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How is "restorative nursing care" defined and how is it currently provided in the United States?
Hi there! Thanks for asking about how restorative nursing care is defined, as well as how this type of care is provided within the U.S. The short answer is that restorative nursing care consists of nursing interventions designed to promote independent living and optimal quality of life. Approximately 67% of nursing homes in the U.S. provide restorative nursing care to over 1 million patients, with activities surrounding active range of motion the most-often provided form of restorative nursing care. A deep dive of my findings is presented below.
DEFINITION
In order to assess the official definition for restorative nursing care, I consulted the Center for Medicare and Medicare Services' (CMS) Minimum Data Set (MDS) Resident Assessment Instrument (RAI), which was most recently updated in October 2016 with version MDS 3.0 RAI Manual v1.14 (henceforth, 'MDS'). The MDS lays out the government-mandated process for clinical assessment within certified nursing homes, including the skilled nursing facilities (SNFs) providing care to seniors that you are targeting.
According to the MDS, a restorative nursing program "refers to nursing interventions that promote the resident’s ability to adapt and adjust to living as independently and safely as possible. This concept actively focuses on achieving and maintaining optimal physical, mental, and psychosocial functioning."
In contrast to the forms of therapy you currently provide, restorative nursing may be provided for patients who are not candidates for formal rehabilitation therapies, or it can be provided in conjunction with formalized rehabilitation programs. The MDS notes that residents can be started on a restorative nursing program upon admittance to a facility or later, when such needs arise during the course of a long-term stay. The MDS further notes that "(g)enerally, restorative nursing programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy" (pg. O-36).
The MDS lays out a set of five criteria which must be met in order to code for restorative nursing (pg. O-37):
1. Documentation: "Measureable objective and interventions must be documented in the care plan and in the medical record."
2. Periodic Evaluation: The resident's medical record must contain evidence of periodic evaluation by a licensed nurse. Where allowed by state law, progress notes written by restorative aides and countersigned by licensed nurses are sufficient.
3. Training: Training in the techniques that "promote resident involvement in the activity" is required for nursing assistants/aides.
4. Nurse Supervision: Though restorative nursing care does not require a physician's order, a registered nurse or licensed practical (vocational) nurse must supervise the activities conducted under a restorative nursing program. Licensed rehabilitation professionals or qualified therapists may conduct activities, but nursing staff is responsible for overall coordination and supervision of the program. Importantly, on page O-21, the MDS clarifies that when qualified therapists conduct activities that are not medically necessary (such as maintenance programs after discharge from rehabilitation), those services should be classified as restorative nursing care (assuming all other conditions are met).
5. Group Limit: Only groups of four or less residents per supervising helper/caregiver qualify for the restorative nursing program category.
According to the MDS, restorative nursing programs include three activities that must be provided by restorative nursing staff and seven activities that can be provided by any staff member under the supervision of a licensed nurse (pgs. O-38 and O-39):
Range of motion (passive), range of motion (active), and splint or brace assistance are the activities that must be provided by restorative nursing staff. The remaining seven activities that can be provided by other staff under nursing supervision are: bed mobility, transfer, walking, dressing and/or grooming, eating and/or swallowing, amputation/prosthesis care, and communication.
I was able to find a strong, less formal definition in a 2013 white paper written by a RN: "Restorative nursing is basically person-centered, whole-person nursing care; the kind of nursing that we practice every time we care for a resident. The difference in a formalized restorative nursing program is that activities of daily living are considered therapeutic modalities. Nursing assistants are trained to instruct, encourage, guide, and assist residents to perform self-care skills with as much independence as possible. Quality of life is a natural outcome of restorative care."
PROVISION
Since the MDS is mandated for all Medicare/Medicaid-certified nursing homes, it applies to CMS-certified SNFs. Given your specific interest in provision of restorative nursing care at SNFs, I looked into the most recent data available from CMS on provision of these services.
In the first quarter of 2017, these were the number of patients, nationally, who were coded for each type of restorative nursing care:
In order for provided care to qualify as restorative nursing under the MDS, each type of provided activity must take at least 15 minutes per 24-hour period, although this minimum 15 minutes of care can be broken up until multiple sessions over the 24-hour day. In addition, restorative nursing care must be provided for at least 6 of the last 7 days in order to qualify for reimbursement by Medicare. As such, you might be interested to know that very few of these patients receive restorative nursing care for 6 or 7 days. For each type of restorative nursing care, these are the percentages which are coded for 6 or 7 days, nationally:
Given this data, we can easily see that Range of motion (active) is the type of restorative nursing care that is most often provided in the United States.
A 2015 paper published in The Gerontologist found that while 67% of nursing homes have restorative care programs, fewer than 1/3 of long-stay residents participate in these programs.
CONCLUSION
To wrap it up, restorative nursing care consists of nursing interventions designed to promote independent living and optimal quality of life. Approximately 67% of nursing homes in the U.S. provide restorative nursing care to over 1 million patients, with activities surrounding active range of motion the most-often provided form of restorative nursing care.
I hope this helps! Thanks for asking Wonder. Please let us know if we can help with anything else!