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

One of the most common reasons for denials in both the Medicare and managed care areas is removing e-stim minutes because the documentation doesn’t support a skilled service.

Reminder! No one pays the machine, so the amount of time the machine is running has nothing to do with how much time is billed. What is reimbursed are the minutes that required a skilled brain — so clearly describing the minutes when the brain was engaged is critical!

Typically, the skilled time includes: assessing and prepping the patient for treatment (including a skin check), applying the electrodes, selecting and inputting the parameters, time spent during the treatment assessing for tolerance or accommodation and making any adjustments, and the post-treatment take-down (including another skin check) and assessments.

Patients who rapidly and frequently accommodate to the current, or roll over from sensory response into a pain response, may require skilled attendance the entire duration of the delivery — but that is not common, so when it occurs it must be very well-documented.

Also remember to put billed minutes in the right place! If you’re using e-stim as an adjunct to neuromuscular re-education or therapeutic exercise, make sure you record the minutes properly. Lumping your treatment minutes into the e-stim code creates an artificially high delivery that the documentation will almost certainly not support.

And finally, the cherry on top: Conclude your narrative entry with a summary statement about the billed time for one-on-one skilled intervention, e.g., “Total number of one-on-one skilled time = 16 minutes.” This is even stronger if the run time is detailed in the description of the e-stim parameters.

Please see the Supervised Modalities POSTette on the portal for more details and examples.

By Willow Dea, Therapy Resource

“Comfort is not the objective in a visionary company. Indeed, visionary companies install powerful mechanisms to create /dis/comfort — to obliterate complacency — and thereby stimulate change and improvement /before/ the external world demands it.” -James C. Collins

We take tremendous care to achieve our mission every day: To dignify and transform long-term care in the eyes of the world. We do that by enacting a pledge to our core values, which foster a culture of integrity and compassion for our patients and their families.

These commitments ask everything of us. They require each of us to explore a profound, and continuously evolving understanding of leadership. Every Ensign affiliate is a leader; it’s part of the agreement we made when we accepted our respective positions. As partners in this endeavor, we are offered an opportunity to be part of something much greater than ourselves. It’s in this context that I find myself wondering how to be a better partner to each of you and a better leader, especially in practical terms. What does it actually look like, as a set of behaviors and outcomes, to be a leader?

Good to Great^[1] revealed the traits of great leaders, and we’ve benefited from learning from these examples. We know that taking responsibility, being humble, getting the right people on the bus, being able to ask for help and leading with passion are essential characteristics and skills for building great organizations and realizing our mission.

Yet the question of how to develop those traits remains somewhat elusive for me, even with such clear stories. In practice, this means we get to cultivate new habits and practice new behaviors. To do that, we need to get comfortable with the uncomfortable. Easier said than done, right? Where do we start? It’s been said that habits are more powerful than fear and that “life begins at the edge of your comfort zone.”

Fortunately, many people are asking similar questions, in every industry sector. Extensive research has been done to help us grapple with these central concerns and effectively answer them. Leadership Agility is based on the rigorously researched developmental framework presented in the award-winning book Leadership Agility: Five Levels of Mastery. The three dimensions of this framework are summarized below.

The Developmental Model^[2]

Agility Levels

The first aspect is a description of the “leadership agility levels” that came out of the research. As managers develop, they grow through stages or levels of agility that can be clearly defined and measured. Teams and leadership cultures have the potential to evolve through parallel levels of agility. The three levels of leadership agility most relevant to the vast majority of today’s organizations are:

• Expert: Managers who operate at this level of agility use their technical and functional expertise to make tactical organizational improvements, supervise teams, identify and solve key problems, and sell their solutions to others. Research indicates that approximately 45 percent of today’s managers operate at this level of agility.
• Achiever: Managers who function at this level of agility use their managerial skills to set clear organizational objectives, lead strategic change, motivate and orchestrate team performance, and engage in challenging cross-boundary conversations. About 35 percent of today’s managers operate at this level of agility.
• Catalyst: Those rare managers who have developed this level of agility are visionaries who can lead transformative change, develop high participation teams, and collaborate with others to develop creative, high-leverage solutions to tough organizational issues. About 10 percent of today’s managers operate at this agility level.

