ADL Billing Versus Self CARE Item Set Change

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At Mountain View Care Center, we questioned whether there is a correlation between the amount of activities of daily living (ADLs) the occupational therapy staff has been providing to patients with changes in their’ functional level upon discharge. We chose to compare this by analyzing the percentage of ADLs billed in the facility with the change in CARE item set from admission to discharge.

Methods

We gathered Optima reports from all Bandera facilities to determine service code usage of self CARE ADLs (97535) as a percentage of total billable services for a three-month time period. Functional Outcomes report containing the change in OT Self CARE item assessment was obtained for the same three-month time period. These two reports were analyzed to determine if there was a correlation between the two sets of data.

Results

The amount of billing of 97350 seemed to equate with the amount of change in CARE. However, upon closer statistical analysis, this was not found to be the case. There was no correlation found between use of ADL billing code (97535) and improvement in CARE item set. Billing of the code 97110 had a negative correlation with the improvement in ADL scores.

Data

  1. CARE item set and billing of ADL (97535) code
  2. Correlation between usage of billing codes and change in CARE item set

 

 

 

 

 

 

 

Conclusion

We concluded the following:

  1. The overuse of therapeutic exercise in OT treatment plans has a negative impact on patients’ improvement in functional levels.
  2. Occupational therapy should minimize treatments that involve purely therapeutic exercise in their daily treatment sessions.
  3. It would be more beneficial for the patients to address strength deficits through the use of ADLs and therapeutic activities than using upper body ergometry or tabletop activities.

In the future, we’d like to further our analysis by performing a study using a change in ADL levels instead of CARE to decrease concerns about CARE not being an accurate measure of improvement. Furthermore, after educating the staff on the increased use of ADLS as a modality, we’d like to perform the same analysis to determine if there was an increase in CARE item assessment as a result of increased ADL usage.

By Tonya Haynes, PT, DOR, Mountain View Care Center, Tucson, AZ

Bathing Without a Battle

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It’s not uncommon for residents to resist showering, and as therapists, we work to ease their anxieties while supporting our staff. At Northbrook Healthcare Center, we’ve implemented strategies that have proved successful in encouraging residents to participate in bathing routines and even find enjoyment in the process.

Background

We had a resident exhibiting negative behaviors, i.e., slapping staff, yelling and cursing when CNAs approached her for a shower. Documented refusals resulted in a referral to our occupational therapy department for the Abilities Care Program and our Bathing Without a Battle program.

Using the Life History and Profile, OT was able to identify purposeful and meaningful activities the resident enjoyed, including:

  • Listening to classical piano music through her headphones
  • Painting her wooden birdhouses (she’s an artist)

We also implemented simple changes such as rephrasing the showering task as an opportunity to “freshen up,” language to which this Southern Belle resident responded well. Additionally, we trained nursing staff to provide an alternative to bathing. In the event the resident declined a shower, she would be offered a “Bath in a Bag.” Prior to a shower or bathing task, she was also reassured that her coffee, snack and classical piano music would be ready for her in her room.

Results

Previously, this resident refused any type of shower or bath for two to three months. Now, the resident demonstrates 100 percent active participation and no negative behaviors. Our Bathing Without a Battle program is proving effective for this resident, and undoubtedly, for the staff helping to implement her grooming routine!

 

By Tyler Johnson, OTR/L, DOR and Joni Johnson, COTA/L, TPM, Northbrook Healthcare Center, Willits, CA

A COPD Case Study

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At Northeast Nursing and Rehabilitation, we cared for a 77-year-old white male who had been recently hospitalized for acute cholecystitis. His PMH included CAD, a pacemaker, cardiac stents, HTN and COPD. The patient presented with a variety of problems, including debility, decreased ADLs, poor static/dynamic and sitting/standing balance, decreased mobility, decreased aerobic endurance and breathing abilities, and poor phonation.The patient also had decreased breath control, able to produce only three words without taking a breath. He required constant oxygen and had little diaphragmatic breathing, possibly related to the secondary effects of COPD.

Prior Level of Function

Prior to admission, the patient was ambulatory with a cane for household distances. He was I with ADLs, bed mobility and toileting, as well as I with dressing and hygiene/grooming. He consumed a regular diet, had good aerobic condition and did not require oxygen.

