Facility staff empathizes with the pain and discomfort of the resident with incontinence, but they frequently do not have the opportunity to discuss the issue and bring their practical ideas or feelings about the situation to the clinical team. We need to change that situation by bringing an interdisciplinary focus to the problem of incontinence and how to manage it to ensure that residents maintain a positive quality of life.
To obtain maximum results, the entire care team must focus on the issues related to incontinence and its influence on outcomes as well as the quality of life for all elders. Many interdisciplinary team (IDT) members and clinical leaders express frustrations over programs and plans with poor implementation; some look at the issue as a necessary evil within eldercare, few can discuss the actual causes of the problem and others still believe that incontinence is a normal part of aging and should be tolerated with the use of absorbent products.
Obviously, we need to have a unified focus on the issues surrounding urinary incontinence including proper assessments, medical consultation, staff training and education, and treatment options for elders in the post-acute care setting. Where do we begin to examine the issues and what steps can the clinical and interdisciplinary team take to resolve the barriers to quality care in this area?
NO PLUS SIDE FOR INCONTINENCE
Providing quality care is so important because of the negative implications of incontinence-both clinical and psychosocial-that can impact the outcomes of the care delivery process if it is not properly assessed and treated. The focus from the regulatory side of the industry on the treatment for urinary incontinence, as well as the change in the data CMS required on the MDS 3.0 and the Care Area Assessment process that precedes care planning, has created interest and discussion. Regulatory scrutiny has been steadily increasing.
Survey agencies in all states are responding to incontinence-related risk issues such as skin rashes or breakdowns, falls, social isolation as well as the elder's psychological well-being and social interactions within the structure of the F-tag 315 (Urinary Incontinence) requirements. Facilities must be sensitive to these issues and review the data related to those residents defined as incontinent and the programs and services used to provide quality care.
FACING THE FACTS
The change in the assessment data from the MDS 2.0 to the MDS 3.0 data set should lead your team to discuss the definitions, assessment process and treatment options that need to be coded as well as the revised definitions of the levels of incontinence that need to be reported on the data set. Incontinence is coded according to the definitions in the RAI Manual for the MDS 3.0, Chapter 3, and Section H.1 Start there with your entire team and review the definitions that are now required.
So what does your data say now? Who is coded at the various levels of urinary incontinence and how are their plans set up to address the risk factors and improve their independence and well-being? Senior managers need to address this data and question if the numbers we are reporting into the MDS 3.0 database are correct. High percentages of elders in skilled care are incontinent when the definitions in the new RAI Manual are applied. It is also important that accurate information about the elder's history with incontinence be addressed as well as the impact of the hospital treatment or other factors that would increase the level or frequency of incontinence. This information is often not available in the records and staff accepts the resident's current status as normal when it may be a considerable change from his or her normal function.
The clinical team must understand the physiology of elimination and the issues that impact changes in continence and the ability to control elimination. Start with sharing basic information about incontinence and its prevention and treatment with your frontline caregivers, nurses and other clinical staff. Discuss physician attitudes and topic knowledge with your medical director. The RAI Manual has instructions for coding incontinence and all staff should understand the basic definitions and understand that a high percentage of your residents will be coded into some level of incontinence. Check the accuracy of the facility database now. If your numbers are low you may not be coding correctly. Find a local urologist to use as a consultant and ask about the national programs available to manage incontinence. Expand your discussion to include all members of the IDT.
The clinical team must have leaders that understand the clinical and psychosocial issues connected with incontinence. I strongly recommend a newly published resource for background and reference: Managing and Treating Urinary Incontinence, Second Edition, by Diane Kaschak Newman and Alan J. Wein.2 This book presents a comprehensive clinical review of the problem as well as a thorough discussion of assessment techniques, treatment options and staff education strategies. Most clinical professionals are not trained specifically in this area and lack understanding of what causes incontinence. This is not entirely their fault because little time is spent on the problem in professional preparation programs and few exceptional resources are available to present the treatment options to the industry in general.
In her preface to the book, Newman says: “The lack of knowledge on the part of clinicians about the causes and management options, and their assumption that Urinary Incontinence and Overactive Bladder are not true medical issues, hinder the detection and treatment of these insidious conditions.”