CODE SEPSIS: Understanding the Sepsis Pathway and COVID

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Submitted by Tamala Sammons, M.A., CCC-SLP, Therapy Resource

The Mission:
Improve Sepsis identification early to improve patient outcomes.

The Why:
Sepsis was 20% of our Medicare Readmissions as an Organization in Calendar Year 2019.
With every hour that treatment is delayed for sepsis, the mortality rate increases by 8%. Understanding and educating our facilities on SIRS and a focused vital-sign campaign with an SBAR-specific focus will improve our care delivery and reduce readmissions, improve our patient satisfaction, and help with our change in condition process.

COVID-19 and Sepsis: A Physician’s Lens
While there is still a lot to uncover about the pathology and presentation of COVID-19, we have learned a great deal about this virus and its potential impact in our post-acute care facilities. During our experience at one of the early COVID-19 outbreak facilities, it was discovered that an early presentation of many COVID-19 patients was the presence of a fever. Unfortunately, these fevers were managed with the typical order for acetaminophen and cooling measures, effectively masking the fever and avoiding any further escalation of care until the patient reached a point of medical instability.Sepsis POSTette

As with any patient in a post-acute care facility presenting with fever, even before COVID-19, timing is absolutely critical. Other changes of condition such as chest pain or possible stroke have led to long-standing, conditioned responses to immediately send patients out via 911. Fever is often the hallmark sign signaling the beginning of a patient experiencing sepsis — a diagnosis that carries a much higher chance of mortality, especially in the post-acute care population, but up until now has not received the attention it deserves. Oftentimes a febrile episode is masked or ignored, leading to a cascade of events leading to further demise, accelerated by a virus that now has the potential to spread like wildfire.

We are now at a point where identification of fevers (and other changes of condition) should signal a “code” event, essentially alerting the clinical team to provide immediate identification, isolation, and intervention. With every hour that a fever is ignored, the mortality rate for a potential sepsis patient increases by 8%. This simple, yet widely underappreciated clinical practice can prove to be a pivotal step in reducing the mortality in not just our COVID-19 patients, but in any patient who is on the path of developing sepsis. — Dr. Pouya Afshar

For more information, click here for our Sepsis POSTette

Documenting Justification of Skilled Therapy Services, Part 2

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Symptomless CVAs?
By Lisa Harvey, M.S./CCC-SLP, Documentation Review Resource

A pattern that our PDPM deep diving partners have found is hospital document and/or therapy documentation that reports a history of CVA that then goes…nowhere. Despite this history, no residual speech, language, swallowing, cognitive or neuromotor findings are reported in the therapy assessments (or anywhere else). Yet according to the National Stroke Association, only 10% of people who have a stroke will make complete neurological recovery. This means that many individuals with long-term sequela are going unidentified in our setting.
According to the CDC, the most common long-term symptoms after a CVA include hemiplegia, cognitive impairments, speech and language impairments, dysphagia, incontinence and depression. Most of those symptoms, when properly identified and managed, will trigger PDPM components.

Step 1: Identify the sequela.
Obvious hemiparesis, dysphagia or aphasia will seldom be overlooked. But even minimal impairments can affect a patient’s balance, skin integrity, weight, mood and cognition. It’s critical that when a CVA history is present that the most sensitive assessments are completed to ensure that subtle impairments in symmetrical strength, righting response, complex reasoning, word retrieval, mood or swallowing are not missed.

Step 2: Identify how the patient is impacted.
It’s very unlikely that a long-term residual sequela doesn’t impact the patient’s function, the therapy treatment plan, or both. In addition to therapeutic interventions that may be need to be incorporated into the specific therapy treatment plans, the ways they impact a patient’s function should be part of the patient’s comprehensive care plan. Here are some examples:
• Hemiparesis that affects gait stability or righting response should be careplanned under fall risk management.
• Hemiparesis that affects sensation should be careplanned under skin intergrity.
• Hemiparesis that causes joint instability should be careplanned under risk for injury.
• Apraxia can affect ADL function, gait stability or speech and should be careplanned in the appropriate area.
• Aphasia or dysarthria that effects either comprehension or expression should be careplanned under risk for communication breakdown.
• Dysphagia that requires any degree of adaptation (including supervision or compensatory swallowing technique) should be careplanned under nutritional risk.

