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A Good Welcome: The First 24 Hours

Tip Sheet


WHAT IT IS:
A good welcome focuses on making residents immediately comfortable, physically and emotionally. It starts with a staff person, preferably the person's consistently assigned CNA, attending to personal needs, learning the person's routines and comfort needs. Steps include offering food, helping settle into the room, introducing roommates, and providing information about services, systems, schedules and people. Having an "anchor person" at this time of high anxiety is comforting. As staff know right away about a person's routines and preferences, they can do the little things that lessen anxiety.

When residents first move in, they and their families have heightened stress both from the problems that led them to need a nursing home and from their worries about what it will be like and what the future holds. If residents have to repeat the same information to several staff because the information is not shared, their worry increases and their confidence in the home decreases.

Some required parts in the admission process can increase this anxiety and have unintended unwelcoming affect. Examples include having a resident undress for a full body skin check, asking about Do Not Resusitate orders and about which funeral home a resident wishes to use. Staging how and when these are done so that they become part of settling in will help take away some of their sting. For example, waiting until bedtime to do the skin check when the resident will be changing clothing anyway is more respectful and energy saving for the resident as well. Moving in to a nursing home can be a very energy draining process.

The first 24 hours a resident spends in a nursing home is a pivotal time. Systems to support individualized living and care from Day One help residents and families feel that they are in good hands.

WHY IT IS IMPORTANT:
You only get one chance to make a good first impression. Whether residents are planning a short or a long-term stay, making them comfortable is key to their well-being.

There is considerable evidence about practices that can alleviate transfer trauma. These practices focus on ways of anticipating and meeting people's psychosocial needs, helping them acclimate to unfamiliar surroundings, and providing immediate comfort and security.

Whether residents are entering for a short-stay or for the long-term, this is a big event many are nervous about. They need a lot of support. They also may be very tired from all the preparations relating to coming to the nursing home or from having been at the hospital before they came. When homes provide a good, warm welcome, they establish trust with residents and families that allows for forgiveness and understanding if something does not go according to plan. However, if residents and families get off to a rocky start, their distrust is heightened and any subsequent errors are magnified.

Thirty percent of rehospitalizations from nursing homes occur within a resident's first seven days. These often occur because of communication and care gaps. For example, a resident who arrives in the late afternoon may not get a functional assessment until the next day, yet the staff providing care that evening, night and the next morning need to know how well the person transfers and walks. Without that information, a resident may fall or staff may be overly cautious, initiating use of an alarm. Sleeping with an alarm on someone's first night is not only uncomfortable; it will likely contribute to a poor night's sleep, which has an impact on the resident's mood, appetite, balance, and orientation. In the fragile post-acute state, a difficult first night can have a cascading effect resulting in a rehospitalization. Instead, having consistently assigned CNAs and nurses immediately learn and share information and observations about the person's functional abilities will increase chances that care and support needs will be met abd diminishes risk of negative outcomes.

While nursing home staff have had many residents come and go, for most residents and their families, this is their first experience of being in a nursing home. They don't know how it works and they are afraid and can even be traumatized. When you remember that everything is new and unfamiliar for them, you can make a better welcome.

Residents and families will respond best to their nursing home experience when staff make it a priority to establish their sense of security and "at-home-ness" in a new living environment. Even residents who are short-stay need to maintain their daily rhythms while in a nursing home, so as to make the most of the rehabilitative services and to make a good transition back to their homes.

HOW TO DO IT:
The four foundational practices of consistent assignment, huddles, CNA involvement in care planning and QI huddles among staff closest to the resident are key to providing a good welcome. Consistently assigned CNAs provide the anchor to help residents and families through this transition time. They get to know residents and share what they know with co-workers through huddles. As partners in the care planning process they provide crucial information that gets a resident's stay off to a good start. QI huddles allow staff to share this information and problem-solve to make the adjustments needed for good coordination of care from Day One.