As change accelerates and the world continues to become more complex, the need increases for more Experts to become Achievers and for more Achievers to develop the capacities and skills needed to operate at the Catalyst level. In this increasingly turbulent environment, teams and leadership cultures are challenged to undergo parallel developments.

Action Arenas

As leaders develop through the levels of agility described above, their capacity for taking leadership in all three key leadership arenas expands and becomes more effective:

• Leading organizational change
• Improving team performance
• Engaging in pivotal conversations

The Agility Compass: Four Types of Agility

Joiner and Joseph’s research found that agile leaders employ four types of agility, which work together to increase the effectiveness of leadership initiatives in each of the three arenas. The four types of agility are briefly summarized below:

• Context-settingagility determines how leaders scan their environment, select key initiatives, then scope and set objectives for these initiatives
• Stakeholderagility determines how leaders identify and understand key stakeholders, as well as their ability to create greater alignment with different stakeholder groups
• Creativeagility determines a leader’s ability to identify the key problems an initiative needs to solve, get to the underlying issues, and develop creative solutions that work for multiple stakeholders
• Self-leadershipagility determines how proactive leaders are in experimenting with new leadership behaviors and in learning from their experience

If your curiosity is sparked and you’d like to learn how to reach your next level, reach out to Willow Dea at WDea@EnsignServices.net to take a self-assessment. It takes about 10 minutes, and you’ll leave with a clear understanding of exactly what you can practice to become the leader you aspire to be.

Remember, “The job isn’t to catch up to the status quo; the job is to invent the status quo.” — Seth Godin

^[1] Good to Great, James C. Collins, Harper Business; 1st edition (October 16, 2001)

^[2] Leadership Agility, William B. Joiner and Stephen A. Josephs, Jossey-Bass; 1 edition (October 20, 2006)

Did you know that there is a simple way to measure and reduce the stress response in our bodies? The variability in the heartbeat from beat to beat is called heart rate variability (HRV), and HRV is a powerful indicator of overall health. HRV essentially measures the stress response in our bodies, and through the use of biofeedback, we can actually train our stress response and improve our health! Dozens of our therapy programs across the country are using sophisticated biofeedback devices developed by our partners at HeartMath^® in order to reduce personal stress, and to help our patients improve function and reduce anxiety. Here are a few examples of our success stories!

Angela Anderson at Gateway in Pocatello, Idaho, used the power of HeartMath technology to help a patient who was experiencing anxiety that would lead to cardiac arrhythmias resulting in multiple hospital readmission. Angela began biofeedback training using the HeartMath app and Bluetooth device, and the patient responded immediately with reduced anxiety. Angela set up the patient in her room with a portable device for her to use anytime she felt the anxiety and panic starting to occur. The results have been life-changing for the patient. She is now able to manage her anxiety and no longer is discharged to the hospital with panic attacks. The physicians and staff have been amazed!

Matt Zweig, Occupational Therapist at Park View Post-Acute Care, utilized HeartMath with a patient who came to the facility following a CABG. Even though the patient had just undergone extensive cardiac surgery, he had limited understanding of blood pressure and the anatomy and function of the heart. Matt used HRV training as an opportunity to educate the patient about the overall function of the heart. Matt hooked up the biofeedback device and instructed the patient on the techniques to regulate his autonomic nervous system. The patient was fascinated with the ability to see the results of the techniques through biofeedback and reported greatly reduced anxiety as a result of being able to regulate his heart.

