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.

Tag Busters: Skin Integrity

By Tamala Sammons, M.A. CCC-SLP, Senior Therapy Resource

F-Tag 686: Skin Integrity; Pressure Ulcers/Injuries

Surveyors will assess how a facility is doing based on the comprehensive assessment of a resident, and ensure that:

  1. A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and
  2. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

How can Therapy help be a partner to ensure the facility has a strong skin system? Start by asking a few questions:

● Is skin integrity and risk for pressure ulcers assessed on every Therapy evaluation? Should it be?
● Do therapy assessments include other risk assessments, i.e., tissue tolerance testing? Pain? Nutrition/Hydration? Incontinence?
● When OT is working on showers with patients, in addition to focusing on ADLs, do they assess the patients’ skin?
● How often does PT remove a patient’s shoes/socks to assess a patient’s feet?

There are a wide variety of clinical areas that Therapy can assess and treat to ensure residents have good skin integrity, reduce risk for pressure ulcers/injury, and actively treat wounds.

Pressure Points and Tissue Tolerance
An at-risk resident who sits too long in one position or is known to slouch in a chair has an increased risk for pressure ulcers/injuries. Elbow pressure injury is often related to arm rests or lap boards. Friction and shearing are also important factors in tissue ischemia, necrosis and PU/PI formation. PU/PIs on the sacrum and heels are most common.

● How often does Therapy assess for pressure points and tissue tolerance?
● Does Therapy assist with the completion of the Braden Scale? Your clinical partners would love the assist!

Positioning and Support Surfaces
Once the IDT identifies who is at risk, how do they determine the needed support surfaces, proper positioning and/or repositioning frequency? Do they take into consideration the individual’s level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort? Appropriate support surfaces or devices should be chosen by matching a device’s potential therapeutic benefit with the resident’s specific situation.

● How does Therapy engage in assessing the appropriate positioning and support surfaces?
● How often does therapy assess residents to ensure the recommended positioning and support surfaces are in place, still meet the needs for each resident, and provide reviews/updates of the resident care plan?

Active Wound Care
PT intervention for active wound care is appropriate when any of these exist: Necrotic material is present in the wound bed; the wound is a stage 3 or 4 pressure injury; the rehab potential is good to meet stated goals; and/or the wound has an impaired healing process.

● Do we have a physical therapist on staff who treats wounds?
● Are we up to date on all the various wound care interventions, such as: scalpel debridement; closed pulse irrigation; ultrasound MIST; and/or other modalities?

Incontinence
Both urine and feces contain substances that may irritate the epidermis and may make the skin more susceptible to breakdown and moisture-related skin amage.

● What is Therapy’s involvement with incontinence intervention?

Nutrition and Hydration
Adequate nutrition and hydration are essential for overall functioning. It is critical that each resident at risk for hydration deficit or imbalance, including the resident who has or is at risk of developing a PU/PI, be identified and assessed to determine appropriate interventions.

● Is SLP involved as part of Skin IDT?
● Is the Think Thin program in place?

Contractures
A resident with severe flexion contractures also may require special attention to effectively reduce pressure on bony prominences or prevent breakdown from
skin-to-skin contact. Some products serve mainly to provide comfort and reduce friction and shearing forces, e.g., sheepskin, heel and elbow protectors.

● What is Therapy’s role with contractures? How often is skin/skin hygiene assessed?
● Does Therapy have an active hand/skin hygiene program?
● How often does Therapy assess splints’ effectiveness for not only the contracture but also skin integrity?

Pain
The assessment and treatment of a resident’s pain are integral components of PU/PI prevention and management. Pain that interferes with movement and/or affects mood may contribute to immobility and contribute to the potential for developing or for delayed healing or non-healing of an already existing PU/PI.

● What therapy assessments are completed to determine any pain levels?
● Are modalities used for pain management?
● Is level of pain discussed during skin IDT meetings?

