The vital link: restorative nursing and therapy combine for better outcomes

Nursing Homes, June, 2004

The gentleman was diabetic and his leg had just been amputated below the knee. He arrived at Beverly Healthcare Foley, in Foley, Alabama, where extensive occupational and physical therapy strengthened his balance and helped him with transfers. He was fitted with a prosthesis. Three months later he could walk, put on his own prosthesis, and participate in community outings.

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It wouldn't have happened without restorative nursing, according to Jeff Nobles, occupational therapist and rehab coordinator at the facility. "Without restorative nursing, he would not have maintained the progress he made in therapy," says Nobles. "After being discharged from therapy, traditional nursing would have helped him out of bed, assisted him with his prosthesis, and transferred him into his wheelchair. Restorative nursing worked with him every day and he's maintained a better quality of life."

Restorative nursing, the link between therapy and nursing aimed at maintaining the gains residents achieve while receiving skilled therapy, has been receiving a lot of attention. Some facilities choose to implement a formal program using restorative nursing aides (RNAs) trained by therapists. Others prefer an informal program, with various staff in the facility performing scheduled tasks recommended by the therapist. Whichever way it happens, it seems clear that restorative nursing makes a big difference in resident outcomes and in maintaining a resident's level of independence.

Beverly Healthcare Foley has one part-time and two full-time RNAs who have been trained and certified by therapists. They perform certain activities that are an adjunct to therapy, including ambulation, passive range of motion, splint and orthotics applications, and other modalities, such as hot and cold packs. "They have taken some tasks off the CNA's plate," says Nobles. "Because they have been trained by the therapists, they know what to look for, such as skin degradation, signs of fatigue, or other problems such as pain that may be related to the orthotics."

RNAs also act as the therapists' eyes and ears. "They are in the halls," adds Nobles. "They help us monitor the resident and give us feedback."

Whether the restorative nursing program is formal or informal, communication between nursing and therapy is the key to success. "Good communication means we are addressing residents' needs first and foremost," says Nobles. "Nurses don't know what went on in therapy. Without a restorative nursing program, once therapy is over, nursing doesn't know how to follow through with what was set up for the resident. Restorative nursing has been a huge success because, through interaction, we can carry on what the patient has been doing and it doesn't all get lost."

Facilities can benefit from a restorative program, whether formal or informal, in several ways, according to Mark Besch, vice-president of clinical services at Aegis Therapies. The program can:

1. Elevate the quality of care, which allows residents to maintain the maximum level of function post-skilled therapy.

2. Provide better outcomes in terms of facility statistics and surveys.

3. Contribute to the MDS and, depending upon the timing and level of service, it might move the resident into a rehab low RUG category for a short period of time.

4. In Medicaid case-mix states, raise the case-mix calculation because residents are receiving services beyond normal nursing, which might raise the facility's Medicaid reimbursement level.

5. Contribute to the Quality Measure ratings established by CMS and, in the process, act as an effective marketing tool.

"Since PPS came in, there has been an evolution as to how restorative nursing can contribute to the low-rehab piece on the Medicare Part A side," says Besch. "There's been an increase in sophistication as to how people have been able to utilize that opportunity.

"Anyone can deliver restorative nursing," adds Besch. Indeed, some facilities without a formal program provide excellent therapy follow-up. Where there is no formal restorative program, facility leadership--the administrator, executive director, director of nurses, even the supervising nurse--should be aware of the element of restorative nursing in general nursing care and, when provided, that it is documented in order to capture those minutes on the MDS.

Doing restorative nursing well requires a staff commitment to the idea of scheduling time to follow the therapists' recommendations. On the therapy side, it's important that therapists write a restorative program that is realistic from a time perspective, understandable, and validated by the folks who will deliver it.

"When staff have extra training, they may be a little bit better at it," says Besch. "A formal program, though, allows the facility to have a higher degree of comfort in terms of proper documentation. With delivery logs in place, care can be captured for the MDS or in a case-mix state. Our experience across all our facilities is that those who have dedicated resources have more success with the quality of service being delivered."