Thinking Outside the Box: Modified Diets That Are Tasty and Appealing!

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Submitted by Shelby Donahoo, Therapy Resource, Tucson, AZ
When Sara Mohr, CFY at Sabino Canyon in Tucson, Arizona, was a SLP graduate student at the University of Arizona, the reality for those on modified diets became clear. Often a diagnosis of dysphagia brings confusion and worry. Getting modified diets right seems obvious, but actually can be quite hard. Options seemed few: mashed potatoes, blended meat and yogurt. She found few resources out there for patients in terms of appealing and tasty recipes with easy instructions for cooking and modifying.

She and her colleague, Louisa Williams, had an idea. What if they created a food blog to improve accessibility to quality information on modified diets?

So they established realmealsmodified.com and began creating recipes and posting foods that meet texture requirements of the International Dysphagia Diet Standardization Initiative (IDDSI) while looking appetizing and tasting flavorful!

Sara says her goal with modified diet recipes is that “it should be good enough to bring to a potluck, share with the group, and not be embarrassed.” They do the cooking, test the recipes in various consistencies, and essentially take the guesswork out of modified diets.
If a recipe doesn’t work well modified, they don’t post it. Last year, Sara was working on a potato salad recipe using cauliflower (potatoes would just end up mashed) but reported it was “too soupy, too vinegary.” She’s recently perfected it and it will post the recipe soon.
Recipes include items such as Chicken Pot Pie Puree, Sopa Azteca, Chocolate Chip Banana Bread, Minced Pancakes and Salmon! Portions can be made for individuals or the whole family.

Sara and Louisa are planning a “puree road trip” this summer, with the goal of finding options for those on modified diets to eat when traveling.

What a great resource for our SLPs to share with clients and families!

Importance of Therapy Intervention for Patients Post-COVID

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By Tamala Sammons, MA, CCC/SLP, Therapy Resource
COVID-19 is a respiratory viral disease with multi-organ involvement resulting in potentially temporary and episodic health challenges such as impaired lung function, physical deconditioning, cognitive impairments, impaired swallow and communication, and mental health disorders.

The effect of the virus on the respiratory system appears to range from a simple respiratory tract infection to acute respiratory distress syndrome (ARDS) with multi-organ failure.
People with COVID-19 may also develop coagulopathy that can lead to venous thromboembolism (VTE) and microvascular thrombosis throughout the body, increasing the risk of negative mental health outcomes (https://academic.oup.com/ptj/article/100/12/2127/5903663).

Older adults respond to their own stress and that experienced by staff, which can increase the risk of behavioral problems. Isolation and lack of stimulation may also lead to loneliness and depression. Each of these negative psychological outcomes has a significant impact on an individual’s immune system and the ability to fight infection.

An increasing number of patients recovering from COVID-19 are having lingering cognitive symptoms, including confusion and impaired executive functions, short-term memory issues, and learning difficulties. For those who had compromised cognitive-communication status before COVID-19, we need to be ready for ongoing exacerbation of symptoms.

New survey standards: Surveyors are advised to investigate any concerns as part of the focused infection control survey related to residents who have had a significant decline in condition. Emphasis is on decline with the resident’s condition, both physical and/or psychosocial.
Therapy Interventions must address the clinical changes in our patients from this pandemic.

Occupational Therapy Intervention/Strategies
● Measure the effects of cardiac function and respiration, including any increased oxygen and/or oxygen weaning with ADLs (respiratory rehab ADLs; OT COPD treatment protocol)
● Assess functional mobility — high fall risk
● Provide energy conservation and work simplification interventions
● Consider cognition, cognitive rehabilitation and occupational performance; and address cognitive impairments
● Address psychosocial (OT psychosocial interventions), mental health (AOTA OT’s role with mental health recovery), stress (HRV training), and coping-related PTSD or anxiety disorder post-COVID-19
● Community reintegration

