Introducing Our New Southland I-tool Collection

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By Carlos Pineda, DOR, Southland Care Center, Norwalk, CA

The I-tool is the first “6th vital sign 3-in-1 tool.” Due to the ongoing pandemic, which requires social distancing and isolation, our goal was to bring the evidence-based practice into the patient’s room. Validated standardized tests can be utilized as part of the treatment strategy at the same time. The 3-in-1 tool covers the full spectrum of the patient’s functional skills from low functioning to high. It can be utilized to conduct three standardized tests:

1. The “seated step test,” a low-level aerobic test for frail individuals or those who cannot stand or walk
2. The “2-minute step test,” an assessment of aerobic capacity for those who have concern with walking space
3. “Gait Speed,” or the 6th vital sign, which predicts the patient’s health status including hospitalization, functional decline and even the discharge location

The tool is made of PVC pipes that are carefully measured and fitted to allow for quick assembly and disassembly. The kit’s quick setup process support productivity and encourages therapists to consistently integrate standardized tests. Each part is color-coded, which can be completed in 30-40 seconds.

The attached photos show all of the following pieces.
Needed supplies (all under $50)
4 – PVC pipes ½ x 10
4 – Cross PVC ½
8 – PVC tee ½
1- PVC coupling ½
2- PVC elbows ½
1 – container of PVC glue
3 – different spray paint colors

Now that you have seen the photos and supply list, are you intrigued as to how this all works? The team at Southland put together a live video on how to assemble and use the tool. Contact Carlos Pineda (capineda@ensignservices.net) for more information.

Building LTC Programs at Legend Oaks Fort Worth

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By Kari Rhodes, MS, CCC-SLP, Therapy Resource/DOR, Legend Oaks Health & Rehabilitation, Fort Worth, TX

We have a new and more comprehensive understanding of how we can truly “dignify long-term care” by taking care of the residents that live in our facility. We decided to question some old patterns and beliefs that were preventing us from truly delivering the best possible therapy services to our long-term residents — our extended family.

The change did not happen overnight, but with education and support of our resources, our therapists began to truly understand the extraordinary differences they could make in the lives of residents by addressing many basic needs. We started looking at quality of life rather than waiting for a fall or a decline. We began education on programs including Percutaneous Tibial Neuromodulation (PTNM) for urinary incontinence and Abilities Care for dementia, and although we were improving quality of life, we were still missing something. We were discharging our residents to restorative, but they were still showing declines after therapy ended. How could we make a more permanent impact on their lives?

One of the things I love most about Ensign is the way we work together to make each other better. While attending a Keystone therapy resource meeting, I began hearing more and more about skilled maintenance programming. A light bulb went off in my head. This is what we had been missing! I invited Tiffany Bishop from Keystone North to provide an in-service to my market. She came to Fort Worth and provided the education we needed to implement skilled maintenance programming in Fort Worth. As a team, we were energized! We saw a wonderful way to continue providing quality of life services and keeping our ladies and gentlemen from declining. It was a win-win situation! We added staff to meet these needs. Residents were happier because they were not declining! As therapists, we were relieved to be able to continue providing services to those who needed it the most!

To me, this is one of the ways in which it is easy to see that when you provide as much loving care as you possibly can to these ladies and gentlemen who deserve the best possible quality of life, in ways that may involve thinking outside of the box, the rewards are extraordinary! Our fresh ideas and programming has truly been a game changer for our residents. They are thriving now more than ever!

Our Virtual Student Program Is Up and Running

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Submitted by Kai Williams, Therapy Resource, Keystone East, TX
By late March, therapy students across the United States were dismissed from their onsite clinical affiliations. The wave of COVID-19 created an unprecedented level of displacement for so many therapy students, especially those in the SNF setting. One can only imagine the feeling of despair felt by those who needed just two more weeks to fulfil their affiliation requirements to graduate.

