Outpatient at Vista Knoll

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By Erin Huddock, PT, DPT, DOR, Vista Knoll Specialized Care, Vista, CA

When looking at what programs haven’t been tapped into, my ED and I decided to focus on outpatient and what we could do differently to get our program back up and running again. Outpatient at Vista Knoll Specialized Care has always been something that was never really focused on and was getting by with minimal referrals over the past few years. To start, we looked at our outpatient census and how we could gain more referrals. With that, we decided to make our rehab tech, Diana, the outpatient champion.

We first looked closely at our referral sources. A great way to start was to look into those referrals from patients who are currently in-house. We are already developing a great rapport with the patients and family members; they are comfortable with our therapists and it would provide a smoother continuum of care. And guess what? We can also keep a look-out for our patients who may be struggling or potentially be at risk for readmissions to the hospital and let our admissions coordinator know. It’s a win-win.

Next step, do they have insurance that we can accept? My rehab tech, Diana, will run the common working file on each patient who is here under Medicare or Managed Medicare that we contract with for outpatient. From there, we would discuss those patients who are appropriate to transition to outpatient during our weekly rehab meeting and would have Diana speak with the patients and discuss the benefits of returning to Vista Knoll for outpatient. Those who are appropriate and are interested, we let our case managers and social worker know to encourage the patient to transition to outpatient upon discharge. The biggest barrier that we have run into has been the lack of transportation for our patients who do not drive and do not have family. We do our best to assist those patients with finding options for transportation at the lowest cost possible.

It has been quite the team effort, and I really could not have done this without Diana, who has really taken to heart the care for our systems and the well being of our patients. Prior to starting this transition, we were averaging about four to five outpatients per month. To this day, we have been able to successfully maintain, on average, 17 outpatients per month with 55 percent of those referrals coming from our inpatient population.

Optima Update - Why Clinisign?

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By Aimee Bhatia, OT, DOR, Glenwood Care Center, Oxnard, CA

When we were given the challenge to get our physicians signed up for Clinisign, it seemed daunting. We had tried several years ago with no success and a lot of push-back. After our quarterly meeting in Las Vegas, I came back determined to make a change. I presented in QA that we would be switching to Clinisign and highlighted how much it would cut down on being hunted down for signatures, how much less work it would be for the facility to coordinate signatures and clarification orders to remain in compliance, and how easy it would be to do at their convenience.

I gave the physicians a deadline, and with Mahta Mirhosseini’s help, I got three of our main physicians signed up within a week. Two of our doctors preferred to have their nurse practitioners sign, and that was perfectly acceptable. Setting up the doctors also allowed sister facilities in the area to more smoothly transition to Clinisign because the doctors were already in the system.

Since we started, it is remarkable how much less time myself and the rehab aides spend chasing down doctors for signatures. There is less filing and fewer errors in typing clarification orders into PCC, and overall efficiencies have improved, eliminating the need to print and write clarification orders upon evaluation and re-certifications. Our physicians occasionally need a reminder to log in and sign documents that are waiting for them, but even with that, it is an efficient process.

If you have not mandated that your physicians jump on board, please do. Enlist your administrators if needed. Remember, once your physicians are using Clinisign to sign evaluation and re-certification documents, you will no longer have to write clarification orders, you will no longer have to type signed clarification orders into PCC, and you will not have to print because everything is signed in Rehab Optima. Our facility chooses to print the signed documents so they are accessible when needed in the medical chart, but that is just a preference of our facility. Happy Clinisigning!

Thirst Quencher: The Free Water Protocol for Patients with Dysphagia

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By Elyse Matson, MA CCC-SLP, SLP Resource

The Free Water Protocol is one option SLPs may utilize to help counteract the adverse effects of thickened liquids and/or tube feedings. What is it? How should it be used in your facilities? What are the risks for aspiration pneumonia?

