Tag F741 Non-Pharmacological Approaches – Lean into Meaningful, Interests, and the Person’s Goals

CMS Tag 741 includes a long list of examples of individualized, non-pharmacological approaches to help meet behavioral health needs. We will be reviewing all of them. Food preferences, exercise, pain relief, individualizing sleep, dining, bathroom routines, preferred lighting, comfortable sound levels and assigning staff to optimize familiarity and consistency have been discussed in previous articles and now we highlight:

CMS Tag F741 Non-pharmacological approaches.

Examples of individualized, non-pharmacological approaches to help meet behavioral health needs of all ages may include, but are not limited to:

• Supporting the resident through meaningful activities that match his/her individual abilities (e.g., simplifying or segmenting tasks for a resident who has trouble following complex directions), interests, goals, and needs, based upon the comprehensive assessment, and that may be reminiscent of lifelong work or activity patterns (e.g., providing an early morning activity for a farmer used to waking up early);

Meaningful

Many of us have moved over to talking more about meaningful engagement than meaningful activities. The word activities fails us. It is not a normal word used by adults in the normal world outside of the institutional nursing home and sometimes assisted living. What is meaningful engagement to the individual. I contend we could do more to help people be meaningfully engaged when they are alone. In fact in my 12-part series Proactive Practices to Prevent Falls, meaningful personal engagement is one of the proactive prctices that can help to prevent falls.

Have fun working on collecting items that interest people.

Busywork or being occupied, like sorting buttons or folding towels for no one, ends up being boring. Whereas meaningful engagement is a winner. As we help meaningful engagement take place, we are combatting boredom which is even identified in federal regulations:

F679 Activities. Guidance. Activity Approaches for Residents with Dementia

All residents have a need for engagement in meaningful activities. For residents with dementia, the lack of engaging activities can cause boredom, loneliness and frustration, resulting in distress and agitation. Activities must be individualized and customized based on the resident’s previous lifestyle (occupation, family, hobbies), preferences and comforts.

F689 Accidents. Guidance. Approaches listed below include supervision and other actions that could address potential or actual negative interactions (one of several bullets):

• Eliminating or reducing underlying causes of distressed behavior i.e., boredom….

F880 Infection Control. Guidance. Facility staff should take measures to reduce or minimize any potential psychosocial negative effects of isolation for whom transmission-based precautions are being used. Boredom, anger, withdrawal, or depression are just some of the mood changes that could occur. The facility must proactively ensure that individualized needs (e.g., activities) are met.

Boredom can lead to more problems for people, so we have the privilege to go after boredom. In fact, in the resource listed below, I include an Oath against Boredom you could have every single staff team member take. Its powerful.

Matching individual abilities

I would recommend taking on the challenge to experiment and discover what each individual’s abilities really are. For instance, did you know most people can read at all ages and with dementia? Why? Because it is a long-term learned skill. Reading2Connect offers booklets along themes of interest that have larger print and interesting pictures. We have to help people to continue reading. It is a normal life-long ability. Some read small print with their glasses. Another note regarding language, they don’t still read. Culture change leaders like Dr. Bill Thomas taught us that when we say “and she can still read” or “still drive” we play into the stigma of dementia. The stigma is that she shouldn’t be able to still read. With “still drive” we play into the stigma of aging-she shouldn’t be able to still drive.

Interests

Do you focus on activities or interests? Notice a win here in the regulation, although the title is activities, the entire one long sentence of a regulation boils down to interests.

CMS Tag 679 Activities: The facility must provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community.

Don’t put the Cart before the Horse/Groups before Interests

Often, we put the cart before the horse, so to speak. What I’ve realized is that when we focus on interests, groups happen naturally. In this field I think we tend to jump to the group first. We often put the groups before the interests.

Say someone loves horses. Yes, pun intended but go with me. To tap into and honor that person’s interest and love of horses, have a horse come spend time at the nursing home or assisted living. Have them for a good part of the day. Observe. By the end of the day you know who the horse lovers are that’s for sure. A natural group happens. The interest in horses came first. The group happened naturally, organically, as they say. What if we identified groups this way? I think there is so much more potential for the group now to become friends, to plan their own activities around horses, etc.

As you learn individuals’ interests, potential groups naturally arise. Imagine all the examples. Four people realize they have the same genre of music in common. Two people both love to play double Solitaire. Several love cats and want to pursue having one live there. Soldiers join up to like in in-house neighborhood watch observing who comes and goes, welcoming people at the front door, ensuring they sign in, checking doors that should be locked throughout the building, etc. Sport lovers get together to watch the games.

Stick to asking “What are your interests?” And then ask, “What are some more of your interests?” There is something special about that word that we are not using to our advantage.

Talk the language of my interests and I might be interested.

Another example, watch how often people say an interest is to go outside. Many bring this up; its importance is seen by its inclusion in the MDS.  Calendars are supposed to reflect interests so intentionally planning time to help people enjoy the great outdoors could probably be there more often, particularly in warmer seasons.

Think interest-driven calendars.

Goals

Did you know “the resident’s goals” and “the person’s goals” are woven throughout federal regulations 192 times? Surveyors also ask about goals in the Resident Interview and Resident Representative Interview questions. Prior to 2016, this was not the case. If you aren’t already, step into asking individuals what their goals are. This requirement goes beyond people there for a short rehab stay whose goals of getting stronger and going home tend to be the focus.

There are many requirements that tell us to ask and discover goals for all people living or staying in a nursing home. This would make sense for, and may even be in some assisted living regulations as well.

Tag F636 Comprehensive assessment of a resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument.

Tag F550 The right to participate in the development and implementation of his or her person-centered plan of care ….

–The right to participate in establishing the expected goals and outcomes of care….

Anyone tired of making up goals for another person? Ask people their goals. Beware they are not used to being asked this so explore and help people think about it and articulate. Notice it isn’t quite normal to ask, “What are your goals for your activities?” We don’t talk like that with each other. You may want to explore how you ask. What are your goals for how to spend each day? Charlie told me “To be active”. “What are your goals for your life right now? Pat told me “To help people.”

Lean into and live up to these good regulations. Ask some different questions not because it’s a good idea but because we are supposed to. If you don’t work in the federally regulated setting, consider these excellent standards of practice. Focus on meaningful. Focus on engagement. Focus on asking what the person’s goals are. Focus on interests. See what groups begin to emerge naturally because of individuals’ shared interests.

Carmen Bowman, MHS, Regulator turned Educator of Edu-Catering: Catering Education for Compliance and Changing Institutional Culture is an activities/engagement/community life, regulatory compliance and culture change consultant.  She offers new or not-yet-qualified activity director consultation and personalized continuing education for professionals/teams/associations. At www.edu-catering.com join The Be Encouraged Blog, Become a Leader of Normal Life with the eResource GUARDIANS OF NORMAL LIFE: How Activity/ Recreation/ Engagement/Community Life Professionals can Save the World of LTC and share with your team the eBook Individualizing Medication Administration using Regulations. At the Edu-Catering YouTube channel, see documentaries that highlight changed cultures.