Interventions

We employed several strategies to help the patient, including physical, occupational and speech therapy interventions. For example:

  • PT provided family education on safety/sequencing, continual monitoring of vitals during treatment sessions, kinesio taping to address knee pain, and patellar mobilization.
  • OT addressed ADLs, LB dressing, donning/doffing shoes, UE strength, gross/fine motor UB control to manipulate objects, hygiene/grooming activities, toileting, and safe decision making.
  • ST placed the patient on a COPD program, worked on pursed lip breathing, diaphragmatic breathing, deep breathing exercises, huff cough technique, stretching and strengthening exercises, instruction in use of inspironmeter, fluency and intelligibility exercises in conversational speech.

Outcomes

As as result of our interventions, the patient showed marked improvement in several areas, including functional gait distances with use of a cane, improved dexterity and fine motor control, LB dressing, toileting and more. His phonation improved, and the patient did not require oxygen at home. Ultimately, the patient was able to return home with the support of his family and thanks to the combined efforts of our therapy teams.

By Rochelle Lefton, MA, OTR; Michelle Scribner, MSLP; Heather Cox, DPT; Susan Garcia, COTA; Jesusa Herrera, PTA, Northeast Nursing and Rehabilitation, San Antonio, TX

Improving the Patient Experience Through Patient-Centered Care

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Patient Centered Care isn’t just taking good care of our patients. It is a holistic philosophy of including the patient and their family members in as many decisions and system/facility improvements as possible. It means offering choices whenever possible, thereby giving our elders more control over their lives.

This approach may include asking for their input on anything from what kind of furniture they would like to replace the old furniture in the front lobby, to what we should ask them on a discharge survey, to simply when they would like to go to bed at night. We are still in our infancy with implementing this philosophy, but here is what we have accomplished thus far:

Long-Term Care Residents

  • We invited six LTC residents to help plan our Nursing Home week in May. They offered suggestions and picked the theme for each day, the activity and the special food to be served.
  • We have added an “Activities Calendar Planning” day to our Activities calendar and have begun including LTC residents with the planning of their monthly events.
  • We have included LTC residents on our Dining Experience Performance Improvement Plan (PIP) to get their feedback on what they feel would improve their dining experience.

Rehab Patients

  • We created a PIP for the first 24 to 48 hours, as this has been an area where we either shine or fail to impress.
  • We invited a prior patient and his spouse to meet with us and get their feedback on their experience and collaborated on which areas we needed to improve.
  • Therapy is offering a choice to new patients of what time they would like to be evaluated (before lunch or after lunch).
  • Therapy is also asking each new eval if they would like to make a friend while rehabilitating. We then introduce them to another patient who also expresses an interest in meeting someone.

Through our patient-centered approach, we are able to improve the quality of life for residents and ensure they feel not only well-cared for, but also valued and significant.

By Park Manor Rehabilitation Center, Walla Walla, WA

Passport to Home: An Interdisciplinary Case Report

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We all know it’s true: There’s no place like home. That’s exactly what our 70-year-old female patient expressed upon admission at Olympia Transitional Care and Rehabilitation.

The patient experienced a cardiovascular accident at home resulting in a fall, with left distal femur shaft fracture. Upon admission, her level of function was as follows:

  • Hoyer transfer
  • NWB in LLE for eight weeks
  • 9/10 pain in LLE, TD for toileting and dressing ADLs
  • Mild-mod swallow impairment with mechanical soft and thin liquids
  • Mild dysarthria
  • Mild-mod cognitive communication deficit

The patient lived at home with her spouse with multiple myeloma in a supportive, social community. She was independent with gait in her home and over short community distances; with swallow function, motor speech, functional cognition for her living environment; and with ADLs and IADLs, including cooking and cleaning.

This patient had one simple goal: “To get back to the way it was.” More specifically, she wanted to return home to her spouse and her cats, return to ambulation at household distances, and decrease the level of caregiver assistance for ADLs.