Physical Therapy Intervention/Strategies
● Measure the effects of cardiac function and respiration, including any increased oxygen and/or oxygen weaning with physical performance (respiratory rehab physical exercise; PT COPD treatment protocol)
● Provide strength and mobility interventions — exercise prescription, fall risk, take longer to regain strength
o Note: For exercise prescription, go back to pulmonary rehab principles and exercise prescription for older adults and modify based on symptoms, vital signs and RPE
o Aerobic exercise, strength training, flexibility intervention
o It is critical that physical therapists are aware of the clinical implications of coagulopathy and the prevalence of venous thromboembolism (VTE) in patients diagnosed with and recovering from COVID-19 through the promotion of early mobility and physical activity
● Provide pain assessments and intervention
● Community reintegration as indicated
● Need for outpatient services

Speech-Language Pathology Intervention/Strategies
● Measure the effects of cardiac function and respiration, including any increased oxygen and/or oxygen weaning with communication and swallow (respiratory rehab breathing interventions and using resistive devices; SLP COPD treatment protocol)
● Assess effective communication as it relates to respiratory function
● Assess cognition (great opportunity to use comprehensive cognitive assessments), provide cognitive rehabilitation to address cognitive impairments
o Note: Studies are emerging that suggest some type of association between neurological symptoms and COVID-19. Symptoms like headache, stiff neck, and loss of taste and smell raise suspicion of central nervous system involvement.
● Assess swallow; airway protection and cough strength. Integrate resistive breathing devices for intervention.
● Assess for continued loss of taste and smell and how that impacts hydration and nutrition.
● Need for outpatient services.

A Trio of Wellness: Oral Health, Overall Health and Quality of Life

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By Razan Malkawi, M.S., CF-SLP, Rose Villa Healthcare Center, Bellflower, CA
Research indicates a clear link between oral hygiene and the overall health of patients. Poor oral hygiene can contribute to new arising medical conditions, and it may worsen the existing disease and interfere with the outcomes of treatment. Continuous education and awareness in oral hygiene are essential in our facility. We hold weekly, if not daily, in-services to discuss preventative measures collaboratively. Members of the interdisciplinary team, including but not limited to the speech therapist, occupational and physical therapists, CNAs, nurses, and the administrators, are all involved in providing evidence-based resources to assure a high quality of life for our patients here at Rose Villa Healthcare Center.

Causes of poor oral hygiene may be related to genetic, developmental and environmental factors. Most of our patients receive medications that may have side effects. For example, Xerostomia (i.e., extremely dry mouth) is a common problem that contributes to poor oral hygiene; causes include drugs, smoking, radiation therapy, diabetes Mellitus, etc. (Kapoor et al., 2014). Our role is to assist with and provide instructions and education regarding the different mouth care approaches for our patients. Mouth cleaning and care, including brushing teeth, mouth wash, and the use of sponge sticks, are all vital behaviors to prevent the existing disease’s escalation and the emergence of new ones. A speech therapist often works with patients who suffer from swallowing problems (i.e., dysphagia), as swallowing dysfunction may cause the entry of food or drink particles into the airways, and bacteria from the mouth may reach the patient’s lungs and cause aspiration pneumonia (Shun-Te HUANG, 2020). Safe swallowing strategies like posture adjustment, proper oral care, and motor-exercises contribute to treating dysphagia and reduce the prevalence of aspiration pneumonia (Shun-Te HUANG, 2020).

In a recent in-service, we discussed the necessity of providing oral care to NPO patients as a preventative measure. Education in this area is essential; one may think that if patients do not eat or drink, mouth cleaning is not a priority! Well, this is not true; NPO patients are at risk for infections, aspiration pneumonia, Xerostomia, and dehydration if oral care is neglected (Liddle, 2014). The state of NPO, along with the presence of dysphagia, may cause aspiration or pulmonary pneumonia if appropriate oral hygiene regimens are not in place. The patient may still aspirate on his/her own saliva; commonly, such incidences occur at nighttime when HOB (i.e., head of bed) is minimally elevated. As healthcare providers, let us all take the initiative to provide our patients with the highest quality of life by spreading awareness.

