Patient Success at Shea

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By Jada Exstrom, PT, DOR, Shea Post Acute Care, Scottsdale, AZ
Meet Charles—Charles came to Shea Post Acute Rehab Center after suffering several falls in which he hit his head and suffered multiple fractures, contusions and hematomas. As a result of the multiple falls, he was met with confusion and memory deficits, and he had severe restrictions and limitations both mentally and physically, which impacted his progression in rehab.

Due to his medical complexities, confusion and high risk for falls, he ultimately required one-on-one care and attention, including frequent redirection and reorientation. Due to his deficits and decreased safety and insight, case management worked diligently on alternative discharge planning, including discharge to a group home, ALF, or LTC, for a higher level of care. But, much to our dismay, Charles had other plans. He was adamant about returning home and being reunited with his cats.

With the diligent management of his care, watchful eye of our staff and increased oversight, he was able to persevere. There were some things that many were unsure we would ever see from Charles. Charles started to increase his participation in therapy and even started to direct his care, drive his own rehab, and with Zane’s help (our therapy dog), Charles thrived. Charles became a fixture at Shea, walking through the halls (11 laps at a time), visiting Zane every day, conversing with other residents and brightening everyone’s day with his positive outlook.

Charles was able to walk out of Shea on his own accord, no need for any assistance, and return home to be with his cats. Charles is also planning to return to work. Charles, while you gave us a run for our money, you are a great success!

A New System for IDDSI

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By Sarah Scott, MS CCC SLP, Pointe Meadows, Lehi, UT
On our last call, IDDSI implementation was a shared struggle. With the help of our students and in collaboration with nursing and dietary, we have implemented a new system for IDDSI consistency. On the next call, we can report on any success or challenges with our system.

We have had several inservices with Nursing across the last two weeks. Every nurse will attend training. We completed training with the dietary staff. Each training was an hour long and covered IDDSI, the modified liquids and solids, preparation and testing.

We created a patient identification system for diet modifications. We used the IDDSI colors and round dot stickers for each level in addition to a water droplet sticker for a water protocol. We are placing dots on the doors for easier in-room identification and on a wrist band, which we are placing on the patient’s walker and/or wheelchair for easier identification outside the room and in the dining room.

We created an admission protocol for each nursing station so the admitting nurse can find the diet and place the DOTs with the help of the CNA processing the admission. ST has the same materials so we can change the identification when we change a diet. The key is posted by all of the med carts, nursing stations, gym and dining room.

We also created nice-looking official thickened liquid stations. We have been having difficulty with liquids being the wrong thickness, the spoon being stored in the thickener, and no date on the thickener. Each station is clearly marked and has instructions on laminated cards to support where to get the thickener and how it and the spoons should be stored, specific instructions for our brand of thickener, the quick key to perform a test if needed, and the IDDSI levels.

Our kitchen has ordered single-serving liquids to go out on trays, and each nurse’s station also has a gel pump to support the nurses with ease of thickening amid their many responsibilities.

Partnering with Home Health to Build an OP Business

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By Kelly Alvord, Therapy Resource, Sunstone-Utah
In the Sunstone market, as we continue to partner with ALF to enhance Outpatient (OP) business, a lot of emphasis has been put on strengthening partnerships with Home Health providers versus seeing them as competition. This partnership has led to increased referrals for OP services and OP growth. Here are some insights that the DORs have found helpful.

From Kirk Player, DOR Pinnacle
As far as PDGM goes from a HH agencies prospective:
● It benefits the agencies to get their patients better with as few visits as possible, including therapy. This is basically a 180 turn from the previous HH payment model.
● It also benefits the agencies to have LOS around 40 days when appropriate and possible. This allows them to enter the second 30-day period but still maintain visits to only those necessary.
We realized that in-home or in ALF outpatient therapy can help with both above points by allowing a safe d/c sooner by continuing and likely increasing the frequency of skilled therapy.
● This keeps a skilled clinician in with the patient to observe and assess any change of condition, which reduces readmissions.
● It also keeps the patient progressing with functional mobility and reduces other adverse events such as falls.

From Wes Spivey, DOR Hurricane
I got a head start being the discharge coordinator at St. George Rehab, allowing me to grow relationships with a lot of the home health companies in the area. Because of these strong relationships, we are starting to see our outpatient program grow. We got our first patient this week and will have our second in 1-2 weeks.

I have also met with a few ALF ownership groups through our home health partners, and once we hire a full time PT, OT, and SLP we have the green light to start working in that ALF.

