I find often when trying to help providers improve their quality and operational performance metrics, most of the time they are overlooking or ignoring a major foundational concept. 

Two-thirds of the clinical pathways or critical elements that CMS has sent forth often involve the incontinence ecosystem (See Figure 1). Incontinence, as stated in some of my previous articles, needs to be taken seriously when trying to improve overall quality. 

One example is falls. So many falls happen to take place during transfers to the bathroom due to residents feeling urgency, shame with leakage/odor, or lack attentive caregivers providing toileting or incontinence care. 

And do not get me wrong, I am not stating that staff are neglecting residents, I am simply stating that staff are set up for failure. The standard has been and is to change a resident every two hours. Well, when did the two hours start? Who is tracking the two hours? Where is it documented? Who even stated two hours is appropriate anyway? Do you want your mother to wait two hours to be changed out of the waste residing in her pants?

FIGURE 1: The Incontinence Ecosystem

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Just the sheer numbers are impossible. Each CNA is typically caring for around 15 residents, if they are lucky, on any given day. Even more at night. During the day, that staff member is expected  to 1. know everyone’s toileting schedule, care plan and needs, 2. toilet them on a schedule that is individualized with input from family members and the resident themselves, and 3. manage a toileting plan despite any refusal or aggressive behaviors. The numbers are just not feasible, and the task is too daunting.

I want to challenge our entire industry to look beyond the surface. Inspect your incontinence program. Assess how well you meet objectives (a free self-assessment is available from NADONA and Anavah Health titled, “DRYeR Incontinence Training Toolkit for DONs”). Start initiatives immediately to address areas that are leading to the consequences that show up in our inspection reports and impact the satisfaction, the stress levels and the energy of our frontline staff.

Richard Stefanacci, a professor and researcher in public health at Thomas Jefferson University, recently published research that found staff spend more than 56% of their shifts providing incontinence care, and it impacted about 60% of participant facilities’ turnover rates. Knowing this, it is easy to understand one simple area that can impact the foundation of senior care services. We cannot afford to ignore these facts as we search for ways to end the workforce crisis. 

In my research on this matter, I explored in depth all the critical elements and clinical pathways provided by CMS to the surveyors of the industry to be able to gauge a facility on compliance and quality of care. In doing so, I identified that incontinence care protocols were suggested to be reviewed and potentially enhanced in approximately 33% of them. Ignoring this call to action could put providers at a disadvantage when trying to thrive and survive this post-pandemic environment.

In speaking with Stefanacci about this crisis, he shares: “It is crucial to recognize that successfully improving incontinence management requires understanding the ‘why’ behind the need for change, identifying the ‘what’ can be done to enhance outcomes, and implementing an execution plan that integrates seamlessly into existing workflows. Addressing the challenges of incontinence care will result in significant benefits across the entire senior care industry, aligning with the broader goals of the Quadruple Aim.”

The “Quadruple Aim” he references is what once was referred to as the “Triple Aim” of healthcare improvement encompassing the concepts of enhancing patient experience, improving population health, and reducing costs. However, most recently this has expanded to include a fourth and crucial part of the equation to improving care, which is improving the work life of healthcare providers to include staff and clinicians.


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Smart brief solutions started to enter the picture a while back, tackling parts of the quadruple aim, but failed to meet every quadrant. Newer technologies are addressing the need to reduce caregiver burden in addition to reducing cost and improving the quality of care. When reviewing the Quality Measures used by CMS to measure the performance of a provider, poor incontinence management can impact over 60% of these areas. So, when I speak about incontinence, I don’t just mean which brief to use and how often to change it.

The ideal incontinence ecosystem should include:

Assessment and expertise

Assessment is extremely important to do it as soon as a resident arrives within your community. Not only could it impact reimbursement, but it can also impact the resident’s health, their satisfaction along with their family’s satisfaction, less burden on the front-line staff to try and figure out the needs of the individual, more individualization of the care plan along with coordinating with specialists more expeditiously. If anyone has tried to see a specialist recently, you would know that it may take months for an appointment, not to mention find one that is in network with insurances. So, the earlier the better. 

Treatments remedies and therapies

These will continue to evolve as the individual stays with you or discharges to another environment. A cyclical progression is beneficial for these as one thing may not work alone, some may work, or none may work. Also, aligning with specialists for these initiatives is imperative along with the care team at your community. The most important step here, due to this being a cyclical process, is documentation. The care team won’t know what has been tried by whom, when, and how it impacted the individual unless it is well documented in their medical record.

Scheduling and management

Voiding schedules and management of those schedules can be effective ways to reduce or eliminate incontinence episodes.

Product selection

The first choice would absolutely be a smart brief solution, but next on the list would be a quality product that offers as much wicking as possible. A warning, however, is that the best is not the most absorbent.

Monitoring, trending and anomalies

This may sound simple, but voiding patterns are an important yet overlooked predictor of wellness. Voiding patterns can inform the care team of changes in conditions that can preclude a chronic condition diagnosis or an adverse event. Knowing this information can help providers mitigate risk, elevate quality, and create efficiencies. When examining smart brief solutions on the market, data is essential. Be sure to examine what data will be available, how it will be presented, what alerts for changes of condition can be produced and what quality improvement support is offered. Don’t settle, make sure that the product supports your CQAPI process and plans.

Knowing this information, using technology, and taking this through the CQAPI process is not only beneficial to the provider, but the senior and their caregivers. 

Amy Chidester, LNHA, is a certified gerontologist and caregiver advocate,  a licensed nursing home administrator/preceptor in skilled nursing and assisted living, and provides consulting services to caregivers, operators, innovative Agetech start-ups, and educational institutions. Most recently, Amy is the founder and director of the Global Agetech Innovations Lab (GAIL).

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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