No Pressure – No Pain – No Problem: A Therapy and RNA Program

By Calli Carlson, OTR/L, DOR, North Mountain Medical & Rehab, Phoenix, AZ

“Oh it’s just basic range of motion. That patient doesn’t require therapy anymore.” I’m embarrassed to think of how often I have said these words, and I wonder how many therapists may relate to this same perception.

Previously in our facility, patients who were non-responsive or minimally responsive were transitioned from our skilled physical and occupational therapy to restorative nursing programs for passive range of motion, typically for three days a week. Over time, we began to notice that patients were demonstrating difficulty maintaining their current range of motion, while restorative nursing was likewise reporting increased tone and increased difficulty working with our more medically complex patients.

For patients with complex brain and spinal cord injuries, hypertonicity can worsen with time causing an invariable decline in range of motion as well as increased difficulty for restorative members performing their range of motion treatments and increased difficulty for certified nursing assistants performing basic tasks such as dressing and peri care. With this in mind, the dialogue began to shift from therapy could be involved in these patient cases to therapy should be involved in these patients cases to provide the best possible outcomes and improve quality of life.

Given the depth of therapists’ schooling on anatomy, neuroanatomy, kinesiology, positioning, and modalities, it seemed that therapists could provide enormous benefit simply by increasing their involvement and time with these clinically complex patients while also educating and instructing restorative nursing assistants, certified nursing assistants, and additional floor staff as needed.

A physical therapist at North Mountain Medical Center, Shannon Dougherty, took initiative and recently developed a program titled, “No pressure, no pain, no problem,” focused on improving the health and quality of life of long-term care residents in the facility. The 3-part program encompasses the following:

Part 1: No Pressure: Reducing likelihood of pressure injuries through bed positioning
Part 2: No Pain: Reducing pain through manual techniques, modalities, contracture management
Part 3: No Problem: Identifying ‘problem’ patients and completing CNA/RNA training for improved techniques, removing burden from RNA for especially complex patients that require additional assist.

The program is currently just beginning here at North Mountain, but we have already been surprised and encouraged by results we have seen thus far. One of our patients, in particular, presents with significant hypertonicity and accompanying flexion of upper and lower extremities at rest, placing this patient at high risk of developing contractures without appropriate intervention. Restorative nursing members have reported that this patient is typically averse to passive range of motion and that they have difficulty knowing how to properly complete this task. A formal therapy evaluation and subsequent treatment sessions identified that this particular patient responds well to simple verbal/tactile cueing, gentle massage of the hypertonic muscles, slow and prolonged stretch, as well as stretching muscles in isolation rather than combing several stretches at once (such as hip/knee extension). Therapists have begun educating restorative nursing members on these techniques as well as analyzing non-verbal pain responses such as diaphoresis, increased flexion posturing, facial grimacing, or increased heart rate in order to provide the best quality, patient-centered care.

The plan of care may differ for individual patients. For example, therapy might decrease restorative nursing visits to two times per week and see that patient once or twice per week to supplement their treatments, or therapy might work with that patient five days per week and discontinue restorative nursing at that time while they work to get a baseline and treatment ideas to share with the rest of the staff. Regardless of the method and scheduling, it is important that therapists see the value of their knowledge and skillset, restorative nursing members feel empowered and capable when working with these patients, and patients receive the best quality of care to improve their health and well-being while under our umbrella of care.

We Got Skills at The Hills-A Nursing and Rehabilitation Partnership and Collaboration

By Angelica Reyes RN, DON and Paul Baloy OTD, OTR/L, DOR, The Hills Post Acute Care, Santa Ana, CA

What is a nursing & rehabilitation partnership? Nursing is defined as a collaborative care of individuals that promotes overall health and prevents illnesses. Rehabilitation is the process of restoring and regaining the lost skills caused by an illness or injury.

Although nursing and therapy are two different disciplines, when both work together harmoniously, they become an effective and powerful tool that is deemed vital to our residents’ health advancement and recovery.

At The Hills, nursing and rehab departments collaborate on a daily basis to be able to provide an individualized resident centered care plan. We have developed an effective fall management system, wherein nursing and rehab teams visit residents at bedside for a more direct and involved plan of care, and diligently analyze and discuss which interventions will benefit the resident the most. Other recommendations are also solicited from the other members of the interdisciplinary team and continuously evaluated for their effectiveness.

