Utilizing the Drum Circle at Palomar Vista

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Submitted by Amy Pot, PT, DOR, Escondido, CA

The sound of light drumming and laughter filters down the hallway as the residents and patients start to assemble for drum circle. “I like chocolate cake, that’s the beat we’re going to play,” instructs Amy Pot, Director of Rehab, and Lulu Matos, Director of Activities, to a group of residents and patients at Palomar Vista Healthcare Center. They are drumming along on Turbano drums to I Love Rock and Roll by Joan Jett.

Pot and Matos are passionate about providing opportunities to improve the lives of the residents at Palomar Vista and worked together to build a wellness program using music as a vehicle to address many health aspects. The drum circle was a perfect medium to bridge the goals of each department. “It’s so simple anybody can do it and have a good time. We really wanted to work together to provide a dynamic program that would include everyone,” said Pot. Every week, the drum circle continues to grow. Residents and patients who were hesitant to participate become involved because the buzz is so infectious and the experience can be tailored to address their individual needs.

There are many benefits of senior drum circles, including: decreased anxiety, stress and depression; sense of community and new social connections; improved ROM, posture and coordination; muscular endurance stress relief; decreased effects of senile dementia; and building thought process self-esteem and confidence.

The construction of each drum and drum stick promoted a sense of ownership as each were customized and built by each resident to fit their needs. Some of the residents have limited movements from severe arthritis or Parkinson’s disease or may be wheelchair bound. The drums were built at varying heights to accommodate limitations in ROM, and drum sticks were provided to residents who did not have the muscular endurance to complete a song and promote grip strength. “We had hoped the residents would enjoy it. The feedback from residents and family has been overwhelming. The drum circle has been so positive in promoting a sense of community and being able to bring residents together to create something wonderful. The outcome has been amazing,” says Matos.

The drum circle is strictly driven by residents’ needs. At the request of the residents, they recently performed a Christmas concert for family and friends and are currently working on an 80s music performance for the spring.

Therapist Profile – Dora Alvarez

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Meet Dora Alvarez, a quiet Tucson superstar who prefers to be out of the spotlight! Dora has been with Sabino Canyon Rehabilitation & Care Center for eight years and loves being able to oversee the wonderful work and dedication her team demonstrates in helping one patient at a time. According to Shelby Donahoo, Tucson therapy resource, Dora has really come into her own in the past year and is one of our strongest therapy leaders in the Tucson market.

Dora was inspired to pursue a career in therapy after her mother’s terminal illness. She wanted to be able to help her mom have the best quality of life possible in the time she had remaining, and therapy was a way in which to accomplish that goal. As a leader, she emphasizes CAPLICO in her department by working with her therapists, facing all challenges as a team and helping her team believe in what they do to help improve the lives of others.

Dora would not change a thing about her demanding job — she believes that all the challenges and successes in the past have been a direct path to the positive place the facility is in now. Her favorite thing about her ED and DON is the trust they have in her as a leader, but from an outside perspective, I think Dora has earned that trust over the past eight years!

On a personal note, Dora’s favorite food is seafood, particularly shrimp and lobster. Her favorite Disney character is Simba from the Lion King because he was given a second chance to make a difference in his kingdom, which then helped him to become a great leader. When she is not working, Dora loves to spend time with her family. If you have met Dora, you might be surprised to know that one of the pastimes she shares with her family is big game hunting and fishing!

Nursing Therapy Partnership: Water Protocol for Skilled Maintenance Program

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Submitted by Jon Anderson, Therapy Resource – Keystone

The Power of Two: Recovery and rehabilitation require a comprehensive team working together to achieve a common goal. These goals cannot be accomplished by Therapy or Nursing alone, but a combined effort of a united team between departments. The efforts of nursing staff and therapists working together as a joint task force has brought incredible success stories within skilled maintenance programs.

Skilled maintenance programs are designed to maintain a patient’s current level of function and prevent unnecessary declines. A new skilled maintenance program Speech-Language Pathologists have implemented is a Free Water Protocol for residents on thickened liquids to decrease the resident’s risk for dehydration and increase their quality of life. The program was successful at safely decreasing resident’s risks for dehydration as well as increasing resident’s quality of life, but also provided unexpected success stories in other areas of dysphagia.