The (Frazier) Free Water Protocol was named after Frazier Hospital. In 1984, Frazier Hospital began to give all patients unlimited bedside water and/or ice chips. They found that fewer residents had UTIs and dehydration. They also found that when paired with proper positioning and oral care, there were no incidents of aspiration. Although it has been referred to as the “Frazier Water Protocol” in the past, the proper name is “The Free Water Protocol.” It is best used with patients on thickened liquids or patients who are NPO and on tube feeding.

The free water protocol is not appropriate for all patients. The below table can be used by the SLP to help determine the risk for pneumonia in each patient. As you might imagine, the higher the clinical complexity of the patient, the less likely a Free Water Protocol should be implemented. Remember that a patient on ice chips or free water has not been deemed free of aspiration on these textures; rather a determination is made that the benefits of free water outweigh the risk of pneumonia.

 

 

 

 

 

 

 

 

 

 

 

The Water Protocol is generally defined by these guidelines:

  • Patient is allowed to drink water between meals (minimum of 30 minutes after meals)
  • Water and ice chips cannot be provided during a meal if the resident is prescribed thickened liquids
  • The prescribed thickened liquid is provided at meals
  • Medication cannot be administered with water if resident is prescribed thickened liquids
  • NPO patients can have water anytime
  • Use all other swallowing guidelines
  • Must abide by other fluid restriction orders
  • Position upright always
  • No thin water until oral care is completed or 30 minutes after meal
  • Water is offered freely throughout the day

So what are the best methods to implement the Free Water Protocol? A multi-pronged approach is recommended.

First, a facility-wide training, including:

  • Patient identification methods
  • Facility-wide implementation as facility program not just a speech program
  • Provision of oral care to patients at risk for aspiration
  • Method for writing orders and care plan in PCC only after the oral care component is implemented
  • Communication methods with Dietary, Nursing, MD and family
  • Monitoring systems to assure the program is being followed
  • Communication about the specific methods for each particular patient, including:
  • Method for completing oral care
  • Licensed or nurse aid providing oral care (check your state laws for who can use oral suction)
  • If patient will receive unlimited or limited water or ice chips
  • Swallow strategies required for best safety
  • Documentation in place that states risks and benefits
  • Clarity on who will monitor proper administration of the protocol

In some facilities, especially when first implementing the Water Protocol, the clinical team may prefer a doctor’s order that does not refer to a protocol but rather an order that describes what a patient can and cannot have. “Patient may have Free Water Protocol” verses “Patient may have unlimited thin water via cup (no other liquids) between meals starting 30 minutes after meals and after oral care. Patient to be upright for all PO intake.”

The importance of oral care cannot be emphasized enough. Failures with a Free Water Protocol are almost always because the oral care component has not been fully implemented. Oral care in patients with severe dysphagia should be treated as a nursing treatment and may involve the use of oral suction and MD-ordered oral solutions such as chlorhexidine. If nursing has questions about the safest way to administer oral care in these patients, consult the SLP.

The benefits of the Water Protocol include:

  • Reducing risk for dehydration and the multiple sequelae from dehydration
  • Better adherence to other dietary restrictions
  • Decreased re-hospitalizations

If you are interested in implementing a Free Water Protocol and have questions, feel free to reach out to me at ematson@ensignservices.net.

WELL - Skip the Fast Weight Loss Diets and Go for Long-Term Health

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By Angela Ambrose, contributing writer

With a wide array of diets on the market, it can be tough to weed out all the fad diets and find a nutritionally well-balanced diet that is rooted in sound science and also simple to follow over the long haul.

“It’s easy to be overwhelmed, but don’t get sucked in by all the fad diets,” says Katherine Beals, associate clinical professor of nutrition and integrative physiology at the University of Utah. “Sticking to the tried and true research-based recommendations is the best way to go. It’s pretty basic – fruits, vegetables, whole grains, lean sources of protein and low-fat or non-fat dairy.” These nutrition recommendations stand the test of time and are summed up in the U.S. government’s “Dietary Guidelines for Americans” that have been around for decades.

Not surprisingly, the Mediterranean Diet, which closely mirrors these guidelines, has been rated the No. 1 best diet overall for three straight years by U.S. News and World Report. Tied for second place is the Flexitarian diet and DASH diet, which stands for dietary approaches to stop hypertension.