The better the assessment, the better the patient’s therapy and care plan can be customized to their needs. The more patient-focused the care, the better the patient will respond to it. And an extra bonus is that CMS recognizes the impact that long term neurologic sequela have on a patient’s care and they’ll reimburse accordingly. So we call that a win!

What’s So “Vital” About Vital Signs?

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Submitted by Tamala Sammons, M.A., CCC-SLP, Therapy Resource, Flagstone, Pennant, Sunstone, Milestone, Endura, Monument

Vital signs are the objective measurements of temperature, pulse, respirations, and blood pressure as a clinical means to assess general health. Additionally, many include Pain and Gait Speed as the fifth and sixth vital signs.

Vital signs are critical indicators of patient status, both at rest and during exercise/activity.

 

Therapists treat patients with many complicating conditions, such as:

  • Respiratory conditions — pneumonia, COPD/chronic bronchitis, emphysema, asthma, atelectasis, etc.
  • Cardiovascular conditions — CHF, hypertension, etc.
  • Metabolic conditions — renal failure, diabetes, etc.
  • Infection conditions — sepsis; Systemic Inflammatory Response Syndrome (SIRS), etc.

Taking consistent vital sign measurements will help ensure therapists have good data related to respiratory function, cardiovascular function, endurance, and a patient’s ability to tolerate functional activity.

As clinicians, it’s not only important to take vital signs, but also measure them against exercise/activity. In other words, vitals should be taken:

  • Before the exercise (to establish a baseline);
  • 6 to 8 minutes in the exercise; and
  • 5 minutes after the exercise (recovery).

This information will allow clinicians to determine if target heart rates are being attained, any changes in condition, and/or if treatment adjustments need to be made, etc.

Consistent vital sign measurements also help detect medical condition changes. For example:

Sepsis early warning signs (these changes need to be reported immediately):

  • Temperature higher than 100.4° F or lower than 96.8° F
  • Heart rate greater than 90 beats per minute
  • Respirations greater than 20 breaths per minute

Respiratory rehab considerations:

  • A resting HR > 100 bpm is a relative indicator of patient instability.
  • If lower than 90%, there is an inadequate oxygen supply, and less than 70% is life-threatening.
  • Normal resting respiratory rate is 12-20 breaths per minute. “Normal” respiratory rate for an individual with pulmonary disease may fall outside these parameters. It is important to establish what is “normal” for each patient. Respiratory rate needs to be monitored before, during and after exercise.

Using vital signs to determine exercise termination:

  • Significant blood pressure changes
    • o BP>200/110
    • Lightheadedness; BP drops >20 mmHg
    • No more than an increase of 20mm Hg with activity
    • Oxygen saturation <90%
  • Severe shortness of breath
  • Noticeable change in heart rhythm

It’s important to know the normal ranges for each vital sign along with considerations for an aging population. Additionally, it’s also important to know what medications patients are taking and if those medications may interfere with vital sign measurements.

For example:

  • The medicine digoxin used for heart failure and blood pressure medicines called beta-blockers may cause the pulse to slow.
  • Diuretics (water pills) can cause low blood pressure, most often when changing body position too quickly.

Take time to ensure every member of the Therapy team is taking vital signs consistently and throughout treatment sessions as recommended. Consider hosting a training lab if any skills need to be refreshed. Ensure team members have access to vital sign equipment (consider vital sign kits for each team member).

For more information on the details of vital signs, please refer to the Vital Signs POSTette, Pain Management POSTette, and Clincally Complex POSTette.

For training tools, check out these resources:

• Training video on taking blood pressure: https://www.youtube.com/watch?v=UGOoeqSo_ws
• Training video on all vital signs: https://www.youtube.com/watch?v=JpGuSxDQ8js
• LMS video available on Vital Signs: How to Measure Vital Signs REL-PAC-0-HMVS 1 hour

Therapy to ED Leadership

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Submitted by Brian del Poso, OTR/L, CHC, RAC-CT, Therapy Resource

As you all know and have heard, our organization considers itself a “leadership development company that happens to be in healthcare,” and we are always looking to develop the best and right leaders. On previous Therapy Leadership calls, we’ve had guest speakers who were former DORs who took on the challenge of becoming EDs, quite successfully we might add! Our organization recognizes how special our therapists and therapy leadership are and the potential that many of you possess.
In a continuing effort to tap into that potential and to foster and grow any thoughts you may have or have had about becoming an ED, we are starting a series of interviews with our former therapists/DORs turned ED, to get some further perspective. Here’s the first of the series from Stephanie Anderson out of Rock Creek of Ottawa in Kansas.