Treatment Approach

Taking an interdisciplinary approach, we developed a treatment plan combining physical, occupational and speech therapy. COTA and PTA created a “Passport to Home” document to visually track patient goals and progress:

  • Goals are checked off as they are achieved
  • The patient has an active role in goal-setting and completion
  • Extrinsic motivator for compliance over a lengthy rehab stay

Physical Therapy

  • Pain management — manual therapy
  • Transfer training — progressive strengthening, slide board transfers
  • Gait training — parallel bars, bariatric FWW
  • Balance training
  • Stair training

Occupational Therapy

  • Toileting — Q2 hour toileting schedule, nursing staff in-service for compliance
  • Dressing — adaptive equipment education, timed trials for improved function
  • Tub transfers — tub transfer bench
  • UE resistance to fatigue

Speech Therapy

  • Oropharyngeal dysphasia — OMEX, compensatory strategy training
  • Dysarthria — OMEX, breath support training, compensatory strategy training
  • Cognitive communication deficit — external memory aid training, attention processing strategies

Additionally, we collaborated with nursing staff to ensure:

  • Safe swallow strategy and positioning training (ST, PT)
  • Compliance with toileting schedule with use of external memory aid (ST, OT)
  • Transfer recommendations set up (PT, OT)

Conclusions

Using an interdisciplinary approach with complex patients is essential to realizing the highest level of performance success. The use of standardized testing allowed us to develop a personalized plan of treatment for this patient’s needs and improve the chances of a positive outcome.

Although this patient was quite discouraged at the onset of rehabilitation and did not have high expectations for success, we were able to encourage her along the way and improve her outlook. With a team approach, were developed a detailed treatment plan that ultimately allowed her to return home near her prior level of function.

By Scott Hollander, PT, PDT; Sarah Koning, MSOT, OTR/L; and Megan Bennett, MS, CCC-SLP, Olympia Transitional Care and Rehabilitation, Olympia, WA

Group Therapy Versus Individual Therapy

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As our payers become more complex, we as therapists need to discover ways to get better outcomes, in less time, with less reimbursement. Toward that end, we compared the functional outcomes, using the CARE item set, of our Medicaid skilled patients receiving more minutes of group therapy, as opposed to only individual minutes per our contract guidelines. We also compared the outcomes of our Medicaid patients who received group therapy to all of our patients who received all modes of therapy.

Methods

Group therapy was provided to Medicaid skilled patients following the below protocol for a two-month period:

  • Patients with a POC for five times per week received three days of group therapy (average 45 minutes) and two days of individual therapy (average 15 minutes)
  • Patients with a POC for three times per week received two days of group therapy (average of 45 minutes) and one day of individual (average of 15 minutes)
  • All groups were functional-based and were individualized per each patient’s POC
  • For all other payer types, all modes of therapy were used

Results

Results from the two-month study compared to two months prior (with no group therapy):

  • Physical Therapy functional outcomes per the CARE items improved by 30 percent for the mobility subset
  • Occupational therapy functional outcomes per the CARE items improved by 3.7 percent
  • Culture in the department improved (per staff report)
  • Patients asked to participate in group on days assigned as individual and had increased satisfaction in therapy (per resident reports/survey)
  • Family members asked for their relative to be in groups more often (per family reports)
  • Staff (CNAs) have extra time to attend to other responsibilities when multiple patients are away and patients were easier to care for with great improvement from better outcomes
  • Productivity of the department improved by 5.8 percent
  • Functional Outcomes comparing the Medicaid skilled patients receiving group therapy to all of the therapy patients: the mobility subset had 16.5 percent better outcomes, and the self-care subset had 6.3 percent better outcomes

Data

This chart shows the change in each CARE Item Set area between our control (two-month period) and our case study (two-month period), along with a comparison to the outcomes for all payers for the time period of our case study.

 

 

 

 

Conclusion

In conclusion, group therapy does improve functional outcomes versus individual therapy for Medicaid skilled patients. Additionally, outcomes were better for Medicaid patients who received group compared to all other patients (all payers) during the case study period.

In addition, group therapy provided other positive outcomes, including:

  • Increased patient satisfaction
  • Increased family satisfaction
  • Increased staff satisfaction
  • Improved culture in department
  • Improved productivity

Group therapy has shown to be a valuable mode of therapy to increase outcomes, satisfaction and productivity. Use of this mode of therapy may benefit more payer types and may be a way to continue providing great therapy services by using our resources efficiently to help with our ever-changing world of healthcare.

