Millions Are Likely Suffering from Brain Fog and Other Cognitive Impairments Post COVID-19 Infection

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By Elyse Matson, MA CCC-SLP, SLP Resource/Ensign Services
It is estimated that nearly 100 million people have contracted Covid-19. Long-lasting symptoms occur in nearly one in four people, even when they were not hospitalized. The primary complaints of those with persistent issues are brain fog and cognitive fatigue. That means millions of people are walking around with cognitive issues likely affecting their lives.

In a recent conference from ASHA, Rebecca Boersma, SLP of George Washington University Hospital, described a new outpatient treatment protocol to address these issues. These new patients are primarily female with a mean age of mid-40s. Recovery from these subtle but debilitating deficits does not follow the normal recovery timeline and tends to be remitting and relapsing in nature. Prominent deficits including attention, working memory, word finding, cognitive fatigue and processing speed.

Boersma utilizes assessment and treatment approaches common in the post-concussive population, including motivational interviewing, collaborative goal setting, and a variety of scales and tools to assess patient perception of communication, fatigue and cognition. These include the Modified Fatigue Impact Scale, the LaTrobe Communication Questionnaire, and the Multifactorial Memory Questionnaire.
Treatment focuses on a person-centered approach and utilizes proven treatments such as the meta-cognitive strategy, dynamic coaching and managing fatigue.

In our outpatient programs, we have an opportunity to seek out and help some of those suffering with Long COVID. Is this a program you can implement in your facility? For more information and to obtain the protocol, email Elyse Matson ematson@ensignservices.net.

IDDSI Diet Training Keeps on Giving

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Photo: Kyle Hosman-ST; Karin Martindale-Assistant Dietary; Sarah Lanning-ST

Submitted by Angie Taylor, COTA/TPM, Shawnee Post Acute Care, Overland Park, KS

We usually get to see the beginning stages of new trainings, but it is so important to see that training carry over at the facility level. Shawnee PARC has done an outstanding job of rolling out the IDDSI program and, most importantly, fully collaborating with the Dietary department and Nursing staff to roll out the program completely with ongoing training and reinforcement to ensure accuracy.

It started after our IDDSI diet training from the resources that sparked a full IDT discussion and from collaborating on what strategies would ensure that we roll out a successful program. This included Speech Therapy, Dietary Management, Dietary staff and Nursing staff. The best strategy we determined was establishing a consistent, reliable line of communication. The team decided the easiest and most efficient way was to establish a Tiger Text account that was set up for dietary communication only. We included dietary management/staff and Speech Therapists, and they utilize that platform to request specialty trays to trial, ensure correct diets, communicate specific resident wants/needs, or any pertinent changes.

The IDT then decided to carry over correct diet level for snacks: the Speech Therapist labeled and s/u snack trays in each dining room, clearly labeling the correct diet level and ensuring the appropriate snacks were placed in each bin. This established consistent carryover and facility-wide understanding of the levels. We have enjoyed seeing the collaboration and processes develop, but more importantly, we realized that establishing a partnership and seeing that partnership grow into a strong and sustainable program would have never happened without the training and support the resources provided.

Let’s Talk Long-Term Care Programming: Tips and Tricks for SLPs working with Dementia

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By Nicole King MA, CCC-SLP, Julia Temple Health Care Center, Englewood, CO
Use meal times to your advantage! Not only can you check in on your swallowing patients, but it is a great time to address following directions, sequencing, and attention during simple functional tasks — such as adding cream and sugar to their coffee, hand hygiene, cutting up their food, etc.
It is also a great time to address communication and social interactions. The facility is their home. Tasks that might not be functional for your skilled population are functional and meaningful in LTC and memory care neighborhoods — for example, deciding which snack they want, finding their room, participating in activities, and deciding when and where they will eat.

Partner up with Activities or the Chaplain. They can provide the task, but you can provide the skilled eye, environmental modifications, and dynamic cueing that allows the residents to participate in a meaningful and engaged way. Maybe your restless patient needs to be able to come and go from the area, or certain residents shouldn’t sit near each other. It could be the resident needs parallel involvement that allows them to participate but with less environmental stimuli and/or distractions.

Don’t be afraid to “hang out” in the memory care neighborhood. Using a naturalistic approach allows you to see patterns in behavior, identify triggers of agitation, find other patients to evaluate, and get to know the staff better. I also try to do my documentation there because it provides me with more time to observe and engage.