Thanks for taking the time to check out this interview, and if you want to talk further or have questions about becoming an ED or the AIT program, we encourage you to take the next step and start talking to folks. There are many ways to get more information and insight, such as your ED, Market, therapy resources, Clay Christensen, and/or any of the former DORs who are now successful EDs. If you’d like to talk further with Stephanie or any of our other former DORs, let us know and we’ll get you their contact info!

Question: What is your favorite part about being an ED?
Stephanie: I love that I am able to really take the time to focus on staff and residents. I get to spend my day “people-ing,” as I like to call it. Being on the floor, problem solving, getting to know the staff and residents on another level, and really driving the culture and vision I have for the building all make my day so enjoyable. The impact I can have as an ED in taking our building to the next level is what motivates me each and every day.

Question: As a DOR, you were in a good place in your career. What kinds of things were you thinking about when the thought of being an ED came up?
Stephanie: Can I really do this? Do I want to do this? How will my relationships change with my peers and team if I make this switch? I love this building, as it is in my hometown and I’ve seen the changes that have happened over the years. I joined Rock Creek of Ottawa during the acquisition in November 2018. Prior to the acquisition, the building didn’t have the best reputation, so I love that I can be part of fixing that. I took the DOR job with every intention to change the reputation here. As the ED, I feel I have more impact and push to continue to change. Me stepping into this role allows the community to continue to build trust in us.

Question: How did you come to the decision to push forward into the AIT/CIT program?
Stephanie: Our market lead actually approached me about the idea. My ED at the time had been telling me for a while that I would make a great ED someday, but that day came faster than I was anticipating! It was a little unconventional as I still served as the DOR while I was going through the AIT and I was able to complete the AIT in my home building. There were long days, but I was able to make my AIT experience a positive one. You really are the one responsible for making your AIT program great. My therapy department was operating well and I felt like I needed more. I was also able to connect with other EDs within Ensign that were DORs previously and went through AIT.

Question: You’ve been transitioning to this role during this rough time of the pandemic. Are there qualities or characteristics you took from being a DOR that have helped you with your transition during this time?
Stephanie: How to enhance culture across departments, clinical skillset as far as infection control and isolation room practices, implementing strategies to enhance residents’ quality of life and functional abilities, LTC programming, creative ways to drive revenue, seeing the business side of how the operation works, building a strong team and having the right people on your team to be successful, driving culture.

Question: What advice would you give to a therapist if they are thinking about becoming an ED or even just about the ED role in general?
Stephanie: I’ve been told that DORs who transition to EDs are the most successful. ☺ If you’re considering making the jump, I encourage you to reach out to people who have done it and gain perspective. The beauty about Ensign is that our culture and processes allow awesome things like this to happen!

Documenting Justification of Skilled Therapy Services, Part 1

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By Lisa Harvey, M.S./CCC-SLP, Documentation Review Resource
Of the many exciting and challenging things our therapy teams look forward to doing every day, it is probably safe to assume documentation is not at the top of anybody’s list! Yet, in spite of the wonderful work that is done in our gyms, patients’ rooms and hallways — what we choose to document about those services may result in a denial of payment for your facility down the road.

Some of the most common reasons for claim denials include:

  • Ongoing services did not meet the requirements of medical necessity and reasonableness per Medicare criteria.
  • Documentation did not support the requirement that services shall be of such a level of complexity and sophistication or the condition of the patient shall be of such that services required can only be safely and effectively performed only by a therapist.
  • By (Date) the PT and OT plans of care did not document any significant changes or interventions that were needed or could only be done by or under the supervision of a licensed rehabilitation therapist.

The best defense for these types of denials is a good offense. We must proactively document the medical necessity and skilled interventions provided by our therapy staff.

Although a patient’s medical diagnosis or recent surgical intervention may play a strong role in determining whether skilled intervention is needed, it cannot be the only factor supporting medical necessity.

