Utilizing Restorative Nursing Programs to Optimize Outcomes and Balance Costs Under PDPM

By Pam Truscott, MSN, RN, QCP, DNS-CT - May 30, 2019

With the implementation of the Patient-Driven Payment Model (PDPM) just a few short months away, you may be asking yourself what benefits restorative nursing programs will have under the new system. PDPM will focus less on the volume of therapy minutes and more on the resident’s characteristics and diagnoses. However, SNF leadership must balance the costs of the services provided while achieving successful resident outcomes. Facility leaders may want to consider how a comprehensive restorative nursing program can help them reach these goals, given that such a program can maintain or improve a resident’s function, improve quality outcomes, and reduce costly complications such as wounds.

How does your restorative nursing program fit in with PDPM?

Under PDPM, each Medicare resident will receive a rate from each of the six components (PT, OT, SLP, nursing, NTA, and non-therapy case-mix). However, restorative programs will impact only the Behavioral Cognitive Symptoms and Reduced Physical Function categories under the nursing case-mix component. If a resident achieves one of these two categories on the initial assessment (5-Day PPS), the case-mix group will be split into different case-mix indices (CMI). These indices will then be based on whether two or more restorative nursing programs are provided for at least 15 minutes a day for at least six days a week. Provided a resident’s care has met this criterion, the case mix will result in higher nursing component reimbursement. This means that appropriate restorative programs need to start upon admission, or you risk a lower CMI for those residents who fall into these two nursing classification components.


What is restorative?

Restorative nursing programs are targeted nursing programs that promote independence and safety for the resident. In alignment with regulatory requirements, an effective restorative program focuses on physical, mental, and psychosocial functioning while ensuring the resident is at the center of all care.

Activities that are provided by staff carrying out a restorative nursing program could include:

  • Range of motion (passive and/or active)

  • Splint or brace assistance

  • Bed mobility and/or walking

  • Transfers

  • Dressing and/or grooming

  • Eating and/or swallowing

  • Amputation/prosthesis care

  • Communication

  • Toileting programs (captured in section H of the MDS)



  • Range of motion (passive): A program of passive-movement exercises to maintain flexibility and useful motion in the joints of the body.

    • Mrs. W has lost range of motion in her right arm, wrist, and hand due to a cerebrovascular accident (CVA). To avoid further ROM loss and new contractures, the nursing coordinator develops instructions for providing passive ROM exercises to Mrs. W’s right arm, wrist, and hand three times per day. The nurse aides have been instructed in how to do the exercises. This plan is documented in Mrs. W’s care plan. The total amount of time involved each day in completing the passive ROM exercises is 15 minutes. The nurse aides report that there is less resistance in Mrs. W’s affected extremity when they bathe and dress her.

      • Program: Passive range of motion (PROM) to right arm, wrist, and hand for five to seven minutes, three times daily per instructions, seven days per week for three months.

      • Goal: Prevent further ROM loss to right upper extremity (RUE) as evidenced by absence of new contractures.

  • Toileting program (urinary—bladder retraining): A behavioral technique that requires the resident to resist or inhibit the sensation of urgency (the desire to urinate), to postpone or delay voiding, and to urinate according to a timetable rather than the urge to void.

    • Mrs. W has had an increase in urinary incontinence following her CVA and is now frequently incontinent. The restorative nurse assesses and evaluates Mrs. W and identifies that incontinence episodes could be reduced. A plan is developed and implemented that calls for toileting every 90 minutes while awake for a time period of one month. Then Mrs. W will be reevaluated and the plan will be adjusted as needed.

      • Program: Assist resident to the bathroom every 90 minutes while awake. The resident has requested not to be awakened during the night. The program is to be completed daily for 30 days.

      • Goal: To reduce the number of incontinence episodes.


When the two programs listed above are captured on the 5-Day PPS, Mrs. W will qualify for the restorative end-split for the Behavioral Cognitive Symptoms and Reduced Physical Function categories of the nursing component.



