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Consider the following patient profile: A 19-year-old with traumatic brain injury secondary to assault presented with moderate deficits in immediate and short-term memory as well as temporal and spatial orientation. He was also legally blind as a result of his injury.

The patient has been receiving skilled Speech Therapy at Rock Canyon since March 2017 to address oropharyngeal dysphagia and communication/cognitive deficits. Additionally, our team employed the use of an Alexa device and TBI services for therapeutic interventions, plus an improved quality of life for the patient.

Intervention Components

Caregiver Coaching

• Educating the patient’s mother on programming the device and its features
• Encouraging caregivers to cue the patient to use the device for temporal orientation and checking or adding events to the schedule

Script Therapy and Drill

• Rehearsing with the patient before having the patient activate the device for adding events to the schedule, checking the date and daily schedule, and solving math problems with drill exercises

Education on Device

• New skills, entertainment features (music, books on tape)
• Shift in ownership — allowing the client to take the initiative to use and experiment with the device independently

Quality of Life

• Music (Spotify, Amazon Prime)
• Books on tape (Audible)
• News (NPR)
• General information (Wikipedia)
• Weather
• Horoscopes
• Alarms
• Games (Jeopardy)

Data

At the baseline, the patient was able to answer 0 percent of temporal orientation questions (day of the week, date, year) or his daily schedule. Currently, the patient shows significant improvements in regards to temporal orientation and personal scheduling when verbally cued to use the device. Goals include having the patient answer temporal orientation questions, add events to his schedule and check his schedule without being cued to use the device.

By Rock Canyon Rehabilitation, Pueblo, CO

Occupational therapy and speech-language pathology co-treatment sessions provide comprehensive intervention and could fill a research gap on the benefits of this collaborative approach to advance patient outcomes in a SNF setting. Due to ever-changing and restrictive regulations, clear and effective documentation is necessary to ensure reimbursement and to expand the opportunities currently limited by billing protocols.

A review of current literature identifies information on the benefits of OT and SLP co-treatment sessions in a pediatric setting, but it fails to include outcomes of this collaboration in geriatric environments. The same hierarchy of skills addressed in the pediatric field often needs to be re-addressed as a natural part of the progression of aging. The skilled nursing facility presents multiple diagnoses impacting ADL/IADL performance, which could best be addressed by this underutilized interdisciplinary approach.

Literature Review

OT and SLP collaborations can provide comprehensive interventions during self-feeding, ADLs and general therapeutic activities. Planned meal-time co-treatments can include an OT assessment of wheelchair/seating positioning, ROM, strength and coordination for both hand-to-mouth and utensil manipulation, while an SLP assesses labial seal, oral motor control and other dysphagia concerns.

When an OT is providing skilled education and assistance to increase patients’ independence with ADLs, an SLP can assist by highlighting the necessary cognitive processes to complete the task and provide education and cues for improved carryover of learning.

This interdisciplinary support can also occur when IADLs and community reintegration are appropriate in a patient’s discharge plan. Additionally, increasing the cognitive demand and executive function components during therapeutic activities incorporating standing tolerance, dynamic balance, fine/gross motor coordination, safety, functional mobility and community needs can provide a more holistic approach to patient care (Ellenbaum, 2010).

Methods and Assessments

• Identify patients with varying diagnoses appropriate for skilled OT and SLP treatment
• Discuss treatment plan of each discipline and identify goals appropriate to address during scheduled co-treatment sessions
• Identify appropriate assessment tool/standardized measure to assess patient outcomes pre- and post-certification period with consistent co-treatment sessions

Potential OT Assessments

• Barthel Index
• Daily Activities Questionnaire
• Functional Assessment Scale
• Present Functioning Questionnaire
• Allen Cognitive Level Screening Assessments and Modules
• Safety Assessment of Function and the Environment for Rehabilitation (SAFER)