  • Focus on two key areas: There are two areas that are key to CNA's information gathering in the first few hours after a new resident's admission.
    • Customary routines: CNA's have an immediate need to know bedtime routines, morning routines, showering preference, and dietary choices. Outcomes improve when caregivers immediately begin using knowledge of residents' individual routines in establishing the plan of care. From the outset, have systems in place so that the staff who are caring for a new resident can take the time to get to know the resident and family. For example, CNAs at a nursing home in NY ask in the first few hours about a resident's customary routines and ensure that therapy appointments match the person's preferred schedule. They ask these five questions:
      1. How would you like to be addressed?
      2. What time do you want to shower?
      3. What time do you want to go to bed?
      4. What time would you like to wake up?
      5. What would make you comfortable?

When CNAs ask the resident about their routines and preferences, it is essential that they then are able to follow through with any requests that are made. For example if someone says they are a late riser and want a later breakfast, they have to be able to get a late breakfast. Otherwise asking the question puts the CNA in a very awkward position of having asked and then having ignored the response – the opposite of building trust!

  • Functional status: While physical therapy might not do a complete evaluation until the next day, CNAs and nurses need to know immediately how well someone is able to transfer, balance, etc. While CNAs can't "assess," they can observe and share what they see with the nurse and with the PT and the nurse doing the assessment the next day. Section G of the MDS 3.0 can be helpful in deciding what the CNA will observe while helping a new resident settle in and freshen up. Passing this information to co-workers and on-coming staff helps everyone support safe mobility.
  • Establish a welcome committee: Include people from each department who have a role in a new resident's first 24 hours. To get started, have committee members actually go through the admission process as it presently occurs. Note how welcoming the entryway used by the ambulance is. Take pictures. Are there more "no smoking" signs than "welcome" signs? Follow the path the gurney takes. Where does the attendant stop to ask for directions to the room? Are the staff in that area aware that a new resident is coming in and where the resident needs to go? Take the gurney ride to see what it looks, sounds, and feels like to be flat on one's back staring at ceiling lights while conversation happens around you, compared with sitting upright in the gurney or transferring to a wheelchair so you can see the people and environment as you travel to a room. See if you can spot ways to make improvements that make these first moments more welcoming.
  • Personalized Welcome: Make sure that the new resident has an anchor person - someone available to answer questions and to be there for them as they settle in. Build a system that allows the staff who will be caring for the new resident to be freed up to focus exclusively on providing a good welcome. For example, have the receptionist call to the neighborhood to let staff know that the ambulance has arrived. For late day arrivals, have the staff nearest the entry point know that the resident is coming so they can make the call to the assigned staff. With a quick huddle, staff can share the work load so that the CNA providing the welcome has time to help the new resident and family settle in, get to know the new resident, and meet their immediate needs. Some homes have a manager on duty who serves as the anchor person to trouble-shoot any issues in the welcoming process in tandem with the CNA. This is especially helpful for late afternoon, evening, and weekend arrivals.
  • Get information ahead of time: Gather as much information as possible about new residents before they arrive. Use nurse-to-nurse report with the discharging hospital or other care provider. Establish some common elements to be shared in these reports. Gather the resident's social history, customary routines, skin condition, functional status, equipment needs, medications, and orders.
  • Share information with staff and get information from staff: Share information about pending arrivals with staff through huddles. Have a quick huddle with the admissions coordinator and/or social worker and the staff who will be caring for a new resident, to let them know the person's social history, family, and any other useful information for care and well-being of the resident. Having this information known by the direct caregivers is vital to the new resident's well being. Use quick huddles to keep staff updated on time of arrival and any new information received. Huddle after a person has arrived so CNAs caring for the new person can share with other departments what they have learned in the settling in process.
  • Do what you say you will do: Be sure that the room actually assigned to the new resident is the room that was promised. If a rehab room has been promised, make sure the new resident isn't moved into a long-term care room. This will feel like a bait and switch to the new resident.
  • Comfort, comfort, comfort: Check with the resident upon arrival to see if they need food, to go to the bathroom, help washing up, or anything that will make this transition easier. Have information about what's available to eat, how to make a phone call, how to personalize the room and if possible, how to adjust the temperature to their liking. Invite family members to stay for meals. If a resident is going to be joining a table in the dining room, smooth the way with introductions that help people get comfortable with each other. Help establish ease among roommates by helping them get to know each other. Ask what they need for a good night's sleep and what their normal morning routine is.
  • Encourage personalizing of the room: Even if a person is only planning on a short stay, having belongings that help maintain daily routines will provide enormous comfort. If someone loves to read, or listen to music, or look at pictures of loved ones, having these personal items set up alleviates the tensions of unfamiliarity and provides environmental comfort. A welcome basket and/or a personalized welcome card or table tent on the dresser or bedside table creates a warm welcome.
  • Provide information in chewable chunks: The stress of a move makes it hard to absorb too much information. Rather than having a parade of people introduce themselves or bombarding a resident and family with packets of information, have a welcome packet that serves as an easy reference, such as a directory of key staff's names, positions, pictures, and phone numbers, and a written schedule of meals and other services.
  • Have a checklist: Have a checklist and a system for making sure that everything in the room is in working order. Note everything that has to be completed before the new resident arrives. Make this into a QA process in which every department knows its responsibilities and checks off duties completed. Be sure that all equipment and prescriptions are in place. Don't allow for any gaps in care caused by lack of orders, prescriptions, or of knowledge of the resident's needs and abilities.
  • Evaluate orders initiated in the hospital: Watch for orders for antipsychotics, alarms, sleeping pills, restraints, dietary restrictions, and medications with contraindications. Hospitals have far less time to get to know residents, are not generally focused on the care needs specific to the geriatric population, and often pay less attention to customary routines and the communication inherent in a resident's distressed behavior. Many of these orders might, with proper evaluation, be discontinued.
  • Work on improving transitions: While your admissions coordinator and the hospital's discharge planner play the primary communication roles in navigating an individual resident's transition from a hospital to a nursing home, your clinical leadership's work with the clinical leadership of the hospital will be key in establishing protocols for a better transition process. Have regular meetings with relevant hospital staff and your medical director, attending physicians, director of nursing and QA director to review cases and practices for continuous quality improvement. Part of this collaboration in building working relationships might include agreement on universal communication tools, e.g., Interact2 tools. Greater familiarity with the information to be collected and where to find it on the collection tool will result in more positive outcomes for residents with fewer omissions or gaps. Also, consider establishing a routine process check meeting with the hospital discharge staff where discussion, feedback, improvement suggestions, and debriefing of transitions that did and did not go smoothly are on the agenda.

