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.

Abilities Care Approach for a Win-Win

By Tiffany Bishop, Therapy Resource, Keystone North, TX
For those of us in the therapy world, we all know the value that the Abilities Care Approach can bring to our residents in the form of increased independence, decreased behaviors, and increased ability to function in the environment. Just this past week, our most recent Therapy Experts in the Abilities Care Holistic Approach (TEACHA) team had a brief check-in call. One of the items we identified as a potential for growth is partnering better with our clinical partners to integrate our ACA programming throughout residents’ whole intervention plan.

In a time when our partners are already stretched thin, we identified the need for making any recommendations for our clinical teams more manageable to follow. There were several suggestions that were shared, and Elyse Matson is leading the charge to collect any more that have been effective and putting those ideas in an easy-t- distribute format. Below are some of the tips and tricks that were identified during our call.

● Make sure that we are working around their schedules when training
● Include these caregivers in the process of developing and implementing any adaptive strategies/tools so they can provide input along the way and have ownership in the intervention
● Empower our frontline partners as caregivers to be able to follow through with the day-to-day implementation of any interventions
● Be specific
● Be frugal in our expectations
● Be strategic in when/how we train; consider utilizing Skills Fairs to train common interventions
● Identify and stress how any intervention can be a win for them; how will it decrease their daily burden?

Stay tuned for more details to come from the Long Term Care Think Tank, and if you have any ideas that have worked well in your facility, please reach out to Elyse Matson.

Student Interns Share Transfer Reference Guide

Submitted by Gary Pearson, OT/DOR, Pointe Meadows, Lehi, UT
Here at Pointe Meadows, we had some wonderful students this past summer, including three physical therapy students from the University of St. Augustine. The students are Zachary Dreyer, Austin Jenson and Antonino Russo. In collaboration with these three students we made a Transfer Reference Guide, which is an easy-to-follow pamphlet with hints and tips on multiple techniques for transfers and other precautions related to weight-bearing and gait belt use. Also included are QR codes with links to videos on specific transfer techniques and bed mobility.

As DOR, I have incorporated this pamphlet into my portion of new-hire orientation utilizing the information to guide my transfer training for all new employees with the onboarding process. It has also been presented at two all-staff meetings and a nursing/CNA specific training.

As we are working hard on retention and showing our wonderful staff support in these hard times, our therapy department is attempting to provide expertise in training to all staff in our building. We are trying to support our clinical partners in any way possible and have had good feedback from staff on improved confidence and understanding with the process of transfers throughout our building.

Please let me know if you have any questions or would like more information. I feel this is a way our therapy teams can support our nursing and CNA partners in our buildings.

Teaming Up in Supporting Our Nurses

By Hannah Allen, SLP, St. Joseph’s Villa, Salt Lake City, UT
The Milestone Market SLPs get together for an SLP call once a month to share clinical ideas. During our last call, I was able to lead a discussion about considerations to include in our clinical thinking process when we recommend alternative forms of medication administration due to dysphagia. My husband is a clinical pharmacist who works in the ICU setting and is often involved in determining appropriate adjustments made to medications when patients are not able to take them orally, or not able to take them whole with liquid. He was able to share some great information that can be very helpful in our SLPs teaming up with and supporting Nursing with medication administration.

For example, we discussed how recommendations for crushed medications, or medications taken in any alternative forms, may be affecting the efficacy of the patient’s medication management if appropriate adjustments are not made by a pharmacist. Many medications are OK to be crushed, but some are not. If we crush them, this may make the Therapy of the medications ineffective or less effective. In some cases (such as in the case of seizure medications), we may also have the potential to cause harm. In other cases (such as Parkinson’s medications), we may be making their medications ineffective or less effective, which may decrease the actual therapeutic benefit they get from any of their PT/OT/SLP interventions.