By The Entire Rehab Team, Led by Tracy Carrier, DOR, Chandler Post Acute & Rehabilitation, Chandler, AZ

HeartMath: Utilizing Heart Rate Variability Biofeedback

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Utilizing Heart Rate Variability Biofeedback in a Patient With CVA to Improve Psychophsyiological Coherence

By Amanda Call, MA, OTR/L, Draper Rehabilitation and Care Center, Draper, UT

At Draper Rehabilitation and Care Center, we treated a 74-year-old female patient who sustained L hemispheric hemorrhagic CVA. She presented with a host of symptoms, including R hemiplegia, dysphagia, aphasia, R neglect, malnutrition, HTN, pain, muscle spasms, constipation, depression, anxiety, neuropathy, GERD, nausea/vomiting, hyperlipidemia, and R foot and coccyx wound.

The patient spent approximately two months in a rehab hospital, followed by two months in another SNF, then came to AVR four months after her admission to the hospital. She was six months post-CVA at the time of this intervention and was reaching a plateau with therapies because of difficulty regulating her emotions, which caused increased tone and aphasia.

As the therapists involved with the case brainstormed ideas to address the barriers preventing the patient’s progress, the patient’s ability to self-regulate emotions and physiological states came up as a common barrier that was limiting progress and functioning. At this time, OT learned about heart rate variability biofeedback and theorized that the patient might benefit from this intervention to facilitate self-regulation skills. She suspected that teaching the patient to control heart rate and breathing would help with emotional regulation as well as improving tone and aphasia, which would allow her to progress with her therapy goals and become more independent.

Literature Review

“Heart rate variability is a measure of the naturally occurring beat-to-beat changes in heart rate.” (McCraty et al 2004). When an individual’s respirations and heart rate are at an optimal frequency, this is referred to as coherence. Coherence is “the maintenance of a physiologically efficient and highly regenerative inner state, characterized by reduced nervous system chaos and increased synchronization and harmony in system wide dynamics” and “is conducive to healing and rehabilitation, emotional stability, and optimal performance” (McCraty et al 2004).

Research studies suggest that “individuals with brain injury and impaired self-regulation often display HRV patterns with reduced HRV” and speculate that interventions which address HRV “could directly enhance the ability to self-regulate.” (Kim et al 2015).

A study of individuals with severe brain injury found that there was an association observed between HRV coherence and improved emotional control, attention, life satisfaction, self-esteem and self-awareness and concluded that “HRV biofeedback has promise as an effective, cost-efficient method for improving self-regulation in individuals with severe brain injury” (Kim et al 2015).

An additional study of individuals with chronic brain injury found that there was an association between HRV training and the regulation of emotion and cognition and that “individuals with severe, chronic brain injury can modify HRV through biofeedback” (Kim et al 2013).

Intervention

OT facilitated seven treatments utilizing heart rate variability biofeedback training during a period of three weeks. Interventions were completed using a computer-based system that tracked heart rate using a pulse oximeter and created a visual representation of heart rate variability on the computer screen. The visual representation was in the form of a line graph and a bar graph, but the system also allowed for the feedback to be given in the form of a variety of games. This patient preferred to receive feedback through the games.

This intervention was used as a preparatory activity for ADL tasks such as toileting. At the beginning of this intervention period, intervention focused on discussion of toileting because toileting was a task that caused significant fear for the patient, resulting in increased tone, difficulty communicating and difficulty problem solving to complete the task.

As the patient improved her ability to modify her heart rate variability, intervention progressed to toileting in the therapy gym, then in the patient room and with her CNAs. Furthermore, as the patient became better at regulating her physiological states while using the program, therapists began encouraging her to apply the strategies during ADL tasks. For example, if the patient became upset or frustrated during toileting, the patient was encouraged to close her eyes and picture the biofeedback games.

Example of game available in emWave Pro™ program. As patient coherence improves, the rainbow extends to the pot of gold and gold coins can be earned.

Results

During the three week period after initiating the intervention, the patient showed improvement in the following areas of OT functioning: View here: HeartMath – Draper

 

Alexa and TBI Helps Patient Following Brain Injury

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Consider the following patient profile: A 19-year-old with traumatic brain injury secondary to assault presented with moderate deficits in immediate and short-term memory as well as temporal and spatial orientation. He was also legally blind as a result of his injury.

The patient has been receiving skilled Speech Therapy at Rock Canyon since March 2017 to address oropharyngeal dysphagia and communication/cognitive deficits. Additionally, our team employed the use of an Alexa device and TBI services for therapeutic interventions, plus an improved quality of life for the patient.