Intelligent risk taking remains one of my favorite core values because it is through that core value that progressive ideas are imagined and crafted into programs that transcend into the next level of care. It was through unified brainstorming that the Virtual Student Program was imagined. After several weeks of discussion with our University partner, we drafted a proposal to the Commission on Accreditation in Physical Therapy Education (CAPTE). We successfully received approval to provide a two‐week/80‐hour virtual clinical learning program to 10 students who were dismissed from their clinical site secondary to the COVID‐19 pandemic. We have officially become the first SNF organization to offer this level of experience to therapy students. These 10 students who participated joined us virtually from a variety of states across the U.S. Many of them had no experience within a SNF setting and during their exit interviews stated how overwhelmingly surprised they were about the depth of exposure they received. We will never aim to dismiss the benefits of onsite instruction, but with the supplement of a virtual clinical experience, you can alleviate some of the onboarding constraints many clinical instructors and students face. This also allows the student to build on their level of confidence and readiness in our care setting. Their level of preparation is enhanced, thus giving them a stronger shot to hit the ground running upon their arrival.

So what does the virtual student experience look like? The virtual program is structured with an interdisciplinary education format designed for student occupational therapists, student physical therapists, and student speech and language pathologists. The virtual program included 55 live instruction hours (labor) provided by over 20 clinicians (PT, OT, ST,). Our objectives spanned the topics of memory care, cardiac care, documentation training, and leadership skills in management, Parkinson ’s disease, and live interactive telehealth sessions with a patient, just to name a few. Additionally, the students gained access to our learning management system (LMS), “Ensign University,” where the students were assigned 17 additional courses to support/facilitate their learning. The interactive courses included learning checkpoints and a final test at the end of each module. The students also had a dedicated PT Clinical Instructor to connect with to offer guidance/feedback.

What’s next? Our hope is to host our second cohort of students, which will include both PT and OT. With the support of our University partners along with our affiliated facilities, we would love to create an “enhanced” student standard that would improve the value of our overall student program. Each student would complete a two-week virtual experience prior to beginning onsite at a facility, in accordance with the National Nursing Home Reopening plan.

Documenting Justification of Skilled Therapy Services, Part 1

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By Lisa Harvey, M.S./CCC-SLP, Documentation Review Resource
Of the many exciting and challenging things our therapy teams look forward to doing every day, it is probably safe to assume documentation is not at the top of anybody’s list! Yet, in spite of the wonderful work that is done in our gyms, patients’ rooms and hallways — what we choose to document about those services may result in a denial of payment for your facility down the road.

Some of the most common reasons for claim denials include:

  • Ongoing services did not meet the requirements of medical necessity and reasonableness per Medicare criteria.
  • Documentation did not support the requirement that services shall be of such a level of complexity and sophistication or the condition of the patient shall be of such that services required can only be safely and effectively performed only by a therapist.
  • By (Date) the PT and OT plans of care did not document any significant changes or interventions that were needed or could only be done by or under the supervision of a licensed rehabilitation therapist.

The best defense for these types of denials is a good offense. We must proactively document the medical necessity and skilled interventions provided by our therapy staff.

Although a patient’s medical diagnosis or recent surgical intervention may play a strong role in determining whether skilled intervention is needed, it cannot be the only factor supporting medical necessity.

POC Justification Opportunities:

  • Reason for Referral should make it clear why treating discipline is involved.
    o Sub-optimal: “Physician Order.” “Routine admission evaluation.” “New admit.”
    o Optimal: “Pt. referred by nursing due to increasing weakness noted with recent falls in the patient’s room.” “Pt. referred to PT by physician due to new onset of weakness and reduced activity tolerance with increased assistance needed from caregivers for bed mobility, transfers and gait.” “Pt. referred to ST due to increased episodes of confusion with decreased memory for safety precautions while completing ADLs.”
  • PLOF should be a detailed summary of performance levels of the patient prior to becoming ill and should tie to functional areas addressed in both short-term goals and long-term goals.
  • Clinical Impression should specify areas where deficits were noted on assessment.
  • Reason for Skilled Services based on identified deficits (Clinical Impression) what specific interventions are needed that can only be provided by a therapist? What will happen if skilled interventions are not provided?
    o Sub-optimal: “Pt. would benefit from skilled occupational therapy to improve activity tolerance and strength.”
    o Optimal: “Skilled OT treatment interventions to include instructing and training patient in energy conservation techniques, positioning maneuvers, proper body mechanics, safe transfer techniques, safety precautions and use of assistive device(s) in order to facilitate safe return home alone.”