One resident had been NPO for two years and received all nutrition and hydration by PEG tube. This resident came to Legend Oaks-New Braunfels NPO and was never expected to consume food orally again. The resident was placed on the Free Water Protocol skilled maintenance program to increase her quality of life. The resident rarely wanted to get out of bed, but with the help and encouragement of nursing staff, they had the resident up every day so she can be in a safe position for swallowing. Additionally, nursing staff has assisted the patient with good oral hygiene to decrease the patient’s risk for aspiration pneumonia while on the Free Water skilled maintenance program. The resident was tolerating thin water so well with no s/s of aspiration that the Speech Pathologists began PO trials of puree with the resident. An MBSS was conducted after the resident demonstrated weeks of tolerance of therapeutic PO trials and was recently placed on a puree diet with nectar-thick liquids after not eating for two years!

Another resident on the Free Water Protocol was on a puree diet with honey-thick liquids for over a year. His skilled maintenance program was designed to decrease risk for dehydration. This resident also demonstrated good tolerance of thin liquids during the program, and Speech Pathologists began therapeutic trials of mechanical soft and regular textures with him. An MBSS was conducted, and the patient was upgraded from a puree diet to a regular diet! The resident requires cueing for safe swallow strategies, and the nursing staff has played a key role in ensuring the resident carries out safe swallow strategies on his new diet.

The teamwork between Nursing and Therapy has provided miraculous results in our residents’ lives.

“Never underestimate the ability of a small group of committed individuals to change the world; indeed, they are the only ones who ever have.” — Margaret Mear

DON/DOR/ED: “The Transformational Triad”

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Submitted by Jennifer Raymond, Therapy Resource, Northern CA

trans·for·ma·tion·al/tri·ad/ “able to produce a big change or improvement in a situation; “a group of three connected people or things

The objective of a triad is to create a peer-to-peer-to-peer relationship to accomplish a mutual purpose. “Triads are based on core values and mutual self-interest.”

A triad is not just three people meeting together. It is a relationship where each person is responsible for the quality of the relationship between the other. It is where each person has the other’s back. It’s “I’ve got your back and you’ve got mine” or “All for one and one for all.”

We have traditionally had one-on-one ED/DON relationships in the facilities as the leadership core. By adding that third person, the DOR, the power of the group is enhanced, the exchange of ideas and perception increased, it ensures faster and more accurate communication with the rest of the leadership/facility, it provides support and even friendship to the three members, it allows this core team to grow in their trust of one another, and it provides a place to be honest and safe when dealing with issues big and small.

Transformational Triad Opportunities to Achieve Amazing Things Together:

 

Achieving BHAG Nursing/Rehab team strengthening
CAPLICO/Culture training and events Long term care programming
Census development Managing managed care
Customer satisfaction Program development
Employee satisfaction and retention PDPM updates and planning
Decreasing readmission rates Productivity enhancement for therapy
Facility-wide dementia training QAPI
Facility staffing/Local recruiting Quality measures/QASP-*****
Identification of barriers to facility goal achievement Reasons to celebrate
Fiscal health and growth Relationship building within the community
Holding each other accountable Section GG and other MDS processes
Ensuring we meet Flag criteria Survey prep/follow-up
IDT leadership growth Support and friendship
Improving relationships with our hospital and managed partners “What If” intelligent risk taking brainstorming
Joint educational opportunities for Nsg/Rehab Worker’s comp management

 

“Three is the minimum number of legs required to make a stable structure.”

Therapy/Nursing Partnership at Cedar Health

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By Cathy Champlin DOR, Cedar Health and Rehab, Cedar City, UT

I’m Cathy Champlin, the DOR here at Cedar Health and Rehab in Cedar City, UT. My counterpart is Trent Neilson, the DON here. Cedar was a new acquisition on Jan. 1, 2019. I initially came on board at that time to assist with the transition, with the intention of returning to my home facility after a few months. The DON at acquisition had already given her notice prior to Jan. 1, and the position was temporarily filled by Jeremy Wood, our resource until May when Trent came on board. By the end of January, I had decided to transfer here as DOR and was working closely with Jeremy (and Spencer our ED) on helping to bring CAPLICO to Cedar.

When Trent came on in May, it was a very smooth transition. Perhaps because neither Trent nor I had a long history at the building and were both new in our roles, we were able to help each other without any territorial disagreements. We just put our heads together, bounced ideas off each other and got to work. We have worked hard to ensure that there is no “That’s Nursing’s job” or “I’m the therapist — I don’t do that.” The nurses here are very open to listening when Therapy notices a change in condition, and Therapy does not hesitate to toilet and answer call lights when able.