In addition, we have recently conducted a successful CNA skills fair with the help and support of our Resource team, that encompasses the “customer second, passion for learning, and celebration” of the CAPLICO values. This event, “We Got Skills at The Hills,” allowed us to revitalize and strengthen the skills set of our front liners and bedside care providers for a safer care experience of our residents. Our very own rehab team demonstrated and shared their expertise in transferring, positioning and lifting our residents using bio-mechanically correct and safe techniques and approaches.

We will always have the opportunity to excel individually. It is when we start believing and behaving differently—collaboratively and seamlessly working together—that the magic starts to happen, exponentially multiplying our successes to meaningfully change the lives of those we care for as we continue our quest in dignifying long term care in the eyes of the world.

A New System for IDDSI

By Sarah Scott, MS CCC SLP, Pointe Meadows, Lehi, UT
On our last call, IDDSI implementation was a shared struggle. With the help of our students and in collaboration with nursing and dietary, we have implemented a new system for IDDSI consistency. On the next call, we can report on any success or challenges with our system.

We have had several inservices with Nursing across the last two weeks. Every nurse will attend training. We completed training with the dietary staff. Each training was an hour long and covered IDDSI, the modified liquids and solids, preparation and testing.

We created a patient identification system for diet modifications. We used the IDDSI colors and round dot stickers for each level in addition to a water droplet sticker for a water protocol. We are placing dots on the doors for easier in-room identification and on a wrist band, which we are placing on the patient’s walker and/or wheelchair for easier identification outside the room and in the dining room.

We created an admission protocol for each nursing station so the admitting nurse can find the diet and place the DOTs with the help of the CNA processing the admission. ST has the same materials so we can change the identification when we change a diet. The key is posted by all of the med carts, nursing stations, gym and dining room.

We also created nice-looking official thickened liquid stations. We have been having difficulty with liquids being the wrong thickness, the spoon being stored in the thickener, and no date on the thickener. Each station is clearly marked and has instructions on laminated cards to support where to get the thickener and how it and the spoons should be stored, specific instructions for our brand of thickener, the quick key to perform a test if needed, and the IDDSI levels.

Our kitchen has ordered single-serving liquids to go out on trays, and each nurse’s station also has a gel pump to support the nurses with ease of thickening amid their many responsibilities.

Strength Training for the Respiratory System: SLP Case Study at Olympia

By Suzanne Estebo Simko, M.S. CCC-SLP, Olympia Transitional Care, Olympia, WA
Kathy came to us in early February 2021 due to progressive weakness. When she first arrived at OTC, although she was alert, she had difficulty having the energy to even keep her eyes open. Kathy stated she was first diagnosed with Parkinson’s disease in 1992, but was able to maintain her productive life. After her diagnosis, she continued to work for an additional 10 years as an executive assistant for the WA Army and National Guard. She stated she and her husband are very social in nature and loved to entertain.

During her initial speech evaluation, Kathy was concerned about her vocal volume being recently diminished. She shared that she used to “sing all the time…in the shower, choir, car, and karaoke nights,” and now, “I squeak out.” It also upset her that her condition was affecting communication with loved ones: “My husband can’t understand me at all when I call him on the phone from here,” she said.

SLP Suzanne Simko recently took a CEU course on strength training for the respiratory system. Her patient Kathy seemed like she could really benefit from the information and techniques learned in this course. Due to Kathy’s breath support weakness, she was not able to complete all the recommended repetitions on The Breather device in her first session. However, both ladies were astounded at the noticeable difference in Kathy’s speech intelligibility at the end of the first session! Her vocal volume was much louder, and she had enough air support to produce sentences versus her baseline one- to two-word responses. The next day when seen for treatment, Kathy’s baseline speech was still more intelligible than previous sessions and almost as important, she was smiling and enthusiastic to go to speech therapy and resume her respiratory system training. Kathy now asks for handouts to help her remember oral/motor and breath support exercises to do when she’s not in ST. She stated she feels “hopeful for the future.”