Refer to our SLP Dehydration Risk Free Water Protocol, for additional information including an Oral Health Assessment Tool (OHAT) for non-dental professionals.

Temple View Transitional Care Improves their Self-Care GG Scores

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By Cory Robertson, Therapy Resource, Idaho

Temple View Transitional Care Center in Rexburg, Idaho, Therapy led by Susie Swetter, DPT, DOR, joined the organization in the fall of 2019 during the transition from PPS to PDPM. One area in particular they have been focused on is improving their Self-Care GG scores. The challenge to improve was brought to the team, and their new OT, Neil Marion, stepped up to own it.

The team met to review their GG scores and their coding process. Neil looked at the metrics and said, “I want Temple View to lead the market in the self-care increase score.” At the time, Temple View was behind several other buildings in the Market in self-care. However, within several weeks of continued improvement in self-care scores, Temple View grabbed the top spot in percentage improvement in self-care scores for the ID/NV market.

When asked how Neil did it, his response to getting the top spot was amazing:

“Thanks for all the congratulations! I appreciate that, and when Susie asked me to respond about what I did to increase self-care scores, I simply said, ‘I’m just doing my job as an OT. Don’t hide your skills as an OT or COTA; we can offer so much to the people we care for, from the core self-care tasks with adaptations or full restoration of their skills, positioning in bed or w/c, home assessments, splinting/orthotics, neuro-rehab, cognitive rehab as it relates to ADLs, IADLs, fine/gross motor training, power w/c assessment, and strengthening of the specific muscles to increase independence and so much more! Don’t lose who you are as an OT; that identity is important … what makes us different than PT or ST? My answer: so, so much, and it’s our job to proudly proclaim who we are and show our facilities what we can do.”

Thank you, Team Temple View and Neil, for your ownership of this important measure and ensuring your patients get the very best care!

Managing Lymphedema

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By Calli Carlson, OT/DOR, North Mountain Medical & Rehabilitation, Phoenix, AZ
In the fall of 2020, two of North Mountain Medical Center’s therapists, Tyler Lieberman, COTA/L, and Calli Carlson, OTR/L DOR, spent 145 hours over the course of three weekends to become certified lymphedema therapists. Calli received a brief introduction to lymphedema management in her occupational therapy graduate program but knew there was still a great deal to learn in order to provide the best possible care to residents. Tyler also expressed interest in becoming certified, particularly after observing many residents with edema/lymphedema and the subsequent joint stiffness and skin changes that resulted. North Mountain’s CEO, Jason Postl, and Director of Nursing, Jacque Green, were extremely supportive in providing the means for training and were equally as committed to providing the highest quality, holistic care for residents.

Lymphedema itself is historically ill-understood in clinical practice despite affecting 90 to 250 million people worldwide. Lymph node removals, trauma, surgeries, medications, genetics and obesity are just a few of the contributing factors to disruption of the lymphatic system, which can result in protein-rich fluid in the interstitium and cause a cascade of adverse reactions. Physically, patients may experience extreme heaviness in limbs, itchiness, skin infections, and, in later stages, dermal fibrosis, skin papillomas, and trophic skin changes. Psychologically, physical changes can create anxiety, depression, reduced quality of life, and impaired participation in functional tasks of choice.

Lymphedema management focuses on clearing edematous fluid from the interstitium via manual lymphatic drainage, compression, and/or decongestive exercises with additional focus on skin care and self-care management. Therapists use precise measurements to obtain the volume of the edematous limb and track over time to determine the effectiveness of treatment. At North Mountain, Tyler and Calli have noticed significant improvements in total limb reduction with the use of volumetric measurements, and patients also report that their limbs feel lighter and easier to move.

