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Submitted by San Marcos Nursing & Rehab, San Marcos, TX

By now, many of us are aware of the benefits of using Heart Rate Variability Training (HRVT) with our patients: improved resilience, improved function, reduction in pain and increased therapeutic activity tolerance. At San Marcos Rehab, we have begun to integrate HRVT with a COPD protocol developed by Michele Scribner, SLP, at our affiliate Northeast Nursing and Rehab in San Antonio, Texas, which was based on the work of Jocelyn Alexander. We have seen some truly excellent outcomes as a result.

COPD patients often present with increased anxiety during completion of daily functional tasks and social interactions due to difficulty breathing. This labored breathing often results in increased blood pressure, coughing, fatigue and loss of appetite. This barrage of symptoms in COPD patients is often advanced enough that social isolation becomes a risk due to voice deficits and insufficient respiratory support for communication needs.

In the past, our focus for COPD patients was on compensatory breathing techniques, including pursed-lip breathing, diaphragmatic breathing, deep breathing and the huff-cough technique, followed by stretching/strengthening training. This protocol achieved positive results, with many patients decreasing the volume of supplemental O2 and some patients being completely weaned off supplemental O2. Additionally, many patients were able to incorporate the breathing techniques into their day-to-day routines, but some reported that the techniques “didn’t work” if they became short-of-breath and that it caused a spike in their anxiety, leading to rapid, shallow breathing and spiraling anxiety. To combat these spikes that sometimes occur, we incorporated HRVT in conjunction with the breathing techniques training, and this has led to improved overall outcomes.

Allowing the patient to be more centered and heart-engaged, while focusing on positive feelings, creates coherence.

Trained breathing techniques provided our patients with the tools necessary to short-circuit their anxiety when they started feeling short-of-breath. We typically have the patients use the pursed-lip and diaphragmatic breathing techniques during HRVT sessions. Meanwhile, we’ve found that the deep breathing with the hold technique and huff-cough technique actually interrupt attempts at achieving coherence.

Patients who have worked with our speech therapy team learning both HRVT and the COPD techniques report significantly decreased anxiety, improved communication abilities and increased activity tolerance upon discharge. Many have reported that they were independently able to use the techniques to control their anxiety when a SOB episode occurred. We even had a patient come back to visit our team so that she could show us that she taught her husband with COPD the techniques!

If you are currently using HRVT in your facility, I highly recommend incorporating this protocol into treatment regimens with your COPD residents.

By Lori O’Hara, MA, CCC-SLP, PDPM Resource

In general, altered textures and swallowing problems go hand in hand. While you will occasionally have a patient who wants mechanical soft because they don’t want to struggle with cutting meat, or a patient with severe dysphagia who is NPO, you should almost always see those things happening together.

In PDPM-land, this means that the case mixes that indicate “either” a swallowing component or a mechanically altered diet should be pretty darn rare (less than 10% of the total case mix distribution). For the curious types, those case mixes are SB, SE, SH and SK.

According to ASHA, as many as 45% of patients in nursing homes have swallowing problems, and in most cases those problems (at least in the early days) will be managed with some type of texture alteration.

Here are some tips to capture everything that goes along with those conditions:

1. Any alteration to solid or liquid that is done with goal of making oral intake easier or safer is considered a mechanically altered diet.
2. Section K swallowing impairment questions can be answered based on the SLP/OT interpreting clinical language in the therapy documentation – there does not need to be a word-for-word reflection of the MDS language in the therapy documentation to answer “yes” to a section K item.
3. If the patient doesn’t need dysphagia treatment (typically because the condition is not new or expected to improve), a qualified clinician should always document the reason for the altered diet in a therapy or screening note.

Few patients choose altered textures for pleasure, so the underlying chewing or swallowing problem should be documented. This can include patient report (“I eat the mechanical soft diet because it’s too hard to chew meat” = pain or difficulty with swallowing) or documentation of subtle signs of swallowing impairment that are generally masked to the untrained eye by the altered texture itself. (Trace oral stasis or residue = holding food in mouth; throat clearing or wet voice after eating or drinking = coughing or choking during meals or medications).

By Chad Long, Therapy Resource

Post-acute health care is making a massive shift this October with Medicare’s change to the Patient Driven Payment Model (PDPM), where patient clinical characteristics drive the reimbursement and functional outcomes determine success.

Along with the payment model changing, we are in the midst of a significant population shift (often referred to as the Silver Tsunami) in which we have a growing number of older people, many of whom need a greater number of health care services.

“The Silver Tsunami is already rolling in and projections from the U.S. Census Bureau point to 2030 as a milestone year in which older people will actually outnumber children for the first time in history.” Tom Sullivan, March 15, 2019

https://www.healthcareitnews.com/news/silver-tsunami-coming-healthcare-time-prepare

“As the number of senior people rises in many economies of the world, the need for long-term care and aging-in-place services will increase.” Reenita Das, Aug 11, 2015

https://www.forbes.com/sites/reenitadas/2015/08/11/a-silver-tsunami-invades-the-health-of-nations/#494f73d53efd

So who will help champion the changes in health care delivery and ensure clinical and operational success in Post-Acute? Why not Therapy Professionals?! As licensed therapists and therapy assistants, we have a unique opportunity to move into Skilled Nursing Operations (Nursing Home Administrators, Executive Directors, CEOs, etc.) and work in a new capacity within the Interdisciplinary Team.