Rather than strict diets, all three are more accurately defined as healthy eating patterns with no foods off-limits. Each emphasizes whole, plant-based foods with a few minor differences. The Mediterranean diet adds more healthy fats, such as olive oil and nuts, as well as red wine, if desired. The DASH diet is designed to lower blood pressure and focuses on cutting sodium and saturated fat. The Flexitarian diet is primarily a vegetarian diet with the “flexibility” of adding in an occasional serving of meat or fish, when you get a hankering for it.

The Downside to Fast Weight Loss

Choosing the best diet depends on your ultimate goal. For example, if you want to lose weight very quickly so you can look slim and trim in your wedding dress or tux in five weeks, then a weight loss diet like HMR, Optavia, Atkins or Ketogenic may be a good short-term option. Despite their popularity, these same low-carb, high-fat diets fall to the bottom of the list for diabetes, heart disease and overall health.

“You will lose weight fast, but it’s not sustainable,” says Beals. “You can only do it for so long and then you start adding foods back in that you’re missing. And before you know it, you gain weight back.” Plus, they are nutritionally unbalanced and often require vitamin and mineral supplements.

If you’re looking to cut weight and keep it off, Beals suggests skipping these trendy fast weight loss diets and following the universal rule for shedding pounds.

“I don’t care who you are or what you do – the only way you’re going to lose weight is if you’re eating fewer calories than you’re expending. How you do that is highly individualized.”

The best diet for losing weight is the one that matches your lifestyle, personality and food preferences. For example, if ongoing support and guidance is important to you, consider Weight Watchers (rebranded as WW), which received the U.S. News’ top rating for weight loss and best commercial diet. The Vegan and Volumetrics diets tied for second place in the weight loss category.

Carbs, Protein and Fat – Your Body Needs Them All

Instead of restrictive diets that eliminate entire food groups, look for healthy eating patterns that include all three macronutrients – carbohydrates, protein and fat – and adjust the amounts of each to match your health goals.

While many of today’s fad diets drastically cut or eliminate carbs, Beals says they are a critical part of a healthy diet. “Carbohydrate-rich foods like fruits, vegetables and whole grains are the foods that provide the bulk of our vitamins, minerals and fiber, so if you don’t eat carbohydrates, you’re missing out on all those nutrients,” says Beals. The key is to select nutrient-dense carbs and go easy on the empty calorie carbs like soda, sweets and refined grains that are easy to overeat.

Higher Protein Aids Weight Loss

One proven way to lose weight is to bump up the protein in your calorie-reduced diet. “There’s ample evidence to suggest if you increase your protein intake, while consuming moderate amounts of nutrient-dense carbohydrates and healthy fats, you not only will lose weight, but also the composition of that weight loss will be more favorable,” says Beals. “You’ll lose more fat while maintaining lean tissue.”

Whether it’s a pork chop, chicken breast, salmon fillet or beans, tempeh and quinoa, eating more protein can make you feel full longer, so you’ll be less likely to snack in between meals or fill up on empty calories.

Which diet is right for you?

For those concerned with lowering their risk of chronic diseases such as diabetes, hypertension or heart disease, any of the eating plans that emphasize whole, plant-based foods and low saturated fats are sensible choices – from the Ornish, Mayo Clinic or Nordic diets to the MIND diet, which combines the Mediterranean and DASH principles with a focus on brain-healthy foods such as berries and leafy greens.

No single diet is right for everyone. Select one that is nutritionally balanced, allows you to maintain a healthy weight and matches your palate and lifestyle.

Don’t forget the other key ingredient for overall good health – regular exercise. All eating plans are more effective when combined with daily physical activity. Not only will you burn more calories and be more likely to keep the pounds off, but you will also build stronger muscles, bones and immune system, which may add years to your life.

Utilizing the Drum Circle at Palomar Vista

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Submitted by Amy Pot, PT, DOR, Escondido, CA

The sound of light drumming and laughter filters down the hallway as the residents and patients start to assemble for drum circle. “I like chocolate cake, that’s the beat we’re going to play,” instructs Amy Pot, Director of Rehab, and Lulu Matos, Director of Activities, to a group of residents and patients at Palomar Vista Healthcare Center. They are drumming along on Turbano drums to I Love Rock and Roll by Joan Jett.