Take credit for what you are doing! Don’t assume that the intervention or strategy is obvious to everyone. Sometimes the smallest change can make all the difference. At JT, we had a patient who played with her food during meals and it upset nearby residents. After assessing her response to her environment over a few meals and analyzing how she engaged with her surroundings and staff, it hit me. She only played with her food on the days her appetite was low. It was her way of letting us know she was full.

Think outside the box and step out of your comfort zone! Let go of the idea that your therapy should look a certain way. Language and communication opportunities are everywhere. Remember it isn’t always about restoring lost skills/function, but changing the environment or how we interact with them, or creating opportunities for them to succeed based on the skills they still have.

Documentation. We all know documentation is important, but with LTC therapy and skilled maintenance, it is crucial. To an outsider, it might look like you just sat next to a patient during an activity. But what you actually did was “facilitated optimal patient participation during preferred leisure task by incorporating dynamic cueing hierarchy, environmental modifications, errorless learning techniques, and spared skills.” Always document the functions or presentations that you assessed in order to know what to do, and exactly how what you saw guided the interventions you selected. The skill lies in the assessment you performed, and how you acted on that assessment.

Goals. The questions I get asked most frequently are related to setting goals. Here are a few of my favorites:

  • Patient will demonstrate ability to use verbal and nonverbal communication to make decisions related to preferences during care tasks and daily routine with MOD A to facilitate highest level of independence on nursing unit
  • Patient will maintain ability to complete 3-4 conversational exchanges related to direct and observable topics using multisensory stimuli in order to reduce risk of social isolation and decrease in meaningful interactions
  • Patient will maintain current level of cognitive communication function to actively participate (following along with handout, switching between tasks, singing along, etc.) in weekly worship service with MIN-MOD A in order to preserve quality of life and highest level of independence with leisure activities of choice
  • And finally, remember that being able to support ongoing therapy for maintaining function requires evidence that only you can do what needs to be done. Once the patient’s function looks consistent, or what you need to do changes very little from session to session then it’s time to phase yourself out and hand over those activities to others.

Behind the Scenes Superstar: Lori Whitman

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This month, we are pleased to spotlight an amazing resource and friend, Lori Whitman. Lori is our accounts payable resource and provides incredible support to our therapy department.

Lori just celebrated her 9th anniversary with Ensign Services in May and lives our culture to its fullest. You can see her expressions of culture and focuses during simple interactions over e-mail with a nugget typically added to her signature line, which she changes up to recognize the seasons and the holidays, as well.

Lori is a true California native and grew up in Huntington Beach, CA. She is one of three with an older sister and younger brother. She has been living in Aliso Viejo, CA for 29 years, where she enjoys her weekends hiking with girlfriends and exploring new places, spending time with friends and family and an occasional off-roading jeep adventure with her husband! These off-roading adventures have taken them to beautiful places that they may not have seen otherwise and it has sparked an interest in buying an RV to take them to other areas throughout the United States, which they hope to do next year.

Lori has two sons and her younger son, Austin is 27 and getting married to Kayla in October this year up in Lake Arrowhead. Austin is pursuing his Masters of Family Therapy at Cal State Long Beach, which is Lori’s alma mater. Her older son, Ryan, is 36 and lives in Panama City, Florida. Lori’s mom lives in an IL/AL in Huntington Beach and she also spends time helping her mom and enjoying moments together.

When asked about what she loves most about her job, Lori shared that she loves the interactions with her co-workers and all the people she supports at her WA facilities as well as the Service Center departments and field. She then shot some therapy love our way by saying, “My favorite, of course, is the AP support for our Therapy Department. It puts a smile on my face knowing I am helping in some small way by paying invoices for Seminars/Educational materials for our nurses and therapy resources who bring new innovations to our facilities to help the residents.”

For those who attended this year’s Therapy Leadership Experience in April, you may have had the opportunity to interact with Lori a little bit during the Lip Sync contest. Lori was one of our judges and expressed that it warms her heart to see how much fun everyone was having. If you had the chance to meet her, you’ll notice that she is fit and healthy, which she attributes to the hiking on local trails, hiking on the beach, and working out in the gym. She has also finished many 10Ks and a few half-marathons over the years. Lori is such a positive person and expresses gratitude for her many blessings, which surely contributes to her well-being.

We are all truly blessed to have Lori Whitman a part of our lives as our AP resource and our friend. We are so grateful for everything she does for us. Lori makes US better.