Tyler Johnson, DOR at Northbrook, utilized the HeartMath biofeedback device with a patient with pneumonia, atrial fibrillation and anxiety. The patient was struggling to complete therapy sessions and quickly becoming short of breath (SOB). When the patient became SOB, he became more anxious and O2 saturations would quickly decrease. He was unable to complete functional mobility or ADLs due to SOB and O2 sat decline was also sent to the ER three times in a one-week period with these symptoms. HRV training was implemented with the use of the HeartMath emWave Pro to decrease anxiety, control rate of breathing and improve functional performance. The patient was able to maintain O2 saturations above 90 percent following HRV training and able to participate in training for functional transfers and ADLs with SBA.

Stephanie Winkler is a DOR at Wellington Rehab in Temple, Texas. Stephanie and her staff have multiple personal and patient success stories.

Mrs. T’s story:

Mrs. T had a variety of tests run as she was presenting with LE and UE weakness, but without any diagnosis to support the weakness. She was discharged from the hospital and was initially not making progress with therapy. We introduced the HRV training using HeartMath to see if we could help with focus and reduce her anxiety and depression. After only two sessions, she was able to focus better, participating in therapy and improving each day. She didn’t initially understand that she had underlying anxiety and fear, but with the use of HeartMath, she was able to control her anxiety and ambulate over 300 feet on even and uneven surfaces as well as shower and dress independently, and she was discharged home independently.

Mrs. S’s story:

Mrs. S came to us following a total knee replacement. She was exhibiting high anxiety and fear during her therapy. On the third day, we introduced the HRV training using HeartMath. Through the use of this program, she was able to begin to help with bed mobility and begin her rehabilitation with fewer episodes of yelling. She also was able to overcome her fear of standing and ambulate over 300 feet independently with the use of an assistive device, and she achieved excellent knee range of motion. The use of HRV biofeedback training allowed her to participate with therapy so that she quickly achieved independence with a short length of stay.

Mrs. B’s story:

Mrs. B came to us due to a hip fracture. She had a tremendous amount of fear and anxiety that was limiting her ability to participate in therapy. HRV training using HeartMath was introduced, and she was then able to fully participate in her therapy session, was following one-step commands, and was able to perform functional transfers and gait training with the assistance of therapy within the first week of HeartMath implementation.

Jon Anderson, Texas therapy resource, utilizes HRV and HeartMath both in trainings with therapy staff and also for his own health. One of the most profound changes that Jon has seen personally is his ability to sleep at night. He also has noticed an improved ability to focus and listen to others, reduced muscle tension, and overall reduced pain and fatigue after implementing the biofeedback techniques. Jon has also introduced the technology to his mother to help her with her anxiety and health challenges.

Consider the following patient profile: A 19-year-old with traumatic brain injury secondary to assault presented with moderate deficits in immediate and short-term memory as well as temporal and spatial orientation. He was also legally blind as a result of his injury.

The patient has been receiving skilled Speech Therapy at Rock Canyon since March 2017 to address oropharyngeal dysphagia and communication/cognitive deficits. Additionally, our team employed the use of an Alexa device and TBI services for therapeutic interventions, plus an improved quality of life for the patient.

Intervention Components

Caregiver Coaching

• Educating the patient’s mother on programming the device and its features
• Encouraging caregivers to cue the patient to use the device for temporal orientation and checking or adding events to the schedule

Script Therapy and Drill

• Rehearsing with the patient before having the patient activate the device for adding events to the schedule, checking the date and daily schedule, and solving math problems with drill exercises

Education on Device

• New skills, entertainment features (music, books on tape)
• Shift in ownership — allowing the client to take the initiative to use and experiment with the device independently

Quality of Life

• Music (Spotify, Amazon Prime)
• Books on tape (Audible)
• News (NPR)
• General information (Wikipedia)
• Weather
• Horoscopes
• Alarms
• Games (Jeopardy)

Data

At the baseline, the patient was able to answer 0 percent of temporal orientation questions (day of the week, date, year) or his daily schedule. Currently, the patient shows significant improvements in regards to temporal orientation and personal scheduling when verbally cued to use the device. Goals include having the patient answer temporal orientation questions, add events to his schedule and check his schedule without being cued to use the device.