From Scott Hollander, DOR Pointe Meadows It isn’t just Symbii (Pennant affiliated company) that I work with for ALF marketing. I get in touch with HH marketers and ask for an audience at their company IDT and IDG meetings. At these meetings, I take about 10 min. to share with their therapists and nurses how we can support them (especially with PDGM). They have fewer visits they can offer and I explain how we can come in behind them to continue therapy services. This turns into referrals from their clinicians, and many times during their d/c call to the MD office, they ask for an outpatient therapy order that is given to us!

I educate them on how we can also provide therapy to hospice patients in certain circumstances as long we code the cases as “07” on the billing side and that the hospice MD signs our orders. (This is a whole other conversation to have on another day.)

I also spend time with HH companies that are regulars for our patients that are discharged and ask for the return referral when they are finished. I have spent time actually going to ALFs with HH marketers to market for outpatient to show the ALFs that we are a team and that Pointe Meadows isn’t encroaching on HH patients. We discuss how if our outpatient therapists find a medical problem when treating a resident of theirs, we refer back to the MD, and if nursing is needed, back to HH.

Lately, Symbii HH has seen how much benefit this is to them and have actually been setting up marketing meetings for me! They are partnering with us in offering balance assessment clinics (We use CDC STEADI program for this). From these clinics, we gain patients every time.

Right before COVID hit last March, we had awesome momentum of our outpatient flywheel and were growing in 6 ALFs; then it all stopped. This last month, we’ve been pushing hard on the flywheel, and it is starting to pick up speed. The local ALFs are beginning to open their doors for us again, and we are excited to get back to a powerful outpatient program!

Strength Training for the Respiratory System: SLP Case Study at Olympia

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By Suzanne Estebo Simko, M.S. CCC-SLP, Olympia Transitional Care, Olympia, WA
Kathy came to us in early February 2021 due to progressive weakness. When she first arrived at OTC, although she was alert, she had difficulty having the energy to even keep her eyes open. Kathy stated she was first diagnosed with Parkinson’s disease in 1992, but was able to maintain her productive life. After her diagnosis, she continued to work for an additional 10 years as an executive assistant for the WA Army and National Guard. She stated she and her husband are very social in nature and loved to entertain.

During her initial speech evaluation, Kathy was concerned about her vocal volume being recently diminished. She shared that she used to “sing all the time…in the shower, choir, car, and karaoke nights,” and now, “I squeak out.” It also upset her that her condition was affecting communication with loved ones: “My husband can’t understand me at all when I call him on the phone from here,” she said.

SLP Suzanne Simko recently took a CEU course on strength training for the respiratory system. Her patient Kathy seemed like she could really benefit from the information and techniques learned in this course. Due to Kathy’s breath support weakness, she was not able to complete all the recommended repetitions on The Breather device in her first session. However, both ladies were astounded at the noticeable difference in Kathy’s speech intelligibility at the end of the first session! Her vocal volume was much louder, and she had enough air support to produce sentences versus her baseline one- to two-word responses. The next day when seen for treatment, Kathy’s baseline speech was still more intelligible than previous sessions and almost as important, she was smiling and enthusiastic to go to speech therapy and resume her respiratory system training. Kathy now asks for handouts to help her remember oral/motor and breath support exercises to do when she’s not in ST. She stated she feels “hopeful for the future.”

Sensory Integration Coding

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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.

Local Community Children Spreading the Love

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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.

The Importance of SLP Intervention for Respiratory Function

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Why is respiratory function so important for SLP involvement?
● Successful phonation is dependent upon effective respiration.
● Uncoordinated breathing patterns or open vocal folds increase risk for aspiration. Compromised breath support limits cough strength and effectiveness to remove any substances that pass the vocal folds.
Low oxygen levels can affect:
● The heart due to the need for it to pump harder
● The brain, resulting in mood changes, reasoning and memory deficits (i.e. decreased cognitive function; increased safety risk)
● Physical abilities due to decreased sensory or motor planning (i.e., increased risk for falls)

The focus of SLP respiratory intervention is to improve the patient’s quality of breathing patterns for improved communication, swallow, and patient performance during ADLs or other physical activities. The goal of Respiratory Muscle Strength Training (RMST) is to increase the “force-generating capacity” of the muscles of inspiration and expiration; RMST can be used to target inspiratory or expiratory muscles, depending on patient needs (Sapienza, Troche, Pitts, Davenport, 2011).

Always measure the patient’s oxygen level and respiratory rate pre-, during and post-therapy activities. If oxygen falls below 90%, cue for deep nasal inhalation and/or other breathing techniques such as pursed lip breathing until levels resume. If levels are unable to resume, notify Nursing immediately. Additionally, assess and document the patient’s demeanor/anxiety levels during intervention.