Potential SLP Assessments

• CLQT, MOCA-B, RIPA-G, SLUMS
• MASA, Bedside Swallow Evaluation, MBS/VFSE
• Determine the effectiveness of treatment interventions performed during reporting period including co-treatment sessions using pre- and post-test scores
• Compare pre- and post-test scores of patients with similar diagnoses not receiving co-treatment interventions
• Gather additional qualitative data using daily documentation of co-treatment sessions to determine effects more directly related to this approach

Intervention strategies include but are not limited to:

• ADL sessions
• PENS electrical stimulation protocols
• Therapeutic activities
• Community reintegration
• NMES electrical stimulation protocols
• Synchrony
• Meal assessment
• Diet texture analysis

Documentation

Co-treatment is not suitable for all residents. Therefore, the decision should be made on a case-by-case and even day-to-day basis and needs to be well-documented for each session (Ensign Services, 2016).

According to a joint position statement from AOTA, APTA and ASHA: “Co-treatment is appropriate when coordination between the two disciplines will benefit the patient, not simply for scheduling convenience. Documentation should clearly indicate the rationale for co-treatment and state the goals that will be addressed through this method of intervention.”

“Co-treatment sessions should be documented as such by each practitioner, stating which goals were addressed and the progress made. Co-treatment should be limited to two disciplines providing interventions during one treatment session” (Ensign Services, 2016).

Conclusions

Co-treatment sessions are intended to increase therapy intensity by cohesively targeting multiple goals with the same functional activity and an opportunity to provide increased services that may otherwise be limited by patient fatigue level or willingness to participate. Co-treatments are meant to be planned prior to scheduled treatment to highlight goals being addressed by each discipline and identify his/her role during the session.

A skilled need for a co-treatment approach should be identified before any treatment planning begins. Additionally, clear and effective documentation is the key for conveying the insight and skilled need for providing this service.

By Stacia Kozidis, OTR/L & Caitlin Timmins, MA, CCC-SLP, Clarion Wellness and Rehabilitation Center, Ensign Group & HCR Manor Care Waterloo

 

At Park View Post Acute, the use of Life Story Boards has helped caregivers promote independence, provide appropriate cueing techniques and decrease negative behaviors in residents with dementia. We’ve found these boards to be resident-centered, efficient, economical and creative communication tools in our facility.

What Do Life Story Boards Do?

Life Story Boards share information about the resident gathered in the Life History Profile with caregivers, family and visitors. Each board identifies the stage of dementia via a facility-based color-coding system. Not only do the boards communicate meaningful information about residents in an easy-to-understand format, but they also provide opportunities for residents to have quality interactions with staff throughout the day.

Modified Allen Cognitive Models
 

Results: Improving the Quality of Care With Measurable Success

In addition to the measurable results, we’ve seen subjective success as well. Family and staff have reported decreases in negative behaviors, and front-line caregivers are problem-solving with abilities-appropriate solutions. Residents also have increased participation in out-of-room activities.

Next Steps: Starting Your Own Life Story Board Program

Here’s what you’ll need in order to start your own Life Story Board Program:

• A multidisciplinary team with different perspectives who “share the vision”
• Administrative support and commitment
• Passionate, visionary therapists with a minimum of specialized dementia training
• A dedicated, organized IDT leader
• Openness to “out of the box” ideas and intelligent risk-taking

Here are some examples of ways to use Life Story Boards throughout your facility:

• With lower-level patients — Used to inform caregivers about what was meaningful to the resident and to paint the picture of who that person was, though he or she may not be able to interact with the board
• With higher-level patients — Used to promote meaningful conversation and reminisce with caregivers through pictures and word prompts
• With Abilities Care interdisciplinary teams — Used to incorporate abilities-appropriate, resident-centered information into individualized treatment strategies, behavioral approaches and interventions as part of specialized dementia care plans
• For use as a bridge — Used with the family during care conferences, to enhance new employee orientation, as an ongoing Abilities Care training tool and to ease the care transition when staff assignments change

Implementing Life Story Boards entails training your staff to recognize the meaning of the four color-coded dementia levels. The long-term goal is for staff to understand the associated strengths, challenges and care strategies associated with those levels. From there, they are best equipped to implement that knowledge expertly in providing resident-centered, abilities-driven care.

