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Kevin Moon, SLP, Graduated from Loma Linda University, Loma Linda, CA

Read his awesome winning essay below:
Dr. Atul Gawande, the author of Being Mortal, once said “We think our job is to ensure health and survival. But really it is larger than that. It is to enable well-being.” This quote is powerful and is a philosophy I want to implement to be a spark in the lives of the patients I will be working with.

One way is to provide patient-centered, evidence-based treatments that move towards accomplishing the patient’s goals and wishes. This type of care is what has been emphasized in my training during my externship with Ensign Services and at Loma Linda University. Trying to step into a patient’s world, understand where they are coming from, respecting the patient’s wishes/goals, and delivering inclusive and culturally appropriate treatments are all things that can help better treat patients holistically. In addition, applying the core values of my school which include compassion, excellence, humility, integrity, teamwork, and wholeness of care in conjunction with the training I received during my externship will enable me to provide speech therapy to patients at the highest levels.

The populations that reside in skilled nursing facilities (SNF) are one of the most vulnerable, susceptible, and most in need of our support and skilled help. With the combination of my education and training, I hope to bring speech therapy that not only treats disorders such as cognition, swallowing, speech, and language but also provides patients with exciting, evidence-based therapy using the principles that my university has taught me such as compassion and humility. Hopefully, if I can use my passion for speech therapy to deliver engaging sessions to treat patients and I hope to inspire patients to want to get better. When going into each session during my externship, my goal is to treat the patient as a person first and a patient second. Because these patients are in such a vulnerable stage in their lives, treating them as a person first with humility and respect allows them to keep their dignity and self-worth intact during their stay at the facility. Doing this can really help me get to know my patient and really optimize therapy sessions as well as provide motivation and increase participation. In a setting such as SNFs, there are opportunities to really get to know the patients, and I want to use everything I can (e.g., personality, knowledge, training, rapport, and understanding of the patient) to inspire them so that they want to be in therapy and be an active participant in their recovery process. For example, most recently, I worked with a patient that needed swallowing therapy, but because of her physical and mental state, she had a difficult time participating in sessions and displayed major decreased activity tolerance. Over our first few sessions, I learned that music was a huge part of her life. I discovered her love for R&B
and oldies. Once I learned this about the patient, we incorporated music into our session and got better results. Prior to using music, when her pain was high, we had to stop for a prolonged amount of time or even end sessions. Once we incorporated music into her sessions, we sang her favorite songs when she felt pain and this was able to get her back into focus and continue the session. Sometimes, she would even smile amidst all of her pain.

Another example from my externship was a speech and language patient that I worked with. He was a farmer from Mexico and only spoke Spanish. This language barrier posed to be a problem during our first session together. Although I knew some Spanish phrases for swallowing therapy, my abilities in Spanish, in general, were not up to par. When interacting with this patient, I was able to see that the language barrier was causing some frustration and decreased engagement with the patient. In order to deliver functional and personalized therapy, I started to study Spanish. To start, I learned Spanish related to farming, fruits, and vegetables to work on word finding and circumlocution strategies. After learning words and phrases that were related to things that were familiar to the patient, we started to work on speech and language. The patient’s level of engagement immediately increased while frustrations decreased. At times, the patient would tell stories or go on tangents, and I could see his face light up when reminiscing about his past. He even used language that was more complex than he usually used, thus improving his speech and language while brightening up his day with positive and happy thoughts.

With the benefit of being able to develop relationships with patients, my goal is to foster a culture where therapy provides functional and motivating activities for patients that they are motivated to do. I would love to get to a point where patients smile and want to get to sessions because of the spark I have tried to instill in them. More importantly, the passion that I bring will help improve the quality of life for residents. To ensure that this happens, the therapy delivered must be evidence-based and patient-specific. This is the way I envision delivering therapy.

