Building Your Next One Up: Filling the “Shoes” of a DOR

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By Mary Ann Bowles, Therapy Resource, Endura/Colorado

Quite often leadership will have to take time off, and sometimes it’s lengthy as in a maternity leave. You need an interim DOR!

The questions arise: Who will take charge while you’re gone? Will they know how to do the tasks that are required? Will the systems stay intact? Will the staff they lead follow the direction of interim well? Will the IDT team work well with the interim? Will it feel like there are holes or missing components? Will we still be able to grow our programs??

Well, at the Villas at Sunny Acres (VASA), we can’t believe three months have come and gone! Our DOR at VASA was out on maternity leave. VASA is a busy rehab program that services SNF, ALF, memory care unit, ILF and outpatient.

Kinga Gianna, PT (L) and Jenny Kuehn, DOR, (R), Villas at Sunny Acres, Thornton, CO

Jenny Kuehn, PT, DOR, has always been a proponent of “building your next one up.” She did a poster on it for our Annual Leadership Meeting. She has cross-trained many of her staff that have goals of having a leadership role later in their careers. She has sent two therapists through the DORITO program. Jenny takes pride in building future leaders in our company. She prepped and trained Kinga Gianna, PT, to cover while she was gone.

Kinga has been with Ensign since 2013. Kinga started as a tech and then went on to be a physical therapist, an ADOR and now an interim DOR, filling the shoes of the DOR for three months. It’s not often that you have such a seamless transition when the interim DOR takes over. Kinga made that happen at VASA. She made the position look easy and took on all of the challenges and frustrations like a champ.

It honestly was seamless while Kinga was holding the reins as the director of rehab for these last three months. Not only did she maintain the therapy program, but she built the program, too. She added additional scheduled group therapy sessions, and started a managed care meeting with their NP on a weekly basis and a system to get the information to that NP. We couldn’t agree more with Brian Rupert, ED, at VASA, when he told Kinga, “We could not have hoped for a more seamless, smooth transition. Your ability to adapt to the challenges that came at you daily were reflected in how you quickly found ways to overcome and ensure your team and the residents received the care they required. Thank you very much.”

Shadow Boxes are a Hit at Legend Oaks New Braunfels

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Over the last year, Legend Oaks in New Braunfels, Texas, has implemented shadow boxes for all long-term care residents in an effort to decrease wandering, increase the patient’s ability to engage in meaningful interactions with other residents/staff/caregivers, and provide personalized, meaningful care in accordance with the patient’s Allen Cognitive Level. Residents were evaluated by a licensed therapist and determined if skilled therapy services were appropriate for the design and implementation of an FMP (Functional Maintenance Program).

Skilled therapy services’ typical duration was 2.5 weeks to complete this FMP program “shadow box.” Initial evaluations were utilized to determine the patient’s Allen Cognitive Score, which consisted of the leather lacing test and placemat test to determine baseline (ACL) Allen Cognitive levels; however, the FAST and GDS can also be utilized and converted to an Allen Cognitive Score, if the Allen test(s) are unavailable.

The patient’s Allen Cognitive Level was represented by color-coded dots on the outside of the shadow box, and the clinical staff, nurses and nurse aides received a three-week training course to increase their understanding of Allen Cognitive Levels and what each color represents. Examples of goals for the initial evaluation included:

Short-term goals:

  1. “Patient will reminisce about past for a maximum duration of 30 minutes with min cues provided utilizing items from shadow box.”
  2. “Patient will identify location of room utilizing shadow box visual cue in 10/10 attempts in order to decrease wandering and decrease amount of assistance required to redirect resident back to room.”
  3. “Nursing/caregivers/staff will demonstrate 100% understanding of the patient’s risks/challenges/and preferences in accordance with the patient’s Allen Cognitive Level in order to provide personalized/meaningful care to the resident.”
  4. “Patient will maintain topic for a maximum duration of 15 minutes in order to increase the patient’s ability to engage in meaningful interactions.”
  5. “Patient will engage in conversational speech with other residents regarding content of shadow box for a maximum duration of 15 minutes in order to increase the patient’s ability to engage in social interactions.” (This is a good goal to include to be able to utilize the shadow boxes as a group treatment).
  6. “Caregivers/family/staff will be able to utilize items from shadow box to engage the resident in meaningful interactions with min cues provided.”
  7. “Caregivers/family/staff will demonstrate 100% understanding of the patient’s remaining abilities, risks and challenges in accordance with the patient’s Allen Cognitive Score.”