Gardening is one of the most popular pastimes for Americans. And creating a meaningful treatment incorporating a purposeful treatment activity such as Gardening can leave our patients feeling good in spite of their health conditions, which may limit movement (such as arthritis) or cause fatigue. With a few strategies, gardening can be a great reinforcement for patient’s to practice their modifications within the context of a pleasurable and safe activity. According to the AOTA, occupational therapy professionals take a holistic approach and develop strategies to help people do the things they want and need to do no matter their limitations, disability, disease, or condition. Using Gardening as the therapeutic modality can make a treatment very meaningful to a patient.

– See more at: http://www.aota.org/about-occupational-therapy/patients-clients/health-and-wellness/gardening.aspx#sthash.2kWoDUAw.dpuf

One of the environmental modifications which helps make gardening a more accessible modality for our patients is the Elevated Garden Box, such as the one shown in the picture below. Therapy Resource, Curtis Hoagland, hand-crafted this gardening box for the Occupational Therapy Department at Richland Hills Rehabilitation and Healthcare in Fort Worth. By combining his love of building with wanting to help fill this need for the therapy team, Curtis brought a smile to the face of Jaclynn Stolfus, our OTR at Richland Hills pictured below standing with her newly delivered Elevated Gardening Box.

Shopping List:

2 – 4×4 fir or cedar post (fir is cheaper and lasts nearly as long) I actually used pre-treated lumbar after researching that it is EPA approved for humans and food boxes.
3 – 6×8 cedar boards
3 – 1x3x6 cedar fence pickets (cheaper than cedar board)
1 – roll of 1/4″ hardware cloth 50×24″ (make sure to get hardware cloth with 1/4″ holes, 1/2 inch is too large and all your dirt will fall through)
16 – 3/8 inch x 3 inch lag screws
16 – 3/8 inch flat washers
Box of 1 1/4 inch exterior wood screws

Cut List:

Legs: cut the 4×4’s into 4 – 32 inch legs
Sides: cut 2 of the 6×8 cedar boards into 4 – 48 inch lengths
Ends: Cut 1 of the 6×8 cedar boards into 4 – 24 inch lengths
Bottom slats: cut the 3 – 1x3x6 into 6 24 inch lengths
Bottom hardware cloth: cut the hardware cloth into a 24×50 inch rectangle.

Pre-drill all holes to attach ends, sides and bottom support slats

Attach the 24” ends to the 4×4 post using the 3/8 x 3 inch lag screws (be sure to add a washer to the lag screw prior to driving it into the post). Allow the ends to extend beyond each 4×4 post by 5/8 of inch. This will allow the sides to butt up against the ends and keep the width of the box 24 inches (important to ensure the hardware cloth fits)

Attach the 48” sides (pre-drill holes) using remaining lag screws and washers.

To prevent cracking of the side and end boards, only drive the lag screws in about 2.5 inches and then hand tighten with a 9/16 inch socket until snug.

Cut the hardware cloth to about 50 inches long. Below is a picture showing how to wrap it around the legs. I tucked mine in on the inside of the end boards. Once it is aligned to the edges and tucked in on the ends, use ½ inch staples to secure it to the box on the post, the end board and the side boards (takes lots of staples).

Align the 1x3x24 inch cedar slats to the bottom of the box (equal distance apart) and fasten to the bottom of the sides using the 1 ¼ inch exterior wood screws (Pre-drill holes through the slats and sides to prevent cracking).

