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By Tara Meyerpeter, OT, DOR, Keystone Ridge Nursing & Rehabilitation, Omaha, NE
America’s aging population continues to increase in numbers as well as cultural diversity. Baby boomers of all races and nationalities are entering our senior living communities. It is important to embrace cultural diversity and accept the different customs that contribute to the make-up. As the make-up of seniors changes, front-line staff are provided the opportunity to embrace new cultures and celebrate multicultural diversity.

Here’s how to get involved:

• Create an occupational profile to obtain pertinent information regarding ethnicity and cultural background following development of rapport and trust.
• Identify ways to incorporate preferences into treatment sessions (such as recognition of prayer practices, cultural preference/practices, and routines).
• Provide your staff with education to recognize and accommodate the unique needs that accompany different cultures.
• Provide activities and programs that offer seniors the opportunity to experience a variety of cultures such as a multi-cultural showcase.
• Provide interpreters for those who need it, especially in medical situations.
• Enable the use of interpersonal skills to demonstrate intentional respect for resident’s cultures.
• Offer residents with opportunities to express cultural heritage and to learn about cultural identities of others.

Keystone Ridge celebrates diversity in a multitude of ways. Recently, our OT Woroud (Rosie) Hudson assisted in creating a multicultural diversity group with our residents. Each week for four weeks in the month of August, residents worked on their project to display at our Multicultural Showcase. The residents met every Tuesday for approximately 30 to 45 minutes in preparation for the final presentation. The residents were provided with the level of cognitive assistance needed to fully engage and become immersed in research. Research included reading and locating pertinent information in printed article form and on the internet, locating images to add to posters, and cutting/pasting and organizing printed information on a tri-fold poster to represent countries. Most residents chose countries from which they had ancestry, while others chose countries related to personal interests. Each session, residents reported the history of their country, geography, traditional food and attire, art/music, and shared past experiences. They determined what artifact would be showcased to represent their country, whether it be food, attire, music, or a video displaying their country.

These activities allowed residents to take pride in their accomplishments and promoted an overall sense of both independence and interdependence, which enhanced their quality of life which enhanced QOL. The residents were excited and looked forward to attending the next session/workshop to continue to work on the final project. Residents were motivated to get out of bed and attend workshops during program, which was a motivating factor to increase out-of-bed and out-of-room activity to decrease the risk of excess disability and sensory deprivation. The most powerful benefit accomplished from this program would be the reminiscing-building opportunities developed during the sessions and at final showcase. Residents were able to tap into long-term memories of past experiences related to culture and past traditions and enjoyed sharing past experiences with others.

Countries exhibited included: Italy, Mexico, Poland, Germany, Jordan, and Lebanon.

By Mark Milligan, ADOR, Lake Pleasant Post Acute Care, Peoria, AZ
For my Capstone project, I created a new and improved group therapy sheet to help inform the CNAs on the patients that had group therapy that day.

We have had a lot of mishaps with registry CNAs getting patients up, ready and on time for their group therapy sessions during the week. When I brought the issue to their attention, they had a lot to say. Some registry CNAs told me that they were unsure of how the patient transferred and were unsure of which therapist to talk to because they didn’t know who was who. They were unsure of what time to have them up and ready by or when they should start the process of getting the patient up, seeing how some patients take longer than others. This was causing a lot of stress and more work for the therapist team and our core CNA group because they were having to help a lot more.

With this information, I wanted to create a system where there was little to no gray area when it came to getting our patients up and ready for group therapy. I wanted this new system to help our registry CNAs and our core CNA group as much as possible. I added four total boxes with six rows (one for each patient). Each row consists of a box where we can write in the patient’s room number, their transfer assist level, and what assistive device they use. I added the therapist’s name at the top so that the CNAs knew exactly who to contact if they had any questions or concerns. I also added the time at which the group would start. I put two boxes side by side and color-coordinated them to show a therapy team (PT/OT).

Typically, at Lake Pleasant, when one discipline determines a clinically appropriate group, the next discipline will run a group with most, if not all of the same patients. I would leave this new sheet at the nurse’s station next to the appointment sheet. I did this because the CNA’s often check the appointment sheet throughout the day to see when patients need to be up and ready to go. This would ensure that all of the CNAs would see our therapy list.

Implementing the spreadsheet has brought more efficiency to both our nursing and therapy teams, and as a result, our ability to deliver services in a group has increased. Some feedback I received from the CNAs was that they loved the new system. They expressed how it helped them to manage their time better and to go into a patient’s room confident in knowing how to transfer them safely. This system helped to build a better relationship between the CNAs and our therapy team simply by reducing any miscommunication between the two teams. A lot of the times, things happen due to the lack of communication between teams, and this sheet has helped to minimize that by showing our CNAs exactly what was needed.