For patients with decreased alertness, staff members are trained for the continuation of techniques to ensure carryover from skilled therapy. The ultimate goal of lymphedema therapy is to improve patients’ overall skin integrity, movement, health, and quality of life by moving unwanted fluid from the interstitium back into the lymphatic system to be excreted by the body. It is an area of therapy that is not often explored in the realm of skilled nursing but has the potential to improve patients’ movement and tolerance to standing activities in physical therapy, reduce risk of developing decubiti by increasing blood flow, improve patient’s self-esteem and quality of life, prevent fibrotic changes that can occur from stagnant protein-rich fluid, and overall increase patients’ participation with self-care and functional tasks of choice. It requires interdisciplinary communication and engagement to create lasting results for the patient.

Though not often explored by therapists, Tyler and Calli would strongly encourage anyone interested in better identifying/managing lymphedema to become lymphedema certified to gain the valuable skills required for effective lymphedema management.

Exercising Your Passion for Learning

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By Kai Williams, Therapy Resource, Keystone East, TX
There are many times that we run across clinicians that have such a passion for integrating new and innovative clinical ideas. Some move with hesitancy, unsure if their idea will really gain traction. We say to those that are hesitant, please Exercise your Passion for Learning! Malathy Venkatesh, PhD, CCC-SLP, originally joined our Mason Creek facility in Katy, Texas, in 2019. She recently relocated to our Tempe post-acute facility located in Arizona in late 2020. From the very first time I met Malathy, our conversations revolved around the underutilization of speech therapy services with a goal on how to increase awareness around clinical programming. Malathy has spent the last six months introducing LTC patients to the Montessori Method. Below you will find details about the Montessori approach to dementia from an SLP perspective, along with some ideas on how SLPs can use this approach in the LTC setting with examples of materials and goals.

Applying the Montessori Principles in the Management of Dementia: Speech Language
Pathologist’s Perspective
Malathy Venkatesh PhD CCC-SLP, Tempe Post-Acute, Tempe AZ
Speech Language Pathologists (SLPs) are constantly seeking approaches, materials and activities that place less demand on an impaired and progressively declining cognitive system such as the semantic and episodic memory, and more on engaging the relatively preserved procedural memory, to improve safety and functions in individuals with dementia. One approach that maximizes the preserved skills and abilities such as recognition of stimuli and reading is the Montessori approach for ageing and dementia. This approach, derived from the pedagogical approach to child education, has been developed and implemented successfully in adult day care centers and long-term care (LTC) settings.

One of the important principles of the Montessori approach is to encourage independence in individuals with dementia by engaging them in meaningful and purposeful activities in a prepared environment. The Montessori approach recommends that SLPs evaluate and manage individuals with dementia in their natural environment such as their rooms, dining room and activity room in addition to the clinical setting. The communication performance in a quiet therapy room may differ greatly from their communication abilities in a dining or activity room where they must adapt to the background noise and disproportionate visual stimulation. Two of the most common environmental barriers that affect the communication and interaction ability of individuals with dementia is light and contrast. The recommended environmental modifications for these barriers include incorporating bright but non-glare lighting in therapy spaces and reading spaces, minimizing unevenly lighted spaces, and preparing the environment where the figure contrasts from the background in such a way that it stands out, draws attention and is easy to locate.

The Montessori approach also relies heavily on “cueing,” using explicit visual cues in addition to verbal cues to facilitate initiation, maintenance and completion of an activity, and directions, signs around the facility, and memory books. Both texts and pictures are utilized while developing visual cues. Lighting and contrasts are important factors to be considered while displaying the visual cues. They should be displayed in a way that facilitates ease of recognition and reading and must fulfill the purpose that it intends to achieve, for example, locating rooms in the building.

The Montessori approach taps on the relatively preserved ability of reading aloud by encouraging this skill as a pleasure activity utilizing dementia-friendly books. These books use large-print text with high-contrast pictures and illustrations. They are colorful and, more importantly, they are books designed for senior adults and adults with dementia. Reading books helps maintain language and reading skills, preserve pincer grasp when turning the pages, and maintain attention and focus. As shown in Figure 1, the environment is prepared ahead of the reading task by choosing a well-lit, quiet, distraction-free spot in the room. The book is mounted on a stand for easy reading and for page turning. Also notice that there are no shadows or glare on the book.

