As If by Magic: The Use of Magic as a Therapeutic Intervention at PVPA

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Hands of magician holding cards. Wearing black suit. Studio shot against black.
Hands of magician holding cards. Wearing black suit. Studio shot against black.

I have found that the use of sleight-of-hand magic as a therapeutic intervention has yielded great success and positive outcomes throughout my occupational therapy career. It provides a wonderful opportunity to facilitate functional gains with occupational skills, including pincer grasp, hand-eye coordination, in-hand manipulation, sequencing, problem solving, short-term memory, crossing the midline, activity engagement, concentration, decision making, among many others.

The use of sleight-of-hand magic as a therapeutic intervention also enhances the psychosocial aspects of our clients’ lives. Learning a magic trick that incorporates skill and technique, and then sharing it with friends, family, or other patients, encourages a social component that is vital to support a healthy quality of life. A patient’s self-efficacy immediately rises after successfully showing a magic trick to a family member who comes to visit.

Additionally, the use of magic as a therapeutic intervention breaks up the monotony that may come with a skilled nursing facility stay. It allows for a creative outlet to attempt something new or experience something novel. The use of sleight-of-hand magic as a therapeutic intervention is evidenced-based, dynamic and client-centered. I have found it essential to include magic in my therapeutic “bag of tricks”!

I was working with a gentleman who had a CABG x 3, as well as middle-stage dementia-related decreased short-term memory. He loved magic and the idea of magic tricks but doubted his ability to perform one himself. Some barriers to his ability to perform included cognitive declines and decreased short-term memory.

I graded down a simple magic trick to reflect the patient’s skill level and to compensate for his short-term memory decline. The patient successfully learned the magic trick! After successfully performing this trick, my patient was overjoyed, stating, “It actually worked, and I did it!” He looked forward to showing it to his grandson who was coming to visit later that day!

By Max Zweig, Occupational Therapist, Park View Post Acute Care, Sonoma, CA

 

A Happy Ending at Lake Village Nursing & Rehabilitation

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Johnny Johnson, age 71, has been here at Lake Village Nursing & Rehabilitation Center for about five or six months. He is one of our star patients who has come a long way.

Initially, Johnny would not participate in therapy services, until therapy was presented as an elite exercise club not offered to everyone, with a membership card that was marked off after each exercise session. Once the card was completed, then he moved up to the next level. He chose his membership gift, a steak dinner, and Therapy took him to a local diner for chicken-fried steak with his daughter.

Some of the approaches used by Lake Village therapists included:

  • Barihab to increase standing tolerance/weight bearing
  • SciFit for endurance and total body conditioning
  • Safety awareness
  • Functional activity tolerance
  • Gait training
  • Strength training

We would like to share Johnny’s story, because everyone loves a happy ending! Here is a summary in his own words of his experience at Lake Village.

Back in January, at my country house in Arkansas, I was out hunting for deer on a cool, crisp morning. I fell out of an 18-foot metal deer stand. As I was falling, I remember, I was face-first, but somehow I made myself turn over in the air and land on my back. I laid on the ground for about an hour because I just couldn’t get up. Slowly, I crawled to my four-wheeler and drove home.

I could hardly walk because of the pain, so my wife took me to the Wadley Hospital in Texarkana. It turned out I had trouble with my vertebrae and a head injury. I knew I needed rehab, so my wife asked around and heard great things about Lake Village in Lewisville. It was a good option because my daughter lived here.

I don’t remember much about this time at the Wadley Hospital or even my first few weeks at Lake Village. I was extremely sick and partly crazy. I was cursing more than a sailor, wouldn’t take my medication and wouldn’t do anything they wanted me to. They were needling me all the time with a bunch of pain meds, so I just was out of it.

When I finally felt better, I joined the rehab exercises with a Basic membership. I finally started to walk, build strength and work my mind. I was upgraded to the Gold membership, which focused on even more walking. Now, I’m almost done with Gold, so I’ll be getting a steak dinner. Next, I’ll do the Platinum and Diamond until I’m ready to go home.

The staff here are just wonderful, especially the ones in the fitness center. It’s a nice facility; everybody works with you and gets along with you. I’ve been real satisfied with this place.