Training, Education and IDT Collaboration Resources

● Refer to chapter VIII page 82 of the RNA manual for information that can be used for training CNAs and/or RNAs on skin and positioning. https://portal.ensignservices.net/Departments/Clinical-Resource-Tools/Manuals/manuals Scroll down or type in the search Restorative Nursing Program Manual.
● Refer to the EPIC section of the portal https://portal.ensignservices.net/EPIC/skin for education, information, and other resources for an IDT approach for skin.
● Refer to the Pressure Ulcer/Injury Critical Element Pathway. This can also be found on the portal. https://portal.ensignservices.net/Departments/Clinical-Resource-Tools/CMS-Requirements-of-Participation/CMS-TOOLS/NEW-SURVEY-PROCESS/critical-element-pathways
● Refer to a variety of supportive POSTettes for additional information: Wound Care, Contractures, UI, UTI, Pain, Nutrition/Hydration.

Robust Student Program at Camarillo

By Aimee Bhatia, NCI Therapy Resource, California
Camarillo Healthcare Center, led by Vonn Malabanan, has the most robust student experience I’ve been able to witness. When I visit this facility, there are a minimum of four students, with the average being six in the building at a time. Vonn has continued the student coordinator relationships that Julia Schmutz had initiated and also developed even more in order to provide an inpatient setting for students. Currently, they have a DPT student from Touro University, a DPT student from UNE, two PTA students from Concorde Career College, and two PTA students from Casa Loma College. They also have OT students lined up throughout the year, and Vonn is always the first to respond when someone needs a last-minute placement.

Initially, it was hard to get staff on board with being clinical instructors for the student program, but as they watched their peers interact with the students, sharpen their treatment skills, and experience the benefits of having a student, many changed their minds. Even the most tenured therapists who were the most hesitant now have students, and they feel like they are lost when they don’t have students with them.

We have all been students, and we know how important and impactful it can be to have a great student experience. We also know how challenging it can be to find a facility gracious enough to take on the responsibility of molding our upcoming therapists. Vonn and his team have taken it to the next level and have been a great example for our market. We have taken students in all of the other buildings I support, and most of them very rarely if ever hosted students in the past. We are working to slowly develop a similar model in our other facilities in order to benefit the students, our staff, and the buildings as a whole. Two of the most recent hires for PT in Vonn’s building were actually his students when he was a staff therapist. It goes to show how powerful a good experience for a student can be, how it can positively affect our recruitment efforts, and how when we truly provide a meaningful student clinical experience, it can lead to happy new hires.

I hope we can all strive to have a student program like Vonn and team Camarillo. Seeing buildings with clinical student experiences like this across the organization makes my heart happy, knowing that we have the opportunity to mold our future and hopefully bring young, eager talent to skilled nursing.

Outpatient Opportunities: Bringing the Abilities Care Approach to Your Community

By Gina Tucker-Roghi, Alexis Renfro, and Ali Vandeloo, Rock Creek of Ottawa, KS
Looking for opportunities to increase your community outreach and develop your outpatient program? Rock Creek of Ottawa is putting a new spin on the Abilities Care Approach. Ali Vandeloo, DOR, worked with Alexis Renfro, an OT and TEACHA (Therapy Expert on the Abilities Care Holistic Approach), to bring an abilities-based approach to dementia care to their community through outpatient programming. Ali and Alexis have broadened the scope of services at Rock Creek by promoting aging-in-place for individuals with early-stage dementia.