Long-term goals:

Perhaps you can utilize a “Social Validity Test” to assist with long-term goals. This test asks the resident questions such as: How often do you have difficulty locating your room? How knowledgeable are you of other resident’s lives? How much do other residents know about your own life? Options to answers were: not at all, some, extensive. These were assigned a point from 1-3, with 3 being the highest score. Long-term goals for this test:

  • “Patient will increase shadow box social validity score from 1/6 to 5/6.”

Additional long-term goals can include increasing GDS and Allen Cognitive Scores.

Treatment Approaches:

During treatment, patients and family members (if able) engaged in a Life History and Questionnaire to determine memories of importance to the resident, appropriate items/pictures to reflect these memories, and patient’s preferences to provide personalized care. Timers can be set to measure how long the resident is able to reminisce about past, duration of time for topic of maintenance, and the patient’s ability to engage in conversational speech with other residents.

Additionally, if the resident exhibits difficulty in locating his/her room, measurements can be taken to determine if the resident’s ability to locate their room increases with shadow box cueing. You could also use group treatment to have residents explain their shadow box and engage in meaningful interactions with other residents. Extensive education is provided to caregivers/staff/family regarding Allen Cognitive Scores, providing the patients’ remaining abilities, risks and challenges.

Examples of Daily Treatment Encounter Notes:

  1. “Min cues provided, staff was able to provide three remaining abilities, risks, challenges, and preferences for the resident in accordance with Allen Cognitive Score.”
  2. “Patient was able to engage in meaningful interactions utilizing items from shadow box for a maximum duration of nine minutes.”
  3. “Resident able to locate room in 8/10 attempts utilizing shadow box as a landmark.”
  4. “Extensive education with patient’s family and staff regarding the resident’s remaining abilities, strengths and preferences.”

Group Therapy: F.A.S.T Pace Rehab Program at St. Elizabeth

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By Dennis Baloy, DOR, St. Elizabeth Healthcare & Rehabilitation, Fullerton, CA

Our facility is heavy on short-term patients (HMO and Medicare). Most patients come from St. Jude Hospital. Our payer sources and MDs are as aggressive and enthusiastic as the staff and team that we have. We wanted to capitalize on this and incorporate our group and concurrent treatment along the way. We came up with St. Elizabeth’s F.A.S.T. Pace Rehabilitation Program.

F.A.S.T. stands for Function and Ability based interventions for Safe and successful Transition to Home.

St. Elizabeth Healthcare & Rehabilitation prides itself on improving patient outcomes and providing excellent customer service. Our therapy programs are evidenced-based and patient-centered, implemented within a fun, encouraging and supportive atmosphere. Our goal for each resident is to go back home or to a safe discharge environment.

The F.A.S.T. rehab program includes:

  • Client-centered goals
  • Family involvement during therapy
  • Education with patient and caregiver to increase self-efficacy and empowerment
  • Use of group and concurrent activities (enhances motivation, engagement and commitment to goals)
  • Teaching of home exercise program/home accessibility recommendation
  • Provide adaptive equipment and teach compensatory techniques
  • Address instrumental ADLs (cooking, stair climbing, walking on uneven surfaces, etc.)
  • Program Graduate Certificate for all residents successfully meeting their rehab potential

The following are some groups that have been implemented:

Corn Hole Board Activity — The game is social and involves a number of people from two to four. Physical movements that are required are the ability to toss/throw a beanbag. Cognitive demands include the ability to add and focus on the game. Emotional demands might include the ability to enjoy yourself and to handle competition positively.