Pet Therapy at Willow Bend

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Another facility incorporating pet therapy is Willow Bend Nursing & Rehabilitation, which has similar guidelines and training requirements for its therapy dogs. At Willow Bend, pet therapy consists of supervised visitations in rooms, in hallways and in the gym. The goal of this animal-assisted therapy is to improve residents’ social, emotional, physical and cognitive functioning. The handler’s course for AAT must be completed by at least one staff member, who in turn trains additional staff.

Advocates of the program indicate that AAT can be useful for increasing motivation among participants. Therapists who approach patients with a dog may be viewed as less threatening, thereby increasing rapport between patients and therapists.

Pet Therapy: Something to Bark About at Cambridge Health & Rehab!

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For many residents, the ability to nurture and care for another living being is what gives them a feeling of purpose. Before they were residents, they may have lived their lives caring for their children, their spouses and their communities. Having to give up their caretaking duties and also rely on someone else to take care of their own needs often leads residents to feel as though they are no longer needed.

Enter the pet therapy program at Cambridge Health & Rehabilitation. Through this program, residents are able to interact with trained therapy dogs that allow them to be caregivers once again. The results are nothing short of magical for residents who may have previously experienced feelings of hopelessness, unhappiness and stress.

By caring for and visiting with therapy dogs, our residents:

  • Experience joy and laughter throughout daily life
  • Have a greater ability for newcomers to meet new friends
  • Are more likely to engage in exercise and activities
  • Have an avenue for touch
  • Gain feelings of self-confidence, self-esteem and achievement
  • Are able to reduce stress
  • Have a means to cope with depression and loss
  • Are more likely to communicate

Our patients look forward to their visits with therapy dogs as though they are expecting a visit from family. One patient remarked, “This dog reminds me of my dog at home!” while another commented, “I was proud to be able to stand and walk the dog today!” It’s clear that the residents and dogs have a mutually beneficial relationship that fosters feelings of companionship and self-worth.

To be considered for our therapy program, dogs must be gentle, non-aggressive, sociable and adaptable to new environments. As specially trained working animals, these dogs are tested, observed and certified before they are given the green light to work with people.

Although it may be difficult to quantify the benefits of pet therapy with hard scientific facts, we have enough anecdotal evidence to show that the program is a must at Cambridge Health & Rehabilitation. We welcome any inquiries from facilities looking to implement a similar program at their locations.

Compliance Corner

Compliance Corner

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Compliance Corner

2016 MSCA Process Updates and the Importance of Medicare Meetings

Ironically, the old adage that does not change in healthcare is “The only thing that is constant is change.” Year two of the IRO on-sites is now over, and there is always a lot we can take away as an organization from these audits. Oftentimes, it makes us reflect upon the processes that we have in place in both operations and compliance, and how effective they are in preparing our facilities for success.

With that said, there will be some tweaks in the works for the 2016 MSCA compliance auditing process to help capture where we may be vulnerable and also to mimic the process of IRO on-sites more closely. Also, one of the areas we always focus on but that still needs constant fine-tuning is our Medicare Meeting and how we, as an organization, can be better. A question you may want to ask yourself when looking in the proverbial mirror is, “How can I be better?”

MSCA Process Updates

The MSCA process for 2016 will remain relatively the same in terms of the number of audits and the types of things we will be auditing. One of the things that will be changing is how we select some of the claims we will be auditing. The biggest change with the claims selection process comes with our “High Risk” facilities. We will still have a split audit for these buildings, but for the first portion of the audit, we will use Length of Stay reports found in PCC to help guide the claim selection process. This makes sense, as we know and have learned (sometimes the hard way) that our claims with longer lengths of stay are the most vulnerable.

The other things that are changing are the additions of therapy treatment observations and DOR interviews during the on-site portions of the MSCA. This will closely mimic what is done during IRO visits and will help us not only prepare for possible IRO selections, but also help us at the facility level to identify possible root-cause weaknesses in our processes. Your compliance partners will inform their facilities of the changes and will be happy to go over these new processes with you and your facility teams should there be any questions.

Importance of the Medicare Meeting

The Medicare Meeting is always an emphasis to look at and improve upon, even in the best of our meetings. This year’s IRO on-site helped us identify some areas where we can definitely improve not only as an IDT, but as DORs.

