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By Chad Long, Therapy Resource

Post-acute health care is making a massive shift this October with Medicare’s change to the Patient Driven Payment Model (PDPM), where patient clinical characteristics drive the reimbursement and functional outcomes determine success.

Along with the payment model changing, we are in the midst of a significant population shift (often referred to as the Silver Tsunami) in which we have a growing number of older people, many of whom need a greater number of health care services.

“The Silver Tsunami is already rolling in and projections from the U.S. Census Bureau point to 2030 as a milestone year in which older people will actually outnumber children for the first time in history.” Tom Sullivan, March 15, 2019

https://www.healthcareitnews.com/news/silver-tsunami-coming-healthcare-time-prepare

“As the number of senior people rises in many economies of the world, the need for long-term care and aging-in-place services will increase.” Reenita Das, Aug 11, 2015

https://www.forbes.com/sites/reenitadas/2015/08/11/a-silver-tsunami-invades-the-health-of-nations/#494f73d53efd

So who will help champion the changes in health care delivery and ensure clinical and operational success in Post-Acute? Why not Therapy Professionals?! As licensed therapists and therapy assistants, we have a unique opportunity to move into Skilled Nursing Operations (Nursing Home Administrators, Executive Directors, CEOs, etc.) and work in a new capacity within the Interdisciplinary Team.

Within the Ensign Affiliated Facilities, we are seeing a growing number of Directors of Rehab moving into Operations and having great success. So why would therapy professionals be good candidates for Administrators in Training and, eventually, Executive Directors? At a recent Service Center meeting, led by Spencer Burton, a few reasons were discussed:

Why DOR to ED:

• Clinical backgrounds
• Mini-business leader (HR, Compliance, Billing, Maintenance, etc.)
• Balance of clinical and financial
• Multipliers
• Vision -> Path: Perspective — Push to goals
• Teaching, coaching, developing people
• Creative
• Likeable
• Challengers
• Communication skills
• Well-versed in Ensign culture

Guess who is a Therapist and Facility Operator?

• Salma Moore: Arroyo Vista
• Ryan Goldbarg: Victoria Ventura
• Matt Scott: Mission Hills
• Brian Rupert: Villas at Sunny Acres
• Doug Haney: Bella Vita
• Amy Guiterrez: La Hacienda
• Ediel Barrera: McAllen Transitional
• Marissa Parker: Legacy
• Kyle Martin: Kirkwood
• Kumar Pradeep: South San Antonio
• Amber Thompson: New Braunfels
• Travis Jones: Cornerstone

So what are the requirements to become a Licensed Nursing Home Administrator? Well, that depends on the state in which you live. However, there are a few common requirements. Typically, you must be 19 to 21 years of age, have a bachelor’s degree, complete an Administrator in Training Program (or have a master’s degree in a health-care-related field) and successfully pass the National and State Nursing Home Administrator Exam. Below is a list of basic requirements, per state, and a link to the National Association of Long Term Care Administrators Boards.

If you are interested in growing in a different career path from therapy to more facility operations, please contact Jamie Funk at JFunk@EnsignServices.net, or talk with your facility administrator. Let’s be the change we want to see in our organizations and in health care!

By Cory Robertson, PT, DPT, Therapy Resource

According to a study out of the University of California, San Diego, the answer is no, and yes. How can that be, you ask? Keep reading to get the details and the findings of the study: A pilot randomized study of gratitude journaling intervention on HRV and inflammatory biomarkers in Stage B heart failure patients.

Patients with Stage B heart failure are those who have a structural abnormality of the heart but have not yet developed symptoms. Thus this stage is a therapeutic window of opportunity to deliver interventions to prevent the progression of the disease and to maintain quality of life.

Studies suggest a strong connection between gratitude and well-being. The area of behavioral cardiology is increasing focus on positive psychology like gratitude and how it affects physical health. More studies are needed using objective measures of physical health to understand the disease-buffering effects of gratitude. One of those objective measures studied in this paper is heart rate variability (HRV). As we know, HRV is a measure to quantitatively assess variation in heartbeat intervals that is often used to detect changes in the autonomic nervous system. Psychological factors like mood, satisfaction, depression and chronic stress are related to the autonomic nervous system, suggests the research. So can gratitude journaling improve HRV?

Seventy patients with Stage B HF were randomized into two groups: a gratitude journaling group, and a “treatment as usual” group for a period of eight weeks. Participants were assessed at pre-, mid- and post-intervention for inflammatory biomarkers from a blood draw, basal HRV data obtained, as well given a gratitude and exercise activities questionnaire.