Implementation of restorative programming

A successful restorative program requires more than just offering services. Leadership must ensure that every restorative program is based on an assessment of the resident’s individual needs and that nursing assistants are trained in the techniques of the program. The program must be well supported with daily documentation and periodic evaluations to ensure the resident’s needs are being met. Lastly, there must be a process to audit the required components of the program.

  • Facility training of restorative nursing staff

Restorative programming includes nursing interventions and must be overseen by a licensed nurse. While CMS does not require a formal training or certification for restorative nurses, there may be state requirements. However, it is essential that the nurses overseeing the restorative program have the competency required for this position.

Nursing assistants who are responsible for providing restorative programs need to receive additional training on restorative techniques. This includes additional training on safe mobility practices, assistive devices, range of motion, and evaluation of the environment to ensure safety.

Restorative aides should be educated on the importance of early detection and good communication about changes in resident condition. Catching changes from the resident baseline is extremely important to emphasize to your team, as this means a better chance of returning the resident to a previous baseline status and of decreasing rehospitalizations.

  • Documentation to support the restorative nursing program

With any effective restorative nursing program comes the necessity of documentation excellence. A key concept to keep in mind when building a restorative nursing program and documenting the program for each resident is that the program must occur at least six days each week for at least 15 minutes each day. The only exception to this is toileting programs, which require documented evidence that the program was carried out at least four of the days in the look-back period. The clinical record and the care plan must include measurable objectives and interventions in the documentation. The clinical record should also include evaluations by the licensed nurse that identify whether the interventions and objectives are appropriate and working and whether there are any changes that need to be addressed.

Daily documentation is vital. For each resident identified, it should notate that the specific restorative program was completed and indicate any negative changes in condition resulting from restorative program involvement (e.g., pain, discomfort, shortness of breath). The impact of the restorative nursing program requires daily and continuous communication among members of the IDT to ensure that a true picture of the resident is captured in the individualized person-centered care plan and that an accurate MDS is completed. Each IDT member needs to have appropriate working knowledge of the resident’s needs, functional level, and level of care. Consider and implement a working partnership among the restorative program coordinator and/or nurse assessment coordinator, nursing department, and therapy department, and always remind your team to document, document, document.

  • Set up an auditing process and competency standards

Nursing assistants who are providing restorative interventions and completing the restorative program for residents should receive ongoing, routine competency evaluations to ensure they are properly trained. Documentation of this competency evaluation should be noted in the employee file. You may want to consider outside education resources on restorative nursing programs or consult with your therapy team to see if they are able to provide education to your staff. The restorative program should be aimed at decreasing functional decline, improving or maintaining function, getting the resident back to a prior level of function, and/or progressively increasing the resident’s functional level through meeting each objective and then setting a new objective until the highest practicable function is achieved.


How will restorative optimize outcomes and reduce cost?

While restorative has the potential to impact the nursing component under PDPM, it is also important to look at how it impacts clinical outcomes and can help reduce costs.

  • Improve quality outcomes and Five-Star ratings

An effective restorative nursing program may improve Quality Measures and impact your Five-Star QM rating, in areas such as increased ability to perform ADLs, reduction of falls with injury, and reduction of pressure ulcers. Depending on the individual resident’s needs, the restorative nursing program may also increase the resident’s ability to maintain or improve independence by helping reduce antipsychotic medication use, incontinence, pain, incidence of UTIs, and depression symptoms.

  • Reduce costs

Restorative programs can be used to provide non-skilled programs that may supplement skilled therapy the resident is receiving. For example, the resident may meet goals for transferring and bed mobility with therapy during the first two weeks of the stay, but still require a skilled level of therapy for gait training. PT may transition the resident to a restorative program for bed mobility and transfers to ensure the maintenance of these functional tasks. This can help to reduce costs of therapy services over the course of the Medicare stay.

As the director of nursing services, you should drive home the point to your team members that they can make the difference in residents’ lives through dedication, compassion, documentation, and adherence to the restorative nursing program.


Editor’s note: Do you need assistance achieving an effective restorative nursing program? Review the Guide to Successful Restorative Programs for expert information on the basics of restorative nursing programs, for tools, and for further examples.



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