UPOC Justification Opportunities:
Continued Skill should describe the reason why therapy services need to continue based on the patient’s response to treatment. If the patient is progressing towards their goals, this case can be easily made as progress made before is the best prognostic indicator of more progress to come.

However, if patient is not progressing, this can be more difficult to document and the therapist must modify goals and/or approaches with the expectation that the patient will respond to those changes in the Updated Plan of Care. Sometimes new areas of focus arise during the course of treatment and those new areas are incorporated into the UPOC. These are all examples of why the skills of a therapist are needed to adapt and adjust the therapy plan.

Stay tuned for our next FlagPost when we’ll review how to make the best justification in a progress note and a TEN. We know you can’t wait!

Brookfield Pandemic Heroes

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By Lito Ortiz, Therapy Resource/DOR, Brookfield Healthcare Center, Downey, CA

An interview with Tom Chan COTA and Cristina Amansec SLP.

Brookfield Healthcare Center in Downey, CA is made up of some pretty amazing and selfless therapists. These heroes have truly shown their true colors during this time. At the start of the pandemic, Tom was one of those kind hearted individuals that bought N95 masks and goggles for the CNAs and our front desk out of his own money. He was one of the first people to dedicate himself to treat the COVID patients. Indeed a very courageous individual. Cristina was 4 months pregnant when the pandemic started. Despite her condition, she continued to fight and treated patients with COVID infection. She is courageous and a fighter. She also dedicated her own time to get extra supplies of masks, sanitizer, and reusable gowns. We got all the help we needed to win the fight because of her. After all the initial craziness died down, she focused her energy on getting us free food and goodies. She fed the whole facility for a total of 10 lunches overall. We are so thankful for her because she exemplifies the true meaning of Brookfield culture—being selfless and always looking out for others before herself.

Tom Chan, COTA
How long have you been with the company?
This August will be my 10th year. I started as per diem and was able to see the atmosphere, culture, and dedication of the rehab. The leadership was also strong so I could onboard full time.

What is the meaning of teamwork for you?
Teamwork is the ability of a group of people to come together to accomplish specific goals. The key is to have a shared vision to keep the group motivated and competitive but also provide a safe space where egos are set aside so people can rise and take the lead in some situations but be OK to step back and allow others to step up when their skill set will better serve that particular situation.

How has this pandemic affected you and your team?
The pandemic has affected how I view the frugality of everything that we have. One microscopic being can put the world at a standstill; can destroy families; end businesses and completely change the word normalcy as we know it. But it has also allowed many to take a step back and appreciate what they have, push harder to protect others and give me faith that humanity still exists.

How the pandemic affected the team is taking us through a roller coaster of emotions?
From anxiety, to fear, to relief, to sadness, to acceptance among many, many other feelings. It has forced us to say farewell to some residents, and compelled us to shed more tears as a group and as individuals than necessary. But it has also bonded and reinvigorated the rehab team. We have a trust within each member that we have each other’s back. It’s a good feeling when you know that there are 11 other people keeping an eye on you when you come to work.

Cristina Amansec, SLP
How long have you been with the company?
4.5 years

Why Ensign?
With Ensign, I felt it was a company that would offer the support — clinically and personally — in order for me to grow as a clinician. It took me time to ultimately decide to be full-time with Ensign, but I’m so happy I made the leap!

What is the meaning of teamwork for you?
Teamwork for me means a collaboration not only with my wonderful rehab team, but also with our nurses, kitchen, housekeeping and maintenance personnel. It’s the ability for all our separate job titles to foster together as one entity. As a united front, we are all so equally important and powerful in making a difference in our patients’ lives and experiences here in Brookfield.

