STREAM - Strategies Targeting Resident Elimination Assessment and Management

Empowering People to Live Full, Dignified, Quality Lives.

What Is STREAM?

STREAM (Strategies Targeting Resident Elimination Assessment and Management) is an innovative, evidence-informed quality improvement program developed by Empira to transform the assessment and management of bowel and bladder incontinence in long-term care.

Developed through a collaborative initiative involving 25 Minnesota care communities from January 2020 through June 2023, STREAM challenges traditional approaches to incontinence care by emphasizing individualized assessment, identification of underlying causes, resident empowerment, and interdisciplinary collaboration.

Although incontinence is common among older adults, it is not a normal or inevitable part of aging. Incontinence can significantly affect dignity, independence, sleep, social engagement, skin integrity, mobility, and overall quality of life.

STREAM recognizes that effective incontinence management requires more than products, schedules, and routine care practices. It requires understanding the whole person, identifying the specific causes of incontinence, and developing interventions that align with each resident's abilities, preferences, and goals.

By integrating objective assessment technologies, evidence-informed practices, staff education, and individualized care planning, STREAM helps organizations move beyond routine incontinence management toward meaningful improvements in continence, independence, and quality of life.

The goal is not simply to manage incontinence, but to identify opportunities for improvement, preserve dignity, and empower residents to achieve their highest possible level of independence.

The STREAM Cornerstones

The STREAM framework incorporates interconnected clinical and operational cornerstones that guide comprehensive assessment, individualized interventions, and sustainable improvements in incontinence care.

Know the Person

Empowering residents and promoting quality of life.

Know the Person is foundational to STREAM's person-driven approach.

Effective incontinence care begins with understanding the resident as an individual, including personal routines, preferences, functional abilities, goals, and the impact incontinence has on everyday life.

Rather than developing care plans based solely on diagnoses or standardized routines, STREAM encourages meaningful conversations with residents, families, and direct-care staff to better understand individual needs.

Key strategies include:

  • Identifying resident goals, preferences, and what matters most.

  • Understanding the impact of incontinence on daily activities and quality of life.

  • Establishing meaningful, measurable goals.

  • Observing residents during assessments to better understand abilities and needs.

  • Selecting appropriate products and individualized interventions.

Root Cause Analysis

Understanding why incontinence occurs before determining how to manage it.

STREAM challenges the assumption that incontinence should simply be accepted or managed through routine interventions.

Root Cause Analysis focuses on identifying the underlying factors contributing to bowel and bladder incontinence so that interventions address the actual causes rather than only the symptoms.

Comprehensive assessment considers medical conditions, medications, mobility, cognition, environmental factors, nutrition, hydration, and individual elimination patterns.

Key strategies include:

  • Identifying the type and potential causes of incontinence.

  • Using objective and subjective information to develop a comprehensive understanding of resident needs.

  • Incorporating assessment technology, including bladder scanners and electronic voiding-pattern assessment tools.

  • Developing individualized interventions based on identified causes.

  • Evaluating outcomes and modifying care plans as resident needs change.

Team-Based Approach

Bringing interdisciplinary expertise together to support the whole person.

Successful incontinence management requires collaboration among residents, families, nursing, rehabilitation, therapeutic recreation, dietary services, medical providers, and other care team members.

STREAM emphasizes that each discipline contributes important information to understanding the resident and developing effective interventions.

Direct-care employees play a particularly valuable role because of their frequent interactions with residents and their understanding of individual routines, abilities, and preferences.

Key strategies include:

  • Collaborative interdisciplinary assessments and care planning.

  • Meaningful involvement of residents and families in decision-making.

  • Engagement of nursing assistants and direct-care staff.

  • Integration of findings into care conferences, quality improvement activities, and daily communication.

  • Consistent evaluation and refinement of individualized care plans.

Active Engagement

Supporting mobility, independence, and meaningful participation.

Mobility, physical activity, and functional abilities play an important role in bowel and bladder health.

STREAM recognizes that maintaining or improving a resident's ability to access the bathroom, transfer safely, and participate in daily activities can contribute to more effective incontinence management and greater independence.

The program encourages interdisciplinary approaches that integrate movement, functional maintenance, environmental adaptations, and meaningful activity into everyday care.

Key strategies include:

  • Encouraging movement, exercise, and functional maintenance.

  • Supporting safe transfers and bathroom accessibility.

  • Incorporating core and pelvic floor strengthening when appropriate.

  • Evaluating equipment and environmental barriers.

  • Promoting opportunities for residents to participate in meaningful activities without unnecessary restrictions related to incontinence.