For one, make your voice known. We found yet again, the best meetings were the ones where IDT members were fully engaged and challenging each other, asking the right questions about patient care, discharging of therapy disciplines, appropriate lengths of stay, etc. So, what if you notice your IDT members are relatively quiet or things are going a little too smoothly and everyone agrees completely with everything? Ask yourself if all the right questions have been asked and key factors have been analyzed regarding the patient’s care. Take the onus and help engage your fellow IDT members if need be.

The improvement in use of standardized testing was great to see and was noticed by the IRO. However, let’s not lose sight of the fact that our IDT members may not be as well-versed in these tests as you may be. Take the time to help educate and explain to the team what these tests are and how the scores impact the patient. The more they know, the more relevant the information and conversation you will have with standardized testing.

Finally, we all have full days and run busy programs, relying greatly on our therapy staff to support us. Gathering information from the therapy staff about resident care is vital to providing pertinent information during the Medicare Meeting. I think it’s safe to say that we all do that in one form or another, but how sure are we the information we are providing during the Medicare Meeting is being captured in the actual therapy documentation? Unfortunately, it was a hard lesson learned this year, that that situation can occur. So I ask all of you not to rest on your laurels and your past successes, but rather to re-evaluate your current systems to answer the question, “How can I be better?”

What Is a Clinically Complex Patient?

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A clinically complex patient is described as having co-morbidities of several medical conditions, often with a cardiopulmonary overlay that significantly compromises the patient’s ability to function. Most of these patients have primary diagnoses that require nursing intervention and often have the presence of exacerbation and/or remission. In addition, there are often other challenges, such as low activity tolerance, lack of participation and low motivation.

The most common conditions among medically complex patients include but are not limited to:

  • Respiratory conditions (pneumonia, COPD/chronic bronchitis, emphysema, asthma, atelectasis)
  • Cardiovascular conditions (CHF, hypertension)
  • Metabolic conditions (renal failure, diabetes)
  • Infection (sepsis, systemic inflammatory response syndrome)

Due to the medical conditions present, therapy will need to have strong documentation to justify the need for intervention and the patient’s ability to tolerate intervention, especially at higher intensities. Note: Patients who are clinically unstable (uncontrolled hypertension/hypotension, arrhythmia, angina, etc.) will need to have their conditions stabilized prior to rehabilitation intervention.

Evaluation Considerations

When completing an assessment for a clinically complex patient, be sure to capture information regarding the patient’s respiratory function, cardiovascular function, endurance, polypharmacy and ability to tolerate functional activity. Assess vitals and labs such as heart rate, respiration rate, blood pressure, O2 SATs, pain, mental status and any other labs or pharmacology, and measure vitals at rest and with activity (compare to norms for that age group). Use a Dyspnea Scale such as the Perceived Exertion Scale (modified Borg scale) to record the patient’s respiratory function with and without activity.

When reviewing lab work, remember that normal lab values in the elderly are compromised by the high prevalence of disease and by age-related physiologic and anatomic changes, and drugs may alter the results of lab tests. Use appropriate references to determine normal values for each patient.

Be sure to capture current level of function during activity in the documentation, including percentage of trials, cueing levels and any outcomes from formal assessments (six-minute walk test, 30-second chair stand, arm curl, two minutes step in place, RPE, seated step test, senior fitness test, functional reach, incentive spirometry, etc.). Also include measurements of the patient’s physiological response to the activity, such as oxygen saturation levels, pulse, respiration and perceived exertion.

Establishing Goals

Determine how all of the information collected can be captured in functional goals. Goals need to be measurable, functional and sustainable. Goals for this population need to address:

  • Improving the patient’s ability to perform activities of daily living
  • Decreasing symptoms identified in evaluation that impact function
  • Increasing endurance and strength
  • Improving the patient’s quality of life
  • Decreasing negative consequences of deconditioning
  • Returning the patient to prior level of function (or beyond)
  • Include the patient and family to determine functional goals for discharge
  • Implement small, incremental goals that will be updated frequently for this population (modification of the goals and treatment plan are skilled services).

