Function-Focused Care (FFC) Interventions

As stated in Chapter 6, Age-Related Changes in Health: To restore or maximize physical functioning, prevent or minimize decline in ADL function, and plan for transitions of care.

BACKGROUND

A.  Functional decline is a common complication in hospitalized older adults, even in those with good baseline function (Gill et al., 2010).

B.  Loss of physical function is associated with poor long-term outcomes, including increased likelihood of being discharged to a nursing home setting (Fortinsky et al., 1999), increased mortality (Boyd et al., 2005; Rozzini et al., 2005), increased rehabilitation costs, and decreased functional recovery (Boyd et al., 2005, 2008; Volpato et al., 2007). The immobility associated with functional decline results in infections, pressure ulcers, falls, a persistent decline in function and physical activity, and nonelective rehospitalizations.

C.  Functional decline may result from the acute illness and can begin before admission (Fortinsky et al., 1999) and continue after discharge. Baseline function serves as a useful benchmark when developing discharge goals (-Wakefield & Holman, 2007).

D.  Patient risk factors for functional decline include prehospitalization functional loss; the presence of two or more comorbidities; taking five or more prescription medications; having had a hospitalization or emergency department visit in the previous 12 months; depression; impaired cognition, including delirium; pain; nutritional problems; adverse medication effects; fear of falling; low self-efficacy, outcome expectations, and attitudes toward functional independence; and views on hospitalization (Boltz, Resnick, Capezuti, Shabbat, & Secic, 2011; Brown et al., 2007; Buurman et al., 2011, 2012; Inouye et al., 1999; McAuley et al., 2006; McCusker et al., 2002).

E.  Bed rest results in loss of muscle strength and lean muscle mass, decreased aerobic capacity, diminished pulmonary ventilation, altered sensory awareness, reduced appetite and thirst, and decreased plasma volume (Creditor, 1993; Harper & Lyles, 1988; Hoenig & Rubenstein, 1999; Kortebein et al., 2007, 2008). Care processes, such as curtailing mobility, imposing restraints, and tethering devices, which are associated with low mobility, lead to a higher rate of ADL decline, new institutionalization, and death (Boltz et al., 2010; Boltz, Resnick, et al., 2011; Brown et al., 2004, 2009; Zisberg et al., 2011).

F.   Interprofessional rounds support promotion of function by addressing functional assessment (baseline and current), evaluate potentially restrictive devices and agents, and yield a plan for progressive mobility (Boltz, Resnick, Chippendale, et al., 2014).

G.  Leadership commitment to rehabilitative values is essential to support a social climate conducive to the promotion of function (Boltz, Capezuti, et al., 2011; King & Bowers, 2013).

H.  FFC educational intervention on medical–surgical units has shown improvements in knowledge and outcome expectations associated with function-promoting care (Resnick, Galik, Enders, et al., 2011; Resnick, Galik, Boltz, et al., 2011; Resnick et al., 2015).

FUNCTION-FOCUSED CARE INTERVENTIONS

A.  Hospital care processes (Boltz, Resnick, Chippendale, et al., 2014; Jacelon, 2004; Resnick, Galik, Enders, et al., 2011)

  1. Evaluation of leadership commitment to rehabilitative values
  2. Interprofessional rounds that address functional assessment (baseline and current), evaluate potentially restrictive devices and agents, and yield a plan for progressive mobility
  3. Well-defined roles, including areas of accountability for assessment and follow-through for function-promoting activities
  4. Method of evaluating communication of patient needs among staff
  5. Process of disseminating data (e.g., compliance with treatment plans and functional outcomes)

B.  Policy and procedures to support function promotion (Boltz et al., 2010; Boltz, Capezuti, & Shabbat, 2011, 2015b; Kleinpell, 2007)

  1. Protocols that minimize adverse effects of selected procedures (e.g., urinary catheterization) and medications (e.g., sedative–hypnotic agents) contribute to positive functional outcomes
  2. Supporting policies: identification and storage of sensory devices (e.g., glasses, hearing aids/amplifiers), mobility devices, and other assistive devices
  3. Discharge policies that address the continuous plan for function promotion

C.  Physical design (Betrabet Gulwadi & Calkins, 2008; Boltz, Resnick, Capezuit, & Shuluk, 2014; Boltz et al., 2015b; Capezuti et al., 2008; Ulrich et al., 2008)