Clarifying Skilled Nursing and Therapy

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By Lori O’Hara, CCC-SLP, Skilled Reimbursement Resource
IDRS (Interdisciplinary Documentation and Reimbursement Systems)

From CMS:

  • Skilled nursing/therapy services are those services that are so complex they can only be safely and effectively provided by a nurse or under the supervision of a nurse/therapist.
  • Coverage does not turn on the presence or absence of an individual’s potential for improvement from nursing/therapy care, but rather on the beneficiary’s need for skilled care.
  • A condition that would not ordinarily require skilled nursing/therapy services may nevertheless require them under certain circumstances: the patient’s medical complications require the skills of a registered nurse/therapist to perform a type of service that would otherwise be considered non-skilled; or (b) the needed services are of such complexity that the skills of a nurse/therapist are required to furnish the services.

Frequency:

  • To support a Part A episode, nursing services must be provided (and documented) 7x/week; to support a Part A episode, therapy must provide (and document) services at least 5x/week.
  • Please note: The importance of a particular service to an individual patient, or the frequency with which it must be performed, does not, by itself, make it a skilled service.

Defining Skilled Nursing Services
These nursing services automatically support a Part A episode when provided (and documented). They include but are not limited to:

  • Intravenous or intramuscular injections and intravenous feeding
  • Enteral feeding that comprises at least 26 percent of daily calorie requirements and provides at least 501 milliliters of fluid per day
  • Naso-pharyngeal and tracheotomy aspiration
  • Insertion, sterile irrigation, and replacement of suprapubic catheters
  • Treatment of decubitus ulcers, of a severity rated at Stage 3 or worse, or a widespread skin disorder until/unless the wound is deemed chronic
  • Heat treatments that have been specifically ordered by a physician as part of active treatment and that require observation by skilled nursing personnel to evaluate the patient’s progress adequately

Other interventions are considered skilled nursing in their initial phases but would be considered unskilled once the patient is stable and the regimen well-established:

  • Application of dressings involving prescription medications and aseptic techniques
  • Rehabilitation nursing procedures, including the related teaching and adaptive aspects of nursing, that are part of active treatment and require the presence of skilled nursing personnel, e.g., the institution and supervision of bowel and bladder training programs
  • Initial phases of a regimen involving administration of medical gasses such as bronchodilator therapy
  • Care of a colostomy during the early post-operative period in the presence of associated complications; the need for skilled nursing care during this period must be justified and documented in the patient’s medical record
  • Initial care-planning and comprehensive assessments

Many other things might be skilled, if the documentation supported that they were complex enough that they required the skills of a licensed nurse:

  • Assessment of medical presentation
  • Observation and monitoring of new or potentially unstable conditions
  • Some skin treatments
  • Some respiratory treatments
  • Implementation of physician’s orders

Other things to consider:

  • There are often state regulations that limit a patient’s ability to keep or self-administer medications. But even so, administration of routine medications is not considered a skilled service by CMS.
  • Wound-vac treatments are administered to heal very complex wounds, but because they are not a daily service. they will never, by themselves, be enough to support a Part A episode.
  • Trachs are intimidating apparatus that are generally present only in vulnerable patients. But the presence of a trach is not enough to sustain a Part A episode (although treatments or suction provided through the trach often are).
  • Likewise, just having a PEG tube is not enough to sustain a Part A episode — the patient must be meeting a minimum caloric/fluid amount as it’s the complexity of administering the feeds and assessing for residuals that requires the skills of a nurse.
  • A service that is ordinarily considered nonskilled could be considered a skilled service in cases in which, because of special medical complications, skilled nursing or skilled rehabilitation personnel are required to perform or supervise it or to observe the patient. The key in these situations is great documentation to capture and clarify the “special medical complications.”

Documentation:
It is expected that the documentation in the patient’s medical record will reflect the need for the skilled services provided. The patient’s medical record is also expected to provide important communication among all members of the care team regarding the development, course, and outcomes of the skilled observations, assessments, treatment, and training performed. Taken as a whole, then, the documentation in the patient’s medical record should illustrate the degree to which the patient is accomplishing the goals as outlined in the care plan. In this way, the documentation will serve to demonstrate why a skilled service is needed.

The patient’s medical record must have documentation as appropriate that captures:

  • The history and physical exam pertinent to the patient’s care, including the response or changes in behavior to previously administered skilled services
  • The skilled services provided
  • The patient’s response to the skilled services provided during the current visit
  • The plan for future care based on the rationale of prior results
  • A detailed rationale that explains the need for the skilled service in light of the patient’s overall medical condition and experiences
  • The complexity of the service to be performed
  • Any other pertinent characteristics of the beneficiary

References:
https://www.hhs.gov/guidance/document/benefit-policy-manual-chapter-8-extended-care-coverage

Fall Prevention Program

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By Angela Anderson, PT, DOR, Gateway Transitional Care, Pocatello, Idaho
Therapy at Gateway has been honing in on fall prevention for several months now and has implemented many therapy interventions that are fairly standard in fall prevention. We have the therapists focusing on fall risk and fall prevention during the evaluations and recommending assistive equipment or strategies to prevent falls at that time. We had found that many of the falls were happening in the first day or two and that the therapy POCs weren’t having time to affect the outcomes. So, Therapy and Nursing developed some tools to help implement interventions as preventative measures when the admission nurse does the intake.