Carly Peevers — Passionate About Think Thin

Submitted by Dominic DeLaquil, Therapy Resource, ID/NV

Carly Peevers is an SLP out of Rosewood Rehabilitation in Reno, Nevada. Carly is passionate about giving great clinical care and has recently taken on an educational role within the Pennant, Idaho/Nevada, market.

Carly has been an employee at Rosewood since 2015. In her first year at Rosewood, she worked collaboratively with the kitchen team to revamp the menus so that the diet recommendations match with the diets provided by the food services company. Since then, she has worked hard to train new and existing kitchen staff on diet restrictions and make sure they are comfortable with the administration of current diet orders. She has also worked with CNA and nursing staff to communicate actively when diets change to ensure the entire team is collaborating with regard to patient care.

Carly, along with the entire speech team at Rosewood, believes passionately in upgrading patients to thin liquids as quickly and safely as possible. Carly leads this initiative by educating staff on current lists of patients on thickened liquids and directing care in such a way that they are upgraded as quickly as possible. At any given moment, Rosewood never has more than a few patients on thickened liquids. She also recently trained the SLPs in her cluster on the value of reducing thickened liquids.

When the International Dysphagia Diets Standardization Initiative (IDDSI) was released in May 2019, Carly championed the transition by talking with the kitchen managers and Registered Dieticians and educating nursing staff on the levels to prepare us for the change. She attended trainings with speech therapists from all over the city to create a collaboration through the SLP network of acute, Rehab, SNF and Home Health SLPs.

Carly is truly a dedicated therapist, and Rosewood is so proud of all of her hard work!


Managing Lymphedema

By Calli Carlson, OT/DOR, North Mountain Medical & Rehabilitation, Phoenix, AZ
In the fall of 2020, two of North Mountain Medical Center’s therapists, Tyler Lieberman, COTA/L, and Calli Carlson, OTR/L DOR, spent 145 hours over the course of three weekends to become certified lymphedema therapists. Calli received a brief introduction to lymphedema management in her occupational therapy graduate program but knew there was still a great deal to learn in order to provide the best possible care to residents. Tyler also expressed interest in becoming certified, particularly after observing many residents with edema/lymphedema and the subsequent joint stiffness and skin changes that resulted. North Mountain’s CEO, Jason Postl, and Director of Nursing, Jacque Green, were extremely supportive in providing the means for training and were equally as committed to providing the highest quality, holistic care for residents.

Lymphedema itself is historically ill-understood in clinical practice despite affecting 90 to 250 million people worldwide. Lymph node removals, trauma, surgeries, medications, genetics and obesity are just a few of the contributing factors to disruption of the lymphatic system, which can result in protein-rich fluid in the interstitium and cause a cascade of adverse reactions. Physically, patients may experience extreme heaviness in limbs, itchiness, skin infections, and, in later stages, dermal fibrosis, skin papillomas, and trophic skin changes. Psychologically, physical changes can create anxiety, depression, reduced quality of life, and impaired participation in functional tasks of choice.

Lymphedema management focuses on clearing edematous fluid from the interstitium via manual lymphatic drainage, compression, and/or decongestive exercises with additional focus on skin care and self-care management. Therapists use precise measurements to obtain the volume of the edematous limb and track over time to determine the effectiveness of treatment. At North Mountain, Tyler and Calli have noticed significant improvements in total limb reduction with the use of volumetric measurements, and patients also report that their limbs feel lighter and easier to move.

For patients with decreased alertness, staff members are trained for the continuation of techniques to ensure carryover from skilled therapy. The ultimate goal of lymphedema therapy is to improve patients’ overall skin integrity, movement, health, and quality of life by moving unwanted fluid from the interstitium back into the lymphatic system to be excreted by the body. It is an area of therapy that is not often explored in the realm of skilled nursing but has the potential to improve patients’ movement and tolerance to standing activities in physical therapy, reduce risk of developing decubiti by increasing blood flow, improve patient’s self-esteem and quality of life, prevent fibrotic changes that can occur from stagnant protein-rich fluid, and overall increase patients’ participation with self-care and functional tasks of choice. It requires interdisciplinary communication and engagement to create lasting results for the patient.

Though not often explored by therapists, Tyler and Calli would strongly encourage anyone interested in better identifying/managing lymphedema to become lymphedema certified to gain the valuable skills required for effective lymphedema management.