By Rock Canyon Rehabilitation, Pueblo, CO

Occupational therapy and speech-language pathology co-treatment sessions provide comprehensive intervention and could fill a research gap on the benefits of this collaborative approach to advance patient outcomes in a SNF setting. Due to ever-changing and restrictive regulations, clear and effective documentation is necessary to ensure reimbursement and to expand the opportunities currently limited by billing protocols.

A review of current literature identifies information on the benefits of OT and SLP co-treatment sessions in a pediatric setting, but it fails to include outcomes of this collaboration in geriatric environments. The same hierarchy of skills addressed in the pediatric field often needs to be re-addressed as a natural part of the progression of aging. The skilled nursing facility presents multiple diagnoses impacting ADL/IADL performance, which could best be addressed by this underutilized interdisciplinary approach.

Literature Review

OT and SLP collaborations can provide comprehensive interventions during self-feeding, ADLs and general therapeutic activities. Planned meal-time co-treatments can include an OT assessment of wheelchair/seating positioning, ROM, strength and coordination for both hand-to-mouth and utensil manipulation, while an SLP assesses labial seal, oral motor control and other dysphagia concerns.

When an OT is providing skilled education and assistance to increase patients’ independence with ADLs, an SLP can assist by highlighting the necessary cognitive processes to complete the task and provide education and cues for improved carryover of learning.

This interdisciplinary support can also occur when IADLs and community reintegration are appropriate in a patient’s discharge plan. Additionally, increasing the cognitive demand and executive function components during therapeutic activities incorporating standing tolerance, dynamic balance, fine/gross motor coordination, safety, functional mobility and community needs can provide a more holistic approach to patient care (Ellenbaum, 2010).

Methods and Assessments

• Identify patients with varying diagnoses appropriate for skilled OT and SLP treatment
• Discuss treatment plan of each discipline and identify goals appropriate to address during scheduled co-treatment sessions
• Identify appropriate assessment tool/standardized measure to assess patient outcomes pre- and post-certification period with consistent co-treatment sessions

Potential OT Assessments

• Barthel Index
• Daily Activities Questionnaire
• Functional Assessment Scale
• Present Functioning Questionnaire
• Allen Cognitive Level Screening Assessments and Modules
• Safety Assessment of Function and the Environment for Rehabilitation (SAFER)

Potential SLP Assessments

• CLQT, MOCA-B, RIPA-G, SLUMS
• MASA, Bedside Swallow Evaluation, MBS/VFSE
• Determine the effectiveness of treatment interventions performed during reporting period including co-treatment sessions using pre- and post-test scores
• Compare pre- and post-test scores of patients with similar diagnoses not receiving co-treatment interventions
• Gather additional qualitative data using daily documentation of co-treatment sessions to determine effects more directly related to this approach

Intervention strategies include but are not limited to:

• ADL sessions
• PENS electrical stimulation protocols
• Therapeutic activities
• Community reintegration
• NMES electrical stimulation protocols
• Synchrony
• Meal assessment
• Diet texture analysis

Documentation

Co-treatment is not suitable for all residents. Therefore, the decision should be made on a case-by-case and even day-to-day basis and needs to be well-documented for each session (Ensign Services, 2016).

According to a joint position statement from AOTA, APTA and ASHA: “Co-treatment is appropriate when coordination between the two disciplines will benefit the patient, not simply for scheduling convenience. Documentation should clearly indicate the rationale for co-treatment and state the goals that will be addressed through this method of intervention.”

“Co-treatment sessions should be documented as such by each practitioner, stating which goals were addressed and the progress made. Co-treatment should be limited to two disciplines providing interventions during one treatment session” (Ensign Services, 2016).

Conclusions

Co-treatment sessions are intended to increase therapy intensity by cohesively targeting multiple goals with the same functional activity and an opportunity to provide increased services that may otherwise be limited by patient fatigue level or willingness to participate. Co-treatments are meant to be planned prior to scheduled treatment to highlight goals being addressed by each discipline and identify his/her role during the session.

