Capstone Project: Charting Insurance Rules/Guidelines

Submitted by Stephanie Cole, Bandera Therapy Resource – Arizona
In the spirit of Passion for Learning I would like to share an INCREDIBLE Capstone project with all of you. I am hoping you can use some of the tools in your own buildings!

Kyle Higgins, DPT, our fearless DORITO and DPT extraordinaire at Montecito Post Acute Care & Rehabilitation in Mesa, AZ, is the creator. Kyle has been invaluable to our therapy program, demonstrated excellent clinical skills, leadership and dedication to hundreds of our most difficult patients. It is with great pleasure I share his story and all of his hard work. Please feel free to reach out to Kyle directly with any questions about the forms/tools.

In Kyle’s words:
For my project, I wanted to capture all of the fun insurance rules/guidelines that are pertinent to therapists and turn them into an easy chart. In the past year, we have had multiple new hires, with several of them being new grads. I love teaching and helping them in any way I can, but I often caught myself doubting what I was teaching due to insurance guidelines constantly changing and to be honest, just SO many rules. Thankfully, this chart has been helpful for me and even for our therapy vets as a refresher! I hope this project can be as helpful to other facilities and therapy resources as it has been for Montecito.

I have included a general Insurance Guidelines and LTC Insurance Guideline document that captures general rules for various payers that we have been successfully using at Montecito.

Additionally, during this DORITO program, I have created and implemented a PDPM checklist that our evaluators are using (and MDS director loves). I know the therapy portal had several PDPM checklists already. However, most of them did not seem to include consistent information, so I made one that encompassed everything from every checklist.

Lastly, I have created an IDT communication board. Stephanie Cole and I printed/laminated over 300 copies. We hung hooks on the cabinets in every room and hung the hole punched sheet with a ring for each patient. On eval, the evaluator will fill out the sheet with a dry erase marker. As patients progress, whatever therapist that is working with the patient can update the sheet. Hopefully, this will continue to improve the communication between nursing and therapy. But most importantly, hopefully this has improved the safety of our patients

Legend Oaks Celebrates Black History Month

Submitted by Lana Mathis, COTA, Therapy Director, Legend Oaks Healthcare, Kyle, TX
“Fanga Alafia, Ashé Ashé,” meaning “good health and peace to you”—a traditional West African call and response—echoes throughout Legend Oaks Rehabilitation and Healthcare in Kyle. During the month of February, drums could be heard in the halls as residents made their way to the dining hall or some moved in their bed. The message that we want to bring with Black History Month is: welcome, everybody.

Traditional African music was featured every Tuesday. One week, residents learned about famous Black Americans while also being exposed to soul and Cajun food all in honor of Black History Month, the first event of its kind to be held at the facility to benefit residents and employees alike. “In my seven years of working here, this is the first time we’ve ever come together to celebrate Black History Month,” said Christina Johnson, physical therapist assistant at Legend Oaks. “It was a collaborative effort. Because of these guys (other therapists), we’ve got a whole bunch of new staff that have great energy, great ideas and enthusiasm for the people and introducing everything to our residents.”

“The music helped benefit residents and employees alike in a myriad of ways,” said speech therapist Rachel Obstfeld. “Really learning about where we come from and why we do things ultimately just makes us care better overall. The patients actually enjoy it; they get excited about it. If you treat your patient like your friend or someone that you’re actually going to care for, you get better results.” Christina reiterated that the music itself has healing components.

The dancing is so connected to the African drumming in our culture. A lot of hip hop dancing originated from African cultural dancing, so I like to say, “Let the drum speak,” because the drum will bring medicinal feeling; it brings spiritual healing; it brings a connection. “A lot of our residents here have problems with their memory and a lot of them have dementia and other neurodegenerative disorders like Parkinson’s. Some people have had a stroke and a lot of the time, that limits their abilities to communicate and engage with the world around them the same way we do,” Obstfeld said. “Music has a really special way to access parts of the brain that aren’t otherwise active…so we really like to incorporate songs to help them know you have peace in your life and peace in your days.”

Yoga Clip Reflection - Leaning In

By Michelle Mitev, Therapy Resource, Monument, South Carolina
Well, this happened… (https://vimeo.com/822770838?share=copy) and was subsequently played in front of everyone at the Leadership Experience! After this clip was played (in front of hundreds!), I received high fives, compliments, and praise. Big “wows” and “How did you do that?!”

What folks probably saw was me! Almost an optical illusion. Up in the air, spinning, upside down. Major smiles. An undeniably cool thing.

