs may be the easiest to develop combined restorative and activity groups because of the variety of activities that can accomplish ROM. Work with the activities director to identify a variety of available activities that can be used to complete ROM—such as parachute, ball toss, seated dancing, tai chi, modified yoga, and, of course, rhythm band, just to name a few.
Next, assign up to eight residents for each scheduled group. Both an activities staff member and a restorative aide need to be present for the entire activity to meet the requirements of the resident-to-caregiver ratio. The RAI User’s Manual states that restorative groups “do not include groups with more than four residents per supervision helper or caregiver.” For the eight residents selected, identify preferences for the available activities. Offering activities that meet the residents’ preferences and assessed needs for active ROM will help to ensure the residents’ ongoing satisfaction and motivation to continue with the group program.
Where activities and restorative differ
Unlike activity programs, restorative programs have very specific criteria that must be met. Restorative programs must be individualized to the resident’s needs, planned, monitored, evaluated, and documented in the resident’s medical record. Restorative programs may also be highly scrutinized by auditors—especially in Medicaid case-mix states where restorative programs impact reimbursement.
The restorative program must be supervised by a registered or licensed practical nurse. These programs are nursing interventions and do not require a physician’s order. Nursing assistants helping with these programs must be trained in techniques that promote the resident’s involvement in the activity.
While the activity director must track residents’ attendance and participation, the documentation requirements for activities offered are not as strict as restorative programs. The restorative aide must document the minutes the resident participated in the activity, because only days with at least 15 minutes of participation in the restorative activity can be coded on the MDS.
Most activity programs do not have a limit on the number of residents that can participate at a time. However, since restorative programs do have a limit, when a combined restorative and activity program is offered, it must meet the stricter requirements of the restorative program.
Where restorative transitions to activities
Managing the restorative caseload can be a challenge. Often, residents go through a cycle of having a decline, working with therapy to return to their prior function, transitioning to a restorative program for maintenance, and transitioning off the restorative program when goals are met, only to have another decline and repeat the cycle. However, facilities cannot keep all residents on restorative programs indefinitely. The solution is activities.
In addition to partnering with restorative for small group programs, activities can also offer a non-restorative large exercise group. This large group would not be restricted by the resident-to-caregiver ratio or the other requirements of restorative programming. This exercise group would serve as a step down from restorative exercises, avoiding a discontinuation of restorative programming with no further interventions. However, not all residents will be appropriate for the large exercise group transition, as some residents may require ongoing restorative programming based on their functional level, while others will be able to transition off restorative. The restorative nurse and clinical team will need to monitor and discuss with residents after the transition for signs of decline, voiced loss of function, and the need to restart a restorative program or to have therapy screen.
Where to go from here
The partnership may start between activities and restorative, but to be successful it must include the entire interdisciplinary team. Group restorative programs must be scheduled in advance and communicated to the nurse aides caring for each resident in the group. The nurse aides will need to plan in advance to have the resident up, toileted if needed, and ready for the group program. Programs can also be planned to help ease the workload of the nurse aides. For example, a facility noted a high volume of call lights immediately before and after the noon meal time. The team scheduled two separate restorative and activity group programs during these times, which helped to reduce the volume of call lights and engage more residents in activities.
Start small and develop your restorative programming over time. Find out what your residents prefer. Restorative and activity programs have the potential to not only improve the residents’ function and psychosocial needs, but also improve the residents’ quality of life.
For more restorative resources and ideas, check out AANAC’s Guide to Success Restorative Programs.
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