Skilled Intervention Considerations

  • Depending on the diagnostic results of each patient, treatment approaches will vary and need to tie back to the established goals.
  • Provide treatment during normal daily routines to help conserve energy, especially at the beginning of intervention.
  • Monitor vitals before, during and after activity (know the contra-indications for exercise with this population).
  • Reduce patient anxiety by providing treatment in their room or less active areas.
  • Keep therapy sessions short, or split the treatments as vital signs and patient ability dictate.
  • Make treatment modifications as the patient’s clinical tolerance dictates. Document the modifications and fluctuations in treatment approaches.
  • Integrating rest and assessment into treatment is critical for medically complex patients and is part of the provided treatment session.
  • Assessment of a patient’s condition, changes in recovery time, functional activity tolerance and mentation, assessment of vitals, and addressing levels of pain are all skilled interventions and essential to patients’ recovery.

Skilled Interventions

  • Postural management for pain relief and/or respiratory ease
  • Positioning for adequate respiration at rest and with activity
  • Breathing techniques at rest and with functional activity (resistive breathing, diaphragmatic and pursed-lip breathing)
  • Train coordination of breathing while speaking and other activities
  • Training and education in energy conservation for activity and ADLs (task segmentation, pacing, work simplification)
  • Provide support surfaces for pressure relief in bed and wheelchairs
  • Train clinically appropriate transfers
  • Ensure adequate hydration
  • Train airway protection strategies
  • Train safe coughing techniques
  • ROM exercises for improved strength, flexibility and coordination and peak work capacity
  • Head and neck exercises
  • Aerobic conditioning training
  • Balance and gait training
  • Integration of modalities
  • Psychosocial adaptations
  • Community reintegration
  • Home environment assessments
  • Patient education
  • Repeat diagnostics to compare patient function (six-minute walk test, RPE, Dyspnea Scales, etc.)

Progress Reports

A progress report shows how the patient is responding to intervention and their progress toward the goals, and it justifies continued skilled intervention for the patient. Continuation of services with no or minimal progress in a progress report period must be supported in the documentation. The justification statement also addresses how progress on the treatment goals has helped to move the patient closer toward meeting those goals. Justification statements for continuation of therapy services need to be written at least weekly.

Remember: Describing how the medical history impacts current functional status helps determine the circumstances that led to the need for skilled intervention.

The need for skilled intervention must make sense, support medical necessity and tie back to the goals. It is important to ask what could happen if skilled rehabilitation services were not initiated, such as safety risks and possible further decline.

The skills and techniques that can be taught to this population will improve not only the quality of their functional abilities, but also their quality of life.

 

Meet Our 3rd Quarter SPARC Winner!

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Congratulations to our 3rd Quarter recipient of the SPARC award, Cindy Syrovatka! Cindy is an OT Student at The University of South Dakota, and will graduate in December 2015. Her inspiration and drive for occupational therapy stems from the SPARC Winner - Cindyexample and guidance of peers, family and educators she has experienced. Read her story below, and we think you will agree she is a most deserving recipient of our support.

Cindy’s Essay

A devoted 65-year-old rural farmer with Scleroderma and Type II Diabetes returned to his hospital room after a surgical procedure. The kind gentleman’s comorbid diseases were worsening, and therefore the physician decided to surgically remove all of the farmer’s toes on both feet. The doctor told the farmer he would never be able to walk again. The farmer understood the procedure had to be done, but since he was a dedicated farmer, he worried he would not return to daily farming with his son. The farmer was able to go home with home health services after a few nights stay. Luckily, the farmer had a supportive family who lived nearby, of which one 12-year-old granddaughter invested her time in helping her grandparents daily as needed. The farmer explained to his granddaughter how sad he was that he was not going to be able to walk anymore, which meant he wasn’t going to be able to get in the shower alone, make supper, or get a glass of water, but more importantly, wasn’t going to be able to complete any farming activities. The passionate farmer had tears in his eyes while talking to his granddaughter and depression set in over time. Then, one day, while the granddaughter was at the farmer’s house, a lady came in to the home for an appointment saying she was an “OT.” The lady proceeded to tell the farmer and his granddaughter how she was an occupational therapist and was there to help him find a way to complete his daily tasks as independently as possible. The farmer looked up at the lady and said, “it doesn’t matter what I can do, I just want to be able to farm.” The occupational therapist took this statement as a challenge. The farmer was doubtful that an occupational therapist could help him, but he was determined and worked hard during therapy. Week after week the occupational therapist came to the house to work with the farmer, and the granddaughter observed and participated in as many sessions as possible. With the occupational therapist’s devoted time, passion to help people improve their daily lives, and education and training on ways to modify or adapt tasks, the farmer was able to complete his daily activities independently in a new way. Now, the farmer could independently get in and out of the shower with the help of durable medical equipment, utilize equipment to get dressed, get a glass of water, and most importantly, was able to utilize an automobile four-wheeler with adaptive methods to complete some farming activities once again. The farmer was so delighted and thankful for the occupational therapist’s help.