There are a few things that I want my peers to know …

I was unprepared. I wasn’t stoked for the early wake-up but was determined not to let my new peer down. I didn’t know what “acro yoga” was until Tyrah laid down and told me to lean on her feet (omg!). It was freezing! I felt incapable. I felt unsure what would happen if I tried. I wasn’t even sure what was happening the majority of the time!

What folks might not have noticed: Tyrah, strong and steady, holding me up. What folks might not have heard: Tyrah, calm and confident, instructing me one step at a time.

I left the beach on a high. I felt SO proud (Did I really just do THAT?). I left the beach changed. I had tried something completely new and unknown to me. I literally and metaphorically leaned on my partner. She literally and metaphorically elevated me.

Growth comes from conquering uncomfortable moments. And we are the lucky ones and ought not to forget it! Within our organization our growth is exponential because of who we are as individuals and as peer groups. We are our best when we steadfastly pursue new opportunities while leaning on our relationships to help us through the journey. I am SO grateful to Tyrah.

I suppose my message is to recognize you, Tyrah; to lean into new and potentially uncomfortable experiences; and to let go. Then take pride in your effort. Practice gratefulness. (And repeat indefinitely.)

Celebrating Multicultural Diversity

By Tara Meyerpeter, OT, DOR, Keystone Ridge Nursing & Rehabilitation, Omaha, NE
America’s aging population continues to increase in numbers as well as cultural diversity. Baby boomers of all races and nationalities are entering our senior living communities. It is important to embrace cultural diversity and accept the different customs that contribute to the make-up. As the make-up of seniors changes, front-line staff are provided the opportunity to embrace new cultures and celebrate multicultural diversity.

Here’s how to get involved:

  • Create an occupational profile to obtain pertinent information regarding ethnicity and cultural background following development of rapport and trust.
  • Identify ways to incorporate preferences into treatment sessions (such as recognition of prayer practices, cultural preference/practices, and routines).
  • Provide your staff with education to recognize and accommodate the unique needs that accompany different cultures.
  • Provide activities and programs that offer seniors the opportunity to experience a variety of cultures such as a multi-cultural showcase.
  • Provide interpreters for those who need it, especially in medical situations.
  • Enable the use of interpersonal skills to demonstrate intentional respect for resident’s cultures.
  • Offer residents with opportunities to express cultural heritage and to learn about cultural identities of others.

Keystone Ridge celebrates diversity in a multitude of ways. Recently, our OT Woroud (Rosie) Hudson assisted in creating a multicultural diversity group with our residents. Each week for four weeks in the month of August, residents worked on their project to display at our Multicultural Showcase. The residents met every Tuesday for approximately 30 to 45 minutes in preparation for the final presentation. The residents were provided with the level of cognitive assistance needed to fully engage and become immersed in research. Research included reading and locating pertinent information in printed article form and on the internet, locating images to add to posters, and cutting/pasting and organizing printed information on a tri-fold poster to represent countries. Most residents chose countries from which they had ancestry, while others chose countries related to personal interests. Each session, residents reported the history of their country, geography, traditional food and attire, art/music, and shared past experiences. They determined what artifact would be showcased to represent their country, whether it be food, attire, music, or a video displaying their country.

These activities allowed residents to take pride in their accomplishments and promoted an overall sense of both independence and interdependence, which enhanced their quality of life which enhanced QOL. The residents were excited and looked forward to attending the next session/workshop to continue to work on the final project. Residents were motivated to get out of bed and attend workshops during program, which was a motivating factor to increase out-of-bed and out-of-room activity to decrease the risk of excess disability and sensory deprivation. The most powerful benefit accomplished from this program would be the reminiscing-building opportunities developed during the sessions and at final showcase. Residents were able to tap into long-term memories of past experiences related to culture and past traditions and enjoyed sharing past experiences with others.

Countries exhibited included: Italy, Mexico, Poland, Germany, Jordan, and Lebanon.

Looking for Excellence in Dementia Care?

Check out some of our Summit Facilities
Submitted by Elyse Matson, MA CCC-SLP Resource
On a few recent visits to facilities in Summit, we saw some amazing programming!

In Pennant Washington, the team led by Patrick Amar at Mira Vista in Mount Vernon, Washington, was brimming with positivity and excitement about their dementia care programs. On this particular day, the incredible resources from IN2L (https://in2l.com/) were demonstrated. It was clear this team, including their activities director, had a plan for integrating these tools into both therapy and activities. How amazing it was to listen as the team strategized on ways to use IN2L and better the lives of their residents.

