Here’s what we’re all about!
An IDT Approach to Contracture Management
We hosted the CE at our Legend West Houston facility. Nursing and rehab must be cohesive to a have a strong contracture management program. I sent an email out to our DONs and they welcomed the idea of including our RNAs. John even provided them with certificates. They loved it.
Thank you to those who were able to make it to the Contracture Management Course on Saturday. We had a great turnout from several of your therapists/assistants as well as your RNAs. The course speakers had an opportunity to visit the Katy and West Houston facilities, the day before the course, and provide face-to-face assistance. Tawaine and Brittany gave very positive reviews and stated that several patients were identified for therapy services that were previously overlooked.
Below, you will find the names and contact information of the speakers. Both are available to provide telemedicine support. What does that mean to you? If you have a patient you are considering for an orthotic and/or you need recommendations on the best splints, they are available by phone or FaceTime to provide guidance. They are also available to assist with verification of orthotics (especially for our managed care part B residents). All you need to do is send them the patient’s face sheet, and they will take care of the rest. Please take advantage of this available resource. We have several patients within our facilities with contractures, and our obligation is to provide the best quality of care available. Special Ensign pricing is available to us.
OCSI: Ongoing Care Solutions, Inc.
John Kenney: 949-702-2828 neuroflexjk@gmail.com
Regan Ponto: 970-978-1284 regancap@msn.com
Submitted by Kai Williams, Therapy Resource, Texas
The Power of Creativity: One OT’s take on the Dementia Care Program
Beth Brewer, OTR/ADOR at Legend Oaks Katy, is known to most of us by her acquired moniker, MacGyver. What she creates with “a little bit” of duct tape, PVC pipe and pool noodles is magical! So when we decided to make dementia care one of our focal clinical programs, it came as no surprise that she would create something great.
This is when the Dementia Care Activity Box was born. Using guidelines from Teepa Snow’s The Gems®: Brain Change Model, Beth created Dementia Care Activity Boxes based on various dementia characteristics (gems). All facility staff have received an initial in-service/training on the purpose and use of the activity boxes, which are accompanied by a matching resource binder with descriptors for each gem; dialogue cheat sheets to engage residents in eating, bathing and dressing tasks; as well as general information about dementia. In addition to the activity boxes, Beth also recently piloted a four-resident Dementia Feeding Program using red plates and bowls to increase self-feeding and po intake. So far, we’ve seen a 10 percent to 25 percent increase in po intake depending on the resident’s level of dementia.
Our Dementia Care Program is in its infancy stages; however, with “MacGyver” Beth at the helm, I know that our residents are destined for greatness!
Submitted by Tawaine Vigers, DOR, Legend Oaks of Katy, TX
Accountability and Skilled Documentation
“Employees want to know why they have to produce and deliver services by using certain methods. To be good at holding your staff accountable, you must be good at teaching. Teach about the consequences.” — Crucial Accountability
Did you know that poor documentation quality has a bigger financial impact than productivity does? It’s true! In general, while you save $0.02 for every 1 percent productivity increase, billing minutes pulled out during an audit will have a much greater financial loss:
RUC x 14 days (647.94/day = $9,071.16)
RVC x 14 days ($555.85/day = $7,781.90)
In conclusion, one billing minute removed due to unskilled documentation could result in a $1,289.26 loss.
DOR Role
What is the role of the DOR? We define it as follows:
- Commit to auditing documentation
- Set expectations at the interview
- Give positive feedback as often as constructive feedback
- Audit evaluations and MD orders to catch errors and monitor trends
- Initiate a “standardized test” day
- Include standardized test in “precautions” on POCs, to ensure staff re-test
- Monitor progress notes to look for trends
UR prep and care plans must:
- Create effective care plan process
- Frequently attend care plans to review weekly documentation
- Prep for UR using the “weekly status report”
- Ensure therapists are testing goal-related areas and that discharge dates are
- appropriate
- Report standardized test scores/ADL score during UR
Teach the Why
In order to hold staff accountable for skilled documentation, it’s important to engage your team in dynamic thinking about the “why” behind what they do. That is, educate them as to why quality documentation is important, as it not only reflects their clinical skill, but also ensures we can be billed for services and therefore has a financial impact. Finally, provide lists of commonly used skilled terms descriptive of therapists’ actions.