Our outpatient Abilities Care Approach programming incorporates the familiar aspects of the Abilities Care Approach with training, support and education for family caregivers to target the following clinical outcomes:

1) Increase caregiver self-efficacy through education on approaches and techniques to manage challenging behaviors
2) Prevent falls and injuries
3) Maintain meaningful relationships and engagement with family, friends, and the community
4) Maintain function, prevent functional decline and mitigate risk factors related to dementia

Since launching the pilot of this program, Rock Creek has provided outpatient services to eight individuals living with dementia in the community. One of our first clients was an individual with middle-stage dementia living with her husband in the community. We provided education and support for the caregiver to enhance the care he provided for his wife. Our interventions focused on maintaining a healthy routine, prevention and management of neuropsychiatric behaviors, prevention of falls and injuries, participation in meaningful activities, utilization of sensory strategies to improve engagement, and utilizing their authentic and meaningful context to personalize her care and experience. As a result of our services, he learned new approaches and was more confident in his ability to care for his wife.

Another client was an individual with early-stage dementia and depression. She was living home alone and had been a rehab patient at Rock Creek prior to discharging home. She received outpatient services post-discharge to help her integrate health-promoting behaviors and habits into her daily routines and was able to stay in her home and remain engaged in her community through activities with her church and volunteering.

An outpatient ACA program can help you achieve the following facility and community outcomes:
1) Create rapport and relationships with families in the community that may result in opportunities for future admissions for respite or long-term care services in your SNFs or Als

2) Increase community awareness of the scope of facility services throughout the continuum of care

3) Attract new therapists and grow your therapy department

4) Minimize the stigma of dementia and increase knowledge and understanding of members of your community who interact with individuals living with dementia

Here are a few tips if you are ready to get started:

1) Start with patients already under your care (patients discharged from post-acute to home or residents at your on-campus or affiliated ALFs).
2) Become familiar with the existing community resources for individuals living with dementia.
3) Network to get to know service providers for individuals with dementia who live in the community. Here are some examples:
a) Area Agency on Aging
b) Meals on Wheels
c) Geriatrician or dementia clinic
d) Alzheimer’s Association
e) Dementia caregiver support groups
f) Adult day health programs

If you are interested in giving Outpatient ACA a try, join our bi-weekly call of early adopters. We gather every two weeks on Wednesday at 9 a.m. PST. Our next meeting is April 20. Please email Gina Tucker-Roghi groghi@ensignservices.net to be added to the call invite.

TAG BUSTERS: FALL PREVENTION FOCUS

Partnering with Nursing: F-Tag 689

Submitted by Tamala Sammons, M.A. CCC-SLP, Sr. Therapy Resource
Federal Tags (F Tags) are the minimal Federal and State Standards of Care that are used to survey Skilled Nursing Facilities as a measure of performance. Rehab Services provides an important role in order to ensure compliance with these standards by having strong systems for IDT collaboration, patient identification, and providing skilled intervention programming.

“Assistance Device or Assistive Device” refers to any item (e.g., fixtures such as handrails, grab bars, and mechanical devices/equipment such as stand-alone or overhead transfer lifts, canes, wheelchairs, and walkers, etc.) that is used by, or in the care of a resident to promote, supplement, or enhance the resident’s function and/or safety.

  • Are Safety Assessments part of therapy evaluations? Are they completed during different times of the day with various scenarios?
  • How often does therapy engage in assessing assistance devices and providing staff education on proper use? How often does therapy assess to see if those devices are still the best option for each resident?
  • Does therapy use a gait belt on patients anytime they require more than a supervision level of assistance?
  • Is Therapy familiar with what’s on the care plan and helping to ensure it’s accurate for device usage?
  • Is Therapy familiar with the CCA audit specific to this tag?

“Fall” refers to unintentionally coming to rest on the ground, floor, or other lower level, but not as a result of an overwhelming external force (e.g., a resident pushes another resident). An episode where a resident lost his/her balance and would have fallen, if not for another person or if he or she had not caught him/herself, is considered a fall. A fall without injury is still a fall. Unless there is evidence suggesting otherwise, when a resident is found on the floor, a fall is considered to have occurred.