Evidence-based practice is composed of three components: the best external evidence, clinical expertise, and patient preference. To ensure that true evidence-based therapy is delivered, each component must be fulfilled. By tapping into the desire to continually learn, I can find the best, most up-to-date research through avenues such as continuing education, self-research, and collaboration with others. This ensures that patients receive well-documented, well- researched methods of therapy. The patient’s preference is also paramount to finding the right treatments for therapy. This is done by really listening to what the patient and their families have to say. The patient should not be a passive participant in the rehabilitation process, rather, an active participant in their healing process. This is one of the biggest things that can keep me accountable. By keeping the patient in the driver’s seat of their journey, the patient and their progress are the factors that will ensure I stay accountable. My purpose is to help patients and I plan to keep myself accountable to them. Clinical expertise is the last component of having evidence-based practice. I have built a strong foundation with my experience as an extern at Ensign and building my clinical experience will be an ongoing journey because clinical learning should not stop.

Finding my meaning in evidence-based practice and how to deliver it is one of the biggest things I learned during my 10-week externship at Brookfield Healthcare Center and Downey Post-Acute facilities. I also learned many other things that will help me deliver evidence-based, patient-centered, and holistic therapy to the patients I will be working with. One lasting lesson I have learned about working in SNFs, which I will take with me throughout my career, is best stated by Mark Parkinson: “Instead of just keeping your residents alive, give them a reason to live.” This plays hand in hand with Dr. Gawande’s ideas about enabling well-being rather than just ensuring health and survival. Instead of pursuing the sole goal of extending someone’s life, giving patients dignity and purpose to residents during their stays at SNFs is something that was emphasized during school and my externship. This can not only have an impact on the patient’s treatment, but it can have an effect on other aspects of their lives such as mental health and overall well-being. Thus, providing therapy that is beyond just doing exercises is very important. It requires giving respect, dignity, and purpose combined with therapy exercises to deliver high-quality treatment to patients.

Many times in therapy, the patient’s therapy needs are siloed into their respective disciplines (OT, PT, SLP). Rather than focusing on only the specific treatments that need to be provided by each specific discipline, by looking at the person and their lives as a whole with an interdisciplinary lens, treatment can be designed to promote purpose, engagement, and collaboration. This opens up a world of avenues where the different disciplines of therapy can work together to not only help with the patient’s deficits but to promote well-being and give them more motivation to keep pushing forward. Furthermore, this idea can be used to promote efficiency by finding ways to provide different therapies the patient needs in one session using an interdisciplinary approach. Using a strategy that can increase therapy efficiency across the different disciplines along with increasing quality of life for patients provides benefits to both the patient and the business. And in this way, it gives me opportunities to make a difference and create a spark in any way possible. Even a smile, a simple gesture, a kind word, a listening ear, or an honest compliment has the potential to create a spark in patients and give them dignity. When this happens, everybody wins.

By Carlos Pineda, CTO/DOR, Southland Care Center, Norwalk, CA
We are launching our “prototype” Tandem Backward Walking I-Southland Tool in a Lunch and Learn training. This maintenance series is dedicated to the person who inspired Southland to pursue greatness with maintaining the function of our beloved residents: Bertha Spaeder (pictured with Roger Pavon, PTA). Bertha has been my inspiration in pursuing greatness for our beloved patients. I named this tool after Bertha. ” B.S.MP01″ –Stands for Bertha Spaeder Maintenance Program series 01. Standardized testing and strategies are also part of the training. This evidence-based group therapy program aims to minimize fall risk.

Bertha Spaeder Maintenance Program Series 01
Walking backward is essential in our daily life: when opening a door, backing away from a kitchen sink, stepping from the curb as a swiftly-moving bus passes, during toileting, or opening the refrigerator. An effective compensatory stepping response is the first line of defense for preventing a fall during sudden large external perturbations. Falling backwards is common among our elderly population especially with comorbidities like Parkinson’s disease and CVA.

A validated standardized test, “Backward Walk Test,” assesses ability to walk backward. On the 3-meter backward walk test, if the individual completed the backward test in more than 4.5 seconds, the person is at risk for falling. Following is the procedure:

Procedure:

1. Check Vital Signs
2. Introduce the patients to each other
3. Educate patients on the purpose
4. Demonstrate the procedure
5. Start with slow pace (60bpm on metronome) or let patient count on every step or state which leg will go first (Right…, Left…)
   a. For Progression – increase by 10 bpm every week or as needed, if safe.
   b. To add cognitive challenge, ( 1. ) Ask the patient to count backward simultaneously with the metronome beat. (2.) Instruct patient to turn head Right<>Left while walking backward.
6. Assess for any gait deviation
7. Repeat

Group activity should be graded and have enough stimulus/challenge to promote physiological changes. This can be effectively done using the Borg Scale. It is a skilled and billable service provided by qualified therapists that requires continuous analysis, assessment and monitoring during the intervention. Tandem Backward Walking group therapy promotes teamwork and a sense of purpose. As biopsychosocial therapists, we address not only the impairments but also the psychosocial wellbeing of the patient. We identify and take aim on what is important to the patient and on how they define quality of life.

