5 Strengths of a DON/DOR Team

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By JB Chua, DOR, PT, CEEAA, Summerfield Healthcare, Santa Rosa, CA

“If you play for the name in front of the jersey, then everybody will remember the name on the back.” — Sherwood Bassin

I did a book review with one of my employees this month, and we read The 5 Dysfunctions of a Team by Patrick Lencioni. After I finished the book, I reflected on these dysfunctions and how my relationship with my coworkers is, specifically with my Director of Nursing, Enedina De La Cruz. I am so proud to realize that we have overcome all these dysfunctions, and I would like to share the strengths (antonym of dysfunction) that we possess. Hopefully, it will serve as an inspiration to some of our partners.

  1. Presence of trust: Dina and I are not afraid to be vulnerable with each other. We are open to admitting our weaknesses as well as acknowledging our strong instincts in our unique characteristics as people as well as leaders.
  2. Acceptance of conflict: Conflicts are bound to happen between Nursing and Therapy teams. But instead of creating an artificial harmony by not addressing the problem and being satisfied with inferior decisions, Dina and I engage in a healthy debate where we listen to each other’s opinions to come up with the best possible solution to our facility’s problem.
  3. Unwavering commitment: When a decision is made after our debate, we know that we are both in, even when it may not have been the idea we had in mind. For us, it is not about who is right; it is about our opinion being heard and how we can do things right.
  4. Extreme accountability: From making sure that UDAs are being done, to what time the fall committee should happen, Dina and I make sure that we are holding ourselves accountable. We call each other out when we notice that something is getting dropped.
  5. Paramount attention to results: Whether we get good or bad results, we make it a point to make sure that we understand how we get there, how we can make it again or how we can be better. Dina and I understand that we are not just aiming for the success of the Nursing or Therapy department; we are aiming at a much bigger picture: the success of Summerfield Healthcare Center.

PDPM Lessons Learned - Section GG

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Submitted by Jennifer Raymond, Therapy Resource – Northern CA

During a recent NorCal Weekly DOR call, a question came up that prompted discussion regarding how Section GG scores are being determined when there is a discrepancy between Nursing and Therapy.

When we have differences between Nursing and Therapy scoring for GG, this must be reconciled per the RAI MDS manual criteria by answering the following question:

“What is the usual/baseline performance (days 1, 2, 3) BEFORE therapeutic interventions occurred?”

We cannot average or modify the assist levels that have been documented but instead through discussion and chart review need to determine which of those scores best represents the “usual/baseline performance” for this patient before the onset of any therapeutic intervention.

Therapy/MDS folks are clearly collaborating well to compare Nursing/Therapy documentation as part of the daily technical GG process. The next step is to ensure that when these values differ we are determining which documented assist level best describes the patients’ usual/baseline performance at the time of admission and discharge and are recording that score on the MDS.

Thank you NorCal DORs for bringing up this important topic.

Please reach out to your MDS/Therapy resources if you have additional questions and share this info with your Daily Technical Team!

Why I Love Running

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By Julie Uychiat, Clinical Market Lead – Arizona

Discovering running at a much later stage in life has been the greatest gift life has given me. It came at a perfect time when I needed a lift, to be reminded of my life’s purpose and overcome my self-imposed limitations. Running has given me everything … my renewed self-love, my self-confidence, my fearlessness, my grateful attitude and my purpose. It has inspired my new direction and outlook. It has taught me to push forward when things get difficult. In return, I am giving it my heart.

I come from zero running background. I hated running. In late 2015, my sister started running with my best friend. I remember asking her how she is able to run when I can’t even run from my house to the next stop sign without getting short of breath. She told me to just slow down my pace and keep going … further saying, “You won’t die.” Her words stuck with me as I attempted to give running one more shot that afternoon. I ran my very first 2.5 miles that day and remembered how incredible that feeling was. It gave me the confidence to join our Bandera Ragnar team in 2016, but I still wasn’t serious about running at that point.

In March 2017, I ran my first individual race, which was a half marathon with my sister. We decided to follow the 2:30 pacer. I wasn’t serious about it at first, conversing with her while running, answering texts during the race until around mile 8-9 when I saw how serious and competitive other runners were and thought to myself that maybe I should take it more seriously, too. I started giving it my best and got ahead of the 2:15 pacer to the finish. This race gave me a glimpse of the possibilities, although a full marathon was still out of the picture at that time.

