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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.

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.”

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!

 

By Jimmy Dale Smith, PT, DPT, The Healthcare Resort of Plano, TX

Myofascial decompression (MFD), or cupping, is a form of IASTM (Instrument Aided Soft Tissue Manipulation), where a pump and a cup are used to create negative pressure and placed on the skin to improve circulation/blood flow, reduce pain, improve tissue pliability/mobility and to improve healing.

Additional benefits of cupping may include improved quality/quantity or ROM, improved tolerance to ROM/PROM exercises, and excellent neural input to improve motor output. Contraindications include open wounds, fever/active infection, severe disease (cardiac, renal failure, bleeding disorder, hemophilia, active cancer and dermatitis), first trimester of pregnancy, unhealed or possible fracture, severe strain/sprain, or already inflamed/swollen tissue, burns and acute flare-ups of skin disease (psoriasis, eczema or rosacea).

• When: Depends; early in POC to assess patient’s response
• Where: Location of pain/perceived stiffness, myofascial line, neurovascular junction
• Why: ROM, pain, blood flow, soft tissue adhesions
• Who: Patients who do not have contraindications
• What: Reassess, test and retest

Pilot Study: Plano Health Care Resort

The Physical Therapy department at Plano HCR is currently one of our affiliates in Keystone that is piloting usage of cupping across patients with differing diagnoses, which has resulted thus far in varying degrees of success. Predominantly, the facility has observed a positive response to MFD. Through the observations, benefits range from an hour (to the end of the session) up to five to seven days of pain relief. One specific “home run” of treatments is the following case study.

Case Study: Mr. T.

Mr. T. is a mid-70s male s/p R TKA. He presented to PT as an outpatient seeking further rehab after his SNF stay. His primary limiting impairments were stiffness, pain and weakness. When he initially attempted basic OKC (open kinetic chain) activities, the patient would report moderate to severe pain at end-range knee extension. The team attempted to modify to a CKC (closed kinetic chain) to assess differences in symptoms. Stiffness remained. Moving to manual therapy, the patient responded decently well with anterior tibiofemoral mobilizations. The patient reported less pain, but the stiffness remained. The PT team applied three hard plastic cups with 1.5 pumps of pressure proximal to the knee as a gross stabilization point for the fascial system and one silicone cup just distal to those cups with the intent to perform a dynamic mobilization technique. Post-treatment, the patient reported that not only was the pain nearly eliminated, but the stiffness was gone as well.

By Tamala Sammons, MA CCC-SLP, Senior Therapy Resource

Contributed from the American Speech and Hearing Association (ASHA.org) https://www.asha.org/practice/reimbursement/medicare/medicare-patient-driven-payment-model/#Fall

SLPs can help increase the rate of discharge back to the community and decrease avoidable rehospitalizations. Specifically, SLPs can positively influence the following factors that contribute to discharge back into the community:

Communication: A primary purpose for addressing communication and related disorders is to affect positive measurable and functional change(s) in a person’s communication status so that they may participate in all aspects of life — social, educational and vocational.

Communication is central to discharge back into the community, especially in individuals with speech/language impairments or cognitive deficits associated with a variety of diagnoses. Several studies have indicated that communicative competence predicts individuals’ safe discharge back to the community.

• For example, a 2013 study found that deficits in auditory and reading comprehension and oral spelling to dictation were significantly associated with increased odds of discharge to a health care facility (e.g., SNF), rather than to a community-based environment, after adjustment for physical therapy and occupational therapy recommendations (González-Fernández, et al., 2013).
• Functional dependence and comorbidities, such as chronic aphasia, have been found to be a significant predictor of a non-home-based discharge setting in post-stroke individuals (Mees, et al., 2016).

The SLP’s scope of practice and unique training specifically equips them to prepare individuals to return home with appropriate communication facilitators, as needed, ensuring maximum safety.

Cognition: Cognition is an important predictor of safety and functional independence in determining discharge to home, even in individuals undergoing purely orthopedic-related rehabilitation (Ruchinskas, et al., 2000).