After eight weeks, these data were re-acquired; also, both groups were assessed for HRV responses to a specific gratitude journaling task. Here is the wording of the journaling instructions, and if you’re like me, just reading the instructions summons a sense of well-being: “For the next eight weeks, you will be asked to record three to five things for which you are grateful on a daily basis. Think back over your day and include anything, however small or great, that was a source of gratitude that day. Make the list personal and try to think of different things each day.”

Basal HRV measures between groups after eight weeks showed no significant differences — though at the eight-week assessment during the specific journaling task, there were medium to large effect sizes between the groups’ HRV. So assessing the different groups’ HRV separate from the act of gratitude showed no difference, but during a gratitude task, there was a significant difference. The authors surmise that “increases in parasympathetic cardiac tone … [during] journaling may reflect state changes that occur while contemplating items or feelings of gratitude during daily life.” Moreover, the gratitude journaling group had a significant reduction in inflammatory biomarkers, which are related to morbidity and mortality in patients with HF.

I’m grateful for this research and for the opportunities to learn more about the heart and how I can do something to help my heart function. Do you think reading research regarding gratitude and its benefits also improves HRV?

By Maryann Bowles, Therapy Resource — Colorado

The ENDURA Market in Colorado gathered 10 of their physical and occupational therapists to complete their LSVT BIG live training together at the Villas at Sunny Acres. The group spent a full day going through treatment and practice of the evidence-based neurologic patterns and movements for the treatment of symptoms associated with Parkinson’s disease.

Specifically, research shows that LSVT BIG treatment can lead to faster walking with bigger steps and arm swings, better balance and more ability to twist at the waist. Clinicians also report that LSVT BIG often helps people with buttoning their clothes, writing and other smaller-movement (“small motor”) tasks, as well as large (“large motor”) movements like dressing, getting up from a seat and getting into bed.

Because PD makes it harder to remember to use these bigger movements consistently, treatment includes a lot of repetition and progressive challenges, as well as daily home practice and assignments for using bigger movements in everyday life.

Ultimately, LSVT BIG helps improve the mismatch between what you feel you’re doing and what you’re actually doing, making you more confident, comfortable and empowered. With one month of hard work, LSVT BIG can open doors to a more active and independent life.

The ENDURA market therapist will now have a local network of fellow therapists to help support their development of a strong Parkinson’s and movement disorder treatment program in their buildings.

By Elyse Matson, MA CCC-SLP, SLP Therapy Resource

IDDSI stands for International Dysphagia Diet Standardization Initiative. The purpose of the initiative was to create standards across all environments so that the foods and liquids have the same texture or viscosity.

For example, when a patient arrives to your facility on nectar liquids, how do we determine if the hospital’s version of nectar is the same as ours?

The IDDSI framework consists of a continuum of 8 levels (0-7), where drinks are measured from Levels 0–4, while foods are measured from Levels 3–7.

There are specific testing methods to determine the levels, including a flow test with use of a 10 ml syringe and a fork test to determine food particle size and food softness.

Implementation

So should you implement IDDSI at your facility? There are several factors to consider. The first is, who is your menu vendor? The vendor supplies the menus to the kitchen and provides instructions/wording on which diets your facility uses and how to prepare the meals. It is up to this vendor to adopt IDDSI and provide the new language/instructions to the kitchen.

The next question is whether your local hospitals/referral sources are adopting IDDSI. This may create a need to address the diets sooner rather than later. We have created a conversion chart below to provide to your admitting nurses so they can convert the IDDSI diets back to your current diets.

Finally, you will need to work closely with your SLP, Dietary Department and IDT to determine if your facility is ready for this change. For further questions, please go to www.iddsi.org or reach out to Elyse Matson, SLP Resource (ematson@ensignservices.net).

By Lori O’Hara, MA, CCC-SLP, Therapy Resource — ADR/Appeals/Clinical Review

Setting the ARD

The purpose of the lookback period is to capture those conditions and characteristics that impact the patient’s treatment plan in such a way that they can 1) be reported to oversight agencies and 2) calculate a reimbursement rate.

Under PDPM, since the whole premise of the rate is that it is commensurate with how complex the patient is, it’s then essential that the lookback period capture as many of those things as possible. And it may be that capturing hospital activity is important!