In May 2017, two months after that race, I was at the Service Center for a meeting. There were about seven or eight of us in the conference room. Jess Dalton had his laptop open and told me that he wouldn’t be starting the meeting until I signed up for the St. George Marathon with him that October. I quickly refused and told him to give me at least a year, but he insisted. I made a deal and told him that if there was another person in the room who would sign up with us, then I would commit to doing it. The first person I asked was Rebecca Higbee, whom to my surprise said yes without hesitation. I didn’t know then that she was a runner, so I was committed.

Marathon training presented opportunities to discover the deepest parts of me at age 44. I didn’t know I had the discipline, passion and commitment to endure the hard work in spite of my very hectic work schedule and weekly travel commitments.

I Boston-qualified my first race that year, and that opened things up to a whole new exciting world for me. I am currently chasing the 6 Major Marathons in the world and since 2018 have completed four of six (Berlin, Chicago, Boston and New York). From these races, I have earned a respectable world ranking and received an invite to run the Wanda Age Group World Championships inaugural race in London this April. This is where I will be competing against 84 other top world runners in my age group.

I recently surprised myself when I ran my best race at the Phoenix Marathon on Feb. 8. I got very emotional when I crossed the finish and saw my time, 3:19:30. It exceeded our expectations (coach and I), and my heart was full once again.

I believe in Hal Elrod’s Miracle Equation:

Unwavering Faith + Extraordinary Effort = Miracles.

My marathon journey is a true testament to this. In fact, this equation applies to every other area in our lives. We just need to first believe that WE.ARE.LIMITLESS and put forth the effort to see the miracles happen.

From Ultra “High” to Ultramarathon

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By Dennis Baloy, OTR/L, OTD/DOR, St. Elizabeth Rehabilitation, Fullerton, CA

It’s 5:05 a.m.

You’ve already hit the snooze button twice. You get up, fix your coffee and open your laptop. You check the assignment board and check patient projection and staff scheduling. You take a sip of your coffee. You open your email, read your email and reply accordingly. You take another sip of your coffee. You are now more awake and you’ve started planning your day.

You take a shower, brush your teeth, and wake up your kids and get them ready for school. You finish dressing up and you drop off your kids, and now you are on your way to work. By this time, you have already replied to five people (both coworkers and family members). You might have taken or made a phone call or two. By this time, you’ve probably browsed some daily news, greeted some friends on social media and read some inspiring quotes to start your long day. You are ready. Well, sort of. Still, you feel like there’s a lot of things not accomplished, but you come to work as prepared as you can be.

Then your eight-hour workday commences.

You are done with the day. You’ve tied up loose ends. Made a lot of people smile. You feel productive, though there’s a couple more pending items that you are left to do. You did your best, and there’s another day waiting to finish it all up. You get the job done and another one awaits. “I can do this,” you say to yourself.

On your way home, you pick up your kids, run errands, fix dinner and help them with their homework. You take them to shower, read them a book and you finally have a few more minutes (sometimes when you are lucky, an hour or so) for you and your spouse to spend.

Then 5:05 a.m. strikes, and it’s back to the daily grind.

If this routine sounds familiar, then we are all in the same boat. Truly, we are creatures of habit, bound to do things over and over again. And it’s all good! After all, we try to manage our time in the best possible way, expecting the best possible productive result.

So where did my running affair start?

I am an average joe. I hated running and could barely run a mile. My knees would start hurting, and it just didn’t feel right. I know as a therapist, there are countless full-body workouts I can do to achieve the physical fitness that I want. But one thing I know about myself is I am always up for the challenge — physically and mentally. There is an inner adventurer in me wanting to experience life to its fullest. I love sunshine, the oceans and the outdoors. I can be a very laid-back person, yet I can switch it on to be a very competitive one.

So why do I run, and why run an ultramarathon?