Alternate option (which I did): Add a 1×2 inch furring strip to the inside of each side about 5/8 of an inch from the bottom. Attach the hardware cloth to these furring strips and then align and attach the 1x3x24 inch cedar slats to the furring strips instead of the sides. This way the bottom slats are not visible on the finished project and anchor the hardware cloth more securely.

Lightly sand all edges. And then add a layer of compost or coconut cloth on the inside bottom of the box and then fill with potting soil or other planting soil of choice. The compost / coconut cloth helps prevent the planting soil from sifting through the bottom hardware cloth.

http://www.ana-white.com/2012/11/plans/counter-height-garden-boxes-2-feet-x-4-feet

 

Sabino Canyon Rehabilitation & Care Center is always working to create a sense of community. Our dedicated, compassionate staff strives to exceed expectations and make a difference in the lives of those we serve by providing exceptional care and service and remembering they are the reason we are here. As part of this commitment to our community, we opted to participate in the Bundled Payments for Care program on Oct. 1, 2015.

Methods

The BPCI initiative is comprised of four broadly defined models of care, which link payments for the multiple services that beneficiaries receive during an episode of care. For example, Sabino Canyon’s focus is on medical non-infectious orthopedic and major joint replacement of the lower extremity. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care. These models may lead to higher quality and more coordinated care at a lower cost to Medicare.

Results

By participating in the BPCI program, we were able to reduce the average length of stay by five days for all payers. We also implemented 90-day tracking for participants to reduce re-hospitalization. These participants became rehab candidates versus hospice patients.

Our goal is threefold with this program:

1. To manage the length of stay with a continuum of care.
2. To reintegrate participants back into the community.
3. To track participants for 90 days, by ensuring they have follow-up appointments and continue to function in the community with participant education.

By providing these services, we help to reduce the cost of healthcare, improve the patient experience and better the lives of those we serve.

By Dora Alvarez, COTA/L Therapy Program Manager, Sabino Canyon Rehabilitation & Care Center, Tucson, AZ

 

At Victoria Healthcare Costa Mesa, we conducted a Q&A with one of our doctors, Dr. Hani Bashandy, about our newest Optima product, called Clinisign. Victoria Healthcare is one of the pilot facilities of Clinisign. So far, we have signed up three doctors to this program. Dr. Bashandy has been a huge supporter of Clinisign, and he was kind enough to share his thoughts about the product. Below is the interview.

What are the differences between the hospital and a SNF setting in terms of documentation?

It is very different in a hospital setting. Everything in the hospital setting is computerized. We do everything on the computer. Documentation is immediate. We sign our documents immediately from the computer.

In the SNF setting, all documentation are hand-written. We always have way too many papers to sign that I just discovered lately when I started following my patients from the hospital.

What are the usual challenges you have when you go to a SNF regarding signing rehab documents?

The biggest challenge I have is trying to find them exactly where they are in the chart. It takes a lot of time browsing through the chart and looking for them. I make sure that I know what my patient’s progress is since I base my decisions off what I see on therapy documents when I need to discharge them or keep them in the facility.

When did you hear about Clinisign?

It was introduced to me by Victoria Healthcare through the Director of Rehab.

How long have you been using Clinisign?

I’ve been using it since October 2016.

How has Clinisign helped you enhance your practice as a physician who follows patients in a SNF setting?

Clinisign definitely makes it easy for me to look and check the rehab documents quickly and sign them in real time. It also gives me flexibility as to when and where I can check the documents. I can check it anywhere and anytime. I can also sign the documents where I don’t have to be present in the facility. This definitely saves me time.

Are there any suggestions that you can give to enhance and improve your experience using Clinisign and Electronic Rehab Documentation?

One suggestion that I would like to make is for the system to generate a summary of the patient’s progress on a day-to-day basis that would be sent to me through emails or texts. This will help me work more efficiently and at the same time provide me information that would be useful to update when I talk to my patients and their families on how they are doing with therapy.

Submitted by Franco Estacio, DOR, Victoria Healthcare, Costa Mesa, CA