Take control of incontinence

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.

TEAMWORK COUNTS

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.”

Chapter 4 of the RAI Manual (pages 4-25 and 4-26) has planning information about the Urinary Incontinence and Indwelling Catheter Care Area Assessment, and in Appendix C, the Care Area Resource Guide (pages C-25 to C-28) has the specific guidance for planning. This is the basic structure of the assessment, definitions, and basic information about incontinence as a care delivery problem and the related indicators and other issues that could impact the problem. Clinical and medical staffs need additional information related to the issue and that can come from clinical practice guidelines, resources as cited above or associations, such as AMDA-Dedicated to Long Term Care Medicine (www.amda.com).

MANAGING INCONTINENCE

The types of incontinence need to be addressed on assessment and during planning along with proper diagnostics, when indicated. Interventions must be individualized and specific so the care delivery staff is consistent with its interventions. A thorough discussion of the anatomy and physiology of the lower urinary tract with learning materials must be provided for the lead clinical managers as well as a review of the interventions and programs that can reverse or impact the frequency of incontinent episodes.

Urology programs throughout the country are researching and developing interventions with success. Mobile urology diagnostics are available in a few areas of the country and have been met with great enthusiasm and success. Retraining and scheduled toileting programs are being offered with exercise programs combining nursing and therapy disciplines. Restorative programs that include toileting programs with specific goals and interventions need to be developed along with strong clinical support and therapy input when necessary.

All toileting programs need to be reviewed for efficacy and specifics for individualization in the plan as well as MDS coding since the MDS 3.0 transition. The MDS 3.0 has new definitions for coding urinary continence that include the outcome of toileting programs by counting episodes of continent voiding or episodes of incontinence during the look-back period as well as the coding of the current toileting programs in item H0200-C.

The guidance and definitions in the RAI Manual Chapter 3, Section H must be discussed by the clinical and care planning team. Pay particular attention to the Planning for Care instruction on page H-3, which contains the regulatory references and a significant guidance on how to handle many issues. It lists steps to ensure that appropriate treatment is given to restore as much bladder function as possible. The IDT should use this section as a guide for discussions as well as the Care Area Resource guidance on all comprehensive assessments.

Have the clinical team do a complete evaluation of the types of incontinence products being used as well as the sizing options. A variety of product types and sizes are necessary to meet the residents' needs. Some toileting programs use a mixture of retraining or scheduled voiding programs along with some product use.

The RAI Manual also contains the Steps for Assessment of the Current Toileting Program or Trial, item H0200C in Chapter 3, page H-5. This instruction lists three requirements that must be documented for the toileting program to be included in the coding for this item. All the requirements must be met before a toileting program is identified in the plan or in this section of MDS 3.0. On page H-6 of the RAI Manual, there is a list of programs that are not to be included in the coding for this section. This is important information for the MDS nurse and the clinical leadership on the unit.

DATA TRACKING

Proactive data tracking in this area is important to identify if declines are being recorded. Look at your data now and identify the residents needing toileting programs and specific interventions as part of your quality assurance program before issues become part of the survey process. The data that we send to CMS on the MDS 3.0 data set identifies the facility's percentage of incontinent residents and the new Quality Indicators will track this issue. Many facilities underreported this issue on MDS 2.0, and it will be a regulatory and policy issue on the MDS 3.0. Database accuracy is paramount.

SUMMARY

Incontinence is a complicated issue that impacts a high percentage of our elders in skilled beds and it must be addressed by the IDT and the clinical team with specific focus on policy, CMS guidance through the F-tag 315 and the information in the RAI Manual for coding section H of the MDS 3.0 data set. Clinical professionals need to have excellent current references related to urinary incontinence and be able to access diagnostics as well as current treatment. Many new interventions are available now that were not tested or proven five years ago, therefore clinical leaders and medical directors need to identify availability in their area and begin to use high-quality consults and diagnostics to identify the cause of the incontinence as well as the proper interventions. To do so may require a consultation with urology and coordination with therapy to implement a program.

The care plan should be individualized for the toileting programs and outcome tracking is essential. If the resident does not respond to the toileting program or the cause of the incontinence is irreversible, then an individualized program of absorbent product sizing and use should be implemented. The entire team-including the resident-needs to assess, investigate options, properly document and plan care that is focused on improving the individual's continence status through programs and clinical interventions. The goal should be to interfere with as much incontinence as possible or manage the care so other risks stay low and the resident's quality of life is as positive as possible.

Leah Klusch, RN, BSN, FACHCA is Founder and Executive Director of The Alliance Training Center, Alliance, Ohio. As an educator and consultant, she has extensive experience presenting motivating programs for a variety of healthcare professionals. She can be reached at (330) 821-7616.

References

1. RAI User's Manual Updates.
2. Newman DK, Wein AJ. Managing and Treating Urinary Incontinence. Baltimore:Health Professions Press, 2008.

Long-Term Living 2011 August;60(8):34-37

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