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Healthcare Training Institute - Quality Education since 1979

Section 27
Appendices A & B

Table of Contents | NCCAP/NCTRC CE Booklet

Appendix A
Quality Indicator (QI) Based Care Planning

More and more large corporations have computer software that automatically generates a QI flag when the percentage of resident in your facility goes over that designated level set by your geographic area and level of care. 

If you do not happen to be that fortunate, here is an easy way for you to get a rough estimate as to where your activity program stands.  In an informal poll taken of Activity Directors, if 75% to 80% of your residents are coded a 2 or a 3 for Item N2 on the MDS chances are this QI will be flagged for the survey.  This flag tells the CMS Surveyor  to examine this area more in depth for the quality of the resident’s activity program provided.

Calculating Your QI Percentage and How to Delete Flags
• To calculate your percentage, first, count the total number of residents in your facility.  Then subtract the number of comatose residents.  For example, if you have 102 residents in your facility and 2 of your residents are comatose, you would be left with the number 100, for your total number of residents.
• Second,  count the number of residents you have coded as a 2 or a 3 for MDS Item N2.  This coding indicates the resident is involved less than 1/3 of the time in activities.  Let’s say for example you counted 85.
• Third, divide your total number of residents, 100, into your total of residents coded as a 2 or a 3 in Item N2, 85.  The answer is .85 .  To convert . 85 into a percentage,  move the decimal point two places to the right.  Your QI percentage is 85%. 
• Fourth, if you are over my proposed 80%, try various values for the Number of MDS Items coded 2 or 3, until you get a percent equal to or less than 80%.  Then subtract this from your actual figure coded a 2 or a 3.  In my example 85 - 80 = 5 over the amount that caused the flag. 
• Fifth, go back to your MDS and list in a notebook low functioning residents coded a 2 or a 3 in Item N2 .  In my example, select 5 with whom to try the seven ST® Activities in this Course to increase their involvement.  When their involvement is increased, change their coding from a 2 or a 3 to a 1.  There you have it... QI based Care Planning.

Appendix B
Index of Care Plan Goals and Approaches
Caps-in-a-Bowl

Goal: to drop the cap in the bowl with total physical assistance
    Approach: to move the resident’s thumb or index finger to facilitate their dropping the cap into the bowl
Bank Exercise
Goals: to do the Bank Exercise with a three-inch circular or rectangle hole; to drop the cap in the Bank with a two-inch hole; to drop three caps in the Bank with total physical assistance 
    Approaches: to use the resident’s name; to have eye contact; to request resident to drop the cap into the Bank
Color Sorting
Goals: to do Color Sorting after four demonstrations; to do Color Sorting after one demonstration; to sort three caps; to sort eight caps
    Approaches: to explain that this is a hand exercise; to explain that this is a game


Color Pattern Cards
Goals: to do a three-dot pattern card, after three to four demonstrations; to do a three-dot pattern card independently once started; to do a seven-dot Color Pattern Card independently; to do a three-dot Color Pattern Card matching the correct colored cap with the corresponding dot 
    Approaches: to demonstrate the activity; to encourage with praise; to remind them that they are helping to keep their fingers from being stiff; to lower working surface to convenient height; to provide a towel-rest for resident’s elbow or wrist 
Geometric Puzzle
Goals: to do a Geometric Puzzle with one geometric shape; to do a Geometric Puzzle with three or four geometric shapes
    Approach: to provide a Geometric Puzzle with black or dark background and a light foreground for the geometric pieces
Shape Sorting Box
Goals: to do Shape Sorting with physical assistance; to do Shape Sorting independently once started; to do Shape Sorting             independently; to do Shape Sorting with two shapes; to Shape Sorting with four shapes; to do Shape Sorting with two shapes using large holes and slots
    Approaches:  to encourage with praise; to encourage with the fun aspect of a game or a puzzle; to remind the resident that picking up and pushing the pieces through the holes is a good finger exercise
Can Rolling
Goals: to do Can Rolling independently once started; to do Can Rolling after demonstration; to do Can Rolling upon request
Approaches: to physically assist the resident in placing their hand on the can

Closing Commentary

This course has provided you with the seven low-functioning and Alzheimer’s projects I would use the most often during my consultations.  I would use them the most often because they were at a simple enough level to be appropriate for low-functioning residents’ limited physical and mental abilities.  So actually if you purchase this course and no others, you have enough from which to create a program, and more than enough when you add your own creative adaptations to my ideas. 