Pot and Matos are passionate about providing opportunities to improve the lives of the residents at Palomar Vista and worked together to build a wellness program using music as a vehicle to address many health aspects. The drum circle was a perfect medium to bridge the goals of each department. “It’s so simple anybody can do it and have a good time. We really wanted to work together to provide a dynamic program that would include everyone,” said Pot. Every week, the drum circle continues to grow. Residents and patients who were hesitant to participate become involved because the buzz is so infectious and the experience can be tailored to address their individual needs.

There are many benefits of senior drum circles, including: decreased anxiety, stress and depression; sense of community and new social connections; improved ROM, posture and coordination; muscular endurance stress relief; decreased effects of senile dementia; and building thought process self-esteem and confidence.

The construction of each drum and drum stick promoted a sense of ownership as each were customized and built by each resident to fit their needs. Some of the residents have limited movements from severe arthritis or Parkinson’s disease or may be wheelchair bound. The drums were built at varying heights to accommodate limitations in ROM, and drum sticks were provided to residents who did not have the muscular endurance to complete a song and promote grip strength. “We had hoped the residents would enjoy it. The feedback from residents and family has been overwhelming. The drum circle has been so positive in promoting a sense of community and being able to bring residents together to create something wonderful. The outcome has been amazing,” says Matos.

The drum circle is strictly driven by residents’ needs. At the request of the residents, they recently performed a Christmas concert for family and friends and are currently working on an 80s music performance for the spring.

Therapist Profile – Dora Alvarez

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Meet Dora Alvarez, a quiet Tucson superstar who prefers to be out of the spotlight! Dora has been with Sabino Canyon Rehabilitation & Care Center for eight years and loves being able to oversee the wonderful work and dedication her team demonstrates in helping one patient at a time. According to Shelby Donahoo, Tucson therapy resource, Dora has really come into her own in the past year and is one of our strongest therapy leaders in the Tucson market.

Dora was inspired to pursue a career in therapy after her mother’s terminal illness. She wanted to be able to help her mom have the best quality of life possible in the time she had remaining, and therapy was a way in which to accomplish that goal. As a leader, she emphasizes CAPLICO in her department by working with her therapists, facing all challenges as a team and helping her team believe in what they do to help improve the lives of others.

Dora would not change a thing about her demanding job — she believes that all the challenges and successes in the past have been a direct path to the positive place the facility is in now. Her favorite thing about her ED and DON is the trust they have in her as a leader, but from an outside perspective, I think Dora has earned that trust over the past eight years!

On a personal note, Dora’s favorite food is seafood, particularly shrimp and lobster. Her favorite Disney character is Simba from the Lion King because he was given a second chance to make a difference in his kingdom, which then helped him to become a great leader. When she is not working, Dora loves to spend time with her family. If you have met Dora, you might be surprised to know that one of the pastimes she shares with her family is big game hunting and fishing!

Nursing Therapy Partnership: Water Protocol for Skilled Maintenance Program

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Submitted by Jon Anderson, Therapy Resource – Keystone

The Power of Two: Recovery and rehabilitation require a comprehensive team working together to achieve a common goal. These goals cannot be accomplished by Therapy or Nursing alone, but a combined effort of a united team between departments. The efforts of nursing staff and therapists working together as a joint task force has brought incredible success stories within skilled maintenance programs.

Skilled maintenance programs are designed to maintain a patient’s current level of function and prevent unnecessary declines. A new skilled maintenance program Speech-Language Pathologists have implemented is a Free Water Protocol for residents on thickened liquids to decrease the resident’s risk for dehydration and increase their quality of life. The program was successful at safely decreasing resident’s risks for dehydration as well as increasing resident’s quality of life, but also provided unexpected success stories in other areas of dysphagia.