POC Justification Opportunities:

  • Reason for Referral should make it clear why treating discipline is involved.
    o Sub-optimal: “Physician Order.” “Routine admission evaluation.” “New admit.”
    o Optimal: “Pt. referred by nursing due to increasing weakness noted with recent falls in the patient’s room.” “Pt. referred to PT by physician due to new onset of weakness and reduced activity tolerance with increased assistance needed from caregivers for bed mobility, transfers and gait.” “Pt. referred to ST due to increased episodes of confusion with decreased memory for safety precautions while completing ADLs.”
  • PLOF should be a detailed summary of performance levels of the patient prior to becoming ill and should tie to functional areas addressed in both short-term goals and long-term goals.
  • Clinical Impression should specify areas where deficits were noted on assessment.
  • Reason for Skilled Services based on identified deficits (Clinical Impression) what specific interventions are needed that can only be provided by a therapist? What will happen if skilled interventions are not provided?
    o Sub-optimal: “Pt. would benefit from skilled occupational therapy to improve activity tolerance and strength.”
    o Optimal: “Skilled OT treatment interventions to include instructing and training patient in energy conservation techniques, positioning maneuvers, proper body mechanics, safe transfer techniques, safety precautions and use of assistive device(s) in order to facilitate safe return home alone.”

UPOC Justification Opportunities:
Continued Skill should describe the reason why therapy services need to continue based on the patient’s response to treatment. If the patient is progressing towards their goals, this case can be easily made as progress made before is the best prognostic indicator of more progress to come.

However, if patient is not progressing, this can be more difficult to document and the therapist must modify goals and/or approaches with the expectation that the patient will respond to those changes in the Updated Plan of Care. Sometimes new areas of focus arise during the course of treatment and those new areas are incorporated into the UPOC. These are all examples of why the skills of a therapist are needed to adapt and adjust the therapy plan.

Stay tuned for our next FlagPost when we’ll review how to make the best justification in a progress note and a TEN. We know you can’t wait!

Respiratory Rehab Using EStim

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Submitted by Cory Robertson, Therapy Resource, Idaho

Did you know that electrical stimulation can be used for more than a really fun demonstration in high school physiology class? Yes, it is great for that, but the evidence-based applications of electrical stimulation are myriad. A recent meta-analysis (yes, a meta-analysis, the king of the hierarchy of scientific evidence) concluded that e-stim effectually strengthens quadriceps and enhances exercise capacity in moderate to severe COPD patients.

A large barrier to therapy for those with respiratory conditions is their tolerance. They fatigue quickly and get short of breath and struggle with dyspnea. That is in part due to the changes in muscles when the ability to deliver oxygen to them decreases. There is an increased reliance on less fatigue-resistant muscle fibers. One method to address that barrier is the use of neuromuscular electrical stimulation to activate those muscles most important to functional activities. But how do you do it?

Like most therapeutic interventions, there is skill involved, and if done incorrectly, at best it is a placebo. The goal is to use the NMES effectively to get the best outcomes as evidenced by the meta-analysis and many more research articles. Please check out article for Respiratory Rehabilitation EStim from the portal for a refresher on how electrical stimulation works and some best practices. It will help to get the therapeutic dose to the target tissue, leading to great outcomes, while enhancing the tools in your therapy tool bag.

Let’s use the tools available to us, supported by evidence, to best treat those who rely on us to improve their function and quality of life. Electrical stimulation can be more than a last resort, or why Mr. Wilson gets the best reviews in his physiology class.

 

Skill in Place Considerations

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By Kelly Alvord, Therapy Resource – Sunstone

Goal of the Waiver: To keep beds open at the hospitals for more critical patients

Three things to consider to skill in place; however, please refer to our Ensign Affiliates Skill In Place Tool Kit that is available on the Portal for more detailed guidance:

1. Did the episode or change of condition occur after March 1, 2020, when the waiver went into effect? We are getting further away from this date, so this isn’t going to be as relevant.

2. Does the patient need Daily Skilled Services? 7x/week of Nursing Services and/or 5x/week of Therapy Services. This hasn’t changed for Medicare Daily Skilled Criteria. Therefore, keep in mind what is medically necessary to meet Medicare Part A criteria to assist you in determining if the resident is appropriate to be Skilled in Place.

3. Qualified Hospital Stay Considerations impacted by the COVID Emergency (keeping the hospital beds open)

● Bypass/skipping the hospital for bed access or to avoid exposure to COVID

o In the past, would we send or the provider send the patient to the hospital due to the change of condition? This needs to be an IDT discussion with the ultimate decision made by the physician. (See additional questions and considerations below.)

● Signs of or close exposure to COVID
o Are we isolating the patient and nursing is providing daily skilled care to assess the patient due to COVID, whether or not the patient has been tested positive to COVID?
o If we are waiting for the COVID test results, use the Med Dx of R09.89 and Z20.828.
o If the patient has a positive test or physician has diagnosed the patient with COVID, use the Med Dx U07.1 (only if the date of the test results or diagnosis is after April 1).