  1. The ultra “high”: Studies have shown that running and other physical activities release endorphins and decrease cortisol levels. Running definitely has a positive effect not only on your body, but also in your mind. A good run will leave me a clear mind and calmer self. Every time after I run, I come home a completely different person — more positive, understanding and caring. It’s definitely a mood changer. The lasting effects are definitely noticeable by your family, friends, coworkers and loved ones.
  2. Empowering, develops resilience (and humility!): The feeling of accomplishing a goal, whether it’s buying a new pair of shoes, having your kid graduate from school, cooking a new dish, learning a new language or perhaps running your first 5K, will leave you feeling like a champion. There is no better satisfaction knowing you are able to accomplish the personal goals you’ve set. Conquering distances, facing hardships and dealing with pain during runs translate to life in general. Knowing you can push through these obstacles allows you to do the same in life. Not all runs you will finish, and not all life’s struggles you can face, thus running is also a very humbling experience.
  3. Happily disconnected: It’s rare that we get disconnected in this technological world that we live in. We are always on our laptops, phones and TVs— so much so that being “disconnected” is a blessing. It is also by all means a choice. Being outdoors, may it be with or without music, and running give you this wonderful experience of being one with the world. It’s a religious experience that connects you and everything else that you see, feel and hear (the sights of nature, the sounds of wildlife and the drizzle of rain). It’s equally soothing, stress-relieving and euphoric.
  4. You vs. you: As competitive as I can be (most of my close family and friends can attest to this <insert emoji of choice here>), I always believe in the Ironman mantra, “You vs. You.” Oftentimes you want to go faster, you want to go longer and you want to be the athlete you idolize. In the end, you are always reminded that the best part about this journey is just to be a better version of yourself. You want to be stronger, wiser and better than you were yesterday. This is more than enough.
  5. Community: Lastly, running brings people together. Runners are such happy people in general. You all undergo the same painful yet satisfying experience. The community of runners helps each other finish their goals. There were numerous times when a running buddy helped and carried me ‘til I finished, and I’ve done the same — motivating and physically assisting them to the end. No wonder there are tons of running charities out there that aim to bring awareness of all different sorts (health, socio-civic, for-a-cause, running-tributes, etc). You get the above benefits, but more importantly, you are helping make this world a better place to live in. How cool is that?

My Journey kicked off way in 2017. I started with the Angels Stadium 5K, then completed all the Spartan Races, the 70.3 Ironman in Arizona last year and recently the 50K ultramarathon. I hope this story resonates with all runners or non-runners. We can all break our routine and try out this spiritual experience that not only yields physical gains, but also emotional, mental and psychosocial benefits.

….and before you know it, it’s 5:05 a.m.

Are you ready to lace up?

Leaders Made Here - TJ Petty

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Submitted by Chad Long, Therapy Resource

For those of you who have never had a chance to meet Tyler “TJ” Petty, DOR at Montecito Post-Acute and Rehabilitation in Mesa, AZ…you should. TJ is a leader full of charisma, compassion and focused on moving his team and facility forward in a CAPLICO manner. He started his journey with Montecito in 2008 as a PRN Physical Therapist, then a full-time staff member in 2009 and has been the DOR since 2010.

Over the last 10 years, TJ has developed a dynamic therapy department in a very successful facility. Montecito has grown to an average census of 190 with 100 skilled patients. It is also a large Ventilator and Trach-dependent facility caring for acutely ill patients and fragile LTC residents, boasting 156 admissions and discharges per month!

I was able to ask TJ a few specific questions about his views on Leadership in order to gain a little insight into the success of Montecito:

How do you on-board and orient new therapy team members to a CAPLICO culture?

During interviews, TJ performs the first meeting on his own. Then the entire therapy team must interview the candidate and come to a unanimous decision to recommend the hire; “That new person will only be successful if we are all on board.” This process encourages healthy and vigorous debate among the team.

Next, the new team member’s first day on the job must be “memorable, in a good way.” Having the name badge and orientation paperwork ready, along with ensuring the mentor/trainer is prepared, is key to showing that Montecito therapy is proactive, professional and FUN. TJ loves to quote his former ED, Forrest Peterson, during orientation, “Our building will go as far as our therapy team takes us.” This sets the tone for the new member that therapy is looked to as leaders, ensuring the vision for the facility, so they should conduct themselves accordingly. “Once you get the ball rolling, the team will take over.”

Finally, TJ sits down with each new staff and discusses their personal/professional goals so he can facilitate the growth of that therapy leader.

What specifically do you do to grow leaders in your therapy department?