Keller Oaks: The Culture is in the Details (#startamovement)

Submitted by Jon Anderson, DPT, Therapy Resource
KO Let’s Go, Let’s Go KO!” This is the rally cry at Keller Oaks in Keller, Texas, and it is a commonly heard anthem when you visit the facility. In a year that has been difficult at best in healthcare, the culture has done nothing but improve at Keller Oaks. When you look deeper to see what is in the air at Keller Oaks, it goes far beyond COVID.

Kristin Ryther, the therapy program manager at Keller, has been a breath of fresh air in a very trying year at a facility that has been hit hard by COVID on multiple occasions. We asked her to share a bit of her best practices and were blown away by what is developing there.

Starting with onboarding, Keller embraces culture by conducting group interviews and hiring only those people who the team agrees can be grown into great leaders. They agree on all hires and then make sure that the process does not stop there. According to Kristin, “Love is in the details.” She ensures that the new employee is greeted with everything that they need to be successful. She has their log-ins ready, an itinerary for their first day, and a team member assigned to them as a mentor. Kristin provides them with a bit of “swag” and has a ready-made reference form entitled “KO NEED TO KNOW” that includes everything from door codes to restroom locations to documentation tips and PCC locations of interest.

Culture at KO does not stop at onboarding. The team meetings incorporate music and moments of gratitude. Kristin has become a champion of championing others. She works to identify strengths in each of her team members and then assigns responsibilities appropriately. Each member has a strength; slow down and find it! It may be that they have special attention to individual treatments; they may be strong at scheduling, growing programs, or even leading the infection control of the gym. List them out and recognize them.

Ensure that you are communicating everything to your team. Utilize dry erase boards, address at team meetings, keep up-to-date information in binders. Use all means necessary to ensure that your team members have the communication they need to do their best work! Don’t forget to prioritize individual communication. Get to know your therapists and be transparent as well as approachable. Don’t be afraid to just listen and allow them to be heard.

Set clear goals and expectations. Kristin sets goals for “2 week sprints.” Some programs are short projects. She assigns a leader and assists with facilitation but allows for teamwork so they meet their goals. She posts the sprints on the communication board, writes about it, takes pictures and then celebrates it. Short-term goals like this make it manageable, and then the challenge is less likely to be pushed off down the road.

Celebrate the wins! Find the team member who loves to do this and assign it to them. Celebrate the day-to-day achievements and find 10 positives for every negative. Make sure the team feels appreciated and celebrated.

That is not to say that there will not be challenges. There will always be hurdles. When that happens, keep your positive vibes on! Start with yourself, and look in the mirror. Stay consistent. Be transparent. Don’t expect others to do something you wouldn’t do yourself. Hold them accountable after you have asked yourself, “Did I educate? Did I communicate? Did I reinforce?” Maintain accountability and expectations, but never be afraid to give each other grace. Most importantly, be yourself! Your team will recognize the authenticity and appreciate the transparency. Let them know it is okay to enjoy your work and have fun while you are doing it!

Why Take the Vaccine?

By Patrick Amar, DOR/PT, Mountain View Rehabilitation & Care, Marysville, WA
Here at Mountain View, we’ve experienced close to 100% facility staff vaccinations, and attribute our success to a couple of key reasons: the scars left on our minds and hearts as we reflect back over the past 13 months that we never want to repeat again, and communication, communication, communication. Looking back, we never thought the virus would hit so close to home. We heard about it in the news from China, but that’s a world away. We were taken by surprise when the first case of COVID-19 in the United States happened here in our backyard in January 2020. Shortly after, the first outbreak also happened in our area; it was just across the county line. Suddenly we were thrust into the epicenter of the virus, and it seemed the whole world was watching how we managed.

We quickly saw the virus spread in a nearby facility, then in another facility, and then in our community, like an uncontrollable wildfire. In June of that year, it finally came on our doorstep. We knew it was just a matter of time. I think the only positive thing about this pandemic is that it brought our team together even closer. We’ve seen the impact that the virus has had on our patients — their health, their emotions, their psyche and not just them, the family members, too, and the staff. This was the main reason why our staff was so determined to do something about this pandemic by way of getting vaccinated.