Figure 1: Dementia-friendly book (Courtesy of Susan Ostrowski, Reading2Connect at
www.Reading2Connect.com)

Another example applying the Montessori philosophy for a simple verbal expression task is utilizing a picture cube and wh-questions cue cards as illustrated in Figure 2. The purpose of this activity would be to facilitate word retrieval, improve comprehension of wh-questions, maintain language skills, maintain conversational skills, maintain attention and focus, and maintain reading skills. The level of complexity of the task can be modified based on the degree of impairment.

 

Figure 2: Verbal expression task

SLPs have a well-researched and successfully implemented approach that taps into the preserved abilities of individuals with dementia to address the impaired system, making their interactions more meaningful and improving their communication skills.

 

 

 

References:
Brush, J.A., (2020). Montessori for Elder and Dementia Care. Baltimore: Health Professions Press, Inc.

 

So You Want to Hire a CFY?

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By Elyse Matson, MA CCC-SLP, SLP Resource
One of our initiatives for 2021 is to increase our SLP programming, thus providing a more cohesive and multi-disciplinary approach to care. Hiring SLPs can be challenging depending on the market. One way to increase the number of candidates for SLP positions is to consider hiring a newly graduated SLP, also referred to as a CFY.

What is a CFY? CFY stands for Clinical Fellowship Year. Think of it like a residency. It is a mentored experience to better transition SLPs from student to licensed and certified clinician. In order to hire a CFY, a licensed and certified SLP needs to agree to mentor for approximately nine months if it is a full-time position. This involves some supervision and guidance of the CFY, depending on the state regulations. In addition, the licensed SLP needs some training in supervision. These regulations vary by state.

There are numerous benefits to hiring a CFY. The new grad is likely to be motivated to learn, eager to build a caseload and willing to accept guidance. A CFY is not a student. If you hire a new grad SLP, they are a regular employee. The only difference is they require some supervision from another SLP. During the COVID-19 pandemic, ASHA is allowing tele-supervision. The mentor needs to be licensed in the state where the CFY will be working. See the changes for 2020 here: 2020 requirements ASHA SLP Crosswalk.

If the new grad will be the only SLP in the facility, make sure to talk with them about how they will handle that challenge so they are clear on what their role in the facility will look like. To help with recruiting efforts, consider stating in the position “CFY accepted,” which will help let new grads know they can apply. Whether they will join a team of SLPs or be the sole provider, hiring a CFY might be just what’s needed to invigorate your SLP programs.

Please feel free to reach out to me if you need assistance with interviewing and decision making with CFYs. Click here for more information from ASHA : https://www.asha.org/certification/completing-the-clinical-fellowship-experience/

Caitlin Colteryahn, OT, TEACHA at The Healthcare Resort of Leawood, KS

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By Danielle Banman, DOR, The Healthcare Resort of Leawood, KS
Caitlin Colteryahn is our lead occupational therapist here at The Healthcare Resort of Leawood and has been with us for four years. Caitlin graduated from Rockhurst University in 2014. She has been married for 10 years and has two boys. She loves spending time outdoors and traveling, especially with friends and family.

Caitlin is an outstanding occupational therapist and is passionate about developing programs for maximizing independence for our residents with dementia. She received advanced training in dementia care in March 2020 to earn the title of Therapy Expert for Abilities Care Holistic Approach (TEACHA). Caitlin has developed an amazing program here at our facility and enjoys teaching other occupational therapists in our market about this program to improve the quality of life for all individuals with dementia that we have the privilege to serve.

Caitlin says this of our program: “I believe it is incredibly important, now more than ever, that we as clinicians use the tools available to us and our clinical knowledge to help develop and implement strategies based on our residents’ functional cognition and strengths to reduce their risk of decline, promote engagement, and for overall quality of life. I love and it is an honor to work with this population, as we have the resources to really get to know who our residents are, what makes them the person they are today, and then to use that knowledge to help them achieve their goals. As a TEACHA, the pandemic has complicated the ability to be able to go into other facilities to help implement programming. However, I have been able to collaborate with other clinicians in and outside of our market through email/phone in order to help support them to utilize the Abilities Care strength-based programming to help reach the needs of their residents.”