With such a large team and busy case load, TJ noticed the weekly therapy meeting was not focused and inefficient. Thus, he created his “rope teams.” Using the analogy from mountain climbing and how 3-4 members of a team are roped together and have different responsibilities, TJ linked teams of one licensed therapist to 2-3 assistants. The “Lead” therapists meet weekly with the assistants to discuss the patients, etc., AND THEN they also discuss anything else to build relationship and camaraderie. This is the rope team’s opportunity to build each other up, have fun and develop leadership skills.

Also, TJ meets one-on-one with his team, teaching them to bring problems with solutions and coaching them in their professional goals. From this process, TJ has helped grow two DORs and said, “Any therapist could take my job.”

How do you/your therapy team cross over and support other departments in your facility?

Each month the therapy department formally recognizes a CNA letting the individual and facility know how much therapy appreciates all the hard work and collaboration. Another example is having therapy take a teaching role with their nursing partners. Currently, therapy and nursing are learning the Ranchos Los Amigos Scale for their brain inured patients to coordinate therapy-nursing care effectively. The therapy staff also take IDT roles throughout the facility: Speech Therapy works closely with Respiratory to ween patients off the ventilator and progress them along in the trach process; Physical Therapy supports the Falls Committee, and each lead therapist is responsible for patient care conference; and TJ meets with nursing to identify LTC residents with mobility issues for the purpose of discharging them to a more independent level of care. “Who can we help get out of here.”

Also, every therapy staff member is ready to help support Marketing/Admissions with tours or supporting the facility in the community.

Who is a mentor to you and what specifically did/does that individual do that impacts your leadership today?

Three individual were immediately identified:

Forrest Peterson, former ED at Montecito and current Bandera Market Leader. TJ described, “seeing the way he would develop people and his thought process,” as very formative. Forrest would (still does) spend time with others, hold them accountable in a consistent process that TJ likened to the Mr. Myiagi approach of the 1980’s iconic movie, The Karate Kid.

His Father. “My Dad told me, once you get that job, make yourself as valuable as possible.” Thus, TJ makes sure he gets involved in every department, “whenever I can to figure out where I can help.”

Pat Tillman, football player with TJ’s beloved Arizona State University Sun Devils and professionally with the Arizona Cardinals, who enlisted with the U.S. Army after the attacks of September 11th. Pat Tillman was killed in April of 2004 in Afghanistan. “What a cool leader; he knew what was right for him and he did it, not for the recognition, but because he knew it was right.”

SPARC Therapy Scholarship

Congratulations to Our Newest SPARC Winners: Jarrett Henderson and Primo Arredondo

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Congratulations to Jarrett Henderson, First Place SPARC Winner, and Primo Arredondo, Runner Up! Read their awesome essays below:

Jarrett Henderson, OT (have photo)

Grad Date May 2020, University of Utah, Salt Lake City, UT

While contemplating the “SPARC” program, I started thinking about the origination and culmination of a spark. A high energy source initiates a spark. They can produce a light that can be seen by many, but it also can ignite a flame that can burn bright, providing light, warmth, and means to perform tasks of everyday living. As a future Occupational Therapy (OT) provider, I want to be that energy needed to spark clients to overcome barriers and ignite the fire within to achieve their rehabilitation goals.

When thinking about how I can become this energy source, I realized much of my school experience has already prepared me. If you had the opportunity to sit in my OT classes, you would see my hand regularly raised. I would be asking questions about theories, evaluations, treatments, and current evidence for OT practice. My consistent inquiry for clarification has not only helped me academically but has inspired my work in research, as noted on this application. Whether it is in a classroom, doing research, or with a client, I like to know the “whys.” Wanting to know about the “Whys” helps me better understand and utilize client factors to develop more efficient interventions that will result in better outcomes. For example, when you ask why someone is experiencing paralysis, you get the information needed to select the appropriate evidence-based treatment. If the “why” was not addressed, someone could mistakenly use the theory of motor control to guide the treatment of a peripheral nerve injury. Doing so would lead to disappointment and unmet goals. This kind of defeat is something that cannot be afforded by patients or therapy specialists. I want to help avoid this defeat by continuing to ask the whys in my practice and push a little deeper to help come up with answers to the “hows.” How can this be fixed? How can we do better? How can therapy be more efficient? Below are some of the ways I plan to contribute to this movement.