The best option is to make sure we (or someone) is consulting the pharmacist to ensure medications are compatible with crushing. If they are not, a pharmacist may have suggestions on adjustments or changes to medications that will facilitate the safest form of delivery while maintaining medication efficacy. Some of us may have something like this in place in our facilities already, but some of us may not. This may be a process to build into our practice and the procedures of our facilities as we recommend alternative medication administration methods for our patients with dysphagia.

Below are some of the resources that were shared:
Podcast Episode: Swallow Your Pride Episode 173 — Crushing Meds: What’s an SLP to Do?
http://file.lacounty.gov/SDSInter/dmh/1042766_MedicationsDoNotCrushList.pdf
ISMP Do Not Crush List:
http://file.lacounty.gov/SDSInter/dmh/1042766_MedicationsDoNotCrushList.pdf
Blog Post by Karen Sheffler all about Pill Dysphagia
https://swallowstudy.com/trouble-swallowing-pills-what-to-do-for-pill-dysphagia/
Attached items:
-Article on effects of thickened liquids and puree on medication absorption


-PILL-5 Questionnaire, a patient-reported outcome measure; may be a good measure to utilize when we get consulted specifically for patients struggling with medications.


-Show Notes for the Podcast episode with many of the same resources and a quick rundown of the episode in written form

Myth Busting Medicare Part B: Training Therapists at New Acquisitions

By Dominic DeLaquil, Pennant ID/NV Therapy Resource

New acquisitions are not only a great opportunity to welcome a new facility to a market and the organization but they also give us an opportunity to provide culture and clinical training opportunities. This is really important early on as we need to understand what myths or rumors therapists from other organizations might be bringing with them. (This is also important with any new hires!)

Therapy programming on the long-term units was immediately identified as an opportunity for our residents. We saw a great opportunity to meet with the therapists, and ask questions to uncover any barriers, misunderstandings or prior trainings that they might have toward therapy interventions.

Understanding the benefits of maintenance therapy to keep residents at their highest practicable level of function was an identified area of educational opportunities. The training focused on the three things that are required to be in place to support the need for therapy services:

  1. Services must require the skills of a therapist
  2. Services must be reasonable and necessary for the patient’s condition
  3. Services must be rehabilitative in nature OR require the skills of a therapist to maintain function or prevent decline

It’s important to provide training on maintenance programs, including preventing decline, training aides and caregivers, and how we might attempt to transition to a maintenance program that can be carried out by our CNAs or RNAs. For example, training included how to adjust frequency to measure if therapy can discharge altogether without decline setting in and documenting those changes to the POC as evidence of the need for ongoing therapy skill if that’s the case. Training was also tied into the importance of QMs and survey tags related to failure to prevent a decline in function.”

Here are the key areas that constitute material impact other than progress:
• Assessment and analysis (Vitals, standardized tests)
• Preventing decline or deterioration
• Decreasing medical risk (Vitals)
• Training others to facilitation improvement or prevent decline

The training then focused on examples of what to capture in the documentation to support therapy services. Overall the response was a collective sigh of relief knowing that they, the therapists, could build a LTC program using their clinical judgment and knowing that they had the resources and support to ensure services were supported in the documentation.

Urinary Incontinence Program

By Danielle Banman, OT/DOR, The Healthcare Resort of Leawood, KS
Here at The Healthcare Resort of Leawood, we have the privilege of serving our LTC and ALF residents, rehab patients, and community outpatients with our urinary incontinence program. We provide training on exercises to improve pelvic floor muscle strength and education on bladder emptying strategies, adequate water intake, and bladder irritant avoidance during the first 30 days. If the patient has not made significant improvement within 30 days, we are able to initiate PENS during weeks five and six per Medicare guidelines. We are then able to provide continued training and PENS with the addition of MFAC during weeks six to 10 to help the patient make as much progress as possible.

I have been helping people with this program for over 20 years and keep seeing great results! Patients tell us how much it has changed their lives time and time again. They are often able to attend activities and events they love, travel, and have improved quality of sleep, to name just a few benefits. If your team would like to know more about this great program, we would love to help you get started!