Another factor in the success of our vaccine rollout was having good education and communication from the get-go. Once the news of the vaccine was even hinted at, Clayton, our ED, was already preparing the staff for its arrival. Information quickly disseminated from the IDT to floor staff. We knew people would have questions, concerns and even doubts. Educational efforts ensued in huddles, staff meetings and therapy meetings. Even our medical director was involved in the education.

I’d also like to thank our clinical partners for the research and the materials provided for our educational efforts. It helped, too, to hear support for the vaccine not just from us, the IDT, but also from other specialists and healthcare providers who are experts in their field. Questions were welcomed freely and answered objectively. I really believe that our staff understood the common goal. The communication and education, coupled with what we’ve been through, were the driving factors of this success — for our patients, our families and our community.

Transitioning Our STOP AND WATCH Program into a True Conversation

By Kari Rhodes, MS, CCC-SLP, Therapy Resource – Keystone – West, TX
At Legend Oaks of Fort Worth, there have been a fair share of ups and downs in communication. As with most skilled nursing facilities, there are some struggles to get nursing and therapy on the same page, especially regarding changes in a patient’s condition. However, a recent change in structure for daily morning meetings has made a significant impact on both communication and patient care.
Initially, staff were encouraged to complete paper STOP AND WATCH forms that were turned in to the charge nurse. This was helpful in reporting noted changes, but it did leave room for improvement. Papers were misplaced, the change was forgotten, or multiple forms may be completed on one resident.

Staff were then trained in entering the STOP AND WATCH forms on the clinical dashboard in PCC. This improved the chance that the alert was seen by more people and addressed by a clinician. Unfortunately, the electronic alerts also were, at times, inadvertently left unaddressed by a busy nurse or well-meaning staff member.

Fortunately, what has been an amazing change for the team at Legend Oaks Fort Worth was a very simple addition to the morning meeting. In addition to reviewing metrics and culture topics, our ED implemented a review of the daily STOP AND WATCH alerts for the whole team to address. Each alert is discussed by the team. What condition or behavior caused the alert? What was done to address the change? How is the resident doing on a daily basis? This has significantly increased the topic of conversation regarding change in condition.

Here at Legend Oaks of Fort Worth, we are continuing to strive for improved care and communication. This simple change in a system that was already in place has opened the door for more conversation, increased discussion regarding change of condition, and decreased discharges back to the hospital.

Celebrating Success at Beacon Harbor

By April Trammell, SLP, DOR, Beacon Harbor Health & Rehabilitation, Rowlett, TX
Jimmy arrived at Beacon Harbor on April 13, 2020. He was in a very devastated state following a spinal fusion, which was compromised, leaving him with hemiparesis from the chest down. Because he was unable to feel his legs and feet, he was having frequent falls, required a hospital bed with assist rails in order to maneuver in and out of bed, and was wheelchair-bound. “I was brought to Beacon Harbor for my last days on earth to be comfortable and to give my wife Dianne a respite.”

Plans for Jimmy were to transition here to Beacon Harbor long-term care. But Jimmy had other plans in mind. He was successfully determined to wean off of all pain medication. “Then I started doing therapy — that wore me out — but I had it in my head that I wanted to recover.” Jimmy and his team of therapists were determined to help him gain his independence. “Day after day, week after week, I started improving not just a little bit — a lot! No explanation ‘why’ except my therapy and my willingness to do what is asked of me. They have challenged me on so many things, and they are holding me up, allowing me to improve.” He progressed to being able to transfer independently in and out of bed, and to be able to complete basic self-care such as dressing, bathing and toileting independently. “I feel like I am being rebuilt. There’s something about this place that draws it out of you.”

Jimmy and his therapists continued to focus on neuro re-education, and he slowly began to regain full sensation in his body. “I am able to feel hot water and take a hot shower for the first time in over 35 years!” He did not give up; Jimmy continued to thrive in therapy and began walking with a walker for the first time in 10 years. “I started taking control of my life slow, but every day it was a very hard road to walk down — for myself, for my wife and family. I would say Beacon Harbor is just one of the best rehab centers that I’ve ever been in in this nation, and I have been in quite a few from state to state over the years. The bottom line, Beacon Harbor: You have an amazing PT, OT, ST and Nursing staff. I’m getting ready for my second phase of taking my life back. I’m going to move into assisted living, and from there, back home. Thank you for a second chance at life.”