CONTINUAL LEARNING:

Through fieldwork, I have developed the understanding that education is not only in a classroom, but opportunities to learn are everywhere. Becoming a valuable therapist means I will use patient homes, clinics, and other work environments to continue to develop an understanding of individuals, groups, and the community’s needs. Allowing the world to be my classroom will allow me to cater my skilled therapy services in any setting.

BEING A TEAM PLAYER:

As is commonly stated, Rome wasn’t built in a day, nor was it made by one person. Significant accomplishments are a result of the combined effort of many. During my second year of OT school, I found value in an interdisciplinary approach while participating in the Hotspotting program. This program identified individuals in a specific geographical area that utilized healthcare services more than normal. Once a patient was detected, we created targeted interventions that addressed all client factors with the goal of better health, well-being and reduced healthcare costs. Team members included OTs, SLPs, NPs, RNs, and other health professions; by collaborating with these clinicians, we developed more effective and efficient client-centered interventions that resulted in quantifiable positive outcomes. As I reflect on those outcomes, I have started to interact more with other health professionals. I have come to the belief that I must be an active interdisciplinary team member if I hope to create dynamic approaches to patient care.

ADVOCACY:

I have seen the value therapy brings to rehabilitation and general well-being. Unfortunately, this value is not always recognized, resulting in policy changes that decrease coverage for therapy services like OT. These changes affect patient outcomes and increase medical charges due to such things as hospital readmission. As a future OT practitioner, I will stay current on evidence-based practice and advocate when legislative action is needed. My documentation of patient outcomes will support the need for skilled therapy service and ensure patients’ well-being.

SEARCH OUT NEW TECHNOLOGY:

In the last few years, I have seen the development of 3D printing, AI, biometrics, and now NASA just announced the creation of a supersonic aircraft. Growth with technology is constant. If complacent with incorporating it, rehab treatments will quickly become outdated, resulting in decreased return on client performance and satisfaction. Decreased performance is not why I decided to become an OT. To prevent this, I will be actively engaged in learning about new technology through conferences, expos, and other continuing education courses.

While attending the 2018 and 2019 annual American Occupational Therapy Association conference, I learned about new technology. I had conversations with OTs about how client needs could be met with such technology. By continuing to search out and learn about new technology, I will provide the needed resources to spark change in patients’ lives. These actions are all a part of my drafted professional development plan. I plan to continue to add to this list so I can produce the needed energy to create that “SPARC” and ignite positive change in my patients and future team members. As an upcoming OT, I look forward to creating evidence-based resources, and toolkits, that will support therapy practitioners and patients with a way to reach their goals. If chosen for this award, I would be honored by your support in helping me work towards excellence as an OT, allowing me to continue to provide the needed “SPARC” in our field.

 

Primo Arredondo, PTA

Grad Date: December 2020, Navarro College, Midlothian, TX

My motivation to attend college is to attain the skills necessary to help improve a person’s quality of life. I graduated from Texas Woman’s University with a Bachelor of Science degree and a major in Kinesiology. My plans were to continue with school and earn a master’s degree to become a Physical Therapist. However, after graduating college, I held a job as a Cardiac Tech at a Cardiopulmonary Rehabilitation Center in Lewisville, TX. Shortly after that, I was fortunate enough to land a job at Lake Village Nursing and Rehabilitation Center as a Rehabilitation Technician.

Becoming a Physical Therapist was no longer in my plans, but rather to become a Physical Therapy Assistant. By becoming a Physical Therapist Assistant, I will be able to advocate for the elderly as well as positively influence their quality of living. I can only imagine how self-rewarding it might be to actually execute your knowledge and skills to improve a patient’s well-being! My passion for learning will ensure that I will stay up to date on new therapy interventions that are most beneficial to my patient population. Also, by acquiring continued education to enhance my professional competence, I will demonstrate accountability as a therapy professional. Only by keeping up with updated literature, current technology, and innovative therapeutic methods will I see the best outcomes in my patients’ rehabilitation.