If a patient received IV hydration or nutrition while in the hospital, it can impact our Nursing case mix. This makes sense — patients who were dependent on an enteral delivery of fluid or calories are quite fragile in the period after this treatment concludes. The lookback on this item is seven days and includes delivery while in the hospital.

So the IDT’s job is to decide what the right ARD is to capture all the important info. We may choose to set the ARD on day one, knowing that capturing the hospital intervention paints the most accurate picture of the patient’s complexity. Or, if an IV medication starts after admission on day 7, that might be the right date for a lookback to capture the clinical picture. Or, if the patient had fluids through the day of discharge and has wound treatments ordered on day five, then a lookback that captures part of the hospital activity and part of the post-admission activity may be what’s best.

The good news is that up through day eight, the ARD can be moved forward and backward as needed to make sure that we’ve captured all the complexities of the patient we’re taking care of.

Section GG Reconciliation

Mythbuster time! Therapy should not be the only source of data for Section GG. One of the sources, sure! But not the only one.

Data sources should include therapy evaluations, nursing documentation and the MDS Coordinator’s observation of CNA care. All of this data should be recorded in the record, and then the IDT’s job is to reconcile this through the Section GG UDA.

So what does “reconciliation” mean? It means looking at all the available data and deciding what really represents the “usual and baseline” performance through analysis and discussion.

Say you’re looking at toilet transfers. The Occupational Therapy evaluation says Mod Assist, the nurses’ notes say Partial/Moderate Assistance, and the MDS Nurse documents Partial/Moderate Assistance in her entry. Then Partial/Moderate Assistance seems like the perfect answer.

But what if the OT says Moderate Assist, one nursing entry says Moderate/Partial but one says Substantial/Maximal — and the MDS Coordinator’s note also says Substantial/Maximal? What’s the right answer?

That’s the reconciliation part. And there’s no CMS mandated formula — it’s your IDT looking at the data and the overall performance of the patient and deciding. Do you suspect the patient performs a little more independently with therapy, but that really they’re requiring more help? Then landing on the more dependent score is probably the right answer. Do you know that later in the day they become a lot heavier? Then again, their usual performance is probably the more dependent one.

The critical element is having as much data as you can (and sometimes that will be a very small amount, if therapy is starting the day of admission!) and making a reasoned decision based on the information you have. You want to be able to point to the data you had available and your IDT’s decision-making process to support your coding should you need to defend it later.

By Mary Ann Bowles, Therapy Resource, Endura/Colorado

Quite often leadership will have to take time off, and sometimes it’s lengthy as in a maternity leave. You need an interim DOR!

The questions arise: Who will take charge while you’re gone? Will they know how to do the tasks that are required? Will the systems stay intact? Will the staff they lead follow the direction of interim well? Will the IDT team work well with the interim? Will it feel like there are holes or missing components? Will we still be able to grow our programs??

Well, at the Villas at Sunny Acres (VASA), we can’t believe three months have come and gone! Our DOR at VASA was out on maternity leave. VASA is a busy rehab program that services SNF, ALF, memory care unit, ILF and outpatient.

Jenny Kuehn, PT, DOR, has always been a proponent of “building your next one up.” She did a poster on it for our Annual Leadership Meeting. She has cross-trained many of her staff that have goals of having a leadership role later in their careers. She has sent two therapists through the DORITO program. Jenny takes pride in building future leaders in our company. She prepped and trained Kinga Gianna, PT, to cover while she was gone.

Kinga has been with Ensign since 2013. Kinga started as a tech and then went on to be a physical therapist, an ADOR and now an interim DOR, filling the shoes of the DOR for three months. It’s not often that you have such a seamless transition when the interim DOR takes over. Kinga made that happen at VASA. She made the position look easy and took on all of the challenges and frustrations like a champ.

It honestly was seamless while Kinga was holding the reins as the director of rehab for these last three months. Not only did she maintain the therapy program, but she built the program, too. She added additional scheduled group therapy sessions, and started a managed care meeting with their NP on a weekly basis and a system to get the information to that NP. We couldn’t agree more with Brian Rupert, ED, at VASA, when he told Kinga, “We could not have hoped for a more seamless, smooth transition. Your ability to adapt to the challenges that came at you daily were reflected in how you quickly found ways to overcome and ensure your team and the residents received the care they required. Thank you very much.”

By Lori O’Hara, MA, CCC-SLP, Therapy Resource – ADR/Appeals/Clinical Review

CMS thinks that speech therapy is so special that it gave speech five different considerations for the payment category. Thanks, CMS!