Several studies emphasize the importance of cognition in the ability to return to completely independent living after medical rehabilitation in geriatric patients (MacNeill, et al., 1997). The Scope of Practice in Speech-Language Pathology (ASHA, 2016), as it relates to cognitive-communication impairments, indicates that the practice of speech-language pathology includes providing prevention, screening, consultation, assessment and diagnosis, treatment, intervention, management, counseling, and follow-up for disorders of cognitive aspects of communication (e.g., attention, memory, problem solving, executive functions).

Swallowing: SLPs with appropriate training and competence diagnose and manage oral and pharyngeal dysphagia. SLPs also recognize causes, signs and symptoms of esophageal dysphagia and make appropriate referrals for diagnosis and management. Presence of dysphagia represents a significant barrier to returning home, specifically in neurogenic diagnoses. Those individuals with dysphagia, post-stroke, are more likely to be discharged to institutional settings, such as SNFs, after inpatient stroke rehabilitation, and experience longer stays at these facilities (Nguyen, et al., 2015). Aside from the significant costs resulting from chronic dysphagia and associated care, these conditions have a negative impact on an individual’s quality of life.

Health Literacy: More than just a measurement of reading skills, health literacy also includes writing, listening, speaking, arithmetic and conceptual knowledge.

According to the IOM report (2004), health literacy is “the degree to which individuals have the capacity to obtain, process and understand basic information and services needed to make appropriate decisions regarding their health.” Inadequate health care literacy affects all population segments but is predictably more common in certain demographic groups such as the elderly.

Patients with aphasia or other neurological disorders affecting speech, language or cognition, or those with severe hearing loss, are at risk when presented with vitally important written or verbal medical information. In addition, patients who face the stress of a medical crisis, possibly without an advocate or a significant other being present, or while in a state of pain, confusion or depression, may have difficulty understanding written or verbal medical information.

SLPs have a vital role in effective patient-provider communication. As federal laws, regulations, guidelines and accreditation standards mandate improved patient provider communication, it is vital to maximize the SLP’s contributions to this significant area of practice that impacts patients’ safe discharge back to the community. The rate of hospitalization and use of emergency services is higher among patients with limited health literacy (Kindig, et al., 2004). SLPs can assist with discharge planning while considering an individual’s health literacy to minimize these costs (Rasu, et al., 2015).

Submitted by Tamala Sammons, MA CCC-SLP, Senior Therapy Resource

Contributed from the American Speech and Hearing Association (ASHA.org)

https://www.asha.org/practice/reimbursement/medicare/medicare-patient-driven-payment-model/#Fall

Factors such as depression, hearing loss, medication management, cognitive impairments and poor sleep all impact a patient’s risk for falls as well as their ability to report them in a timely fashion. Good clinical practice dictates determining whether these risk factors play a role in the care of the patients in SNFs. Approximately 60% of older adults with cognitive impairment fall annually, almost two times more than their peers without a cognitive impairment (Eriksson, et al., 1993). Among individuals with dementia, fall frequency can even reach as high as 80% (Shaw et al, 2003). The high prevalence of falls among patients with dementia, despite relatively intact motor function, highlights the idea that falls are often not just a motor problem (Van Iersel, et al, 2006). Risk of persistently high expenditures for fall-related injuries among older Medicare community-dwelling fee-for-service beneficiaries is significantly higher for individuals with cognitive impairments, which leads to hospital/facility readmissions (Hoffman, et al., 2017).

SLPs can help detect cognitive impairment to identify older adults who are at higher risk for falling. Cognitive impairment can be a risk factor for falls and a barrier to safe/independent discharge to prior living environments consequent to the fall. SLPs have a critical role in assessing cognitive-communication and cognitive deficits in patients of all ages, including patients who have had a stroke, traumatic brain injury, or suffer from a neurodegenerative condition such as Parkinson’s disease, and all forms of dementia. Appropriate referrals can help SLPs design interventions so the patient can reduce their fall risk (e.g., designing memory aids and cues to help the individual follow safety precautions and self-regulate impulsive behaviors). Emerging evidence indicates that cognitive interventions have effects that carry over from the cognitive to the physical domain to enhance gait, and may reduce fall frequency (Segev-Jacubovski, et al, 2011).