By Tara Meyepeter, OT, DOR, Keystone Ridge Nursing & Rehabilitation, Omaha, NE
Keystone Ridge is a facility with a typical census of 72. Keystone is unique in the population in which they serve. Most typically, we serve residents who suffer/experience diagnoses that include homelessness, drug/alcohol addiction, and mental health disorders. With such disorders, we often see an increase in adverse behaviors, including self-isolation and denial of care. Our therapists have embraced looking at residents using an holistic approach. How do we serve their needs?

In one recent referral, a: 76-year-old female presented with a diagnosis that includes major depressive disorder and anxiety. She was referred to therapy due to her refusal to complete ADLs and her adverse behaviors (yelling, screaming) with caregivers. So often, we may look at this resident as “that’s just how she is.” The challenge to the team is, what can we do for this resident? Are we looking at the person as a whole?

In what way can we bring purpose? How do we increase their quality of life?
● Start building rapport. Be consistent. Trial different times to determine the most appropriate part of the day based on patient engagement.
● Establish likes/dislikes. A great tool to use is the Interest Checklist or Life History and Profile.
● Why are they refusing care? Is it more than behaviors? Find out their why. Most often it is more than just refusing. We used a sensory profile to determine sensory needs.

We have developed a friendship and trust. I discovered that my resident is sensory avoiding. She prefers the dark and is highly sensitive to clothing. She is very deconditioned from years of self-isolation and refusal to get out of bed. As a result, she is a high fall risk; however, she has good insight that it is not safe to walk alone. We determined her love for animals, specifically elephants. To work on sitting balance, we would watch the virtual zoo on the computer while seated at EOB. Little by little, I gained her trust.

Through these approaches, my resident has allowed me to cut off 12 inches of unkept matted hair, and most importantly, she is accepting my help with ADLs like showering. Now this took time, 1.5 months in fact! This is the person most often people chalk up to “That’s just the way she is.” My challenge to everyone is, are you treating at your optimal level of practice? Are we looking at the whole person?

By Elyse Matson, MA CCC-SLP, SLP Resource/Ensign Services
It is estimated that nearly 100 million people have contracted Covid-19. Long-lasting symptoms occur in nearly one in four people, even when they were not hospitalized. The primary complaints of those with persistent issues are brain fog and cognitive fatigue. That means millions of people are walking around with cognitive issues likely affecting their lives.

In a recent conference from ASHA, Rebecca Boersma, SLP of George Washington University Hospital, described a new outpatient treatment protocol to address these issues. These new patients are primarily female with a mean age of mid-40s. Recovery from these subtle but debilitating deficits does not follow the normal recovery timeline and tends to be remitting and relapsing in nature. Prominent deficits including attention, working memory, word finding, cognitive fatigue and processing speed.

Boersma utilizes assessment and treatment approaches common in the post-concussive population, including motivational interviewing, collaborative goal setting, and a variety of scales and tools to assess patient perception of communication, fatigue and cognition. These include the Modified Fatigue Impact Scale, the LaTrobe Communication Questionnaire, and the Multifactorial Memory Questionnaire.
Treatment focuses on a person-centered approach and utilizes proven treatments such as the meta-cognitive strategy, dynamic coaching and managing fatigue.

In our outpatient programs, we have an opportunity to seek out and help some of those suffering with Long COVID. Is this a program you can implement in your facility? For more information and to obtain the protocol, email Elyse Matson ematson@ensignservices.net.

By Elyse Matson, MA CCC-SLP, SLP Resource/Ensign Services
Swallowing is one of the most complex actions we perform, involving more than 30 muscles and nerves. The average person swallows approximately 600 times per day — about 350 times while awake, 200 times while eating, and around 50 times while asleep.

Dysphagia indicates any difficulty or problem with swallowing normally. A swallowing disorder not only affects safety but also quality of life. Dysphagia is a serious medical condition that affects between 300,000 and 600,000 individuals in the United States each year.

Common signs and symptoms of dysphagia include: difficulty with weight gain (in children), unintentional weight loss (in adults), coughing during eating/drinking, recurrent aspiration pneumonia, food/liquid coming out of the nose/mouth, and a feeling of food remaining “stuck” in the throat/upper chest, to name a few.

Dysphagia is associated with a wide variety of conditions, including congenital and developmental disorders (e.g., cleft lip/palate, Down’s syndrome), head and neck cancers, pulmonary conditions (e.g., chronic obstructive pulmonary disease), and a variety of neurologic conditions such as stroke, dementia, amyotrophic lateral sclerosis (Lou Gehrig’s disease), Parkinson’s disease, muscular dystrophy, cerebral palsy, and many more. Since it is a common symptom in many of these diseases, it often goes unnoticed and is often under-reported, despite having significant consequences.