  1. Toilets, beds, and chairs at appropriate height to promote safe transfers and function
  2. Functional and accessible functional furniture and safe walking areas with relevant/interesting destination areas with distance markers
  3. Adequate lighting, nonglare flooring, door levers, and handrails (including in the patient room)
  4. Large-print calendars and clocks to promote orientation
  5. Control of ambient noise levels
  6. Policy on storage of glasses and hearing aids, access to sensory aids, hearing amplifiers and magnifiers

D.  Education of nursing staff and other members of the interdisciplinary team (e.g., social work, physical therapy) regarding (Boltz et al., 2010; Boltz, Capezuti, et al., 2011; Gillis et al., 2008; Resnick, Galik, Enders, et al., 2011):

  1. The physiology, manifestations, and prevention of hospital-acquired deconditioning
  2. Assessment of physical capability
  3. Rehabilitative techniques, use of adaptive equipment
  4. Interprofessional collaboration
  5. Engagement in decision-making
  6. Communication that motivates is associated with a function-promoting philosophy.

E.  Education of patients and families regarding FFC, including the benefits of FFC, the safe use of equipment, and self-advocacy (Boltz, Resnick, Chippendale, et al., 2014; Boltz et al., 2010, 2015b; Resnick et al., 2015)

F.   Clinical assessment and interventions (Boltz et al., 2015b; Boltz, Capezuti, et al., 2011; Boltz, Resnick, Chippendale, et al., 2014; Nolan & Thomas, 2008; Resnick, Galik, Enders, et al., 2011; Wakefield & Holman, 2007)

  1. Assessment of physical function and capability (baseline, at admission, and daily) and cognition (at a minimum daily)
  2. Establishing functional goals based on assessments and communication with other members of the team and input from patients
  3. Social assessment: history, roles, values, living situation, methods of coping
  4. Addressing risk factors that impact goal achievement (e.g., cognitive status, anemia, nutritional status, pain, fear of falling, fatigue, medications, and drug side effects such as somnolence) by the interprofessional team optimizes patient participation in functional and physical activities
  5. Developing discharge plans that include carryover of functional interventions and addressing the unique preferences and needs of the patient

EXPECTED OUTCOMES

A.  Patients will:

  1. Be discharged functioning at their maximum level

B.  Providers can demonstrate:

  1. Competence in assessing physical function and developing an individualized plan to promote function, in collaboration with the patient and the interprofessional team
  2. Physical and social environments that enable optimal physical function for older adults
  3. Individualized discharge plans

C.  Institution will experience:

  1. A reduction in incidence and prevalence of functional decline
  2. Reduction in the use of physical restraints, prolonged bed rest, and Foley catheters
  3. Decreased incidence of delirium and other adverse events (pressure ulcers and falls)
  4. An increase in prevalence of patients who leave the hospital at baseline or with improved functional status
  5. Physical environments that are safe and enabling
  6. Increased patient satisfaction
  7. Enhanced staff satisfaction and teamwork

RELEVANT PRACTICE GUIDELINES

Several resources are now available to guide adoption of evidence-based nursing interventions to enhance function in older adults.

  1. Agency for Healthcare Research and Quality (AHRQ). National guideline clearinghouse. Retrieved from http://www.guideline.gov
  2. McGill University Health Centre Research & Clinical Resources for Evidence Based Nursing (EBN). Retrieved from http://www.muhc-ebn.mcgill.ca
  3. National Quality Forum. Retrieved from http://www.qualityforum.org/Home.aspx
  4. Registered Nurses Association of Ontario (RNAO). Clinical practice guidelines program. Retrieved from http:/www.rnao.org/Page.asp?PageID=861&SiteNodeID=270&BL_ExpandID
  5. University of Iowa Hartford Center of Geriatric Nursing Excellence (HCGNE). Evidence-based practice guidelines. Retrieved from http://www.nursing.uiowa.edu/sites/default/files/documents/hartford/EBP%20Guideline%20Catalog.pdf

ABBREVIATIONS

ADL            Activities of daily living

FFC             Function-focused care

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 18:   Boltz, M., Resnick, B., & Galik, E. (2021) Preventing Functional Decline in the Acute Care Setting.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 281-294).  New York: Springer.

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