When asked what our “secret” was, I truly didn’t know. Perhaps, like I said, it was that we were both new to our roles and did not feel the need to “defend our territory” or that we had a similar vision for the building as shared by our ED. I will point out, though, that Trent and I carpooled to work most days for the first six months (45 minutes each way). That much one-on-one time definitely gave us a chance to talk, exchange ideas and get to know each other in a way that just time at work does not offer. So maybe that is the key.

As far as PDPM goes, I feel like we do well working as a team. Trent, Robert (MDS coordinator) and I look at all of the patients together. Trent and Robert have access through iCentra to all of the acute care records for most of our referrals, and I bring in the patient report piece as well from the therapy evals. We hand out assignments and use a color-coded tab system to keep track of where we are on each patient so we don’t waste time re-looking at things. Red is for new and not yet really started, yellow is for still looking for NTAs, but GG, BIMs, etc., are in green for “ready for fine tuning” and white is for sent. We often tease Robert, who gets nervous going to green, that it’s not easy being green!

The Beauty of PDPM – What MIGHT Be There

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By Lori O’Hara, MA, CCC-SLP, PDPM Resource

One of the miraculous things about PDPM is that we are incentivized to go learn things! And … we have the patient with us, 24/7, sometimes for weeks! There is no other provider — not the acute, not home health, not outpatient, not anyone who gets to have their arms around the patients as closely as we do and who are also told to go learn absolutely as much as we can.

Just us, baby!

So this presents an incredible opportunity to be the best assessors, the best investigators and the best, most impactful providers a patient will come into contact with.

This means that we if work superficially — if we’re content with just the diagnoses on the transfer list and just the treatments that come to us — that we’ll miss out on the potential for incredible impact to a patient, which, super conveniently, is pretty reimbursable when we do it.

So part of being a PDPM Ninja is knowing where the arrows are pointing. What conditions tend to come in clusters? What treatments should we be advising the MD that we can do? What low-impact, non-invasive interventions could have a big payoff for this patient if we just think about doing them?

So here’s an exercise for you. Look at the diagnosis list below. And before you scroll down, think through all the “maybes.” What might related conditions be? What treatments should be considered? What condition might mask another where you should take a close second look?

So what did you find?

Here’s what I found:

        • Sepsis and Bacteremia = Need records to confirm or r/o septicemia
        • Diabetes and insulin = Check for diabetic retinopathy and proactive management of insulin regimen in case order changes are needed
        • Diarrhea = Investigate source (radiation, infection, c-diff?) to confirm or r/o inflammatory bowel disease
        • Convulsions and seizures = Investigate control status (25% of seizure disorders are poorly controlled/intractable)
        • Klebsiella PNA and sepsis = Query for labs for drug resistance status
        • Alzheimer’s disease and encephalopathy = Cognitive impairment
        • Obesity = Score BMI, assess if patient’s weight warrants morbid obesity diagnosis
        • PNA = Assess for need for RT interventions
        • UTI = Assess voiding and s/s of retention for straight cath medical management
        • Multiple malnutrition markers present (infections, dementia, diarrhea, dysphagia)
        • Dysphagia = Should trigger on Section K, which should then correlate to altered texture diet trigger for altered texture diet

Did you spot any others? You can also do this exercise with medical documentation from the upstream provider. And the more clinical brains, the better! Each clinician carries their own training and experience into the room, so one brain might pick up on something another brain might not spot. And when you find four or five “maybes,” you know that not every one of them will result in a new condition to code and care for. But you’ll probably find a thing or two, and maybe find something else — completely unrelated to payment — that will have a big impact on your patients’ health and recovery.

Like I said — miraculous!

 

What Makes a Good Leader?

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Submitted by Jennifer Sowers, DOR, McCall Rehabilitation, McCall, ID

I believe leadership is a position earned and appointed by those who have taken recognition of your ability to follow, listen, try harder to be a better person, think outside the box and be willing to learn.

Jocko Willink, a retired Navy Seal Commander, has written several books on leadership that are all worth the read if you want to be a better leader. Several truths to live by jump out in his books and podcasts, and the one that speaks loudly is: Discipline equals Freedom. What does this mean? First, why do we need discipline as a good leader?

In a leadership role, we are being watched. Our team is watching us; even those not on our immediate rehab team are watching us. The cooks, the CNAs, the Activity Director, not to mention our ED and the DNS. They are watching our attitude, our behavior, how we react in conflict or under pressure. Are we late for meetings? Do we roll our eyes? Did we yawn? How are we dressed? A full-time employee in our facility told me recently, “The rehab team is like the cool kids in high school — everyone wants to be like them and hang out with them.” At first it was a compliment, but then I started to think, why are we a separate “click” outside the big team? Do other employees think we are above reproach in the building? That’s when it really struck me how important it was that we as a team, and especially me as a leader, must demonstrate excellent leadership. We are in a spotlight. And we all know that with great power comes great responsibility, and as a leader, we are in a position of power.