How has this pandemic affected you and your team?
This pandemic has definitely brought our rehab team closer together! It has been mentally and physically challenging, but I am so proud and humbled by the feats our team has endured and our perseverance to push through the fear of the unknown. I am so grateful for the familial protectiveness and doting that we all equally provided each other — I couldn’t fathom what I would have done in this pandemic without such a loving and compassionate team.

When Life Gives You a Pandemic, You May Find Something Amazing

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

As mid-March was approaching and COVID-19 was spreading, I stopped at a facility in the Momentum market and there was a temperature checkpoint. I knew we were in for some changes. For a while, I carried on as best I could, but I kept thinking there must be more I can do to help. Then, I received a call from Tali Gerassi, DOR at Grossmont Post-Acute (GPAC) in the San Diego market. They had suddenly lost their long-time SLP and desperately needed help.

At first, I just tried to do what we SLPs do: find patients who need us and treat them. But soon I realized this wasn’t going to be an ordinary experience. This team was like no other I have met before, and I wanted to tell our whole organization how special they are.

GPAC is a busy post-acute facility with a rehab staff of nearly 20! The entire team has been so wonderful to me and helped me find my way. Most mornings I work with our general population patients. I watch the more experienced PTs and OTs build rapport with their patients and use innovative methods to get their patients back home. They play music and engage in personalized therapy sessions, and it is clear they want the best for their patients.

In the afternoon, I move to the observation unit where many of the therapists are brand-new grads. What a fantastic crew they are. I have learned so much from these young PTs and OTs! I have seen some of the best evidenced-based therapy from both PT and OT and a sense of teamwork that warms my heart.

Tali, DON Abigail Angeles and ED Katherine Oh have taken great measures to ensure the entire staff and I feel safe during this uncertain time, including meetings, frequent communications when policies change, and systems so that the staff can continue to be successful in caring for the patients.

I went to GPAC to help out, but I have received so much more in return!

Respiratory Rehab Using EStim

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Submitted by Cory Robertson, Therapy Resource, Idaho

Did you know that electrical stimulation can be used for more than a really fun demonstration in high school physiology class? Yes, it is great for that, but the evidence-based applications of electrical stimulation are myriad. A recent meta-analysis (yes, a meta-analysis, the king of the hierarchy of scientific evidence) concluded that e-stim effectually strengthens quadriceps and enhances exercise capacity in moderate to severe COPD patients.

A large barrier to therapy for those with respiratory conditions is their tolerance. They fatigue quickly and get short of breath and struggle with dyspnea. That is in part due to the changes in muscles when the ability to deliver oxygen to them decreases. There is an increased reliance on less fatigue-resistant muscle fibers. One method to address that barrier is the use of neuromuscular electrical stimulation to activate those muscles most important to functional activities. But how do you do it?

Like most therapeutic interventions, there is skill involved, and if done incorrectly, at best it is a placebo. The goal is to use the NMES effectively to get the best outcomes as evidenced by the meta-analysis and many more research articles. Please check out article for Respiratory Rehabilitation EStim from the portal for a refresher on how electrical stimulation works and some best practices. It will help to get the therapeutic dose to the target tissue, leading to great outcomes, while enhancing the tools in your therapy tool bag.

Let’s use the tools available to us, supported by evidence, to best treat those who rely on us to improve their function and quality of life. Electrical stimulation can be more than a last resort, or why Mr. Wilson gets the best reviews in his physiology class.

 

To The Lifters

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Submitted by Tiffany Bishop, DOR/Therapy Resource, Legend Healthcare & Rehabilitation, Greenville, TX

Our amazing ADOR George Palin and his wife have been working tirelessly to provide the entire building (and a few to our sister buildings) with cloth masks, and they are now working on gowns to keep us all safe. Today the team wanted to say a special thank-you to him. One of our other amazing PTAs, Heidi Carmichael, thanked George for providing her with a more comfortable mask (pictured — you gotta laugh sometimes, right?) and read the following poem as a thank-you. I thought this is so true of George and so many others who are going above and beyond to take care of each other and our residents.