By Elyse Matson, MA CCC-SLP, Clinical Resource
Cognition and Swallowing are among the common challenges persisting for many Americans after COVID-19. Speech-Language Pathologists (SLPs) can help patients regain health and quality of life.

With an estimated 10 to 30% of COVID-19 survivors experiencing a post-COVID-19 syndrome, including brain fog and swallowing difficulties, it is more important than ever to utilize the full range of services provided by SLPs.

The pandemic tested everyone as a society, but one of the persistent challenges is the daunting set of difficulties many of our residents and those in our communities are experiencing after contracting and recovering from COVID-19. Many continue to demonstrate diminished function, including with cognitive skills, communication of needs and swallowing abilities.

This is an excerpt from the new COVID-19 Clinical Pathway, available on the Portal. This tool guides SLPs through the specific treatment needs of residents at various phases of recovery from COVID-19.

Impairments SLPs can assess

● Cognition
Many residents who had COVID-19 report persistent brain fog as a debilitating symptom after recovering from the virus. This can prevent a return to home as well as impact independence with ADLs. SLPs engage with individuals to improve their memory, attention, organization and planning, problem solving, learning and social communication — such as re-learning conversational rules or understanding the intent behind a message or behind nonverbal cues. The focus is on the person’s specific challenges as well as regaining the skills that are most important to their daily life and priorities.

● Swallowing
Residents diagnosed with COVID-19 may experience swallowing problems that can put them at risk for choking, aspirating, decreased appetite and diminished sensory feedback while eating (loss of taste and smell). This may be the result of time spent on a ventilator, or it may be another side effect of the virus. SLPs are part of the team who decide on the best course of action with the patient and their family. SLPs may recommend modified textures of food and drink for patients; therapy exercises to strengthen the tongue, lips, and muscles in the mouth and throat; and strategies to make eating and drinking safer, such as modifying the pace of chewing/eating, size of food, and more.

● Communication
People diagnosed with COVID-19 are also experiencing speech and language difficulties. Some, such as those who spent a significant amount of time on a ventilator or experienced low oxygen to the brain, may have muscle weakness or reduced coordination in the muscles of the face, lips, tongue, and throat — making it difficult to talk. Others, particularly those who experienced a COVID-related stroke, may experience aphasia, which makes it hard for someone to understand, speak, read or write. SLPs intervene with patients through targeted therapy to improve their communication and understanding.

People who have severe speech and/or language difficulties may need to find other ways to answer questions or tell people what they want, such as through gesturing with their hands, pointing to letters or pictures on a paper or board, or using a computer. These are all forms of augmentative and alternative communication (AAC). SLPs help find the appropriate AAC method to meet an individual’s needs.

For questions about SLP scope of practice or program development, contact Elyse Matson, SLP Resource, at ematson@ensignservices.net.

Resident K is a 52-year-old man who was referred to Physical Therapy for chronic, non-healing pressure ulcers of the coccyx and ischial tuberosity and severe pain.

• PMH: Spina Bifida, B AKA, HTN, colostomy; wounds have been present approximately 10 years. Patient underwent flap surgery five years ago; wound vac has been unsuccessful in promoting healing
• PLOF: Modified Independent in transfers and wheelchair mobility; has resided in nursing homes for 10 years; history of being non-compliant with pressure relief and positioning

Evaluation status (4/2020):

• Mobility: Modified I transfers and wheelchair mobility; tilt in space motorized chair with ROHO cushion
• Strength or ROM deficits: No
• Wound 1: Coccyx: Stage 4 pressure ulcer: 1.5L x.7W x.6D; necrotic <25%
• Wound 2: Ischial Tuberosity: Stage 4 pressure ulcer: 3.5L x 3.0W x 3.0D
• Pain: 7/10 with any movement, related to wounds