  • Do all disciplines get involved to determine who is a fall risk and what interventions to use?
  • The evaluative phase for fall prevention shouldn’t end with one assessment. Patient behavior over time needs to be measured to determine the best interventions.
  • Are we using various standardized tests that tell us who is at increased risk for falls such as:
  • Do we assess gait velocity or just distance?
  • Does therapy take time to ensure a new admit or a resident with a room change is oriented to their new environment? Is the environment set up in the best way for this patient’s success?
  • Does Therapy use a gait belt on patients anytime they require more than a supervision level of assistance?
  • Is Therapy familiar with the CCA audit specific to this tag?
  • Does Therapy attend COC/Falls meetings?

Best Practice Ideas

  • We have Therapy representation attending and contributing ideas for Incident and Fall meetings.
  • We do ongoing therapy assessments for positioning, transfers, seating set up, etc. as fall prevention. NOTE: also ensure Care Plan is updated with the correct recommendations!
  • We provide education to Nursing on how Therapy can help with both fall reduction and post-fall support. ALL disciplines! Be sure to cover how much SLP can do around cognition. Our SLPs work on fall reduction as much as PT!
  • Therapy has increased communication to nursing in PCC in addition to various “paper forms” many facilities use.
  • We do CNA huddles to ask about their concerns or recent changes with any residents.
  • We complete a full battery of dx tests over more than one day to get a more comprehensive picture of how patients are performing.
  • We participate in facility rounds/safety committee
  • We participate in ongoing reviews of care plans for level of assist recommendations. We avoid ranges of assist (i.e., 1-2) and really dig into what each resident needs for that activity.
  • We do an IDT post-fall meeting outside of a meeting room; we go to the resident and ask them to “re-enact” what happened. We assess environment and figure out any unmet needs of the resident at the time of the fall.
  • Vital signs, vital signs, vital signs! We measure vital signs pre-, during, and post-treatment to assess for changes; we also complete orthostatic blood pressure testing on all residents and know who is at risk.
  • Environment: We assess room setup, bathroom setup (i.e., does the current position of grab bars work for the residents in that room, toilet height, etc.).
  • New admits and room changes: we assess the success of residents’ ability to function safely upon admission or after a room change (maybe they were closer to the bathroom and now they are not), as this is a new environment and it can be confusing to navigate, especially at night.
  • Our OT has helped tremendously with our low vision population, adjusting the lighting in rooms and adding colored codes to remotes/call lights.
  • We noticed a pattern of skilled patients falling within a day or two of admission. The Falls Team felt that this was due to the fact that there was no wheelchair available upon admission, as Nursing was waiting for Therapy to eval for transfers, etc. It led to patients attempting to transfer themselves because they did not have that visual reminder to wait for assistance. We attempted to solve this problem by having the rehab tech place a wheelchair in the patient rooms prior to admission so the reminder was there upon arrival. We noted a decline in subsequent falls around 18% month over month following this implementation.
  • We noticed that quite a few falls were happening due to the patient’s need to toilet. The PTs jumped on board and decided to start a day shift toileting program whereby we scheduled time daily for the skilled patients who had fall risk factors. One therapist would have those patients scheduled for regular therapy and then follow up during the second half of their day to perform the toileting for the assigned patients for the day. They were successfully able to get those patients to the toilet twice throughout the four-hour shift, while also being able to bill time for functional activities as indicated. The two weeks we were able to run the program so far evidenced no falls on shift (and high patient satisfaction 😊). Our next step is to include all PTs and OTs on a rotating basis to perform toileting rounds on day shift and see how this impacts our falls.
  • We communicate important updates and changes using the KARDEX for CNA/Nurse Easy Access.

Group and Concurrent: How the Organizational LEADER Gets It Done! (Hint: It’s About Teamwork 😉)

By Shelby Donahoo, Therapy Resource, Arizona

Month in, month out, COVID or no COVID, Sabino Canyon in Tucson, AZ, leads our organization in group and concurrent metrics. Averaging around 30% in both skilled and long-term care provision, it’s just become part of the facility culture. Executive Director Jaron Watson, DNS Quinny Mazzola, and TPM Dora Alvarez spoke to the Tucson market at an ED/DNS/DOR meeting last month to discuss.