MSCA Data
Skilled documentation is a critical part of our systems at Granite Creek Health and Rehabilitation. By implementing training in this area, we saw an improvement in the MSCA therapy score and a decrease in the financial error rate:
By Larissa Osio, DOR, MS OTR/L, Granite Creek Health and Rehabilitation, Prescott, AZ
View full poster here: Accountability and Skilled Documentation -Granite Creek
Oral Hygiene Program
At Grand Terrace Rehabilitation and Nursing, we have implemented an Oral Hygiene Program with great success for residents. The purpose of the program is multifold:
- Decrease potential for complications from oral bacteria
- Increase resident level of independence and dignity
- Improve quality of life
- Develop restorative nursing programs and decrease caregiver assistance
Methods
- Identify appropriate residents (G-tube, dementia, bed-bound, cognitively impaired, high-risk aspiration, etc.)
- Create individualized oral hygiene box including: toothbrush, toothpaste, cup, mouthwash, oral swab, etc.
- OT addresses processing, sequencing, grasp, UE strength and coordination, postural control and compensatory training
- ST addresses oral desensitization, risk of aspiration, oral-motor coordination and strength, oral functions and cognitive abilities
- Provide daily visual schedule for oral hygiene in restroom for appropriate residents
- Provide caregiver education to nursing staff and family members
- Refer to Restorative Nursing Program for carryover
Results
As a result of the program, our residents have gained an improved quality of life and decreased caregiver dependence. We have increased CNA productivity due to residents requiring less assistance, while also decreasing hospitalizations due to medical complications associated with poor oral care. In addition, we have seen increased interdisciplinary team communication.
The oral hygiene program has benefited residents, caregivers, therapy and the facility. Not only have we boosted awareness of the importance of providing good oral care, but we have also enhanced residents’ self-efficacy.
By Grand Terrace Rehabilitation and Nursing, Therapy Department, McAllen, TX
Navigating and Surviving the Managed Care Jungle
Our skilled population has gradually shifted from traditional Medicare Part A to Managed Care Part A. Therefore, our treatment focus has had to shift as well. We are no longer focusing on progressing to prior level of function, but rather progressing to next level of care.
Methods
With the goal of reducing the length of stay, we determined that we needed to aggressively treat at onset of stay. To jumpstart our therapists and create a routine for the patients, we implemented the following days:
- Training Tuesday — We schedule patient families to come in on Tuesdays, and we provide training on transfers, functional ADLs and HEP.
- Working Wednesdays — On this day, we focus on all of the household tasks that patients require as they return home. We have patients sweep, mop, cook and clean the kitchen, dust, do laundry and simulate vacuuming. We have them “shop” at our stocked pantry for grocery store management.
- Functional Fridays — The focus on this day is all functional tasks, such as bathing/toileting, car transfers, tub transfers, dressing and fall recovery.
Results
Since the implementation of our protocol, the length of stay has decreased on our managed care from 18.4 days to 15.6 days. Reviewing the length of stay of our Medicare A patients, it has dropped from 30 days to 27.9 days. During the course of review, which was a six-month period, we had 196 Managed Care patients and 58 Medicare A patients.
Conclusion
Our goals include the following:
- Manage the length of stay while obtaining better outcomes. Goal effective May 2017 is less than 14 days length of stay regardless of payer sources.
- Finish development of the theme for Monday and Thursday. Manic Monday will be a crossfit-based day, and Relaxation Thursday will be leisure activities to promote a more active lifestyle.
- With the measures in place, we will have increased customer satisfaction of both the MCO and the patient.
- Utilize our preferred status with the Managed Cares to convert our discharging patients to become outpatients to better serve our community.
By Andy Cisneros, PTA, Therapy Program Manager, Legend Oaks, West San Antonio, TX
ADL Billing Versus Self CARE Item Set Change
At Mountain View Care Center, we questioned whether there is a correlation between the amount of activities of daily living (ADLs) the occupational therapy staff has been providing to patients with changes in their’ functional level upon discharge. We chose to compare this by analyzing the percentage of ADLs billed in the facility with the change in CARE item set from admission to discharge.