RESOURCE:
Pioneer Network
  • Pioneer Network's website provides links to many affiliate resource organizations.

  • Pioneer Network National Learning Collaborative Webinar 6 provides information about a Good Welcome. It is available for a fee for five on-demand viewings of each webinar. All 12 webinars are also available for purchase as a set of discs, at a discounted rate. To purchase viewings of one or more of the webinars, or the entire package of 12 webinars, go to Pioneer Network store.

  • This tip sheet is from the Pioneer Network Starter Toolkit: Engaging Staff in Individualizing Care. The entire toolkit, with additional tip sheets, starter exercise and resources, is available at www.pioneernetwork.net/Providers/StarterToolkit
Advancing Excellence in America's Nursing Homes www.nhqualitycampaign.org
Data collection can help determine whether the changes being made are working, and continue to work. The Advancing Excellence in America's Nursing Homes campaign has the tools and excel sheets for collecting data on consistent assignment (are we REALLY doing this?) and on Person Centered Care (are the wishes and preferences of the residents actually being delivered, and are the direct care workers attending and participating in the care plan meetings?), as well as other organizational and clinical goals. www.nhqualitycampaign.org

B&F Consulting www.BandFConsultingInc.com
Short videos available under free resources at www.BandFConsultingInc.com

Tools to aid communication between care settings during transitions are available at www.interact2.net



Download A Good Welcome: The First 24 Hours Tip Sheet (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.
All webinars in this series are available as archived recordings at
http://eo2.commpartners.com/users/pioneerlive/all_series.php.
In addition, the full series is available as packaged DVD set in the Pioneer Network store.