At Owyhee Health and Rehab in Homedale, Idaho, our Abilities Care Refresher was an incredible learning experience about how great dementia programs really help the lives of the residents. Residents were asking to show us their life story boards, and we saw functional plans in action as Lexi Haigh, SLP, DOR, and Fresca Stewart, COTA, explained and demonstrated how abilities care is working in their facility.

Finally, at Rosewood Rehab in Reno, Nevada, DOR Whitney Wilding and team displayed a phenomenal understanding of dementia care and of the needs of all their residents. As we reviewed the concepts of Can do, Will do, May do and discussed the Evaluative, Intervention, and Maintenance phases of Abilities Care, ALL THREE disciplines actively participated and knew all these concepts equally well. Talk about a singular mission! As we visited residents and saw story boards and interventions, it was clear that Rosewood is dedicated to great dementia care for their residents.

Increasing Group/Concurrent Communication for CNAs

By Mark Milligan, ADOR, Lake Pleasant Post Acute Care, Peoria, AZ
For my Capstone project, I created a new and improved group therapy sheet to help inform the CNAs on the patients that had group therapy that day.

We have had a lot of mishaps with registry CNAs getting patients up, ready and on time for their group therapy sessions during the week. When I brought the issue to their attention, they had a lot to say. Some registry CNAs told me that they were unsure of how the patient transferred and were unsure of which therapist to talk to because they didn’t know who was who. They were unsure of what time to have them up and ready by or when they should start the process of getting the patient up, seeing how some patients take longer than others. This was causing a lot of stress and more work for the therapist team and our core CNA group because they were having to help a lot more.

With this information, I wanted to create a system where there was little to no gray area when it came to getting our patients up and ready for group therapy. I wanted this new system to help our registry CNAs and our core CNA group as much as possible. I added four total boxes with six rows (one for each patient). Each row consists of a box where we can write in the patient’s room number, their transfer assist level, and what assistive device they use. I added the therapist’s name at the top so that the CNAs knew exactly who to contact if they had any questions or concerns. I also added the time at which the group would start. I put two boxes side by side and color-coordinated them to show a therapy team (PT/OT).

Typically, at Lake Pleasant, when one discipline determines a clinically appropriate group, the next discipline will run a group with most, if not all of the same patients. I would leave this new sheet at the nurse’s station next to the appointment sheet. I did this because the CNA’s often check the appointment sheet throughout the day to see when patients need to be up and ready to go. This would ensure that all of the CNAs would see our therapy list.

Implementing the spreadsheet has brought more efficiency to both our nursing and therapy teams, and as a result, our ability to deliver services in a group has increased. Some feedback I received from the CNAs was that they loved the new system. They expressed how it helped them to manage their time better and to go into a patient’s room confident in knowing how to transfer them safely. This system helped to build a better relationship between the CNAs and our therapy team simply by reducing any miscommunication between the two teams. A lot of the times, things happen due to the lack of communication between teams, and this sheet has helped to minimize that by showing our CNAs exactly what was needed.

Treating Adverse Behaviors

By Tara Meyepeter, OT, DOR, Keystone Ridge Nursing & Rehabilitation, Omaha, NE
Keystone Ridge is a facility with a typical census of 72. Keystone is unique in the population in which they serve. Most typically, we serve residents who suffer/experience diagnoses that include homelessness, drug/alcohol addiction, and mental health disorders. With such disorders, we often see an increase in adverse behaviors, including self-isolation and denial of care. Our therapists have embraced looking at residents using an holistic approach. How do we serve their needs?

In one recent referral, a: 76-year-old female presented with a diagnosis that includes major depressive disorder and anxiety. She was referred to therapy due to her refusal to complete ADLs and her adverse behaviors (yelling, screaming) with caregivers. So often, we may look at this resident as “that’s just how she is.” The challenge to the team is, what can we do for this resident? Are we looking at the person as a whole?

In what way can we bring purpose? How do we increase their quality of life?
● Start building rapport. Be consistent. Trial different times to determine the most appropriate part of the day based on patient engagement.
● Establish likes/dislikes. A great tool to use is the Interest Checklist or Life History and Profile.
● Why are they refusing care? Is it more than behaviors? Find out their why. Most often it is more than just refusing. We used a sensory profile to determine sensory needs.

We have developed a friendship and trust. I discovered that my resident is sensory avoiding. She prefers the dark and is highly sensitive to clothing. She is very deconditioned from years of self-isolation and refusal to get out of bed. As a result, she is a high fall risk; however, she has good insight that it is not safe to walk alone. We determined her love for animals, specifically elephants. To work on sitting balance, we would watch the virtual zoo on the computer while seated at EOB. Little by little, I gained her trust.