Contact dbanman@ensignservices.net, livewellatleawood.com, or 913-484-5234.

Oral Infection Control at City Creek

By Gary McGiven, Therapy Resource, Milestone, UT
Since converting to a COVID-designated facility, City Creek has seen a more acutely ill patient population with an increased reliance on staff support for oral infection control. As COVID-19 patients are significantly more likely to experience complications if they also have poor oral health, City Creek’s SLPs have implemented a system to better track data on how frequently oral infection control support is being offered.

Even for patients who are cognitively and physically capable of performing it for themselves, staff support in the form of set-up assistance or verbal reminders has been valuable. Each patient has a laminated chart displayed in their room. It shows which staff member performed oral care and when. We note patterns of support being offered and frequently refused, or observing patients completing oral care independently.

For patients on the free water protocol, for example, the use of this chart has been extremely valuable. This system has increased patient and staff awareness of the importance of frequent oral care, and individual accountability in staff members. When we can identify patterns, for example, the frequency with which oral care is offered during AM versus PM shifts, we can better target staff education. We’re striving to move the perception of oral care toward an oral infection control program.

An Often Overlooked Powerful Muscle to Increase Gait Speed

It’s no news flash that walking requires quite a bit of lower-body strength. You need powerful glutes, quads, hamstrings and calves to propel you forward. You might also recognize the crucial role your abs play in keeping you upright and lightening the load on your lower half. But there’s one muscle you probably never even think about when it comes to your stride. We’re talking about your “lats” (or latissimus dorsi), the biggest muscle of your upper body. Affording itself a large attachment centrally from the T7 to L5 spinouses, laterally to the iliac crest and thoracolumbar fascia, to the lower three or four ribs and inferior angle of the scapula, to travel superiorly and laterally to attach to the medial lip of the intertubercular sulcus, it is perfectly situated to effect both the upper and lower extremities in a large variety of movements. It is one of the quintessential and often overlooked muscles in gait. It is generally quiet electrophysiologically (EMG) during pre-gait activities (1,2) but as speed increases, the muscle becomes more engaged and active (2-4). The latissimus dorsi is the functional link between the upper and lower extremity, particularly through its connections with the thoracolumbar fascia (5,6).

The lat muscle is a key driver in the Posterior Oblique Sling System, which helps explain the relationship between the arms and legs during the gait “walking” cycle. The posterior oblique sling is a cross-body pattern composed of the gluteus maximus, thoracolumbar fascia (TLF) and contralateral latissimus dorsi muscle, which connects the shoulder with the opposite hip to facilitate locomotion. Dysfunction in this system puts the brakes on power, strength, speed and performance. To understand how your lats affect your walking performance, think about your gait or your movement pattern while you walk: “As your left leg steps forward, your right arm swings forward, thus you’re creating a rotational force, the abdominals and lats help with this rotational movement. The stronger your lats, the easier this twisting motion becomes and the more efficiently you nail your stride. Plus, strong lats help ensure the rest of your muscles don’t have to work in overdrive. Translation: You won’t tire out so fast and you’ll be able to walk/jog/run for longer time frames. Whatever was fatiguing you before won’t fatigue as fast, because you’re bringing more muscles to the party. You’ll be surprised just how much your lats are a part of the equation once you focus on strengthening them.

An easy way to tell whether you need to increase your patient’s or perhaps even your own lat strength is to assess form. Here are a couple of tell-tale signs to look for when walking: If the patient/client starts to fall forward or slouch their head forward, and if the shoulder blades are creeping up by the ears, this most likely indicates an opportunity to strengthen the lats. But before you get started with those strengthening exercises, you need to make sure the surrounding muscles aren’t getting in the way, for example, tight triceps (the backside of the arm) or upper trapezius (where your shoulder meets your neck) can inhibit the lats from activating during exercises. This would work against the patient/clients best efforts. Once you have had the patient/client complete a few tricep and upper trap stretches, it’s time to start strengthening the lats. Some suggestions to start with include:

  1. Seated Row
    ● Using a resistance band or a cable row machine, sit upright with your legs out straight. If using a resistance band, hook it around your feet. No matter the equipment, roll your shoulders back and down, “packing” them into your lats.
    ● Keeping the elbows tight and close to your body, row your elbows straight back, pinching your shoulder blades together.
    ● Reset with control, then repeat.
    ● Do 3 sets of 10 to 15 reps.
  2. Bent-Over Fly
    ● Stand with soft knees, holding a dumbbell in each hand by your sides. Hinge forward at the hips with a flat back and neutral neck. Allow your arms to hang down under your chin with a slight bend in the elbows.
    ● Leading with your elbows, bring your arms back and imagine you’re hugging a tree backward, squeezing your shoulder blades together. Hold for one second before lowering down with control.
    ● Do 3 sets of 10 to 12 reps with dumbbells appropriate for your patient/client.
  3. Superman Lift
    ● Lie face-down on the floor with your arms and legs extended. Squeeze your glutes to glue your ankles together and lock your arms tight next to your ears. Keep your neck neutral, and gaze down toward the floor throughout the whole movement.
    ● Use your back to lift your legs off the ground, trying to lift your quads off the ground without bending at the knees. Lower with control. Repeat with just the upper body.
    ● Once you’ve mastered isolating the lower and upper, add them together, lifting all four extremities off the ground and holding at the top before lowering with control.
    ● Do 4 sets of 15 to 20 reps.

Beyond strengthening and stretching the lats to improve gait function, it’s also important to remember that if the patient/client has latissimus dorsi pain and/or referred pain, this can also impact range of motion and muscle activation patterns, including the patient’s gait quality. Dry needling is one modality that PTs may be able to use to decrease lat pain and improve the overall performance of this muscle by improving its function, thus improving range of motion and muscle activation patterns (7-9).

By Jon Anderson, DPT, Therapy Resource

References:

  1. Houglum P, Bertoti D in: Brunstrums Clinical Kinesiology 6th Edition, FA Davis 2012 p.558
  2. G. Cappellini, Y. P. Ivanenko, R. E. Poppele, F. Lacquaniti Motor Patterns in Human Walking and Running Journal of Neurophysiology Published 1 June 2006 Vol. 95 no. 6, 3426-3437 DOI: 10.1152/jn.00081.2006
  3. Shin S, Kim T, Yoo W. Effects of Various Gait Speeds on the Latissimus Dorsi and Gluteus Maximus Muscles Associated with the Posterior Oblique Sling System. Journal of Physical Therapy Science. 2013;25(11):1391-1392. doi:10.1589/jpts.25.1391.
  4. Kim T, Yoo W, An D, Oh J, Shin S. The Effects of Different Gait Speeds and Lower Arm Weight on the Activities of the Latissimus Dorsi, Gluteus Medius, and Gluteus Maximus Muscles. Journal of Physical Therapy Science. 2013;25(11):1483-1484. doi:10.1589/jpts.25.1483.
  5. Vleeming A, Pool-Goudzwaard AL, Stoeckart R, van Wingerden JP, Snijders CJ. The posterior layer of the thoracolumbar fascia. Its function in load transfer from spine to legs. Spine (Phila Pa 1976). 1995 Apr 1;20(7):753-8.
  6. Willard FH, Vleeming A, Schuenke MD, Danneels L, Schleip R. The thoracolumbar fascia:anatomy, function and clinical considerations. Journal of Anatomy. 2012;221(6):507-536.doi:10.1111/j.1469-7580.2012.01511.x.
  7. Dar G, Hicks GE. The immediate effect of dry needling on multifidus muscles function in healthy individuals. J Back Musculoskelet Rehabil. 2016 Apr 27;29(2):273-278.
  8. Ortega-Cebrian S, Luchini N, Whiteley R. Dry needling: Effects on activation and passive mechanical properties of the quadriceps, pain and range during late stage rehabilitation of ACL reconstructed patients.Phys Ther Sport. 2016 Sep;21:57-62. doi: 10.1016/j.ptsp.2016.02.001. Epub 2016 Feb 24.
  9. Dommerholt J. Dry needling — peripheral and central considerations. The Journal of Manual & Manipulative Therapy. 2011;19(4):223-227. doi:10.1179/106698111X13129729552065.