“It’s about partnership,” they all said. “There aren’t ‘department goals’ but all-inclusive “facility goals.” Nursing is just as invested in rehab metrics as their own, and vice versa. There is an understanding of the benefit of group and concurrent for the residents and the facility from an IDT perspective, so it’s considered a group effort to achieve this metric.

Sabino Canyon runs an extremely busy skilled and long-term care program and services, so services need to be focused on function from day one. With a combination of group and one-on-one services, we get to spend more time with our patients overall, and our patients receive longer rehab services during a given day,” said Dora. This is a philosophy adapted with PT, OT and SLP.

With results creating buy-in from the Rehab team, a full understanding of more patient rehab time = better outcomes, and operational impact is discussed on all levels. Having patients up and ready for groups throughout the day becomes an expectation. Systems and flexibility are critical to this project:
● Each nurse’s station has a group schedule dry-erase board, showing time of group and patients scheduled for the group daily
● Rehab front-loads “on the unit” sessions the first few days of stay to incorporate much CNA training and sharing of individual patient goals
● Dry-erase boards with pictures of patient levels (mobility, device, etc.) are in each patient’s closet; Nursing uses a report sheet with diagnosis, precautions, etc. for quick reference as to patient concerns and assist needs
● Nursing, Therapy and Admissions consider the ability to do groups and concurrent treatment provision with roommate placement

Skilled long-term care groups have morphed into RNA groups. Self-ROM and AAROM groups are popular. Specific exercise groups are taught to Activities. One 3x/week exercise group is led by one of the residents.

Congrats, Sabino ,on your ability to “think out of the box” and amazing teamwork!

Falls Management: Collaboration is KEY

By Tamala Sammons, M.A., CCC-SLP, Senior Therapy Resource

Part 1: Fall Reduction: Focus on Strategies for Prevention
How do we identify who is at risk for a fall? Generally, we assess a resident’s physical and cognitive performance to determine who is a fall risk. However, many residents score as a fall risk, so how do we really sort it out? Do we really know who is most likely to attempt to move and why? That is a key difference.

The Challenge: Identify fall risk residents by finding out who is motivated to move and then find out what that motivating factor is. Give the residents a voice … give the CNAs a voice. Ask the resident and CNA about any changes, challenges and unmet needs.

Complete fall rounds on the floor, not in a meeting room! Assess the environment. How is the resident room set up? How is the bathroom set up? Where is the bed in relation to heating/cooling systems? How is the closet designed? What is lighting like at night? Ask the resident about their environment: how it is set up, temperature preferences, access, lighting, etc.

Provide the nurses with a tool kit based on activity prescriptions: Complete a thorough evaluation, determine who is motivated to move, determine what activities they enjoy being engaged in, determine what they can do alone and with caregivers, create activity-based prescriptions based on eval and treatment findings. Have this information and the supplies in the tool kit for nurses to easily access.

Create a Falls IDT with Nursing, Activities/Rec Therapy, RNA, and Therapy. Re-think how to really identify who’s at risk (motivated to move). Do rounds together. Have daily huddles to review the 24-hour report. Share interventions. Keep building the tool kits.

Part 2: Fall Reduction: Focus on Strategies Post-Fall
Partner with clinical to determine the cause of the fall. Ask the resident what they were doing/wanting. See if they can re-enact what they were doing prior to the fall. When reviewing a fall, ask: Is it cursory, perfunctory with the same approaches/interventions? Or are we creative, thorough and using great detective work to truly develop individualized interventions?

Complete a comprehensive evaluation. If currently on caseload, consider a re-evaluation … head to toe! Engage all therapy disciplines. Leave nothing out of the investigation to the root cause. It may take a few days to figure it all out.