Respiratory treatment interventions need to address:
● Proper breath control/breathing patterns
● Pursed lip/diaphragmatic breathing
● Sustained phonation
● Phrase production
● Respiration with swallow when issues are identified
● Airway protection

Create a Breath Support Tool Kit
● Straws, whistles, cotton balls, pinwheels, party horns, bubbles, etc.
● Professional tools, i.e., The Breathertm; EMST 150/75

Resistive Device Training Videos:

The Breather
https://www.pnmedical.com/lessons/in-service-video/

EMST 1500
https://emst150.com/how-to-train/

Sustained Airflow/Phrasing
● Have patient draw circles or other items while sustaining “ah”
● Blow bubbles at a target, blow cotton balls across a table/into a cup, blow pinwheels, whistles, etc. Add a straw for resistance.
● Utilize pre-made phrases already established in the number of syllables needed.
● Dual task: have patient read phrases while on exercise bike

Refer to SLP Respiratory Rehab POSTette for additional information

 

CPT Coding Tips - Wound Care CPT Codes 97597 and 97598

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Wound debridement codes are intended for acute wounds that are debrided of devitalized tissue. Debridement is measured in total depth and surface area, going from skin level down to the bone.

● 97597 Debridement (e.g., high pressure waterjet with/without suction, sharp selective debridement with scissors, scalpel and forceps), open wound (e.g., fibrin, devitalized epidermis and/or dermis, exudate, debris, biofilm), including topical application(s), wound assessment, use of a whirlpool, when performed and instruction(s) for ongoing care, per session, total wound(s) surface area; first 20 sq cm or less.

● 97598 Debridement each additional 20 sq cm, or part thereof (list separately in addition to code for primary procedure). Use 97598 in conjunction with 97597. Note: Log 97598 for each occasion of 20 sq cm after the initial 20 sq cm.

Example: If the treatment area is 60 sq cm
Log codes as follows:
97597 x 1
97598 x 2

Please see WoundCare POSTette for additional information and clinical examples when using the Wound Debridement CPT codes.

CPT Coding Tips - 96125 (Standardized Cognitive Performance Testing, Per Hour)

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Log this code when:

  1. The combined time it takes to conduct the evaluation, interpret the results, and write the evaluation report* is at least 31 minutes to report the first hour, 91 minutes to report the second hour, and so on.
  2. The test is completed using a standardized assessment, independently or in conjunction with subjective observations and findings.

*Note: Clinicians may count interpretation and documentation time toward the minimum minutes only when billing for 96125, and only for Medicare Part B patients. Medicare Part A minutes still follow RAI manual guidelines of direct face-to-face time, which is followed regardless of code definition. Additionally, when administered as the initial evaluation, this code is non-MDS for Part A payers.

Completing standardized assessments supports evidence-based practice and helps to clearly identify where to target intervention for the best results. While tools like the SLUMs offer insight as to where a deficit may be occurring, they only allow a general categorization of cognitive impairment: normal, mild, or severe/dementia.

Utilizing formal standardized assessments for cognition will help determine which component of the cognitive impairments need intervention. With so many components of cognition, it’s best to assess as many areas as possible. Cognition is the greatest predictor of function. The more areas assessed, the stronger the plan of care and better patient outcomes.

Please refer to the Cognitive Performance Assessment POSTette for additional information.

Carly Peevers — Passionate About Think Thin

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Submitted by Dominic DeLaquil, Therapy Resource, ID/NV

Carly Peevers is an SLP out of Rosewood Rehabilitation in Reno, Nevada. Carly is passionate about giving great clinical care and has recently taken on an educational role within the Pennant, Idaho/Nevada, market.

Carly has been an employee at Rosewood since 2015. In her first year at Rosewood, she worked collaboratively with the kitchen team to revamp the menus so that the diet recommendations match with the diets provided by the food services company. Since then, she has worked hard to train new and existing kitchen staff on diet restrictions and make sure they are comfortable with the administration of current diet orders. She has also worked with CNA and nursing staff to communicate actively when diets change to ensure the entire team is collaborating with regard to patient care.

Carly, along with the entire speech team at Rosewood, believes passionately in upgrading patients to thin liquids as quickly and safely as possible. Carly leads this initiative by educating staff on current lists of patients on thickened liquids and directing care in such a way that they are upgraded as quickly as possible. At any given moment, Rosewood never has more than a few patients on thickened liquids. She also recently trained the SLPs in her cluster on the value of reducing thickened liquids.

When the International Dysphagia Diets Standardization Initiative (IDDSI) was released in May 2019, Carly championed the transition by talking with the kitchen managers and Registered Dieticians and educating nursing staff on the levels to prepare us for the change. She attended trainings with speech therapists from all over the city to create a collaboration through the SLP network of acute, Rehab, SNF and Home Health SLPs.

Carly is truly a dedicated therapist, and Rosewood is so proud of all of her hard work!