How to Build a Successful Outpatient Program

With our focus on meeting all the needs of our communities, we wanted to provide some information about our Colonial Manor of Randolph outpatient program. Randolph, Nebraska, is a town with a population of 894. Despite that, they have found a way to operate as one of the largest outpatient programs as an Ensign Affiliate. Here is what Eric Feilmeier, OT, CLT, DOR, has to say about why they have been able to have success!

When working to build a successful outpatient clinic, it is important to begin with Core Values. Here are few values that we have found to be important:

  1. Deliver WOW through service.
  2. Embrace and drive change.
  3. Create fun.
  4. Be adventurous, creative and open-minded.
  5. Pursue growth and learning.
  6. Build open and honest relationships with communication.
  7. Build a positive team and family spirit.
  8. Do more with less.
  9. Be passionate and determined.
  10. Be humble.

We have had success in our Nebraska market due to a number of reasons. First and foremost, be supportive of your therapists. Provide clinically centered CEU opportunities that focus on problems in your area. Here at Colonial Manor, we are LSVT certified and are going through power moves certification, urinary incontinence certification and Lymphedema Certification. Provide programming around the skills of your Therapists so they can get to the bottom of each patient’s problems. It’s important to educate on HEP for patients, but then leave that to them and focus on the true needs, utilize the specialty equipment in our gyms and provide proper intensity of treatment.

  • Make sure the patient feels that they got a lot out of each session.
  • Provide proper frequency. MAKE IT COUNT IN THE GYM! Remember, the patient won’t typically do as much at home. Modalities: We work closely with ACP rep to provide the best adjunct treatment options to assist with improving care. Patient’s Love modalities- modalities provide physical and psychosomatic results.

When working with your outpatient, always assess additional problems and needs that the patient may not realize themselves. Ask questions, because there might be a higher need for another discipline to step in. We are always looking out for one another’s skill sets and the potential benefit to collaborate our services to further meet the needs of our client.

Cancellation Management is the biggest obstacle of our Outpatient business. We do our best to stop cancellations, but that is not always easy. Some tips to reduce cancellations include:

Evaluations:

  • Provide a message. Ask the patient why they are in your clinic, what they expect and what they want to gain.
  • Hold their answers against them (In a positive way). Always have a conversation during the evaluation about the frequency and the importance of coming to therapy when they are scheduled, expressing to them that we can help them but they must come to scheduled appointments to make a difference (hold them accountable).Call ins: Problem-solve
  • When you get the patient on the phone and they want to cancel, ask, Why? What are you experiencing? Many times, the reason for the cancelation is exactly why they should be coming into their appointment. Be adamant and convince them to come in, if you believe you can help them.
  • When a patient leaves a message, call them and ask them the same questions. They may just need to be convinced that you can help them!
  • Move treatment times to another time of day or to a whole other day. Flexibility in your clinic is the key!

Last but not least, build and maintain relationships with your Physicians and Nursing. Frequent updates to communicate patient results to Physicians is always appreciated. Send notes or small updates with the patient to their next doctor appointments, even if the doctor doesn’t request it. These notes can be a quick word Doc, a progress note that is timed with an appointment, or even a nicely handwritten note.

All in all, have goals to grow your Outpatient clinics. Focus on the patient, and you will see excellent results. I even encourage devising a patient satisfaction survey to monitor your success and areas of opportunity. Good luck!

By Eric Feilmeier, OT, CLT, DOR, Colonial Manor, Randolph, NE, and Ryan Hough, Therapy Resource, Gateway, NE