One resident had been NPO for two years and received all nutrition and hydration by PEG tube. This resident came to Legend Oaks-New Braunfels NPO and was never expected to consume food orally again. The resident was placed on the Free Water Protocol skilled maintenance program to increase her quality of life. The resident rarely wanted to get out of bed, but with the help and encouragement of nursing staff, they had the resident up every day so she can be in a safe position for swallowing. Additionally, nursing staff has assisted the patient with good oral hygiene to decrease the patient’s risk for aspiration pneumonia while on the Free Water skilled maintenance program. The resident was tolerating thin water so well with no s/s of aspiration that the Speech Pathologists began PO trials of puree with the resident. An MBSS was conducted after the resident demonstrated weeks of tolerance of therapeutic PO trials and was recently placed on a puree diet with nectar-thick liquids after not eating for two years!

Another resident on the Free Water Protocol was on a puree diet with honey-thick liquids for over a year. His skilled maintenance program was designed to decrease risk for dehydration. This resident also demonstrated good tolerance of thin liquids during the program, and Speech Pathologists began therapeutic trials of mechanical soft and regular textures with him. An MBSS was conducted, and the patient was upgraded from a puree diet to a regular diet! The resident requires cueing for safe swallow strategies, and the nursing staff has played a key role in ensuring the resident carries out safe swallow strategies on his new diet.

The teamwork between Nursing and Therapy has provided miraculous results in our residents’ lives.

“Never underestimate the ability of a small group of committed individuals to change the world; indeed, they are the only ones who ever have.” — Margaret Mear

DON/DOR/ED: “The Transformational Triad”

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Submitted by Jennifer Raymond, Therapy Resource, Northern CA

trans·for·ma·tion·al/tri·ad/ “able to produce a big change or improvement in a situation; “a group of three connected people or things

The objective of a triad is to create a peer-to-peer-to-peer relationship to accomplish a mutual purpose. “Triads are based on core values and mutual self-interest.”

A triad is not just three people meeting together. It is a relationship where each person is responsible for the quality of the relationship between the other. It is where each person has the other’s back. It’s “I’ve got your back and you’ve got mine” or “All for one and one for all.”

We have traditionally had one-on-one ED/DON relationships in the facilities as the leadership core. By adding that third person, the DOR, the power of the group is enhanced, the exchange of ideas and perception increased, it ensures faster and more accurate communication with the rest of the leadership/facility, it provides support and even friendship to the three members, it allows this core team to grow in their trust of one another, and it provides a place to be honest and safe when dealing with issues big and small.

Transformational Triad Opportunities to Achieve Amazing Things Together:

 

Achieving BHAG Nursing/Rehab team strengthening
CAPLICO/Culture training and events Long term care programming
Census development Managing managed care
Customer satisfaction Program development
Employee satisfaction and retention PDPM updates and planning
Decreasing readmission rates Productivity enhancement for therapy
Facility-wide dementia training QAPI
Facility staffing/Local recruiting Quality measures/QASP-*****
Identification of barriers to facility goal achievement Reasons to celebrate
Fiscal health and growth Relationship building within the community
Holding each other accountable Section GG and other MDS processes
Ensuring we meet Flag criteria Survey prep/follow-up
IDT leadership growth Support and friendship
Improving relationships with our hospital and managed partners “What If” intelligent risk taking brainstorming
Joint educational opportunities for Nsg/Rehab Worker’s comp management

 

“Three is the minimum number of legs required to make a stable structure.”

Therapy/Nursing Partnership at Cedar Health

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By Cathy Champlin DOR, Cedar Health and Rehab, Cedar City, UT

I’m Cathy Champlin, the DOR here at Cedar Health and Rehab in Cedar City, UT. My counterpart is Trent Neilson, the DON here. Cedar was a new acquisition on Jan. 1, 2019. I initially came on board at that time to assist with the transition, with the intention of returning to my home facility after a few months. The DON at acquisition had already given her notice prior to Jan. 1, and the position was temporarily filled by Jeremy Wood, our resource until May when Trent came on board. By the end of January, I had decided to transfer here as DOR and was working closely with Jeremy (and Spencer our ED) on helping to bring CAPLICO to Cedar.