However, if you have an interest, to give you an overview of other courses, Volume 2 provides you with a DVD showing my interviews with residents, implementing these and other low functioning activities.  Volumes 3 and 4 provide you with DVDs in seminar format, which provides additional activity ideas and motivational approaches. 

However, here’s the problem.  The first four volumes provide you with literally hundreds of activity ideas.  However, if you don’t feel you have the time to implement these ideas for even the seven in this Course, chances are you won’t.  So, Volume 5 answers this question regarding creating time for the ideas presented in the first four volumes.

In addition to the challenge of finding time, the second challenge to implementing the hundreds of ideas presented in Volumes 1 through 4 is coping with domineering residents that have a strong, vested interest in not having you shift your program away from its possible current group emphasis, and towards one-to-ones.  Thus, Volume 6 deals with specifically how to deal with these domineering residents. 

Also, the ideas presented in the first four Volumes take volumes of time.  Of course, according to Culture Change, CNAs and other staff are to facilitate this process.  However, it goes without saying a thriving, active, dependable, substantial volunteer contingent adds a much-needed dynamic to your program.  In Volume 7, you receive a specific recruitment and volunteer organizational plan that is proven to work.

Feeling stressed after hearing the preceding?  Are you overwhelmed with Culture Change and the added responsibility of giving CNA Inservices, for example?  Volume 8 provides you with, not generic, but stress reduction techniques specifically geared to Activity Directors in long-term care.  Culture Change clearly requires staff support, and teamwork.  Volumes 9 and 10 provide you with a dynamic system that really works regarding interdepartmental relationships. 
So here’s what I think may be going on in your mind right now.  As you read this Closing Commentary, if you don’t see or feel a need for additional information, this is the only Volume you will buy, and that’s fine.  I am glad you have these seven core ideas, and hopefully you will use them. 

But the fact of the matter is… you are only fooling yourself if you feel reading this Manual and playing the CDs are enough.  Agree?  Clearly, the only way the quality of your resident’s lives will improve is to have your Activities staff and other staff, etc., actually doing Caps-in-a-Bowl, Color Sorting, the Bank Exercise, etc., with residents. 

Over my years of consulting, I would find I could give the Activity Director the most practical ideas possible.  I knew they were practical because I had implemented them with residents in his or her facility myself.  But month after month, when I would come back, I would ask, “How did Caps-in-a-Bowl go with George?  How did the Bank Exercise go with Helen?”  At the risk of sounding too negative, but to be honest, more times than what I would like to admit, the reply would be, “Oh, well, I haven’t started that yet.”  So I began to look into reasons why viable ideas were never started, and that’s how Volumes 5 through 10 evolved.  So do a self-analysis as you look at the following graph.

The above is a pie graph depicting the relative importance, I feel, of key concepts in building a really dynamic Activity program that meets the needs of all of your residents.  I very strongly feel that receiving practical ideas, which are found in the first 4 Volumes, are about 25% of what you need.  I feel of equal importance, or another 25%, is getting staff support.  However, equal to having practical ideas and staff support, as you can see, I have allocated another 25% to finding time for implementing these ideas, communicating with other staff, giving Inservices, recruiting volunteers, etc.  As you can see, 12.5% each, has been allocated to reducing stress and recruiting volunteers.

So yes, in this course, you have the seven basic ideas that will work with many of your Low-Functioning and Alzheimer’s residents.  To the right of my pie graph,  I would like for you now to make your own graph.  What topics would you put in your graph that you feel are needed to have a truly dynamic Activity Program?  How large is each section?  There are no right or wrong answers here, and the graph you create today may be different from the one you would create tomorrow.  The important thing is to think about the times you have said, as mentioned at the beginning of this Commentary, “Oh, well, I haven’t started that yet.”  By thinking beyond these seven ideas, you start to set additional priorities that will facilitate and support your implementation of activities in a Culture Change environment for the Low Functioning and Alzheimer’s residents in your facility.

The ideas in these ten Volumes represent well over ten years of my life as Activity Director, Consultant, and Seminar instructor.  Thus, they are my life’s work.  I have given you the very best that I have.  I hope you will set these ideas as a priority and give them the very best that you have.  That Low-Functioning and Alzheimer’s resident is sitting in the hall right now, or in their room, just waiting to have you discover what hidden capabilities he or she has, if you give them an opportunity for success at their level.  I wish you the best of luck, and look forward to talking to you in another Course.