 

Intervention Components

Caregiver Coaching

  • Educating the patient’s mother on programming the device and its features
  • Encouraging caregivers to cue the patient to use the device for temporal orientation and checking or adding events to the schedule

Script Therapy and Drill

  • Rehearsing with the patient before having the patient activate the device for adding events to the schedule, checking the date and daily schedule, and solving math problems with drill exercises

Education on Device

  • New skills, entertainment features (music, books on tape)
  • Shift in ownership — allowing the client to take the initiative to use and experiment with the device independently

Quality of Life

  • Music (Spotify, Amazon Prime)
  • Books on tape (Audible)
  • News (NPR)
  • General information (Wikipedia)
  • Weather
  • Horoscopes
  • Alarms
  • Games (Jeopardy)

Data

At the baseline, the patient was able to answer 0 percent of temporal orientation questions (day of the week, date, year) or his daily schedule. Currently, the patient shows significant improvements in regards to temporal orientation and personal scheduling when verbally cued to use the device. Goals include having the patient answer temporal orientation questions, add events to his schedule and check his schedule without being cued to use the device.

By Rock Canyon Rehabilitation, Pueblo, CO

OT and SLP Co-Treatments in a Skilled Nursing Facility

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OT SLP
Occupational therapy and speech-language pathology co-treatment sessions provide comprehensive intervention and could fill a research gap on the benefits of this collaborative approach to advance patient outcomes in a SNF setting. Due to ever-changing and restrictive regulations, clear and effective documentation is necessary to ensure reimbursement and to expand the opportunities currently limited by billing protocols.

A review of current literature identifies information on the benefits of OT and SLP co-treatment sessions in a pediatric setting, but it fails to include outcomes of this collaboration in geriatric environments. The same hierarchy of skills addressed in the pediatric field often needs to be re-addressed as a natural part of the progression of aging. The skilled nursing facility presents multiple diagnoses impacting ADL/IADL performance, which could best be addressed by this underutilized interdisciplinary approach.

Literature Review

OT and SLP collaborations can provide comprehensive interventions during self-feeding, ADLs and general therapeutic activities. Planned meal-time co-treatments can include an OT assessment of wheelchair/seating positioning, ROM, strength and coordination for both hand-to-mouth and utensil manipulation, while an SLP assesses labial seal, oral motor control and other dysphagia concerns.

When an OT is providing skilled education and assistance to increase patients’ independence with ADLs, an SLP can assist by highlighting the necessary cognitive processes to complete the task and provide education and cues for improved carryover of learning.

This interdisciplinary support can also occur when IADLs and community reintegration are appropriate in a patient’s discharge plan. Additionally, increasing the cognitive demand and executive function components during therapeutic activities incorporating standing tolerance, dynamic balance, fine/gross motor coordination, safety, functional mobility and community needs can provide a more holistic approach to patient care (Ellenbaum, 2010).

Methods and Assessments

  • Identify patients with varying diagnoses appropriate for skilled OT and SLP treatment
  • Discuss treatment plan of each discipline and identify goals appropriate to address during scheduled co-treatment sessions
  • Identify appropriate assessment tool/standardized measure to assess patient outcomes pre- and post-certification period with consistent co-treatment sessions

Potential OT Assessments

  • Barthel Index
  • Daily Activities Questionnaire
  • Functional Assessment Scale
  • Present Functioning Questionnaire
  • Allen Cognitive Level Screening Assessments and Modules
  • Safety Assessment of Function and the Environment for Rehabilitation (SAFER)

Potential SLP Assessments

  • CLQT, MOCA-B, RIPA-G, SLUMS
  • MASA, Bedside Swallow Evaluation, MBS/VFSE
  • Determine the effectiveness of treatment interventions performed during reporting period including co-treatment sessions using pre- and post-test scores
  • Compare pre- and post-test scores of patients with similar diagnoses not receiving co-treatment interventions
  • Gather additional qualitative data using daily documentation of co-treatment sessions to determine effects more directly related to this approach

Intervention strategies include but are not limited to:

  • ADL sessions
  • PENS electrical stimulation protocols
  • Therapeutic activities
  • Community reintegration
  • NMES electrical stimulation protocols
  • Synchrony
  • Meal assessment
  • Diet texture analysis

Documentation

Co-treatment is not suitable for all residents. Therefore, the decision should be made on a case-by-case and even day-to-day basis and needs to be well-documented for each session (Ensign Services, 2016).