Even though the farmer was told he would never walk again, he was motivated and devoted, and achieved much more in his life. He even verbalized to his granddaughter and therapist that he had a better quality of life and felt he had a purpose to live. Not only did the therapist spark and motivate the farmer, but the granddaughter as well. The granddaughter knew that someday she wanted to be able to enrich the lives of all individuals, just like the occupational therapist did for her grandfather. Today, the granddaughter is completing her fieldwork clinical experience using her education, training, and her grandfather’s story to help motivate others as well as identify ways to help all individuals engage in meaningful occupations in order to improve their daily living skills. The granddaughter in the story… is me.

As an occupational therapy student and future occupational therapist, I envision using my education and training to advocate and spark my patients and all individuals about the importance of occupational therapy, what it is, what it can do, but most importantly what it can help individuals do in their lives. I visualize myself using evidence-based interventions, to continue learning, being an accountable therapist, and advocating for the best interest of my patients.

I decided I wanted to be an occupational therapist because I have a passion for helping individuals gain the ability to be as independent as they can as well as helping them engage in meaningful daily activities. As a student, I’ve developed a passion to learn what specific interventions and strategies truly help each individual improve their skills. Learning evidence based strategies helps me during my level-two-fieldwork placement that I am currently completing, and will continue to benefit me as a therapist. During my therapy sessions, I strive to utilize evidence based practice techniques and educate my patients on the success of these strategies. Throughout my school years, I have participated in various research opportunities that help demonstrate my passion for learning. Currently, I am working on an evidence based systematic review focusing on the interventions that modify, establish, or maintain occupations of adults living with dementia or other related disorders. My passion for learning helped me strive to not only complete the difficult school work and time associated with graduate school, but also an additional time consuming task of completing extra research. Therefore, I have already started utilizing evidence-based practices into my daily routine with patients, and I envision myself to continue completing research during my career and keep it as an important aspect of my own daily routine. My dedication to enhancing my patient’s well-being not only links to my passion for utilizing evidence based practice, but my understanding that everyone is different and unique in their own way. Knowing that everyone is different reminds me that not all interventions are appropriate or successful with all individuals. I will need to continue learning not only from textbooks, but from my patients in order to learn what intervention strategies are successful for each patient specifically. Being client-centered will help me find and ignite each individual’s own spark to believe in themselves, improve their abilities and engage in meaningful occupations.

My desire to be client-centered with my patients will help me establish accountability with them as well as my employer. My education and training has helped me gain the ability to establish rapport with patients and coworkers. I will demonstrate accountability with my patients by providing them with the skilled services I have gained from my education and training. I will be held accountable as a professional by ensuring that I am up to date with research and new therapy practices and technologies. My accountability as a therapy professional will benefit my employer in regards to being able to perform successfully, clinically, and culturally with all patients, as well as increase success rates and patient caseloads for my employer. Essentially, my provider will be able to hold me accountable to provide adequate safe care to my patients, be well educated and trained to make appropriate clinical judgments and complete documentation appropriately. I will also practice client-centeredness, provide just right challenges for my patients, and be able to establish an appropriate level of revenue.

As mentioned previously, I envision my future self to be efficient at documentation skills and I understand the value and importance of documentation. However, with this said, if I had freedom from corporate limitations in healthcare, I would attempt to have all therapists complete more one on one time with their patients and less time solely completing documentation. To allow for these changes, productivity rates may need to be lowered at first and overall documentation amount may need to be reduced. Essentially, I would educate therapists on the importance of documenting more efficiently and to have more one on one time with their patients instead of alone documentation time. I will train therapists to complete their paperwork while they are educating patients on various topics such as their personal goals. I believe that by completing documentation while with the patients, this will help keep the therapists more goal oriented during treatment, as well as keep the patient up-to-date on their progress overall. Providing more one on one care is a valuable component that I hope to establish in my treatments.