Wound care: Dakins solution

Patient reluctantly agrees to PT POC to initiate in-wound electrical stimulation (HVPC) five times a week to facilitate increased wound bed granulation, decrease necrotic tissue, decrease pain and facilitate wound healing. Patient states, “These wounds won’t heal; they’ve been there forever and I’ve tried it all.”
D/C plan: reside in skilled nursing facility

Discharge status (10/2020):

• Wound 1: Coccyx: Resolved
• Wound 2: Ischial Tuberosity: .3L x .3W x .2D
• Pain: 0/10
• Patient is discharging to an Assisted Living Facility

As the wounds began to improve, patient K began to be compliant with positioning and pressure relief. During the course of treatment, estim protocol changed from negative to positive polarity in wound, and then finally peri-wound as wounds became too small for in-wound electrode placement. Dressing changes occurred through IDT wound team consultation. Treatment included patient/caregiver education throughout.

Kudos to the Pueblo team for being willing to tackle the “impossible” wounds and having the perseverance to hang in there! They understood that chronic healing takes time. Meeting requirements of documenting progress every 30 days, changing protocols when healing began to plateau, and using skilled assessment allowed them to continue the POC to closure/near closure of the wounds.

Submitted by Shelby Donahoo, M.S., OTR/L, Therapy Resource, Bandera

By Kelly Alvord, Therapy Resource, Sunstone UT
The Sunstone DONs and DORs recently participated in a combined meeting. This meeting of minds was designed to make sure we understand the challenges and initiatives of each other’s departments and to really collaborate where we could to help each other meet goals and obtain great clinical results.

Key partnership topics discussed:

• We first pulled the “Rehab Screen Consultation F TAGs” POSTette from the portal. Each DOR presented on an F-tag from the POSTette and how the Therapy team will support and take the ownership of these tags for survey. For example, F Tags F684, F676, F677, and F810 all have to do with Activities of Daily Living (ADLs). The teams addressed their strategies for therapy partnership with ADLs for this group of F Tags. We discussed specific actions and roles Therapy has to support the DONs to prepare for survey. The DONs learned how their DORs are truly their clinical partners. This discussion was very interactive. The DONs were excited to know we “have their back” when it comes to involvement with patients to prevent decline and help with survey results.
• Deb Bielek introduced our Excellence in Programming and Clinical Care (EPIC) Programs. EPIC programs. The DONs and DORs all committed to collaborating and establishing an EPIC program for each of their facilities based on clinical needs and trends.
• Clay Christensen presented on the 5 Dysfunctions of a Team, which focused on establishing trust, being vulnerable, and not fearing conflict. This information was further validation of power of a strong DON and DOR partnership.
• We also had fun together and had cluster competitions with an offsite activity.

With these dynamic partnerships with DONs and DORs, Sunstone is unstoppable!

I think most of us would answer yes to this question!

I wanted to share a cool program that Adina Gray, SLP/DOR, and her team at Lake Village have started to meet the needs of their residents and see great improvements in this area:

At Lake Village in Lewisville, Texas, the therapy department saw a need for residents who either: didn’t enjoy showers, refused showers, had a decline in personal hygiene, and/or could benefit from some modifications and adaptations to their daily wash routine.

The OTs started by identifying the residents, and then we went about finding inexpensive but functional shower caddies (the Target College Essentials ones were perfect). They then talked to the residents and their families, and obtained the items that the patients would utilize and enjoy specific to them. For example, some families brought nice-smelling body wash, specific hair products for different hair textures,, good shavers and shaving cream for the men, etc. Items were labeled as necessary to help with carryover and ease of use.

We also established grooming and hygiene routines with laminated visual schedules for those who could follow them for doing things such as daily teeth brushing, washing their face and combing hair. And when OTs have established the routines and a patient is demonstrating good independence with the program, we then refer to ST in order to continue with carryover and use of visual aids and daily schedule to complete tasks as independently as possible.

Feel free to reach out to Adina (adhill@ensignservices.net) or your therapy resource with any questions!