Through these approaches, my resident has allowed me to cut off 12 inches of unkept matted hair, and most importantly, she is accepting my help with ADLs like showering. Now this took time, 1.5 months in fact! This is the person most often people chalk up to “That’s just the way she is.” My challenge to everyone is, are you treating at your optimal level of practice? Are we looking at the whole person?

Millions Are Likely Suffering from Brain Fog and Other Cognitive Impairments Post COVID-19 Infection

By Elyse Matson, MA CCC-SLP, SLP Resource/Ensign Services
It is estimated that nearly 100 million people have contracted Covid-19. Long-lasting symptoms occur in nearly one in four people, even when they were not hospitalized. The primary complaints of those with persistent issues are brain fog and cognitive fatigue. That means millions of people are walking around with cognitive issues likely affecting their lives.

In a recent conference from ASHA, Rebecca Boersma, SLP of George Washington University Hospital, described a new outpatient treatment protocol to address these issues. These new patients are primarily female with a mean age of mid-40s. Recovery from these subtle but debilitating deficits does not follow the normal recovery timeline and tends to be remitting and relapsing in nature. Prominent deficits including attention, working memory, word finding, cognitive fatigue and processing speed.

Boersma utilizes assessment and treatment approaches common in the post-concussive population, including motivational interviewing, collaborative goal setting, and a variety of scales and tools to assess patient perception of communication, fatigue and cognition. These include the Modified Fatigue Impact Scale, the LaTrobe Communication Questionnaire, and the Multifactorial Memory Questionnaire.
Treatment focuses on a person-centered approach and utilizes proven treatments such as the meta-cognitive strategy, dynamic coaching and managing fatigue.

In our outpatient programs, we have an opportunity to seek out and help some of those suffering with Long COVID. Is this a program you can implement in your facility? For more information and to obtain the protocol, email Elyse Matson ematson@ensignservices.net.

Clarifying Skilled Nursing and Therapy

By Lori O’Hara, CCC-SLP, Skilled Reimbursement Resource
IDRS (Interdisciplinary Documentation and Reimbursement Systems)

From CMS:

  • Skilled nursing/therapy services are those services that are so complex they can only be safely and effectively provided by a nurse or under the supervision of a nurse/therapist.
  • Coverage does not turn on the presence or absence of an individual’s potential for improvement from nursing/therapy care, but rather on the beneficiary’s need for skilled care.
  • A condition that would not ordinarily require skilled nursing/therapy services may nevertheless require them under certain circumstances: the patient’s medical complications require the skills of a registered nurse/therapist to perform a type of service that would otherwise be considered non-skilled; or (b) the needed services are of such complexity that the skills of a nurse/therapist are required to furnish the services.

Frequency:

  • To support a Part A episode, nursing services must be provided (and documented) 7x/week; to support a Part A episode, therapy must provide (and document) services at least 5x/week.
  • Please note: The importance of a particular service to an individual patient, or the frequency with which it must be performed, does not, by itself, make it a skilled service.

Defining Skilled Nursing Services
These nursing services automatically support a Part A episode when provided (and documented). They include but are not limited to:

  • Intravenous or intramuscular injections and intravenous feeding
  • Enteral feeding that comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day
  • Naso-pharyngeal and tracheotomy aspiration
  • Insertion, sterile irrigation, and replacement of suprapubic catheters
  • Treatment of decubitus ulcers, of a severity rated at Stage 3 or worse, or a widespread skin disorder until/unless the wound is deemed chronic
  • Heat treatments that have been specifically ordered by a physician as part of active treatment and that require observation by skilled nursing personnel to evaluate the patient’s progress adequately

Other interventions are considered skilled nursing in their initial phases but would be considered unskilled once the patient is stable and the regimen well-established:

  • Application of dressings involving prescription medications and aseptic techniques
  • Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing, that are part of active treatment and require the presence of skilled nursing personnel, e.g., the institution and supervision of bowel and bladder training programs
  • Initial phases of a regimen involving administration of medical gasses such as bronchodilator therapy
  • Care of a colostomy during the early post-operative period in the presence of associated complications; the need for skilled nursing care during this period must be justified and documented in the patient’s medical record
  • Initial care-planning and comprehensive assessments

Many other things might be skilled, if the documentation supported that they were complex enough that they required the skills of a licensed nurse:

  • Assessment of medical presentation
  • Observation and monitoring of new or potentially unstable conditions
  • Some skin treatments
  • Some respiratory treatments
  • Implementation of physician’s orders

Other things to consider:

  • There are often state regulations that limit a patient’s ability to keep or self-administer medications. But even so, administration of routine medications is not considered a skilled service by CMS.
  • Wound-vac treatments are administered to heal very complex wounds, but because they are not a daily service. they will never, by themselves, be enough to support a Part A episode.
  • Trachs are intimidating apparatus that are generally present only in vulnerable patients. But the presence of a trach is not enough to sustain a Part A episode (although treatments or suction provided through the trach often are).
  • Likewise, just having a PEG tube is not enough to sustain a Part A episode — the patient must be meeting a minimum caloric/fluid amount as it’s the complexity of administering the feeds and assessing for residuals that requires the skills of a nurse.
  • A service that is ordinarily considered nonskilled could be considered a skilled service in cases in which, because of special medical complications, skilled nursing or skilled rehabilitation personnel are required to perform or supervise it or to observe the patient. The key in these situations is great documentation to capture and clarify the “special medical complications.”

Documentation:
It is expected that the documentation in the patient’s medical record will reflect the need for the skilled services provided. The patient’s medical record is also expected to provide important communication among all members of the care team regarding the development, course, and outcomes of the skilled observations, assessments, treatment, and training performed. Taken as a whole, then, the documentation in the patient’s medical record should illustrate the degree to which the patient is accomplishing the goals as outlined in the care plan. In this way, the documentation will serve to demonstrate why a skilled service is needed.

The patient’s medical record must have documentation as appropriate that captures:

  • The history and physical exam pertinent to the patient’s care, including the response or changes in behavior to previously administered skilled services
  • The skilled services provided
  • The patient’s response to the skilled services provided during the current visit
  • The plan for future care based on the rationale of prior results
  • A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences
  • The complexity of the service to be performed
  • Any other pertinent characteristics of the beneficiary

References:
https://www.hhs.gov/guidance/document/benefit-policy-manual-chapter-8-extended-care-coverage

What Is Dysphagia? (Taken from the Dysphagia Research Society)


By Elyse Matson, MA CCC-SLP, SLP Resource/Ensign Services
Swallowing is one of the most complex actions we perform, involving more than 30 muscles and nerves. The average person swallows approximately 600 times per day — about 350 times while awake, 200 times while eating, and around 50 times while asleep.

Dysphagia indicates any difficulty or problem with swallowing normally. A swallowing disorder not only affects safety but also quality of life. Dysphagia is a serious medical condition that affects between 300,000 and 600,000 individuals in the United States each year.

Common signs and symptoms of dysphagia include: difficulty with weight gain (in children), unintentional weight loss (in adults), coughing during eating/drinking, recurrent aspiration pneumonia, food/liquid coming out of the nose/mouth, and a feeling of food remaining “stuck” in the throat/upper chest, to name a few.

Dysphagia is associated with a wide variety of conditions, including congenital and developmental disorders (e.g., cleft lip/palate, Down’s syndrome), head and neck cancers, pulmonary conditions (e.g., chronic obstructive pulmonary disease), and a variety of neurologic conditions such as stroke, dementia, amyotrophic lateral sclerosis (Lou Gehrig’s disease), Parkinson’s disease, muscular dystrophy, cerebral palsy, and many more. Since it is a common symptom in many of these diseases, it often goes unnoticed and is often under-reported, despite having significant consequences.

Complications and consequences of dysphagia include pulmonary aspiration, malnutrition, dehydration, pneumonia and even death. In hospitalized patients, dysphagia has been shown to significantly lengthen the hospital length of stay and is a negative prognostic indicator. In addition, those with dysphagia often report a feeling of isolation and depression, as many are no longer able to take part in social gatherings that so often revolve around eating and drinking. It is estimated that dysphagia is responsible for between $4.3 to $7.1 billion in additional hospital costs per year. Despite the significant detrimental impact dysphagia has on health and quality of life, only a third of those afflicted seek medical treatment.

Assessment of dysphagia frequently includes a clinical assessment and instrumental assessment. A clinical bedside swallow assessment is typically completed by a speech-language pathologist (SLP) and is used to describe the characteristics of the individual’s swallow function, determine the presence/absence and characteristics of a swallowing disorder, determine the safest route of nutrition/hydration, and help provide additional recommendations for an instrumental assessment and appropriate treatment. The two most common instrumental assessments are fiberoptic endoscopic evaluation of swallowing (FEES) and modified barium swallow study (MBSS).

Once a diagnosis of dysphagia has been made, the healthcare team determines the most appropriate plan for treatment. Management of dysphagia may involve medical/surgical intervention by a physician and/or behavioral intervention by an SLP. The focus of any dysphagia intervention is to optimize the swallow to be as safe and efficient as possible, as well as to maximize the patient’s quality of life.