I, as a current occupational therapy student and future occupational therapist, will attempt to utilize evidence-based practice, continue to learn, be an accountable therapist, and advocate for the best interest of my patients. My occupational therapy education, training, passion, and values, will help individuals, such as the rural farmer, overcome barriers and engage in meaningful occupations to improve their daily living skills

Cindy’s Service and Volunteer Activities

The University of South Dakota has provided me with various involvement opportunities where I have been able to service others and volunteer. Specifically, as part of the University of South Dakota’s Occupational Therapy Club, I have gratefully been given opportunities to help increase the quality of life for numerous people through my dedicated service. For example, I served as the 2014-2015 University of South Dakota Occupational Therapy’s Institute of Health Care Improvement (IHI) representative where I was able to meet with other healthcare disciplines and discuss ways to promote and advocate for healthcare. We, as an organization, advocated for healthcare in various ways such as displaying movies about healthcare for community members or students to attend, and created and dispersed handouts about healthcare. I also participated in a panel for USD’s pre-occupational therapy club where I advocated for occupational therapy by sparking students’ interest towards the field as well as general knowledge about occupational therapy. I have also completed numerous phone and email interviews for high school students who were interested in an occupational therapy career. In these interviews I explained what occupational therapy is and how important it is to health care. I have volunteered my time for Vermillion, SD’s Community Health and Wellness Fair, Meals on Wheels, played Wii at an assisted living community residence in Vermillion, and provided faculty supervised occupational therapy treatments to a community member in need. Additionally, I have volunteered my time at a local backpack program where food was gathered, bagged, and then sent to schools to be dispersed to lower social economic status school-aged children to ensure the they would have adequate food to eat during the weekend. During my time as an occupational therapy student, I donated to local book drives to help disperse books to children in need. I also donated to Special Olympic programs. Lastly, as a student, I was given the opportunity to implement a program at a rural long-term care center to help improve leisure participation in older adults. These volunteer and service activities have helped me advocate for a career field I love as well as obtain a more diverse appreciation for all different people. Gratefully through these activities mentioned previously, I was able to provide opportunities for individual’s to be involved in activities and improve or enhance their participation in enjoyable activities.

Poster Presentations

Research Involvement

  • Systematic review (January 2014-present): Currently co-author/researcher completing a systematic review through the American Occupational Therapy Association, focusing on interventions designed to establish, modify, and maintain occupations for adults with Alzheimer’s disease and related disorders.
  • Presentation speaker at 2015 National AOTA Conference in Nashville, TN: Systematic Review on Occupational Therapy and Alzheimer’s Disease and Related Disorders
  • Presentation speaker at 2015 University of South Dakota School of Health Sciences Research Day: Systematic Review on Occupational Therapy and Alzheimer’s Disease and Related Disorders • Presentation speaker at 2015 University of South Dakota Occupational Therapy Research Symposium: Impact of Tablet Technology Use on Social Isolation Among Older Adults: A Pilot Study
  • Biochemistry Lab Technician at South Dakota State University (October 2011-May 2012): Aided researchers in cardiac testing and performed basic lab functions such as making transparent gels

Poster Presentations/Critically Appraised Topic Presentations:

  • Effectiveness of Pet Assistive Intervention to Help Improve Social Participation in School-Aged Children with Autism
  • The Effectiveness of Early Mobilization within 1 week of a proximal humeral fracture compared to immobilization for 3 or more weeks for decreasing pain levels in adults aged 40-85
  • The Effectiveness of Behavioral/Cognitive Behavioral Strategies in Facilitating Transition to Supportive Employment Compared to Less Directive Client-Centered Strategies with Adults Diagnoses with Schizoaffective Disorder
  • Effectiveness of Sensory Integration with School Aged Children with Disabilities

About SPARC

Ensign Therapy SPARC (Scholarship Program And Recognition Campaign) is inspired by its namesake and the sense of liveliness and excitement that therapy students and new graduates bring to our facilities and in-house therapy programs. With this scholarship program, we are deliberately seeking out those individuals who ignite a desire for excellence in themselves, their patients, their colleagues and co-workers.