A skilled need for a co-treatment approach should be identified before any treatment planning begins. Additionally, clear and effective documentation is the key for conveying the insight and skilled need for providing this service.

By Stacia Kozidis, OTR/L & Caitlin Timmins, MA, CCC-SLP, Clarion Wellness and Rehabilitation Center, Ensign Group & HCR Manor Care Waterloo

 

At Park View Post Acute, the use of Life Story Boards has helped caregivers promote independence, provide appropriate cueing techniques and decrease negative behaviors in residents with dementia. We’ve found these boards to be resident-centered, efficient, economical and creative communication tools in our facility.

What Do Life Story Boards Do?

Life Story Boards share information about the resident gathered in the Life History Profile with caregivers, family and visitors. Each board identifies the stage of dementia via a facility-based color-coding system. Not only do the boards communicate meaningful information about residents in an easy-to-understand format, but they also provide opportunities for residents to have quality interactions with staff throughout the day.

Modified Allen Cognitive Models
 

Results: Improving the Quality of Care With Measurable Success

In addition to the measurable results, we’ve seen subjective success as well. Family and staff have reported decreases in negative behaviors, and front-line caregivers are problem-solving with abilities-appropriate solutions. Residents also have increased participation in out-of-room activities.

Next Steps: Starting Your Own Life Story Board Program

Here’s what you’ll need in order to start your own Life Story Board Program:

• A multidisciplinary team with different perspectives who “share the vision”
• Administrative support and commitment
• Passionate, visionary therapists with a minimum of specialized dementia training
• A dedicated, organized IDT leader
• Openness to “out of the box” ideas and intelligent risk-taking

Here are some examples of ways to use Life Story Boards throughout your facility:

• With lower-level patients — Used to inform caregivers about what was meaningful to the resident and to paint the picture of who that person was, though he or she may not be able to interact with the board
• With higher-level patients — Used to promote meaningful conversation and reminisce with caregivers through pictures and word prompts
• With Abilities Care interdisciplinary teams — Used to incorporate abilities-appropriate, resident-centered information into individualized treatment strategies, behavioral approaches and interventions as part of specialized dementia care plans
• For use as a bridge — Used with the family during care conferences, to enhance new employee orientation, as an ongoing Abilities Care training tool and to ease the care transition when staff assignments change

Implementing Life Story Boards entails training your staff to recognize the meaning of the four color-coded dementia levels. The long-term goal is for staff to understand the associated strengths, challenges and care strategies associated with those levels. From there, they are best equipped to implement that knowledge expertly in providing resident-centered, abilities-driven care.

Gardening is one of the most popular pastimes for Americans. And creating a meaningful treatment incorporating a purposeful treatment activity such as Gardening can leave our patients feeling good in spite of their health conditions, which may limit movement (such as arthritis) or cause fatigue. With a few strategies, gardening can be a great reinforcement for patient’s to practice their modifications within the context of a pleasurable and safe activity. According to the AOTA, occupational therapy professionals take a holistic approach and develop strategies to help people do the things they want and need to do no matter their limitations, disability, disease, or condition. Using Gardening as the therapeutic modality can make a treatment very meaningful to a patient.

– See more at: http://www.aota.org/about-occupational-therapy/patients-clients/health-and-wellness/gardening.aspx#sthash.2kWoDUAw.dpuf

One of the environmental modifications which helps make gardening a more accessible modality for our patients is the Elevated Garden Box, such as the one shown in the picture below. Therapy Resource, Curtis Hoagland, hand-crafted this gardening box for the Occupational Therapy Department at Richland Hills Rehabilitation and Healthcare in Fort Worth. By combining his love of building with wanting to help fill this need for the therapy team, Curtis brought a smile to the face of Jaclynn Stolfus, our OTR at Richland Hills pictured below standing with her newly delivered Elevated Gardening Box.