And that is where ownership comes into play as a leader. If you make a mistake, don’t cover it up; admit mistake and then make a plan to do better. If your team makes a mistake, take ownership. When are we not responsible for the performance of our team? Never. If our team is not performing, then maybe they need more training, more assets, more support, more mentorship. Ask your team what they need and then follow up with them. That’s when a job will get done. Is the mission clear, concise and understood? Make sure professional expectations are clear and don’t compromise standards. As a leader, lead by example and take responsibility for your team. The other day a patient got extremely upset about a new RA not doing a specific exercise as she expected. The RA came to me, warning me this patient was mad and going to complain to me. I listened to the patient and then apologized to her, saying I had instructed the RA incorrectly and it was my fault she did not understand the specific exercise. The RA came to me later, smiling, and told me the patient had apologized to her and their relationship was restored. She was relieved and the patient was happy. If you make a mistake, own it. Don’t make excuses or cover it up. Neither the RA nor the patient were mad at me for not doing thorough training. It was amazing how quickly me taking ownership dissolved the conflict.

Leadership is all on you but it’s not all about you. The team is way more important than you are. Keep your team’s interests above your own, and use all the tactics you can to make your team better, not yourself. If your goal as a leader is to help others and your team, then you will accomplish the mission. If your team succeeds, then you win as a leader and your people will win. That is true leadership. But, it does start with you and that is where the truth that discipline equals freedom rings so true to the core of leadership. Here is a quote by Jocko Willink regarding the application of discipline:

Discipline starts with waking up early, it really does. But that is just the beginning; you absolutely have to apply it to things beyond waking up early. Is it working out, every day, making yourself stronger and faster and more flexible and healthier? Is it eating the right foods, to fueling your system correctly? Is it disciplining your emotions, so you can make good decisions? Is it about having the discipline to control your ego, so it doesn’t get out of hand and control you? Is it about treating people the way you want to be treated? Is it about doing the tasks you don’t want to do, but you know will help you?

Discipline is about facing your fears so you can conquer them. Discipline means taking the hard road, the uphill road. To do what is right. For you and for others. So often, the easy path calls us: to be weak for that moment. To give in to desire and short-term gratification.

Discipline will not allow that. Discipline calls for strength and fortitude and Will. It won’t accept weakness. It won’t tolerate a breakdown in will. Discipline can seem like your worst enemy. But in reality, it is your best friend. It will take care of you like nothing else can. And it will put you on the path to strength and health and intelligence and happiness. And more important, discipline will put you in the path to Freedom.

I think about freedom equaling discipline as a leader and a lot comes back to doing the right thing even when we don’t feel like it. Freedom for me is getting all my progress notes done on time, getting my discharges done on time so when I do closeout I don’t get a screen of red. Freedom is showing up for work early so I have good numbers to present at stand-up and my team has their schedules ready when they arrive. I have a running calendar, and the other day I flipped the page and it said, “I love running because it’s the one thing I do every day and never regret.” I’ve never said, gosh, I’m sure bummed I got up and ran this morning. Wish I hadn’t made my bed today. Or, I’m sure bummed I got all my notes done on time, or I’m sure disappointed I took a shower today, or ran my metrics, or did some continuing education. We’ve never said that. When we’ve had the discipline to go on the run, finish the progress note, pack a healthy lunch, we have freedom and we can lead our team to have the same freedom by example.

Lastly, a leader will never ask their team to do something they will not. As a leader, we need to care about our team. Advocate for your team, whether it’s new equipment, continuing education, time off, negotiating with nursing. Have their back and they will have yours. If your team knows you have their best interest in mind as their leader, you will have their respect. And, then when you need to give criticism, it will be accepted more easily. And celebrate! Set goals and celebrate with your team! Don’t forget to recognize victories and show them how much they are appreciated.

A lot goes into being a great leader, and these are just a few but they are the ones that have hit home with me lately. Take ownership, discipline equals freedom, lead by example, your team comes first, and show them you care.

Birds of Different Feathers

Building Therapy Leaders Learn

Improving Work Relationships

Are you objective, analytical, and logical? Are you a natural team player? Are you lively and entertaining? Are you a natural born leader? The answer to these questions and more may help you to better understand your work style, but more importantly, the work style of your coworkers.