Cooking Activity — Participating in meaningful, client-centered occupations is a cornerstone in the profession of occupational therapy in promoting health and well-being for patients. Occupational therapists can use group-based cooking interventions to increase quality of life, social participation and autonomy, and to decrease depression of patients who reside in LTC. (1)

Graduate Program — Every Wednesday, we hold a mini graduation rite for patients discharging home or to a lower level of care. We have staff (rehab and facility staff) line up in our lobby and hold a mini program that celebrates their journey in therapy.

Optima Update

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By Mahta Mirhosseini, Therapy Resource

Have you wondered what it would be like to go paperless with Therapy documentation? You can stop wondering, because our Optima software has features and modules that can help us go paperless today!

Clinisign is Optima’s answer for getting timely and efficient physician signatures for our therapy documents. Facilities that utilize Clinisign do not have to print out any of their therapy documents, because each eval and/or recert is electronically sent to the physician for signature. Once the physician e-signs the document, it is automatically returned to Optima and PCC, thereby getting rid of the need to scan our therapy documents into the Misc tab of PCC!

And that’s not all. Did you hear the great news about the revision to our therapy clarification orders policy? If you joined our last leadership meeting, you also heard that we do not need to write clarification orders for Part A residents whose physicians are using Clinisign. This is because our therapy evals/recerts have all the required fields of a clarification order, and by getting an MD Clinisign signature on our therapy document, we are meeting the requirements for a physician order. This is another huge step toward going paperless while maintaining compliance. Please reach out to me or your local therapy resource if you are not already using Clinisign, or if you want to use Clinisign to its full functionality.

Nursing/Therapy Partnership

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By Angela Anderson, DOR, Gateway Transitional Care, Pocatello, ID

Travis Jacobsen (DON) (L) and Brooke Burt (ADON)(R) with DOR Angela Anderson, Gateway Transitional Care, Pocatello, ID

At Gateway in Pocatello, Idaho, we are blessed to have a very cohesive team that believes in making a difference for our patients. We have been able to create a task force with Nursing, CNA staff, RNS and activities, as well as PT/OT/SLP, to identify the greatest risks and needs for our patients and implement a true IDT approach.

This collaboration has empowered the different departments to develop new ways to address a common goal. It started years ago when our nursing leadership, Travis Jacobsen (DON) and Brooke Burt (ADON) started coming to the weekly rehab meeting. It was in this setting that the Therapy and Nursing teams started building trust and working on patient impairments as a team.

Travis and Brooke have led the nursing department with IDT programs such as HeartPARC, and have pushed the education and team approach that allows the entire team from the CNAs to Social Services to Therapy and Nursing to address cardiac conditions and achieve great outcomes! The wound team was Travis’ baby even before I started at Gateway; however, he was quick to bring Therapy into that team and together we can address wounds and skin breakdown from multiple angles and several approaches.

Travis has been instrumental in developing interdisciplinary management of ESRD patients in conjunction with a local nephrologist. With his help, we have developed programs addressing fall risk and quality of life in addition to excellent medical management. Because of the team approach and leadership of our DON/ADON, we have been able to approach all patients from a patient-centered perspective and treat the “whole person.”

PDPM Ready – Speech Therapy

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By Lori O’Hara, MA, CCC-SLP, Therapy Resource – ADR/Appeals/Clinical Review

CMS thinks that speech therapy is so special that it gave speech five different considerations for the payment category. Thanks, CMS!

So here are a few tips for being an SLP CMI Ninja Warrior:

  • If you have a patient with concomitant ortho and CVA diagnoses driving their stay, you will generally select the ortho condition for the principle medical condition. But then you should always get an SLP co-morbidity because Active Dx: CVA/TIA (item I4500) would be checked on the MDS. There might be additional co-morbidity diagnoses coded from the SLP treatment conditions, but you only need one to count!
  • While we no longer require the inclusion of an ICD-10 medical diagnosis on our therapy POC/UPOCs, the treatment plan still needs to make sense. That means that a patient who needs treatment for a cognitive impairment without a clear medical condition that causes cognitive impairments will necessitate conversations with the attending medical team. A hip fracture still doesn’t cause a cognitive decline.
  • When your SLP (or OT, too!) are treating cognition and are going to perform the BIMs, it’s a good idea to do this before the patient’s cognition function is changed by treatment. The recommendation is that the BIMS is done the day of or day before the ARD, but we are allowed to complete it anytime during the lookback. Special note: If the ARD is day 8, a BIMS completed on the day of admission cannot be counted in the MDS. Watch those lookback periods!
  • It is best practice to have your SLP screen all patients admitted on an altered diet. First, if the patient has the potential to advance to normal foods, we should endeavor to make that happen. Second, an altered texture can mask the presence of swallowing problems — if the altered diet improves the function sufficiently, it can be difficult for a non-expert eye to see an underlying impairment. An SLP will often choose to intervene in that instance for the optimum health and safety of the patient, but even in those rare cases where SLP intervention isn’t indicated, the screening note can document the observed symptoms such that they can be properly included in the MDS.
  • When an SLP is involved for swallowing, make sure they report diet changes to the IDT. Day 7 or 8 diet adjustments can sneak under the radar of even the most diligent MDS Coordinator, so make sure your SLP is making noise about those changes.

Pilot Programs Provide New Ideas for Enhancing Patient Care

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By Deb Bielek, Therapy Education Resource

Currently, several of our facility therapy teams have been supporting efforts toward identifying best practice approaches as well as new tools and resources available to help us continue on our path toward effective and efficient delivery of therapy to our residents and patients. Not only do we see more and more specialty programs popping up where our patients and residents are receiving state of the art care and getting better because of it, but we are also finding effective ways to engage them in care throughout their recovery process. Currently we have facilities who have been participating in Pilot Programs with focus on innovative care delivery systems partnering with technological resources, enhancements to our therapy software system, interdisciplinary assessment processes for measuring functional outcomes through Section GG, leadership of Restorative Nursing programs.

The following Pilot Programs have been used over the recent weeks to help us grow in our understanding of how these tools and approaches can help us succeed in our current operations. We are excited to share some detailed results of the following pilot programs during our Leadership WebEx meeting scheduled for Friday, August 9 from 12:15 – 12:45 pm Pacific:

  • Jintronix is a PDPM-ready, “gamified” clinical product that is transforming the therapy experience in both Post-Acute and Long-Term Care. The treatment allows therapists to enhance their skills by customizing specific treatment protocols for individuals, resulting in patients who are much more engaged and applying themselves in a whole new way and we’re seeing the positive impact on outcomes. The results during the pilot program have been exciting.
  • Section GG is being used as part of our Quality Reporting System to demonstrate functional outcomes with the Medicare Part A patients, and we are expanding this outcomes tool into all of our post-acute payers beginning August 1! Our recent pilot program with 9 facilities across the organization yielded best practice approaches to accurate Section GG reporting, which will be critical to our Case Mix groupings for PT, OT and Nursing under the new PDPM. There are also some unique findings with the role therapy can play in the accuracy of these results.
  • Optima is creating tools to streamline documentation that is relevant for outcomes tracking, clinical pathway implementation and documentation that supports the Case Mix classifications under PDPM. Hear about the exciting results so far as shared by some of our pilot leaders.
  • Do you use Home Exercise Programs to enhance your SLP, PT, OT service delivery? Our pilot project with Medbridge is giving us the opportunity to incorporate the HEP experience through some unique offerings to our patients. We are also beginning to integrate the idea of HEP as an extension to the therapy program by incorporating RNA support into the HEP practice prior to discharge. We are analyzing our NOMS and GG Data to begin honing in on best practices for the HEP. Hear directly from some of our therapists using these unique tools!
  • Is your facility struggling to maximize the effectiveness of the RNA program to achieve better results with your patients and residents? Our East Texas Market has been trialing a new approach to RNA Management, and we’ll be sharing more about the program, therapy’s involvement, how it works and the status of the early results.

Exciting Changes to Reduce Administrative Burden of our Therapy Teams!

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By Tamala Sammons, Senior Therapy Resource

In an effort to ensure our clinical practice and policies match regulatory requirements, we frequently review therapy policies and POSTettes. Recently, we identified a number of areas where we could make changes to help reduce the administrative burden of our therapists.

