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Step Three: Operationalizing Individualized Care


The third step in the method is to individualize care. This section provides how-to information on three individualized care practices:

• Individualizing mornings

• Flexible dining services

• Individualizing night time routines

As incubator homes' staff used customary routines to make clinical improvements, they see the value in doing so, and learned how to make it happen. In step three, homes take what they have learned by individualizing for a few residents to expand how they individualize for all.

OBRA '87 and the implementing regulations recognized that quality of life and quality of care need to work hand-in-hand to provide the "highest practicable physical, mental, and psychosocial well-being for each resident." The law and regulations drew from the Institute of Medicine's study, Improving the Quality of Care in Nursing Homes (1986), which found a substantial body of medical evidence that individualizing care is the best way to get the best results. A seminal piece of research, by Judith Carboni (1987), a gerontological nurse researcher, documented the negative impact for residents when they felt displaced and "homeless," and the positive impact when residents' feel at home. She found that when residents feel "homeless" they experience psychic despair with severely adverse medical consequences.

Quality of life regulations and survey guidelines detail each person's right to make choices over: Activities; Schedules; Health care; Interactions with members of the community; and Aspects of his or her life that are significant to the resident. The guidelines explain that choices over schedules include waking, eating, bathing, going to bed at night, and health care schedules.

These areas of choices are incorporated into the Customary Routines section of the MDS 3.0, and into resident interviews conducted by survey teams. Surveyors are instructed to determine that homes actively seek information, are "pro-active" in assisting residents to fulfill their choices, and make residents' choices known to caregivers.

The CMS Initiative to Improve Dementia Care references these customary routines as surveyors explore the root cause of use of antipsychotics in response to a resident's distressed behaviors.

Operationalizing residents' customary routines starts small, one resident at a time, one part of the day at a time. As teams build experience and see the benefits, it is a continuous process of improvement. This final step engages staff in individualizing care as a way of maximizing the MDS and QAPI as tools for every day improvement.

Individualizing Mornings

Individualizing Mornings Tip Sheet

Individualizing Mornings Starter Exercise

Individualizing Mornings Video Clip - Hear from the team at Glenridge Living Communities in Augusta, ME, how they implemented gentle awakenings for residents as they individualized mornings according to residents' customary routines.

Flexible Dining Services

Flexible Dining Tip Sheet

Flexible Dining Services Starter Exercise

Flexible Dining Services Video Clip - Hear from the team at St. Camillus Health Center in Whitinsville, MA, how they transformed dining to maximize residents' choices, eating pleasure, and overall well-being, not to mention better clinical and financial results.

Individualized Night Time Routines

Individualizing Night Time Routines Tip Sheet

Individualized Night Time Routines Starter Exercise

Individualized Night Time Routines Video Clip - Hear how the team from Buckingham at Norwood in Norwood, NJ, learned and followed a resident's night time routines and thereby eliminated the man's distress and the resulting antipsychotic medications.

Download Step Three: Individualized Care Practices Introduction (PDF)

Starter Toolkit Home          Step One          Step Two          Step Three          Self-Assessment
Prepared by B&F Consulting for Pioneer Network's National Learning Collaborative on Using the MDS as the Engine for High Quality Individualized Care. Funded by The Retirement Research Foundation.