Within the Ensign Affiliated Facilities, we are seeing a growing number of Directors of Rehab moving into Operations and having great success. So why would therapy professionals be good candidates for Administrators in Training and, eventually, Executive Directors? At a recent Service Center meeting, led by Spencer Burton, a few reasons were discussed:

Why DOR to ED:

• Clinical backgrounds
• Mini-business leader (HR, Compliance, Billing, Maintenance, etc.)
• Balance of clinical and financial
• Multipliers
• Vision -> Path: Perspective — Push to goals
• Teaching, coaching, developing people
• Creative
• Likeable
• Challengers
• Communication skills
• Well-versed in Ensign culture

Guess who is a Therapist and Facility Operator?

• Salma Moore: Arroyo Vista
• Ryan Goldbarg: Victoria Ventura
• Matt Scott: Mission Hills
• Brian Rupert: Villas at Sunny Acres
• Doug Haney: Bella Vita
• Amy Guiterrez: La Hacienda
• Ediel Barrera: McAllen Transitional
• Marissa Parker: Legacy
• Kyle Martin: Kirkwood
• Kumar Pradeep: South San Antonio
• Amber Thompson: New Braunfels
• Travis Jones: Cornerstone

So what are the requirements to become a Licensed Nursing Home Administrator? Well, that depends on the state in which you live. However, there are a few common requirements. Typically, you must be 19 to 21 years of age, have a bachelor’s degree, complete an Administrator in Training Program (or have a master’s degree in a health-care-related field) and successfully pass the National and State Nursing Home Administrator Exam. Below is a list of basic requirements, per state, and a link to the National Association of Long Term Care Administrators Boards.

If you are interested in growing in a different career path from therapy to more facility operations, please contact Jamie Funk at JFunk@EnsignServices.net, or talk with your facility administrator. Let’s be the change we want to see in our organizations and in health care!

By Cory Robertson, PT, DPT, Therapy Resource

According to a study out of the University of California, San Diego, the answer is no, and yes. How can that be, you ask? Keep reading to get the details and the findings of the study: A pilot randomized study of gratitude journaling intervention on HRV and inflammatory biomarkers in Stage B heart failure patients.

Patients with Stage B heart failure are those who have a structural abnormality of the heart but have not yet developed symptoms. Thus this stage is a therapeutic window of opportunity to deliver interventions to prevent the progression of the disease and to maintain quality of life.

Studies suggest a strong connection between gratitude and well-being. The area of behavioral cardiology is increasing focus on positive psychology like gratitude and how it affects physical health. More studies are needed using objective measures of physical health to understand the disease-buffering effects of gratitude. One of those objective measures studied in this paper is heart rate variability (HRV). As we know, HRV is a measure to quantitatively assess variation in heartbeat intervals that is often used to detect changes in the autonomic nervous system. Psychological factors like mood, satisfaction, depression and chronic stress are related to the autonomic nervous system, suggests the research. So can gratitude journaling improve HRV?

Seventy patients with Stage B HF were randomized into two groups: a gratitude journaling group, and a “treatment as usual” group for a period of eight weeks. Participants were assessed at pre-, mid- and post-intervention for inflammatory biomarkers from a blood draw, basal HRV data obtained, as well given a gratitude and exercise activities questionnaire.

After eight weeks, these data were re-acquired; also, both groups were assessed for HRV responses to a specific gratitude journaling task. Here is the wording of the journaling instructions, and if you’re like me, just reading the instructions summons a sense of well-being: “For the next eight weeks, you will be asked to record three to five things for which you are grateful on a daily basis. Think back over your day and include anything, however small or great, that was a source of gratitude that day. Make the list personal and try to think of different things each day.”

Basal HRV measures between groups after eight weeks showed no significant differences — though at the eight-week assessment during the specific journaling task, there were medium to large effect sizes between the groups’ HRV. So assessing the different groups’ HRV separate from the act of gratitude showed no difference, but during a gratitude task, there was a significant difference. The authors surmise that “increases in parasympathetic cardiac tone … [during] journaling may reflect state changes that occur while contemplating items or feelings of gratitude during daily life.” Moreover, the gratitude journaling group had a significant reduction in inflammatory biomarkers, which are related to morbidity and mortality in patients with HF.

I’m grateful for this research and for the opportunities to learn more about the heart and how I can do something to help my heart function. Do you think reading research regarding gratitude and its benefits also improves HRV?

By Maryann Bowles, Therapy Resource — Colorado

The ENDURA Market in Colorado gathered 10 of their physical and occupational therapists to complete their LSVT BIG live training together at the Villas at Sunny Acres. The group spent a full day going through treatment and practice of the evidence-based neurologic patterns and movements for the treatment of symptoms associated with Parkinson’s disease.