So here are a few tips for being an SLP CMI Ninja Warrior:

• If you have a patient with concomitant ortho and CVA diagnoses driving their stay, you will generally select the ortho condition for the principle medical condition. But then you should always get an SLP co-morbidity because Active Dx: CVA/TIA (item I4500) would be checked on the MDS. There might be additional co-morbidity diagnoses coded from the SLP treatment conditions, but you only need one to count!
• While we no longer require the inclusion of an ICD-10 medical diagnosis on our therapy POC/UPOCs, the treatment plan still needs to make sense. That means that a patient who needs treatment for a cognitive impairment without a clear medical condition that causes cognitive impairments will necessitate conversations with the attending medical team. A hip fracture still doesn’t cause a cognitive decline.
• When your SLP (or OT, too!) are treating cognition and are going to perform the BIMs, it’s a good idea to do this before the patient’s cognition function is changed by treatment. The recommendation is that the BIMS is done the day of or day before the ARD, but we are allowed to complete it anytime during the lookback. Special note: If the ARD is day 8, a BIMS completed on the day of admission cannot be counted in the MDS. Watch those lookback periods!
• It is best practice to have your SLP screen all patients admitted on an altered diet. First, if the patient has the potential to advance to normal foods, we should endeavor to make that happen. Second, an altered texture can mask the presence of swallowing problems — if the altered diet improves the function sufficiently, it can be difficult for a non-expert eye to see an underlying impairment. An SLP will often choose to intervene in that instance for the optimum health and safety of the patient, but even in those rare cases where SLP intervention isn’t indicated, the screening note can document the observed symptoms such that they can be properly included in the MDS.
• When an SLP is involved for swallowing, make sure they report diet changes to the IDT. Day 7 or 8 diet adjustments can sneak under the radar of even the most diligent MDS Coordinator, so make sure your SLP is making noise about those changes.

By Deb Bielek, Therapy Education Resource

Currently, several of our facility therapy teams have been supporting efforts toward identifying best practice approaches as well as new tools and resources available to help us continue on our path toward effective and efficient delivery of therapy to our residents and patients. Not only do we see more and more specialty programs popping up where our patients and residents are receiving state of the art care and getting better because of it, but we are also finding effective ways to engage them in care throughout their recovery process. Currently we have facilities who have been participating in Pilot Programs with focus on innovative care delivery systems partnering with technological resources, enhancements to our therapy software system, interdisciplinary assessment processes for measuring functional outcomes through Section GG, leadership of Restorative Nursing programs.

The following Pilot Programs have been used over the recent weeks to help us grow in our understanding of how these tools and approaches can help us succeed in our current operations. We are excited to share some detailed results of the following pilot programs during our Leadership WebEx meeting scheduled for Friday, August 9 from 12:15 – 12:45 pm Pacific:

• Jintronix is a PDPM-ready, “gamified” clinical product that is transforming the therapy experience in both Post-Acute and Long-Term Care. The treatment allows therapists to enhance their skills by customizing specific treatment protocols for individuals, resulting in patients who are much more engaged and applying themselves in a whole new way and we’re seeing the positive impact on outcomes. The results during the pilot program have been exciting.
• Section GG is being used as part of our Quality Reporting System to demonstrate functional outcomes with the Medicare Part A patients, and we are expanding this outcomes tool into all of our post-acute payers beginning August 1! Our recent pilot program with 9 facilities across the organization yielded best practice approaches to accurate Section GG reporting, which will be critical to our Case Mix groupings for PT, OT and Nursing under the new PDPM. There are also some unique findings with the role therapy can play in the accuracy of these results.
• Optima is creating tools to streamline documentation that is relevant for outcomes tracking, clinical pathway implementation and documentation that supports the Case Mix classifications under PDPM. Hear about the exciting results so far as shared by some of our pilot leaders.
• Do you use Home Exercise Programs to enhance your SLP, PT, OT service delivery? Our pilot project with Medbridge is giving us the opportunity to incorporate the HEP experience through some unique offerings to our patients. We are also beginning to integrate the idea of HEP as an extension to the therapy program by incorporating RNA support into the HEP practice prior to discharge. We are analyzing our NOMS and GG Data to begin honing in on best practices for the HEP. Hear directly from some of our therapists using these unique tools!
• Is your facility struggling to maximize the effectiveness of the RNA program to achieve better results with your patients and residents? Our East Texas Market has been trialing a new approach to RNA Management, and we’ll be sharing more about the program, therapy’s involvement, how it works and the status of the early results.