Effective Aug. 1, 2019, the following changes were put into practice:

  • Because the IDT determines the reason for skilled admission, the need for a Medical ICD-10 code on therapy documents was removed for Part A Payers. Clinicians can now add a treatment ICD-10 code in both sections of the POC and UPOC. No changes were made to Part B documentation, because therapy determines the Medical ICD-10 in most cases.
  • With clinical measures shifting to section GG for functional outcomes, we removed the need for therapists to also have to complete CARE Item sets data.
  • We removed the requirement for Part A payer clarification orders when the POC/UPOC documents are signed by MDs using Clinisign. Optima’s Clinisign product ensures timeliness of MD participation with therapy POCs/UPOCs. Clarification orders for Part A payers are still required for documents that are not signed by MDs through Clinisign.
  • We identified that IDT discussion around Part A payers should be different than Part B payers. We removed the requirement for a Med B UDA and updated the IDT policies to allow the IDT process of Part A and Part B payers to be different.
  • We also updated triple check forms to match these changes where applicable.

Our goal is to continue to ensure our policies and practices are designed to support clinical treatment and care of our patients and only require the administrative activities that are supported by a state or federal requirement. We hope these changes help the teams to be able to provide more hands-on care.

Host an Entry-Level OTD Capstone Student

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A Great Way to Extend the Reach of Your Department! By Ciara Cox, Therapy Resource

As many of you know, entry-level occupational therapy degrees are available at the master’s and doctoral level. Excitingly, part of the requirements for an entry-level OTD included is a 14-week Capstone experience.

The students will have finished their internships and will be looking for 14 weeks’ in-depth exposure to one or more of the following areas:

  • Clinical practice skills
  • Research skills
  • Administration
  • Leadership
  • Program and policy development
  • Advocacy
  • Education
  • Theory development

The students can work fairly independently; their onsite mentor does not have to be an OT, and the onsite role is mentoring rather than supervising. (If the student is treating as part of their Capstone, then student-supervision rules apply.)

Some examples of planned Entry-Level OTD Capstones at SNFs include:

  • Environmental Modifications to Increase Participation and Quality of Life for Individuals with Dementia
  • The Abilities Care Approach: Life Story Boards for Individuals with Dementia
  • Cultural Competency in Dementia Care
  • Mindfulness Education for Stress Reduction

You can find a university offering an entry-level OTD by clicking on this link: https://www.aota.org/Education-Careers/Find-School/AccreditEntryLevel/DoctoralEntryLevel.aspx

Please email ccox@ensignservices.net if you would like more information.

Using HeartMath Spontaneously!

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Heart Math Variability, By Casey Murphy, Therapy Resource

I was at our Legend Greenville facility to assist with Mock survey, and I ended up (organically and unplanned) doing an impromptu in-service with the therapy team on HeartMath. I demoed the Bluetooth device on one of the therapists who told me she was “stressed,” and we saw amazing results just with a three- to five-minute session (in front of a bunch of therapists!). She felt more relaxed afterward and was smiling a lot more for the duration of the day.

The team was so impressed, they wanted to try it on one of their patients. I sat with a speech therapy student with a patient who had dementia (and a pacemaker). I was able to sit and talk to her, taking her through the breathing exercises and talking about her family for a total of 6.5 minutes. She was only in high coherence for 12% of the time, but was in medium coherence for a whopping 41% of the time. We ended things with her smiling and thanking me for taking the time to talk to her about her family. The supervising SLP told me that she normally is not able to hold her attention; in fact, they had a goal for holding attention span for five minutes. She also told me she is usually very anxious.

Later that afternoon, I walked back into the gym and noticed the patient on the bike working with a PT, smiling and waving at me as I walked by. The PTA (who I demoed the unit on) pulled me into the charting office elated! She informed me that the patient hasn’t been able to ride the bike previously because she would scream out in pain. The staff couldn’t believe she was participating and enjoying working with everyone! The team was convinced it was the HRV session. Who knows, maybe we got lucky, but it was really cool to see that therapist and patient benefit from just one short session each!

So, needless to say, the Greenville therapy team is very interested in learning more. I loaned them my device so they can practice on their patients and themselves.