When Trent came on in May, it was a very smooth transition. Perhaps because neither Trent nor I had a long history at the building and were both new in our roles, we were able to help each other without any territorial disagreements. We just put our heads together, bounced ideas off each other and got to work. We have worked hard to ensure that there is no “That’s Nursing’s job” or “I’m the therapist — I don’t do that.” The nurses here are very open to listening when Therapy notices a change in condition, and Therapy does not hesitate to toilet and answer call lights when able.

When asked what our “secret” was, I truly didn’t know. Perhaps, like I said, it was that we were both new to our roles and did not feel the need to “defend our territory” or that we had a similar vision for the building as shared by our ED. I will point out, though, that Trent and I carpooled to work most days for the first six months (45 minutes each way). That much one-on-one time definitely gave us a chance to talk, exchange ideas and get to know each other in a way that just time at work does not offer. So maybe that is the key.

As far as PDPM goes, I feel like we do well working as a team. Trent, Robert (MDS coordinator) and I look at all of the patients together. Trent and Robert have access through iCentra to all of the acute care records for most of our referrals, and I bring in the patient report piece as well from the therapy evals. We hand out assignments and use a color-coded tab system to keep track of where we are on each patient so we don’t waste time re-looking at things. Red is for new and not yet really started, yellow is for still looking for NTAs, but GG, BIMs, etc., are in green for “ready for fine tuning” and white is for sent. We often tease Robert, who gets nervous going to green, that it’s not easy being green!

The Beauty of PDPM – What MIGHT Be There

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

One of the miraculous things about PDPM is that we are incentivized to go learn things! And … we have the patient with us, 24/7, sometimes for weeks! There is no other provider — not the acute, not home health, not outpatient, not anyone who gets to have their arms around the patients as closely as we do and who are also told to go learn absolutely as much as we can.

Just us, baby!

So this presents an incredible opportunity to be the best assessors, the best investigators and the best, most impactful providers a patient will come into contact with.

This means that we if work superficially — if we’re content with just the diagnoses on the transfer list and just the treatments that come to us — that we’ll miss out on the potential for incredible impact to a patient, which, super conveniently, is pretty reimbursable when we do it.

So part of being a PDPM Ninja is knowing where the arrows are pointing. What conditions tend to come in clusters? What treatments should we be advising the MD that we can do? What low-impact, non-invasive interventions could have a big payoff for this patient if we just think about doing them?

So here’s an exercise for you. Look at the diagnosis list below. And before you scroll down, think through all the “maybes.” What might related conditions be? What treatments should be considered? What condition might mask another where you should take a close second look?

So what did you find?

Here’s what I found:

        • Sepsis and Bacteremia = Need records to confirm or r/o septicemia
        • Diabetes and insulin = Check for diabetic retinopathy and proactive management of insulin regimen in case order changes are needed
        • Diarrhea = Investigate source (radiation, infection, c-diff?) to confirm or r/o inflammatory bowel disease
        • Convulsions and seizures = Investigate control status (25% of seizure disorders are poorly controlled/intractable)
        • Klebsiella PNA and sepsis = Query for labs for drug resistance status
        • Alzheimer’s disease and encephalopathy = Cognitive impairment
        • Obesity = Score BMI, assess if patient’s weight warrants morbid obesity diagnosis
        • PNA = Assess for need for RT interventions
        • UTI = Assess voiding and s/s of retention for straight cath medical management
        • Multiple malnutrition markers present (infections, dementia, diarrhea, dysphagia)
        • Dysphagia = Should trigger on Section K, which should then correlate to altered texture diet trigger for altered texture diet

Did you spot any others? You can also do this exercise with medical documentation from the upstream provider. And the more clinical brains, the better! Each clinician carries their own training and experience into the room, so one brain might pick up on something another brain might not spot. And when you find four or five “maybes,” you know that not every one of them will result in a new condition to code and care for. But you’ll probably find a thing or two, and maybe find something else — completely unrelated to payment — that will have a big impact on your patients’ health and recovery.

Like I said — miraculous!