Submitted by Barbara Mohrle, OTR, Therapy Resource, Keystone North

By Brian del Poso, OTR/L, CHC, RAC-CT and Tamala Sammons, MA, CCC-SLP, Therapy Resources
Sensory Integration (SI) Therapy was originally invented by OT, Jean Ayres, in the 1970s to help children with sensory processing problems. Although less prevalent, SI techniques and theory used to modulate the sensory and proprioceptive systems can also be used with the adult population.

We’ve had a few questions recently around the appropriate use of the 97533 Sensory Integration CPT code. In general, this is an allowable code and covered by our MACs. However, since we know SI is predominantly used with the pediatric population, if utilizing this code as part of therapy intervention with the adult population, it is important that we use evidence-based practice, research, and have clear supportive documentation to demonstrate that sensory processing/modulation is a cause of functional deficits and that the interventions being billed truly fall within SI intervention strategies.

Here is the Sensory Integration 97533 code descriptor:
This activity focuses on sensory integrative techniques to enhance sensory processing and to promote adaptive responses to environmental demands, with direct one-on-one contact by the qualified professional, each 15 minutes.
From AOTA:
“Occupational performance difficulties due to sensory modulation challenges or poor integration of sensation can result from difficulties in how the nervous system receives, organizes, and uses sensory information from the body and the physical environment for self-regulation, motor planning, and skill development. These problems impact self-concept, emotional regulation, attention, problem solving, behavior control, skill performance, and the capacity to develop and maintain interpersonal relationships. In adults, they may negatively impact the ability to parent, work, or engage in home management, social, and leisure activities.”
From the AOTA article: Sensory Integration Use with Elders with Advanced Dementia
“Research of current approaches in treating older adults with dementia to decrease negative symptoms and increase quality of life, revealed the trend of using a multi-sensory protocol designed for this population (Chitsey, Haight, & Jones, 2002; Knight, Adkison, & Kovach, 2010; Kverno et al., 2009; Lape, 2009; Letts et al., 2011; Padilla, 2011). Kverno et al. (2009) noted in their literature review of non-pharmacological treatment of individuals with dementia that “individuals with advanced levels of dementia benefited to a greater extent from nonverbal patterned multisensory stimulation” (p. 840). Multisensory stimulation incorporates the use of tactile, visual, auditory, olfactory, and gustatory sensory pathways, along with movement, to help the individual interpret his or her environment (Lape, 2009).”
The occupational therapy evaluation and treatment plan is designed to “structure, modify, or adapt the environment and to enhance and support performance” (American Occupational Therapy Association, 2015, p. 6913410050p1), in order to re-engage patients.

Adding sensory integration as a treatment approach starts with assessing any comfort or discomfort when a patient is participating in: ADLs (grooming, dressing, bathing, etc.); Meals; Upper extremity movement; Functional transfers; Seating and positioning.
Goals can be developed around any identified areas of discomfort by creating situations to increase episodes of comfort with those tasks.

What do the MACs say? Here is the language from the Novitas as an example:
Sensory Integration 97533
This activity focuses on sensory integrative techniques to enhance sensory processing and to promote adaptive responses to environmental demands, with direct one-on-one contact by the qualified professional, each 15 minutes.

The patient must have the capacity to learn from instructions. Utilization of sensory integrative techniques should be infrequent for Medicare patients.

For more resources, documents, and tools to help provide information to you and your staff, please see the Sensory Integration section under Therapy > Clinical Programming on the Portal.

By John Patrick Diaz, DPT, DOR, Magnolia Post Acute Care, El Cajon, CA
We all know that the mental health of our residents has been directly (through a specific medical condition) or indirectly (via communal isolation or psychological stresses) affected by this pandemic. Any type of interaction, whether it be through Facetime, window visits, regular phone calls, or even texting our loved ones, makes a huge difference in getting them through their day.

As part of Celebration and Loving One Another, Caitlin Dablow, SLP, and Jacalyn Leigh, COTA, guided a group of local community kids in creating Valentine’s Day cards for our residents at Magnolia Post Acute. The parents of the kids were so supportive in getting them together and designing simple but meaningful cards.

The cards were distributed to each resident with the assistance of our kitchen staff during their lunch meal. As each resident read their card, it was such a great sight to see that everyone had a smile on their faces while others became teary-eyed. Everyone appreciated the gesture knowing that the community cares. We may not be able to celebrate together as a group, but we for sure have felt the love and positive vibes within the facility.