Methods
We gathered Optima reports from all Bandera facilities to determine service code usage of self CARE ADLs (97535) as a percentage of total billable services for a three-month time period. Functional Outcomes report containing the change in OT Self CARE item assessment was obtained for the same three-month time period. These two reports were analyzed to determine if there was a correlation between the two sets of data.
Results
The amount of billing of 97350 seemed to equate with the amount of change in CARE. However, upon closer statistical analysis, this was not found to be the case. There was no correlation found between use of ADL billing code (97535) and improvement in CARE item set. Billing of the code 97110 had a negative correlation with the improvement in ADL scores.
Data
- CARE item set and billing of ADL (97535) code
- Correlation between usage of billing codes and change in CARE item set
Conclusion
We concluded the following:
- The overuse of therapeutic exercise in OT treatment plans has a negative impact on patients’ improvement in functional levels.
- Occupational therapy should minimize treatments that involve purely therapeutic exercise in their daily treatment sessions.
- It would be more beneficial for the patients to address strength deficits through the use of ADLs and therapeutic activities than using upper body ergometry or tabletop activities.
In the future, we’d like to further our analysis by performing a study using a change in ADL levels instead of CARE to decrease concerns about CARE not being an accurate measure of improvement. Furthermore, after educating the staff on the increased use of ADLS as a modality, we’d like to perform the same analysis to determine if there was an increase in CARE item assessment as a result of increased ADL usage.
By Tonya Haynes, PT, DOR, Mountain View Care Center, Tucson, AZ
A COPD Case Study
At Northeast Nursing and Rehabilitation, we cared for a 77-year-old white male who had been recently hospitalized for acute cholecystitis. His PMH included CAD, a pacemaker, cardiac stents, HTN and COPD. The patient presented with a variety of problems, including debility, decreased ADLs, poor static/dynamic and sitting/standing balance, decreased mobility, decreased aerobic endurance and breathing abilities, and poor phonation.The patient also had decreased breath control, able to produce only three words without taking a breath. He required constant oxygen and had little diaphragmatic breathing, possibly related to the secondary effects of COPD.
Prior Level of Function
Prior to admission, the patient was ambulatory with a cane for household distances. He was I with ADLs, bed mobility and toileting, as well as I with dressing and hygiene/grooming. He consumed a regular diet, had good aerobic condition and did not require oxygen.
Interventions
We employed several strategies to help the patient, including physical, occupational and speech therapy interventions. For example:
- PT provided family education on safety/sequencing, continual monitoring of vitals during treatment sessions, kinesio taping to address knee pain, and patellar mobilization.
- OT addressed ADLs, LB dressing, donning/doffing shoes, UE strength, gross/fine motor UB control to manipulate objects, hygiene/grooming activities, toileting, and safe decision making.
- ST placed the patient on a COPD program, worked on pursed lip breathing, diaphragmatic breathing, deep breathing exercises, huff cough technique, stretching and strengthening exercises, instruction in use of inspironmeter, fluency and intelligibility exercises in conversational speech.
Outcomes
As as result of our interventions, the patient showed marked improvement in several areas, including functional gait distances with use of a cane, improved dexterity and fine motor control, LB dressing, toileting and more. His phonation improved, and the patient did not require oxygen at home. Ultimately, the patient was able to return home with the support of his family and thanks to the combined efforts of our therapy teams.
By Rochelle Lefton, MA, OTR; Michelle Scribner, MSLP; Heather Cox, DPT; Susan Garcia, COTA; Jesusa Herrera, PTA, Northeast Nursing and Rehabilitation, San Antonio, TX
Improving the Patient Experience Through Patient-Centered Care
Patient Centered Care isn’t just taking good care of our patients. It is a holistic philosophy of including the patient and their family members in as many decisions and system/facility improvements as possible. It means offering choices whenever possible, thereby giving our elders more control over their lives.