As I notice changes within Medicare, there are a lot of opportunities for changes in regards to therapy interventions. As group therapy becomes a very resourceful tool in providing therapy interventions, I would expand therapy gyms to better accommodate therapy treatment sessions. It would be high dollars invested; but therapists, the facility, and above all, our patients, will ultimately benefit from this investment. Current literature shows that group therapy increases participation, decreases depression, increases patient motivation, gives patients a sense of inclusion, and improves overall rehab potential and experience.

Evidence-based practice is one of the most fundamental elements that makes a therapist an exceptional clinician. EBP allows a therapist to distinguish from effective therapy interventions and non-effective interventions and implement the most effective to acquire the greatest outcome in therapy rehabilitation. My daily routine will consist of incorporating evidence-based practice to every one of my patient’s cases in order to find the most effective intervention to attain the greatest rehab outcomes. My co-workers’ expertise is also a valuable resource to use to improve patient rehab outcomes. While I grow as a clinician, I look forward to attaining valuable expertise and sharing it with co-workers and patients.

Outpatient at Vista Knoll

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By Erin Huddock, PT, DPT, DOR, Vista Knoll Specialized Care, Vista, CA

When looking at what programs haven’t been tapped into, my ED and I decided to focus on outpatient and what we could do differently to get our program back up and running again. Outpatient at Vista Knoll Specialized Care has always been something that was never really focused on and was getting by with minimal referrals over the past few years. To start, we looked at our outpatient census and how we could gain more referrals. With that, we decided to make our rehab tech, Diana, the outpatient champion.

We first looked closely at our referral sources. A great way to start was to look into those referrals from patients who are currently in-house. We are already developing a great rapport with the patients and family members; they are comfortable with our therapists and it would provide a smoother continuum of care. And guess what? We can also keep a look-out for our patients who may be struggling or potentially be at risk for readmissions to the hospital and let our admissions coordinator know. It’s a win-win.

Next step, do they have insurance that we can accept? My rehab tech, Diana, will run the common working file on each patient who is here under Medicare or Managed Medicare that we contract with for outpatient. From there, we would discuss those patients who are appropriate to transition to outpatient during our weekly rehab meeting and would have Diana speak with the patients and discuss the benefits of returning to Vista Knoll for outpatient. Those who are appropriate and are interested, we let our case managers and social worker know to encourage the patient to transition to outpatient upon discharge. The biggest barrier that we have run into has been the lack of transportation for our patients who do not drive and do not have family. We do our best to assist those patients with finding options for transportation at the lowest cost possible.

It has been quite the team effort, and I really could not have done this without Diana, who has really taken to heart the care for our systems and the well being of our patients. Prior to starting this transition, we were averaging about four to five outpatients per month. To this day, we have been able to successfully maintain, on average, 17 outpatients per month with 55 percent of those referrals coming from our inpatient population.

Optima Update - Why Clinisign?

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By Aimee Bhatia, OT, DOR, Glenwood Care Center, Oxnard, CA

When we were given the challenge to get our physicians signed up for Clinisign, it seemed daunting. We had tried several years ago with no success and a lot of push-back. After our quarterly meeting in Las Vegas, I came back determined to make a change. I presented in QA that we would be switching to Clinisign and highlighted how much it would cut down on being hunted down for signatures, how much less work it would be for the facility to coordinate signatures and clarification orders to remain in compliance, and how easy it would be to do at their convenience.

I gave the physicians a deadline, and with Mahta Mirhosseini’s help, I got three of our main physicians signed up within a week. Two of our doctors preferred to have their nurse practitioners sign, and that was perfectly acceptable. Setting up the doctors also allowed sister facilities in the area to more smoothly transition to Clinisign because the doctors were already in the system.

Since we started, it is remarkable how much less time myself and the rehab aides spend chasing down doctors for signatures. There is less filing and fewer errors in typing clarification orders into PCC, and overall efficiencies have improved, eliminating the need to print and write clarification orders upon evaluation and re-certifications. Our physicians occasionally need a reminder to log in and sign documents that are waiting for them, but even with that, it is an efficient process.

If you have not mandated that your physicians jump on board, please do. Enlist your administrators if needed. Remember, once your physicians are using Clinisign to sign evaluation and re-certification documents, you will no longer have to write clarification orders, you will no longer have to type signed clarification orders into PCC, and you will not have to print because everything is signed in Rehab Optima. Our facility chooses to print the signed documents so they are accessible when needed in the medical chart, but that is just a preference of our facility. Happy Clinisigning!