● Dislocation due to COVID
o Facility to Facility transfer due to the COVID emergency
o Caregiver Breakdown. Patient unable to stay home due to caregiver being exposed or positive for COVID.

Here are additional questions and things to consider:
Q: What if it’s already our practice to provide high acuity, daily interventions in order to avoid the hospital? Can we still apply the waiver?
A: Yes. The fact that you already have the necessary skills and policies does not preclude you from applying the waiver when the goal of those services is to avoid hospitalization.

Q: How can we tell if what we’re doing is routine, or applicable to the 3 day QHS waiver?
A: The decision is ultimately up to the physician (who must then write the order to initiate a skilled level of care). Collaborate with the attending doctor to reach a decision about whether the patient’s circumstances are impacted by the emergency as required by the waiver.

Final note: Many needs may arise due to decreased out-of-room activity, decreased community access and isolation from families. While these are emergency-related and should be treated, initiating a skilled stay requires that the needs rise to the level of requiring daily skilled interventions, and documentation must incontrovertibly support this. Most of these needs are properly managed with less than 5-7x/week interventions, and frequency should not be inflated in order to artificially justify a Part A stay.

Keep in mind that the skill in place process is new and has many factors to take into consideration. We have many resources available on the portal; please click on this link to take you to our Ensign Affils SIP Took Kit on the portal:

Your MDS and Therapy Resources are ready to help!

How Full is Your KUP?

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By Jack Rolfe, PT, MNA, CHC, RAC-CT, Senior Compliance Partner for Utah
Jack Rolfe is also the Founder and CEO of the School of Life Foundation (http://schooloflifefoundation.org/index.html). This 501(c)3 nonprofit organization has a mission to increase high school graduation rates. The following article was published in the Saint George Health & Wellness Magazine.

The phrase “my cup runneth over” is a biblical reference to receiving an abundance of blessings in life. I believe one of the greatest blessings we can experience is peace. As my physical body grows older and my hair turns a little whiter, my mind seems to ponder more deeply on all that I have learned. Recently, I spent time pondering the following question: How can we obtain true, ongoing peace in our lives? I would say this has been on my mind due to all of the current commotion in the world. Things are unsettled politically and economically. We hear and read about natural disasters, diseases, failed family relationships, and much more. At no other time in human existence has the world been more advanced in technology, knowledge, and resources, yet we appear to be at a low level with the virtue of peace.

During my reflection on this subject, I determined that the way to spell peace is KUP. For me, this acronym is defined as follows:
K = Kindness
U = Understanding
P = Patience

For the past few weeks, my aim has been to apply KUP in my life more each day. I make a conscious effort to apply these steps in all that I do. When I slip up, I reset and try even harder. Guess what? It has been working! As I apply kindness, understanding, and patience each day, my life is filled with an abundance of peace. Does the strife in the world go away? No, it does not. Does the world around me exude more calmness, tranquility, and order? Yes, it does! Thus, I conclude that increased peace comes into the world through my efforts.

Let’s briefly examine why this happens. First, let’s look at kindness. Did you know that performing acts of kindness lowers your blood pressure, relieves depression, boosts self-esteem, and reduces social anxiety by physically changing the brain? Kindness slows the ageing process by reducing wrinkles and promoting muscle regeneration. As if that wasn’t enough, kindness increases the chances of our relationships lasting, cures stress, and makes our lives happier overall. All this evidence is found in the research of former chemist David Hamilton. In his book The Five Side Effects of Kindness, Hamilton shares the scientifically proven health benefits of kindness and how these benefits can transform your life.

Next is understanding. In his book 7 Habits of Highly Successful People, Stephen Covey explains the benefits of habit #5: “First seek to understand, then to be understood.” According to Covey, as we apply this principle in our lives, we gain true insight into the lives of others and into the circumstances that surround us. Our actions show others that we care. Thus, we build synergy and cause others to desire to understand us.

The final piece of the equation is patience. Numerous articles point to the fact that exercising patience in our lives brings about better mental and physical health, allows us to make better decisions, helps us develop compassion, and teaches us to appreciate the process of growth.

Each one of us may discover that our path to peace through kindness, understanding, and patience is achieved differently. That is okay! The key is to start down the path. So, I invite you to step back and ask yourself, “How full is my KUP?”