Jihan Antipolo-Baldonado, Rehab Aide: The Secret Sauce

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By Carlos Pineda, CTO/DOR, Southland Care Center, Norwalk, CA
“Teamwork is the ability to work together toward common vision. The ability to direct individual accomplishment toward organizational objectives. It is the fuel that allows common people to attain uncommon results” – Andrew Carnegie. It is fascinating to watch an organization continue climbing up and inspiring the members to be the best they can be despite unpreventable hiccups. As you dissect this great phenomenon, you will always find those who are the concrete and steel of the institution. They are usually the quiet, humble but full-of-smiles individual or group that is sitting behind. You can feel their presence in any space and even more when they are not around. They are culture lovers. They are the catalyst for innovation. They spark love among individuals.

When the Momentum market gave me an opportunity to manage two great buildings, Southland Care Center and Downey Post-Acute, there was one person who stepped behind me and whispered, “This opportunity is best for our patients and therapists.” She did not see the struggle that I was heading into, but the opportunity of spreading our core values. I always feel proud, with teary eyes, every time I brag about this person to my colleagues when they ask about our best practices. My answer is that our secret sauce is Jihan Antipolo. She has been in Southland Care Center for 17 years, consistently doing great things over and over again, like the hedgehog. I do not consider her as our rehab tech but a “Resource” for all the departments of both facilities. There was a time during the beginning of the pandemic where everyone was so stressed out about where to secure PPE. Jihan did not waste a second to begin reaching out to different organizations giving donations, like PPE, hand sanitizer, alcohols, food, vitamins, etc. Instead of feeling the uncertainty, we felt the sense of being blessed. These were also shared with our sister facilities.

As I witnessed how both buildings experienced their bumpy road and how they continued to drive toward greatness, there is only thing that I know: We have Jihan Antipolo weaving every strand of the web to make it stronger and purposeful over and over again. Thanks, Jhie. We love you!

Jessica Ballera, COTA, St. Elizabeth Healthcare and Rehabilitation, Fullerton, CA

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By Dennis Baloy, OTD, OTR/L, DOR/Therapy Resource, CA
All in the Family
Jessica’s career as a therapist in an Ensign-affiliated facility was inspired from way back. When she was a little girl, she distinctly remembered how her grandmother was being taken care of by therapists of an Ensign affiliated facility. To this date, she vividly remembers her grandma’s smile after every therapy session. She reminisces about this image of her grandmother all throughout her life.

Her family is also not new to the therapy world. Her mom, Jasmine, is also an Occupational Therapist Assistant working with our company. Together with her Mom’s guidance and Jessica’s love of therapy, Jessica eventually obtained her degree as a Certified Occupational Therapist Assistant from Stanbridge University in 2018. She worked as a part time employee to explore her options and eventually was hired full time at St. Elizabeth Healthcare and Rehabilitation in Fullerton, CA.

“I find that the greatest part about the St. Elizabeth team is how they give me the ability to shine and grow in my specialties. I feel supported in all of my out-of-the box ideas.” Jessica explained when asked what she loved about being part of the organization. She also added that what truly motivates her are the “Moments of Truth” she encounters on a daily basis. She looks forward to making a difference in someone’s life, to give them hope, and to help create a purpose for her patients. This for her is the greatest selfless joy she experiences and constantly looks forward to.

Jessica is also always available to help out other facilities around our area. She is well-liked by her peers and patients. She always brightens any room she enters and even more so the lives she touches. All of these attributes lead the Therapy Resources to choose her to be a part of the Momentum Culture Committee whose mission is to help facilitate and promote culture within the clusters. Not to mention, “O” for Ownership is her favorite CAPLICO value! Her inclusion will certainly tap her potential to further her positive influence to other therapists in the market.

Jessica is truly a gem of St. Elizabeth and our Ensign-Affiliated Facilities!