We all have unique personalities and different learning styles. What you appreciate about your work may be different from what others appreciate about their work. What do you think a lot about, value in others, enjoy or dislike? What you have trouble dealing with may be unique to your work style. Knowing and understanding what makes you and your coworkers unique may better strengthen your relationships.

Recently at Premier Care Center, we began a distinctive training style to identify ourselves and our work style. We then share with our coworkers each other‘s work styles in an attempt to strengthen our work relationships. The therapy department took on a fun adventure to better understand our own traits and those of us on our team and how we may improve. We were introduced to a training course called “Birds of Different Feathers”. It is a quick Personal Work Style Self-Assessment. Once everyone has completed the assessment they use the score on the assessment to identify their own ‘Bird Style’. Once you know your bird, you may read the course information that identifies your unique characteristics. Knowing more about yourself is only half the fun. Once everyone shares their own unique ‘Bird Style’ with the group, then we were all able to discuss and learn about each other.

Some don’t like to be micro-managed. Some are natural ‘cheerleaders’ and thrive on the creative energy of groups. Some will respond well when they can be given autonomy and the opportunity to exercise their best professional judgment. Some prefer not to be criticized or embarrassed in front of other people. They are sensitive and care deeply what others think of them.

It was quite enlightening to learn about our teammates. We now use this ‘Bird Style’ terms when we speak to each other and it has given us deeper insight into how better to communicate together. We even presented the course to the Premier Care Center Leadership Team, and they have fully embraced it as well. More recently it was presented to the Ensign Therapy Resources as a culture training piece. So what kind of a bird are you?

Are you an Owl – a data collector? Are you a Dove – a collaborator? Are you a Peacock – an artist/creator? Are you a Hawk – a decision maker? Find out your own unique ‘Bird Style’ and how are you may better influence your communication with your team or coworkers by taking the training on ‘Birds of Different Feathers’.

So what kind of a bird are you?

Assessment: Personal Work Style Assessment (pdf file)
Training: Birds of Different Feathers (pdf file)

Be sure to take the assessment first, then the training.

Cupping Techniques to Improve Quality of Life for Geriatric Patients

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By Jimmy Dale Smith, PT, DPT, The Healthcare Resort of Plano, TX

Myofascial decompression (MFD), or cupping, is a form of IASTM (Instrument Aided Soft Tissue Manipulation), where a pump and a cup are used to create negative pressure and placed on the skin to improve circulation/blood flow, reduce pain, improve tissue pliability/mobility and to improve healing.

Additional benefits of cupping may include improved quality/quantity or ROM, improved tolerance to ROM/PROM exercises, and excellent neural input to improve motor output. Contraindications include open wounds, fever/active infection, severe disease (cardiac, renal failure, bleeding disorder, hemophilia, active cancer and dermatitis), first trimester of pregnancy, unhealed or possible fracture, severe strain/sprain, or already inflamed/swollen tissue, burns and acute flare-ups of skin disease (psoriasis, eczema or rosacea).

  • When: Depends; early in POC to assess patient’s response
  • Where: Location of pain/perceived stiffness, myofascial line, neurovascular junction
  • Why: ROM, pain, blood flow, soft tissue adhesions
  • Who: Patients who do not have contraindications
  • What: Reassess, test and retest

Pilot Study: Plano Health Care Resort

The Physical Therapy department at Plano HCR is currently one of our affiliates in Keystone that is piloting usage of cupping across patients with differing diagnoses, which has resulted thus far in varying degrees of success. Predominantly, the facility has observed a positive response to MFD. Through the observations, benefits range from an hour (to the end of the session) up to five to seven days of pain relief. One specific “home run” of treatments is the following case study.

Case Study: Mr. T.

Mr. T. is a mid-70s male s/p R TKA. He presented to PT as an outpatient seeking further rehab after his SNF stay. His primary limiting impairments were stiffness, pain and weakness. When he initially attempted basic OKC (open kinetic chain) activities, the patient would report moderate to severe pain at end-range knee extension. The team attempted to modify to a CKC (closed kinetic chain) to assess differences in symptoms. Stiffness remained. Moving to manual therapy, the patient responded decently well with anterior tibiofemoral mobilizations. The patient reported less pain, but the stiffness remained. The PT team applied three hard plastic cups with 1.5 pumps of pressure proximal to the knee as a gross stabilization point for the fascial system and one silicone cup just distal to those cups with the intent to perform a dynamic mobilization technique. Post-treatment, the patient reported that not only was the pain nearly eliminated, but the stiffness was gone as well.