Specifically, research shows that LSVT BIG treatment can lead to faster walking with bigger steps and arm swings, better balance and more ability to twist at the waist. Clinicians also report that LSVT BIG often helps people with buttoning their clothes, writing and other smaller-movement (“small motor”) tasks, as well as large (“large motor”) movements like dressing, getting up from a seat and getting into bed.

Because PD makes it harder to remember to use these bigger movements consistently, treatment includes a lot of repetition and progressive challenges, as well as daily home practice and assignments for using bigger movements in everyday life.

Ultimately, LSVT BIG helps improve the mismatch between what you feel you’re doing and what you’re actually doing, making you more confident, comfortable and empowered. With one month of hard work, LSVT BIG can open doors to a more active and independent life.

The ENDURA market therapist will now have a local network of fellow therapists to help support their development of a strong Parkinson’s and movement disorder treatment program in their buildings.

By Elyse Matson, MA CCC-SLP, SLP Therapy Resource

IDDSI stands for International Dysphagia Diet Standardization Initiative. The purpose of the initiative was to create standards across all environments so that the foods and liquids have the same texture or viscosity.

For example, when a patient arrives to your facility on nectar liquids, how do we determine if the hospital’s version of nectar is the same as ours?

The IDDSI framework consists of a continuum of 8 levels (0-7), where drinks are measured from Levels 0–4, while foods are measured from Levels 3–7.

There are specific testing methods to determine the levels, including a flow test with use of a 10 ml syringe and a fork test to determine food particle size and food softness.

Implementation

So should you implement IDDSI at your facility? There are several factors to consider. The first is, who is your menu vendor? The vendor supplies the menus to the kitchen and provides instructions/wording on which diets your facility uses and how to prepare the meals. It is up to this vendor to adopt IDDSI and provide the new language/instructions to the kitchen.

The next question is whether your local hospitals/referral sources are adopting IDDSI. This may create a need to address the diets sooner rather than later. We have created a conversion chart below to provide to your admitting nurses so they can convert the IDDSI diets back to your current diets.

Finally, you will need to work closely with your SLP, Dietary Department and IDT to determine if your facility is ready for this change. For further questions, please go to www.iddsi.org or reach out to Elyse Matson, SLP Resource (ematson@ensignservices.net).

By Lori O’Hara, MA, CCC-SLP, Therapy Resource — ADR/Appeals/Clinical Review

Setting the ARD

The purpose of the lookback period is to capture those conditions and characteristics that impact the patient’s treatment plan in such a way that they can 1) be reported to oversight agencies and 2) calculate a reimbursement rate.

Under PDPM, since the whole premise of the rate is that it is commensurate with how complex the patient is, it’s then essential that the lookback period capture as many of those things as possible. And it may be that capturing hospital activity is important!

If a patient received IV hydration or nutrition while in the hospital, it can impact our Nursing case mix. This makes sense — patients who were dependent on an enteral delivery of fluid or calories are quite fragile in the period after this treatment concludes. The lookback on this item is seven days and includes delivery while in the hospital.

So the IDT’s job is to decide what the right ARD is to capture all the important info. We may choose to set the ARD on day one, knowing that capturing the hospital intervention paints the most accurate picture of the patient’s complexity. Or, if an IV medication starts after admission on day 7, that might be the right date for a lookback to capture the clinical picture. Or, if the patient had fluids through the day of discharge and has wound treatments ordered on day five, then a lookback that captures part of the hospital activity and part of the post-admission activity may be what’s best.

The good news is that up through day eight, the ARD can be moved forward and backward as needed to make sure that we’ve captured all the complexities of the patient we’re taking care of.

Section GG Reconciliation

Mythbuster time! Therapy should not be the only source of data for Section GG. One of the sources, sure! But not the only one.

Data sources should include therapy evaluations, nursing documentation and the MDS Coordinator’s observation of CNA care. All of this data should be recorded in the record, and then the IDT’s job is to reconcile this through the Section GG UDA.

So what does “reconciliation” mean? It means looking at all the available data and deciding what really represents the “usual and baseline” performance through analysis and discussion.

Say you’re looking at toilet transfers. The Occupational Therapy evaluation says Mod Assist, the nurses’ notes say Partial/Moderate Assistance, and the MDS Nurse documents Partial/Moderate Assistance in her entry. Then Partial/Moderate Assistance seems like the perfect answer.

But what if the OT says Moderate Assist, one nursing entry says Moderate/Partial but one says Substantial/Maximal — and the MDS Coordinator’s note also says Substantial/Maximal? What’s the right answer?

That’s the reconciliation part. And there’s no CMS mandated formula — it’s your IDT looking at the data and the overall performance of the patient and deciding. Do you suspect the patient performs a little more independently with therapy, but that really they’re requiring more help? Then landing on the more dependent score is probably the right answer. Do you know that later in the day they become a lot heavier? Then again, their usual performance is probably the more dependent one.

The critical element is having as much data as you can (and sometimes that will be a very small amount, if therapy is starting the day of admission!) and making a reasoned decision based on the information you have. You want to be able to point to the data you had available and your IDT’s decision-making process to support your coding should you need to defend it later.