Complications and consequences of dysphagia include pulmonary aspiration, malnutrition, dehydration, pneumonia and even death. In hospitalized patients, dysphagia has been shown to significantly lengthen the hospital length of stay and is a negative prognostic indicator. In addition, those with dysphagia often report a feeling of isolation and depression, as many are no longer able to take part in social gatherings that so often revolve around eating and drinking. It is estimated that dysphagia is responsible for between $4.3 to $7.1 billion in additional hospital costs per year. Despite the significant detrimental impact dysphagia has on health and quality of life, only a third of those afflicted seek medical treatment.

Assessment of dysphagia frequently includes a clinical assessment and instrumental assessment. A clinical bedside swallow assessment is typically completed by a speech-language pathologist (SLP) and is used to describe the characteristics of the individual’s swallow function, determine the presence/absence and characteristics of a swallowing disorder, determine the safest route of nutrition/hydration, and help provide additional recommendations for an instrumental assessment and appropriate treatment. The two most common instrumental assessments are fiberoptic endoscopic evaluation of swallowing (FEES) and modified barium swallow study (MBSS).

Once a diagnosis of dysphagia has been made, the healthcare team determines the most appropriate plan for treatment. Management of dysphagia may involve medical/surgical intervention by a physician and/or behavioral intervention by an SLP. The focus of any dysphagia intervention is to optimize the swallow to be as safe and efficient as possible, as well as to maximize the patient’s quality of life.

By Tamala Sammons, M.A. CCC-SLP, Senior Therapy Resource

F-Tag 686: Skin Integrity; Pressure Ulcers/Injuries

Surveyors will assess how a facility is doing based on the comprehensive assessment of a resident, and ensure that:

1. A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual’s clinical condition demonstrates that they were unavoidable; and
2. A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing.

How can Therapy help be a partner to ensure the facility has a strong skin system? Start by asking a few questions:

● Is skin integrity and risk for pressure ulcers assessed on every Therapy evaluation? Should it be?
● Do therapy assessments include other risk assessments, i.e., tissue tolerance testing? Pain? Nutrition/Hydration? Incontinence?
● When OT is working on showers with patients, in addition to focusing on ADLs, do they assess the patients’ skin?
● How often does PT remove a patient’s shoes/socks to assess a patient’s feet?

There are a wide variety of clinical areas that Therapy can assess and treat to ensure residents have good skin integrity, reduce risk for pressure ulcers/injury, and actively treat wounds.

Pressure Points and Tissue Tolerance
An at-risk resident who sits too long in one position or is known to slouch in a chair has an increased risk for pressure ulcers/injuries. Elbow pressure injury is often related to arm rests or lap boards. Friction and shearing are also important factors in tissue ischemia, necrosis and PU/PI formation. PU/PIs on the sacrum and heels are most common.

● How often does Therapy assess for pressure points and tissue tolerance?
● Does Therapy assist with the completion of the Braden Scale? Your clinical partners would love the assist!

Positioning and Support Surfaces
Once the IDT identifies who is at risk, how do they determine the needed support surfaces, proper positioning and/or repositioning frequency? Do they take into consideration the individual’s level of activity and mobility, general medical condition, overall treatment objectives, skin condition, and comfort? Appropriate support surfaces or devices should be chosen by matching a device’s potential therapeutic benefit with the resident’s specific situation.

● How does Therapy engage in assessing the appropriate positioning and support surfaces?
● How often does therapy assess residents to ensure the recommended positioning and support surfaces are in place, still meet the needs for each resident, and provide reviews/updates of the resident care plan?

Active Wound Care
PT intervention for active wound care is appropriate when any of these exist: Necrotic material is present in the wound bed; the wound is a stage 3 or 4 pressure injury; the rehab potential is good to meet stated goals; and/or the wound has an impaired healing process.

● Do we have a physical therapist on staff who treats wounds?
● Are we up to date on all the various wound care interventions, such as: scalpel debridement; closed pulse irrigation; ultrasound MIST; and/or other modalities?

Incontinence
Both urine and feces contain substances that may irritate the epidermis and may make the skin more susceptible to breakdown and moisture-related skin amage.

● What is Therapy’s involvement with incontinence intervention?

Nutrition and Hydration
Adequate nutrition and hydration are essential for overall functioning. It is critical that each resident at risk for hydration deficit or imbalance, including the resident who has or is at risk of developing a PU/PI, be identified and assessed to determine appropriate interventions.

● Is SLP involved as part of Skin IDT?
● Is the Think Thin program in place?