  • Vital signs: Review blood sugars and check orthostatic BPs
  • Standardized tests: Assess strength and muscle performance; aerobic capacity; gait and locomotion; range of motion; ADLs; cognition; pain scales; vital signs!; sensory impairments; footwear; seating and positioning/support surfaces; modify their environment — remove hazards, modify the bathroom, modify closets; review medications
  • Toileting/Incontinence: Was the resident attempting to toilet? Were they incontinent at the time of the fall? How is the bathroom set up? What adaptive equipment is in place/needed?
  • Positioning: Does the resident have difficulty maintaining good positioning and is it different in bed versus in a wheelchair? Were all positioning devices in place at the time of the fall? What is needed now?
  • Pain: Were they motivated to move due to pain? Was there a pain treatment in place prior to the fall? Does there need to be one now?
  • Cognition/Communication: Is there any difficulty using the call light? Any difficulty expressing needs? Can they understand and follow requests? Can they explain what happened and why they fell?
  • Strength/Balance mobility: What are the safety concerns with physical movement or use of current devices? Was there sudden weakness or dizziness reported? Can they demonstrate what they were doing when they fell? Complete muscle and sensory testing.
  • Low vision assessment: Can they see the things they need? How is the lighting? Does there need to be color contrast in the room or bathroom?

Provide skilled interventions to address:

  • Difficulty with transfers in/out wheelchair/standard chair/bed
  • Inability to accurately position wheelchair when transferring
  • Inability to safely reach objects in near/far proximity
  • Difficulty crossing midline
  • Losing balance when challenged outside base of support
  • Inability to lift/carry objects
  • Difficulty with ambulation while multitasking (e.g., walking and talking)
  • Losing balance with overhead activities
  • Poor body alignment or losing balance when bending
  • Gait deviations when ambulating
  • Loss of balance with direction change or varying surfaces when ambulating
  • Shortness of breath with increased mobility distance/ambulation distance
  • Confusion or misuse of assistive device(s)
  • Difficulty climbing stairs/curbs
  • Poor recognition of safety hazards with mobility tasks
  • Impaired mobility
  • Impaired vision/hearing/sensation
  • Impaired cognition
  • Modify the environment: lighting, grab bars, raised toilet seats, bedside commodes, add color for low vision or other visual impairments; what about the closet?

Additional Resources

Putting Theory into Practice with Activity Cards

By Carly Peevers, SLP and Andrew Folmar, OT Rosewood Rehabilitation, Reno, NV

You’ve done the assessments, sensory profiles, interventions, accumulated all this information about your residents to create a specific maintenance program within their Allen Cognitive Level, but what now? How do we effectively share and educate the caregivers to create a successful functional maintenance program and have a place where they can reference this information as needed? This was a question we had early on in the Abilities Care Approach, and that’s when our facility implemented activity cards.

Activity Cards are a summary of the information collected throughout the intervention which may include:
• Stage specific recommendations within different environmental and activity demands, personally relevant activities with modifications and strategies for this patient,
• Pertinent life history and
• Sensory information that may assist in engagement and/or management of behaviors
in order to increase meaningful engagement, quality of life, and maintenance of cognitive and/or communicative function.

What does the Activity Card look like on paper? We use a tri-fold pamphlet to present our information. The front has a color outline corresponding to their ACL level (red, orange, yellow, blue). On the inside there are three columns.
• The first provides a list of activities/interests and modification recommendations.
• The second column is a summary and description of current abilities in cognition (attention, problem solving, sequencing etc.), communication, physical strengths and limitations during ADLs, and possible barriers in their cognitive function.
• The third column is a running shopping list that incorporates this patient’s personal interests and functional needs (grooming/hygiene supplies, sensory stimulation tools, clothes, etc.). We attach this pamphlet to the patient’s life history board with Velcro so it is easily accessible to all caregivers and support staff for a quick reference.

We hope this information helps others with their caregiver engagement for dementia residents.