Shopping List:

2 – 4×4 fir or cedar post (fir is cheaper and lasts nearly as long) I actually used pre-treated lumbar after researching that it is EPA approved for humans and food boxes.
3 – 6×8 cedar boards
3 – 1x3x6 cedar fence pickets (cheaper than cedar board)
1 – roll of 1/4″ hardware cloth 50×24″ (make sure to get hardware cloth with 1/4″ holes, 1/2 inch is too large and all your dirt will fall through)
16 – 3/8 inch x 3 inch lag screws
16 – 3/8 inch flat washers
Box of 1 1/4 inch exterior wood screws

Cut List:

Legs: cut the 4×4’s into 4 – 32 inch legs
Sides: cut 2 of the 6×8 cedar boards into 4 – 48 inch lengths
Ends: Cut 1 of the 6×8 cedar boards into 4 – 24 inch lengths
Bottom slats: cut the 3 – 1x3x6 into 6 24 inch lengths
Bottom hardware cloth: cut the hardware cloth into a 24×50 inch rectangle.

Pre-drill all holes to attach ends, sides and bottom support slats

Attach the 24” ends to the 4×4 post using the 3/8 x 3 inch lag screws (be sure to add a washer to the lag screw prior to driving it into the post). Allow the ends to extend beyond each 4×4 post by 5/8 of inch. This will allow the sides to butt up against the ends and keep the width of the box 24 inches (important to ensure the hardware cloth fits)

Attach the 48” sides (pre-drill holes) using remaining lag screws and washers.

To prevent cracking of the side and end boards, only drive the lag screws in about 2.5 inches and then hand tighten with a 9/16 inch socket until snug.

Cut the hardware cloth to about 50 inches long. Below is a picture showing how to wrap it around the legs. I tucked mine in on the inside of the end boards. Once it is aligned to the edges and tucked in on the ends, use ½ inch staples to secure it to the box on the post, the end board and the side boards (takes lots of staples).

Align the 1x3x24 inch cedar slats to the bottom of the box (equal distance apart) and fasten to the bottom of the sides using the 1 ¼ inch exterior wood screws (Pre-drill holes through the slats and sides to prevent cracking).

Alternate option (which I did): Add a 1×2 inch furring strip to the inside of each side about 5/8 of an inch from the bottom. Attach the hardware cloth to these furring strips and then align and attach the 1x3x24 inch cedar slats to the furring strips instead of the sides. This way the bottom slats are not visible on the finished project and anchor the hardware cloth more securely.

Lightly sand all edges. And then add a layer of compost or coconut cloth on the inside bottom of the box and then fill with potting soil or other planting soil of choice. The compost / coconut cloth helps prevent the planting soil from sifting through the bottom hardware cloth.

http://www.ana-white.com/2012/11/plans/counter-height-garden-boxes-2-feet-x-4-feet

 

Sabino Canyon Rehabilitation & Care Center is always working to create a sense of community. Our dedicated, compassionate staff strives to exceed expectations and make a difference in the lives of those we serve by providing exceptional care and service and remembering they are the reason we are here. As part of this commitment to our community, we opted to participate in the Bundled Payments for Care program on Oct. 1, 2015.

Methods

The BPCI initiative is comprised of four broadly defined models of care, which link payments for the multiple services that beneficiaries receive during an episode of care. For example, Sabino Canyon’s focus is on medical non-infectious orthopedic and major joint replacement of the lower extremity. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care. These models may lead to higher quality and more coordinated care at a lower cost to Medicare.

Results

By participating in the BPCI program, we were able to reduce the average length of stay by five days for all payers. We also implemented 90-day tracking for participants to reduce re-hospitalization. These participants became rehab candidates versus hospice patients.

Our goal is threefold with this program:

1. To manage the length of stay with a continuum of care.
2. To reintegrate participants back into the community.
3. To track participants for 90 days, by ensuring they have follow-up appointments and continue to function in the community with participant education.

By providing these services, we help to reduce the cost of healthcare, improve the patient experience and better the lives of those we serve.

By Dora Alvarez, COTA/L Therapy Program Manager, Sabino Canyon Rehabilitation & Care Center, Tucson, AZ