“Peace is not absence of conflict, it is the ability to handle conflict by peaceful means.” – Ronald Reagan

Wound Care During COVID-19

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By Shelby Donahoo, M.S., OTR/L, Therapy Resource – Bandera
We all experience day-to-day (or minute-to-minute!) changes in staffing these days. Pueblo Springs in Tucson, Arizona, found themselves suddenly without a wound nurse for an indefinite time due to illness. With nursing managers working the floor, there was no one to cover this critical task.

So, DOR Josie Gorman, PT, stepped up and volunteered physical therapy to take over most of the wound care program. DNS Paulina Kareko, Josie, and ED Neil Cullen all met to discuss this as a possibility.
The team reached out to Therapy and Clinical Resources, who consulted together to determine if this was viable and considered all options, with the following questions and answers:

  • Is PT qualified for this task? Yes, as verified through licensure, state practice act scope of practice, Ensign job description. Josie had also completed wound care certification training.
  • How will competency be determined? With no wound care Skills Checklist in rehab, PT staff involved in wound care will complete nursing Skills Checklist, to be signed off by nursing leadership.
  • What parts of the wound program will rehab take on? Dressing changes, orders, weekly rounds with MD (via telehealth at this time); nursing to continue admissions assessments, skin checks, etc.
  • Can we add billable therapy wound care services to the POC? Yes, through four avenues: a) Use of Physical Agent Modalities for wound healing per Medicare guidelines for qualifying wounds (training provided); b) Adding pain management standardized assessment and goals as appropriate; c) Including functional goals in the POC pertaining to wounds: positioning, training off loading, bed mobility, therapeutic exercise to increase circulation; d) providing caregiver education and training in regard to above goals.
  • What about documentation? Rehab billable tasks to remain in Optima; for non-billable tasks (weekly rounds, documentation, dressing changes), PT to document in PCC following training from nursing.
  • What about cost allocation? Therapy non-billable wound care tasks to be allocated to nursing cost center.
    What about the exit strategy? PT to relinquish tasks per consistent availability of nursing management and return of wound nurse; IDT discussion bi-weekly.

Hats off to the Pueblo team for thinking out of the box and working together to support patient care! Thanks to awesome Clinical Resources Sheila Summey and Julie Uychiat for collaborating to support nursing/therapy teamwork! And thanks to Pit Crew for input and suggestions.

p.s. Yesterday, a wound-care doc reported progress on a chronic ulcer that’s been plateaued for some time, with patient expressing excitement about this gain. Estim for wounds really does work, y’all, with lots of evidence to support. ☺

Orem OT Medication Reduction

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By Ryan Porritt, OT, Orem Rehabilitation & Nursing, Orem, UT

Occupational Therapy (OT) used non-pharmaceutical mindfulness-based interventions (HeartMath and Acceptance and Commitment Therapy) to support a patient while the physician reduced anxiety medication that she had been on for years. The patient has several mental health diagnoses, including bipolar disorder, PTSD, generalized anxiety disorder contributing to frequent panic attacks and high levels of anxiety. Her independence and quality of life is further complicated by several physical comorbidities that exacerbate the functional impact of her anxiety. She has a history of significant trauma as measured by scoring a 9/10 on the Adverse Childhood Experience scales.


The following are the step-down dosages of clonazepam:
Staring at 1 mg 3x daily
Reduced to 0.5 mg 3x daily on Jan. 21, 2020
Reduced again to 0.5 every 12 hours on Feb. 1, 2020, to present

The OT trained the patient in several meditations to reduce the emotional struggle resulting from her anxiety in order to increase participation in value-based activities. With assistance, the patient identified three value-based activities: writing poems, quilting and facilitating a weekly bible study group for her religious congregation. After 30 years of not writing poetry, she is able to express her pain, anxiety and other emotions through regular poetry writing. She has assumed a leadership position to prepare and facilitate weekly bible study groups, and she is currently being trained to lead a resident-run quilting group in collaboration with Recreation Therapy and the Therapy Department.

While the patient still faces daily challenges resulting from anxiety, she reports the duration and frequency of panic attacks have reduced and that “I am not struggling with my emotions as much anymore.” With less medication, she reports both increased quality of life and increased participation in value-based activities. While significant progress has been noted, she will require continued skilled OT under a maintenance plan due to the complexities of her physical and mental health. As illustrated by this example, skilled therapists are in an ideal position to have a significant impact on both function and quality of life while assisting physicians to reduce medications.