Thirst Quencher: The Free Water Protocol for Patients with Dysphagia

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By Elyse Matson, MA CCC-SLP, SLP Resource

The Free Water Protocol is one option SLPs may utilize to help counteract the adverse effects of thickened liquids and/or tube feedings. What is it? How should it be used in your facilities? What are the risks for aspiration pneumonia?

The (Frazier) Free Water Protocol was named after Frazier Hospital. In 1984, Frazier Hospital began to give all patients unlimited bedside water and/or ice chips. They found that fewer residents had UTIs and dehydration. They also found that when paired with proper positioning and oral care, there were no incidents of aspiration. Although it has been referred to as the “Frazier Water Protocol” in the past, the proper name is “The Free Water Protocol.” It is best used with patients on thickened liquids or patients who are NPO and on tube feeding.

The free water protocol is not appropriate for all patients. The below table can be used by the SLP to help determine the risk for pneumonia in each patient. As you might imagine, the higher the clinical complexity of the patient, the less likely a Free Water Protocol should be implemented. Remember that a patient on ice chips or free water has not been deemed free of aspiration on these textures; rather a determination is made that the benefits of free water outweigh the risk of pneumonia.

 

 

 

 

 

 

 

 

 

 

 

The Water Protocol is generally defined by these guidelines:

  • Patient is allowed to drink water between meals (minimum of 30 minutes after meals)
  • Water and ice chips cannot be provided during a meal if the resident is prescribed thickened liquids
  • The prescribed thickened liquid is provided at meals
  • Medication cannot be administered with water if resident is prescribed thickened liquids
  • NPO patients can have water anytime
  • Use all other swallowing guidelines
  • Must abide by other fluid restriction orders
  • Position upright always
  • No thin water until oral care is completed or 30 minutes after meal
  • Water is offered freely throughout the day

So what are the best methods to implement the Free Water Protocol? A multi-pronged approach is recommended.

First, a facility-wide training, including:

  • Patient identification methods
  • Facility-wide implementation as facility program not just a speech program
  • Provision of oral care to patients at risk for aspiration
  • Method for writing orders and care plan in PCC only after the oral care component is implemented
  • Communication methods with Dietary, Nursing, MD and family
  • Monitoring systems to assure the program is being followed
  • Communication about the specific methods for each particular patient, including:
  • Method for completing oral care
  • Licensed or nurse aid providing oral care (check your state laws for who can use oral suction)
  • If patient will receive unlimited or limited water or ice chips
  • Swallow strategies required for best safety
  • Documentation in place that states risks and benefits
  • Clarity on who will monitor proper administration of the protocol

In some facilities, especially when first implementing the Water Protocol, the clinical team may prefer a doctor’s order that does not refer to a protocol but rather an order that describes what a patient can and cannot have. “Patient may have Free Water Protocol” verses “Patient may have unlimited thin water via cup (no other liquids) between meals starting 30 minutes after meals and after oral care. Patient to be upright for all PO intake.”

The importance of oral care cannot be emphasized enough. Failures with a Free Water Protocol are almost always because the oral care component has not been fully implemented. Oral care in patients with severe dysphagia should be treated as a nursing treatment and may involve the use of oral suction and MD-ordered oral solutions such as chlorhexidine. If nursing has questions about the safest way to administer oral care in these patients, consult the SLP.

The benefits of the Water Protocol include:

  • Reducing risk for dehydration and the multiple sequelae from dehydration
  • Better adherence to other dietary restrictions
  • Decreased re-hospitalizations

If you are interested in implementing a Free Water Protocol and have questions, feel free to reach out to me at ematson@ensignservices.net.

WELL - Skip the Fast Weight Loss Diets and Go for Long-Term Health

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By Angela Ambrose, contributing writer

With a wide array of diets on the market, it can be tough to weed out all the fad diets and find a nutritionally well-balanced diet that is rooted in sound science and also simple to follow over the long haul.

“It’s easy to be overwhelmed, but don’t get sucked in by all the fad diets,” says Katherine Beals, associate clinical professor of nutrition and integrative physiology at the University of Utah. “Sticking to the tried and true research-based recommendations is the best way to go. It’s pretty basic – fruits, vegetables, whole grains, lean sources of protein and low-fat or non-fat dairy.” These nutrition recommendations stand the test of time and are summed up in the U.S. government’s “Dietary Guidelines for Americans” that have been around for decades.