Contractures
A resident with severe flexion contractures also may require special attention to effectively reduce pressure on bony prominences or prevent breakdown from
skin-to-skin contact. Some products serve mainly to provide comfort and reduce friction and shearing forces, e.g., sheepskin, heel and elbow protectors.

● What is Therapy’s role with contractures? How often is skin/skin hygiene assessed?
● Does Therapy have an active hand/skin hygiene program?
● How often does Therapy assess splints’ effectiveness for not only the contracture but also skin integrity?

Pain
The assessment and treatment of a resident’s pain are integral components of PU/PI prevention and management. Pain that interferes with movement and/or affects mood may contribute to immobility and contribute to the potential for developing or for delayed healing or non-healing of an already existing PU/PI.

● What therapy assessments are completed to determine any pain levels?
● Are modalities used for pain management?
● Is level of pain discussed during skin IDT meetings?

Training, Education and IDT Collaboration Resources

● Refer to chapter VIII page 82 of the RNA manual for information that can be used for training CNAs and/or RNAs on skin and positioning. https://portal.ensignservices.net/Departments/Clinical-Resource-Tools/Manuals/manuals Scroll down or type in the search Restorative Nursing Program Manual.
● Refer to the EPIC section of the portal https://portal.ensignservices.net/EPIC/skin for education, information, and other resources for an IDT approach for skin.
● Refer to the Pressure Ulcer/Injury Critical Element Pathway. This can also be found on the portal. https://portal.ensignservices.net/Departments/Clinical-Resource-Tools/CMS-Requirements-of-Participation/CMS-TOOLS/NEW-SURVEY-PROCESS/critical-element-pathways
● Refer to a variety of supportive POSTettes for additional information: Wound Care, Contractures, UI, UTI, Pain, Nutrition/Hydration.

By Gina Tucker-Roghi, Alexis Renfro, and Ali Vandeloo, Rock Creek of Ottawa, KS
Looking for opportunities to increase your community outreach and develop your outpatient program? Rock Creek of Ottawa is putting a new spin on the Abilities Care Approach. Ali Vandeloo, DOR, worked with Alexis Renfro, an OT and TEACHA (Therapy Expert on the Abilities Care Holistic Approach), to bring an abilities-based approach to dementia care to their community through outpatient programming. Ali and Alexis have broadened the scope of services at Rock Creek by promoting aging-in-place for individuals with early-stage dementia.

Our outpatient Abilities Care Approach programming incorporates the familiar aspects of the Abilities Care Approach with training, support and education for family caregivers to target the following clinical outcomes:

1) Increase caregiver self-efficacy through education on approaches and techniques to manage challenging behaviors
2) Prevent falls and injuries
3) Maintain meaningful relationships and engagement with family, friends, and the community
4) Maintain function, prevent functional decline and mitigate risk factors related to dementia

Since launching the pilot of this program, Rock Creek has provided outpatient services to eight individuals living with dementia in the community. One of our first clients was an individual with middle-stage dementia living with her husband in the community. We provided education and support for the caregiver to enhance the care he provided for his wife. Our interventions focused on maintaining a healthy routine, prevention and management of neuropsychiatric behaviors, prevention of falls and injuries, participation in meaningful activities, utilization of sensory strategies to improve engagement, and utilizing their authentic and meaningful context to personalize her care and experience. As a result of our services, he learned new approaches and was more confident in his ability to care for his wife.

Another client was an individual with early-stage dementia and depression. She was living home alone and had been a rehab patient at Rock Creek prior to discharging home. She received outpatient services post-discharge to help her integrate health-promoting behaviors and habits into her daily routines and was able to stay in her home and remain engaged in her community through activities with her church and volunteering.

An outpatient ACA program can help you achieve the following facility and community outcomes:
1) Create rapport and relationships with families in the community that may result in opportunities for future admissions for respite or long-term care services in your SNFs or Als

2) Increase community awareness of the scope of facility services throughout the continuum of care

3) Attract new therapists and grow your therapy department

4) Minimize the stigma of dementia and increase knowledge and understanding of members of your community who interact with individuals living with dementia

Here are a few tips if you are ready to get started:

1) Start with patients already under your care (patients discharged from post-acute to home or residents at your on-campus or affiliated ALFs).
2) Become familiar with the existing community resources for individuals living with dementia.
3) Network to get to know service providers for individuals with dementia who live in the community. Here are some examples:
a) Area Agency on Aging
b) Meals on Wheels
c) Geriatrician or dementia clinic
d) Alzheimer’s Association
e) Dementia caregiver support groups
f) Adult day health programs

If you are interested in giving Outpatient ACA a try, join our bi-weekly call of early adopters. We gather every two weeks on Wednesday at 9 a.m. PST. Our next meeting is April 20. Please email Gina Tucker-Roghi groghi@ensignservices.net to be added to the call invite.