This approach may include asking for their input on anything from what kind of furniture they would like to replace the old furniture in the front lobby, to what we should ask them on a discharge survey, to simply when they would like to go to bed at night. We are still in our infancy with implementing this philosophy, but here is what we have accomplished thus far:
Long-Term Care Residents
- We invited six LTC residents to help plan our Nursing Home week in May. They offered suggestions and picked the theme for each day, the activity and the special food to be served.
- We have added an “Activities Calendar Planning” day to our Activities calendar and have begun including LTC residents with the planning of their monthly events.
- We have included LTC residents on our Dining Experience Performance Improvement Plan (PIP) to get their feedback on what they feel would improve their dining experience.
Rehab Patients
- We created a PIP for the first 24 to 48 hours, as this has been an area where we either shine or fail to impress.
- We invited a prior patient and his spouse to meet with us and get their feedback on their experience and collaborated on which areas we needed to improve.
- Therapy is offering a choice to new patients of what time they would like to be evaluated (before lunch or after lunch).
- Therapy is also asking each new eval if they would like to make a friend while rehabilitating. We then introduce them to another patient who also expresses an interest in meeting someone.
Through our patient-centered approach, we are able to improve the quality of life for residents and ensure they feel not only well-cared for, but also valued and significant.
By Park Manor Rehabilitation Center, Walla Walla, WA
Passport to Home: An Interdisciplinary Case Report
We all know it’s true: There’s no place like home. That’s exactly what our 70-year-old female patient expressed upon 
admission at Olympia Transitional Care and Rehabilitation.
The patient experienced a cardiovascular accident at home resulting in a fall, with left distal femur shaft fracture. Upon admission, her level of function was as follows:
- Hoyer transfer
- NWB in LLE for eight weeks
- 9/10 pain in LLE, TD for toileting and dressing ADLs
- Mild-mod swallow impairment with mechanical soft and thin liquids
- Mild dysarthria
- Mild-mod cognitive communication deficit
The patient lived at home with her spouse with multiple myeloma in a supportive, social community. She was independent with gait in her home and over short community distances; with swallow function, motor speech, functional cognition for her living environment; and with ADLs and IADLs, including cooking and cleaning.
This patient had one simple goal: “To get back to the way it was.” More specifically, she wanted to return home to her spouse and her cats, return to ambulation at household distances, and decrease the level of caregiver assistance for ADLs.
Treatment Approach
Taking an interdisciplinary approach, we developed a treatment plan combining physical, occupational and speech therapy. COTA and PTA created a “Passport to Home” document to visually track patient goals and progress:
- Goals are checked off as they are achieved
- The patient has an active role in goal-setting and completion
- Extrinsic motivator for compliance over a lengthy rehab stay
Physical Therapy
- Pain management — manual therapy
- Transfer training — progressive strengthening, slide board transfers
- Gait training — parallel bars, bariatric FWW
- Balance training
- Stair training
Occupational Therapy
- Toileting — Q2 hour toileting schedule, nursing staff in-service for compliance
- Dressing — adaptive equipment education, timed trials for improved function
- Tub transfers — tub transfer bench
- UE resistance to fatigue
Speech Therapy
- Oropharyngeal dysphasia — OMEX, compensatory strategy training
- Dysarthria — OMEX, breath support training, compensatory strategy training
- Cognitive communication deficit — external memory aid training, attention processing strategies
Additionally, we collaborated with nursing staff to ensure:
- Safe swallow strategy and positioning training (ST, PT)
- Compliance with toileting schedule with use of external memory aid (ST, OT)
- Transfer recommendations set up (PT, OT)
Conclusions
Using an interdisciplinary approach with complex patients is essential to realizing the highest level of performance success. The use of standardized testing allowed us to develop a personalized plan of treatment for this patient’s needs and improve the chances of a positive outcome.
Although this patient was quite discouraged at the onset of rehabilitation and did not have high expectations for success, we were able to encourage her along the way and improve her outlook. With a team approach, were developed a detailed treatment plan that ultimately allowed her to return home near her prior level of function.
By Scott Hollander, PT, PDT; Sarah Koning, MSOT, OTR/L; and Megan Bennett, MS, CCC-SLP, Olympia Transitional Care and Rehabilitation, Olympia, WA