Restorative Sleep

Protecting sleep while supporting individualized nighttime elimination needs.

Restorative sleep is essential to physical health, cognitive function, emotional well-being, and overall quality of life.

Traditional nighttime care routines may unintentionally disrupt residents' sleep through unnecessary awakenings, routine rounding, or scheduled incontinence care that does not reflect individual needs.

STREAM encourages organizations to evaluate nighttime care practices and develop individualized approaches that balance elimination needs, safety, comfort, and uninterrupted sleep.

Key strategies include:

  • Evaluating nighttime care routines and unnecessary sleep interruptions.

  • Understanding individual sleep and elimination patterns.

  • Using assessment tools, including actigraphy when appropriate.

  • Developing individualized nighttime toileting and care approaches.

  • Prioritizing restorative sleep as an essential component of quality care.

Medication Alignment

Recognizing the relationship between medications, nutrition, hydration, and elimination.

Medications, dietary practices, and hydration can significantly influence bowel and bladder function.

STREAM emphasizes thoughtful medication review and individualized approaches that consider potential medication-related contributors to incontinence.

The program also encourages nonpharmacological interventions and recognizes the important role of nutrition, hydration, and bowel management.

Key strategies include:

  • Reviewing medications that may affect bowel and bladder function.

  • Identifying opportunities for medication optimization.

  • Promoting appropriate hydration and nutrition.

  • Using food-based and nonpharmacological approaches when appropriate.

  • Collaborating with medical providers, nursing, dietary services, and other disciplines to develop effective interventions.

Education and Staff Engagement

Building the knowledge and confidence needed to transform care practices.

Sustainable improvements in incontinence care require a shared understanding of evidence-informed practices and a commitment to changing long-standing assumptions.

STREAM provides education, practical resources, and opportunities for staff engagement to strengthen assessment skills, clinical decision-making, and individualized care planning.

Key strategies include:

  • Education on bowel and bladder function and types of incontinence.

  • Challenging myths and misconceptions about aging and incontinence.

  • Training on assessment tools and individualized interventions.

  • Interdisciplinary learning and sharing of successful practices.

  • Integrating STREAM principles into staff orientation, ongoing education, and organizational processes.

 

Demonstrating Measurable Impact

STREAM was developed and implemented across 25 Minnesota long-term care communities over a three-and-a-half-year collaborative initiative.

Quality Improvement Outcomes

29.58% Improvement in Worsening or Serious Bladder Incontinence

34.30% Improvement in Bladder Incontinence Without a Toileting Plan

30.06% Improvement in Bowel Incontinence Without a Toileting Plan

Statewide Quality Performance

By the end of the performance year, all 25 participating STREAM communities achieved:

  • Top 25% statewide performance for bladder toileting plans.

  • Top 30% statewide performance for bowel toileting plans.

These rankings were measured against 335 Minnesota nursing homes.

Additional Improvements in Resident Care

In addition to improvements in formal quality indicators, participating STREAM communities reported positive changes in several important areas:

  • Improved staff workflows and more efficient care practices.

  • Improved attitudes and organizational culture surrounding incontinence.

  • Increased resident participation in activities.

  • Improved resident sleep quality.

  • Reduced falls.

  • Reduced moisture-associated skin dermatitis and urinary tract infections.

  • Fewer incontinence product leaks and associated linen changes.

  • Cost savings related to incontinence products.

  • Greater use of individualized interventions rather than standardized care plans.

  • Improved documentation and interdisciplinary communication.

These improvements demonstrate the broader influence of comprehensive incontinence care on resident quality of life, operational efficiency, and organizational performance.

Challenging the Status Quo

One of the most important lessons from STREAM is that incontinence should not automatically be accepted as an unavoidable consequence of aging.

Incontinence is common, but it is not normal aging.

By questioning traditional assumptions, identifying underlying causes, and emphasizing individualized goals, organizations can move beyond routine incontinence management toward proactive care that promotes independence, dignity, and quality of life.

STREAM demonstrates that improving incontinence care can positively influence far more than elimination alone. It can create opportunities for better sleep, increased engagement, improved mobility, reduced care disruptions, and more meaningful daily experiences.

STREAM is about more than managing incontinence. It is about restoring dignity, supporting independence, and empowering people to live full, quality lives.

Learn More About STREAM

Empira is committed to sharing evidence-informed approaches that challenge traditional practices and improve the aging experience.

The STREAM Program Toolkit provides implementation guidance, assessment resources, educational materials, and evidence-informed strategies to help organizations establish comprehensive, person-driven incontinence care.