Not surprisingly, the Mediterranean Diet, which closely mirrors these guidelines, has been rated the No. 1 best diet overall for three straight years by U.S. News and World Report. Tied for second place is the Flexitarian diet and DASH diet, which stands for dietary approaches to stop hypertension.

Rather than strict diets, all three are more accurately defined as healthy eating patterns with no foods off-limits. Each emphasizes whole, plant-based foods with a few minor differences. The Mediterranean diet adds more healthy fats, such as olive oil and nuts, as well as red wine, if desired. The DASH diet is designed to lower blood pressure and focuses on cutting sodium and saturated fat. The Flexitarian diet is primarily a vegetarian diet with the “flexibility” of adding in an occasional serving of meat or fish, when you get a hankering for it.

The Downside to Fast Weight Loss

Choosing the best diet depends on your ultimate goal. For example, if you want to lose weight very quickly so you can look slim and trim in your wedding dress or tux in five weeks, then a weight loss diet like HMR, Optavia, Atkins or Ketogenic may be a good short-term option. Despite their popularity, these same low-carb, high-fat diets fall to the bottom of the list for diabetes, heart disease and overall health.

“You will lose weight fast, but it’s not sustainable,” says Beals. “You can only do it for so long and then you start adding foods back in that you’re missing. And before you know it, you gain weight back.” Plus, they are nutritionally unbalanced and often require vitamin and mineral supplements.

If you’re looking to cut weight and keep it off, Beals suggests skipping these trendy fast weight loss diets and following the universal rule for shedding pounds.

“I don’t care who you are or what you do – the only way you’re going to lose weight is if you’re eating fewer calories than you’re expending. How you do that is highly individualized.”

The best diet for losing weight is the one that matches your lifestyle, personality and food preferences. For example, if ongoing support and guidance is important to you, consider Weight Watchers (rebranded as WW), which received the U.S. News’ top rating for weight loss and best commercial diet. The Vegan and Volumetrics diets tied for second place in the weight loss category.

Carbs, Protein and Fat – Your Body Needs Them All

Instead of restrictive diets that eliminate entire food groups, look for healthy eating patterns that include all three macronutrients – carbohydrates, protein and fat – and adjust the amounts of each to match your health goals.

While many of today’s fad diets drastically cut or eliminate carbs, Beals says they are a critical part of a healthy diet. “Carbohydrate-rich foods like fruits, vegetables and whole grains are the foods that provide the bulk of our vitamins, minerals and fiber, so if you don’t eat carbohydrates, you’re missing out on all those nutrients,” says Beals. The key is to select nutrient-dense carbs and go easy on the empty calorie carbs like soda, sweets and refined grains that are easy to overeat.

Higher Protein Aids Weight Loss

One proven way to lose weight is to bump up the protein in your calorie-reduced diet. “There’s ample evidence to suggest if you increase your protein intake, while consuming moderate amounts of nutrient-dense carbohydrates and healthy fats, you not only will lose weight, but also the composition of that weight loss will be more favorable,” says Beals. “You’ll lose more fat while maintaining lean tissue.”

Whether it’s a pork chop, chicken breast, salmon fillet or beans, tempeh and quinoa, eating more protein can make you feel full longer, so you’ll be less likely to snack in between meals or fill up on empty calories.

Which diet is right for you?

For those concerned with lowering their risk of chronic diseases such as diabetes, hypertension or heart disease, any of the eating plans that emphasize whole, plant-based foods and low saturated fats are sensible choices – from the Ornish, Mayo Clinic or Nordic diets to the MIND diet, which combines the Mediterranean and DASH principles with a focus on brain-healthy foods such as berries and leafy greens.

No single diet is right for everyone. Select one that is nutritionally balanced, allows you to maintain a healthy weight and matches your palate and lifestyle.

Don’t forget the other key ingredient for overall good health – regular exercise. All eating plans are more effective when combined with daily physical activity. Not only will you burn more calories and be more likely to keep the pounds off, but you will also build stronger muscles, bones and immune system, which may add years to your life.