According to a joint position statement from AOTA, APTA and ASHA: “Co-treatment is appropriate when coordination between the two disciplines will benefit the patient, not simply for scheduling convenience. Documentation should clearly indicate the rationale for co-treatment and state the goals that will be addressed through this method of intervention.”

“Co-treatment sessions should be documented as such by each practitioner, stating which goals were addressed and the progress made. Co-treatment should be limited to two disciplines providing interventions during one treatment session” (Ensign Services, 2016).

Conclusions

Co-treatment sessions are intended to increase therapy intensity by cohesively targeting multiple goals with the same functional activity and an opportunity to provide increased services that may otherwise be limited by patient fatigue level or willingness to participate. Co-treatments are meant to be planned prior to scheduled treatment to highlight goals being addressed by each discipline and identify his/her role during the session.

A skilled need for a co-treatment approach should be identified before any treatment planning begins. Additionally, clear and effective documentation is the key for conveying the insight and skilled need for providing this service.

By Stacia Kozidis, OTR/L & Caitlin Timmins, MA, CCC-SLP, Clarion Wellness and Rehabilitation Center, Ensign Group & HCR Manor Care Waterloo

Happy Feet Effect on Quality of Life

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As the efficacy of medical treatments increases, the average life expectancy has also increased. Geriatric populations are getting older. The life expectancy of a person born in the United States in 1900 was 49 years, which has significantly increased to 78.8 years as of 2014.

As longevity increases, an important factor to consider is an individual’s quality of life. Quality of life is multidimensional and has been measured by the CDC using the health-related quality of life (HRQOL) and the Healthy Days Measure.

The HRQOL measures quality of life considering physical health, mental health and an individual’s ability to perform activities of daily living (ADLs). Another questionnaire used by the CDC is called the Healthy Days Measure, which asks individuals how their last 30 days have been affected by different factors such as pain, sadness, anxiety, sleep and energy.

Studying the Happy Feet Effect

About five or six years ago, Pinnacle Rehabilitation and Nursing had a program called Happy Feet. Residents were brought to the nurses’ station, and then music was played while residents were assisted down the hall to the dining room, either walking or riding in the wheelchair according to their abilities. This program has not been implemented in the past four or five years.

At Pinnacle Nursing and Rehabilitation, we recognize the importance of quality of life and hope that the care the residents receive has a positive impact on their quality of life. The purpose of this study is to see if the implementation of Happy Feet will improve the residents’ quality of life and to see if the number of residents coming to the dining room increases.

To evaluate the effectiveness of Happy Feet on the residents’ quality of life, the residents were asked subjective questions from the HRQOL and Happy Days Measure prior to Happy Feet and then 30 days later. Initial surveys were taken the week of April 17, 2017, and ending surveys taken the week of May 22, 2017. Happy Feet intervention occurred Monday through Friday in the interim. Attendance in the dining room for brunch varies with changes in census.

On April 21, there were 12 residents in the dining room, and 10 regularly attended breakfast and would be in Pinnacle a month later. Of the 10 regular residents, eight were cognitively able to answer the first question and six were able to fully answer the questionnaire. Questions were asked such as: Now thinking about your physical health, which includes physical illness and injury, for how many days during the past 30 days was your physical health not good?

Results

Regarding general health of the eight residents surveyed, on average the health improved from good to very good. On average in each survey, the number of “not good” days decreased.

In the healthy days questionnaire, in all areas the number of unhealthy days also decreased. There was a significant change in unhealthy days related to pain, worry and amount of sleep. The last question asks how many days they felt full of life, and on average this amount went up from 11.7 to 15.8 days.

When the first survey was completed, 12 residents were attending the dining room, and after the second survey, there are now 16 residents at brunch in the dining room.

Conclusions

We cannot say definitively that we improved the quality of life of all the patients who participated in Happy Feet. However, on average, there was an improvement in all areas. Also, during Happy Feet, the residents were usually smiling or expressing that they were having a good time, the staff enjoyed having a change in their day, and we feel it improved the culture in the building. Additionally, the number of residents attending the dining room at brunch increased. Residents also reported that they enjoyed doing Happy Feet and would like to continue to participate in it on their way to brunch.

By Maresa Madsen, DOR, and the Pinnacle Therapy Team, Pinnacle Nursing and Rehabilitation, Price, UT

View Full Poster Here: Happy Feet Effect on Quality of Life – Pinnacle