There are just two kinds of people on earth today,
Just two kinds of people, no more, I say.
Not the rich and the poor, for to count a man’s wealth
You must first know the state of his conscience and health.
Not the humble and proud, for, in life’s little span,
Who puts on airs is not counted a man.
Not the happy and sad, for the swift counting years
Bring each man his laughter and each man his tears.
No, the two kinds of people on earth I mean
Are the people who lift and the people who lean.
Wherever you go you will find the world’s masses
Are always divided in just these two classes.
And oddly enough you will find, too, I ween,
There’s only one lifter to twenty who lean.
In which class are you? Are you easing the load
Of overtaxed lifters who toil down the road?
Or are you a leaner who lets others bear
Your portion of labour and worry and care?
by Ella Wheeler Wilcox

Broadway Villa’s Patient Success Story

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Submitted by Jennifer Raymond, Therapy Resource – Northern CA

Shell was first admitted to BWV on Nov. 29, 2019, following a devastating CVA. At that time, she was nonverbal due to severe expressive aphasia, NPO on a feeding tube and had significant sensory disturbances. She was unable to follow a very simple command, required max to total assist to perform basic self-care and was unable to ambulate at all.

Prior to the stroke, Shell had been independent with all of her mobility, ADLs and communication and lived with her daughter. She had an extensive course of skilled care with all three disciplines and made impressive gains. However, she did not acquire the level of independence necessary to return home, so she was discharged from therapy to RNA and considered a long-term care placement at Broadway Villa.

As a true advocate, DOR Shobha Neupane-Gautam is always looking for ways that therapy can make a difference. During her daily rounds in April, she interacted with Shell and saw positive changes in her and the potential for her to do more. OT re-evaluated and began to see marked improvements during their treatments such that PT and ST also started new courses of care a month later.

Shobha writes:
“Due to our persistent/compassionate care and comprehensive approach, this resident is singing, dancing with rehab folks. She is able to perform functional transfer/ambulation/ADLs requiring supervision to modified independence. She is very interactive and demonstrates happy expression. Rehab folks have coordinated with IDT/family members, based on her progress. Family is ready to take her home and enjoy her life.”

Shobha’s approach demonstrates an ability to not simply interact with our long-term care patients every day, but to really “see” them as individuals who can change and grow and thrive. Thank you, Shobha, and all the Broadway Villa therapists for your commitment to facilitating the “Can Do” in the residents you serve, for never giving up on human potential and always believing in the power of therapy to change lives.

Update from City Creek

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By Jared MacDonald, Operations Manager, City Creek Post Acute Care, Salt Lake City, UT

May 15 marked our one-month mark of becoming a COVID-only building. We are excited at where we’ve been and where we are going.

First off, thank you! Thank you for all the calls, the messages, the food, the signs, the support, the staff, the prayers, and most of all thank you for helping us see what it truly means to love one another. We know it sounds cheesy but honestly, there have been many things in the past month that have brought us to tears of gratitude for your help and support. We could not be where we are today without your help, so thank you.

In the past month, we have admitted 55 patients and discharged 21. Thanks to our remarkable clinical team, both those on site and those from other buildings, we have a live to date hospital readmission rate of 3.63% and a mortality rate of 3.63%. Those numbers are remarkable in comparison to both the state and national average. This truly shows that on the clinical front, we are succeeding. This plan is making a difference, and we thank you for your support in helping us be what and where we are today.

We’ve started a tradition of ringing bells and cheering as our residents are brought down the hall and sent outside to meet family and friends. We will never forget holding the hands of an 87-year-old as we cheered for her successful discharge back home. Tears streamed down her face as she thanked each one of us for helping her fully recover. We hope you know, especially all you DONs, that you were just as much a part of that successful discharge. Thank you!

Thank you to all of you who have rallied your staff, conducted interviews, and spoken with your friends and families.

Today we had a call with members of the state and local task force. They expressed their appreciation for what we are doing. Dr. Spaulding from Intermountain Health said that this was one of the best teams he has ever worked with. We have and we will continue to attribute our success to the support we’ve received from the market. They know of your greatness and of the countless hours you’ve spent in helping make City Creek what it is. Thank you from the bottom of our hearts!