The admission nurses are already doing a fall risk assessment on intake. Our PT, David Cox, helped develop a 48-hour falls checklist that gives the admission nurse a list of areas to focus on and questions to ask that may help decrease the likelihood of fall, such as, “Have they been trained to use the call light and remote?” and “Is the clutter put away?” He also developed potential interventions for low-, medium- and high-fall-risk patients, depending on the result of the falls risk assessment tool. These lists give the admission nurse more interventions to choose from that may be applicable based on why the patients are triggering for higher falls risk.

Falls – 48hr falls checklistDownload
Falls – Risk ChecklistsDownload

This also helps demonstrate that we are proactively looking at fall precautions and putting interventions into place, checking them off and signing the form that can be scanned into PCC. The therapists can then reinforce the interventions that are put into place, modify if necessary, and focus CNAs on these interventions in addition to the traditional Therapy fall preventions.

David and Brooke (ADON) came up with some notification magnets for the doorways of patient rooms that identify high-fall-risk patients (for frequent checks), for patients with unstable vitals and orthostatic hypotension, to identify risks that help alert CNAs and staff to issues that need increased attention. Admissions is reporting that the program has potential to help and she can see the efficacy.

What Is Dysphagia? (Taken from the Dysphagia Research Society)

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By Elyse Matson, MA CCC-SLP, SLP Resource/Ensign Services
Swallowing is one of the most complex actions we perform, involving more than 30 muscles and nerves. The average person swallows approximately 600 times per day — about 350 times while awake, 200 times while eating, and around 50 times while asleep.

Dysphagia indicates any difficulty or problem with swallowing normally. A swallowing disorder not only affects safety but also quality of life. Dysphagia is a serious medical condition that affects between 300,000 and 600,000 individuals in the United States each year.

Common signs and symptoms of dysphagia include: difficulty with weight gain (in children), unintentional weight loss (in adults), coughing during eating/drinking, recurrent aspiration pneumonia, food/liquid coming out of the nose/mouth, and a feeling of food remaining “stuck” in the throat/upper chest, to name a few.

Dysphagia is associated with a wide variety of conditions, including congenital and developmental disorders (e.g., cleft lip/palate, Down’s syndrome), head and neck cancers, pulmonary conditions (e.g., chronic obstructive pulmonary disease), and a variety of neurologic conditions such as stroke, dementia, amyotrophic lateral sclerosis (Lou Gehrig’s disease), Parkinson’s disease, muscular dystrophy, cerebral palsy, and many more. Since it is a common symptom in many of these diseases, it often goes unnoticed and is often under-reported, despite having significant consequences.

Complications and consequences of dysphagia include pulmonary aspiration, malnutrition, dehydration, pneumonia and even death. In hospitalized patients, dysphagia has been shown to significantly lengthen the hospital length of stay and is a negative prognostic indicator. In addition, those with dysphagia often report a feeling of isolation and depression, as many are no longer able to take part in social gatherings that so often revolve around eating and drinking. It is estimated that dysphagia is responsible for between $4.3 to $7.1 billion in additional hospital costs per year. Despite the significant detrimental impact dysphagia has on health and quality of life, only a third of those afflicted seek medical treatment.

Assessment of dysphagia frequently includes a clinical assessment and instrumental assessment. A clinical bedside swallow assessment is typically completed by a speech-language pathologist (SLP) and is used to describe the characteristics of the individual’s swallow function, determine the presence/absence and characteristics of a swallowing disorder, determine the safest route of nutrition/hydration, and help provide additional recommendations for an instrumental assessment and appropriate treatment. The two most common instrumental assessments are fiberoptic endoscopic evaluation of swallowing (FEES) and modified barium swallow study (MBSS).

Once a diagnosis of dysphagia has been made, the healthcare team determines the most appropriate plan for treatment. Management of dysphagia may involve medical/surgical intervention by a physician and/or behavioral intervention by an SLP. The focus of any dysphagia intervention is to optimize the swallow to be as safe and efficient as possible, as well as to maximize the patient’s quality of life.

#APEXStrong

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By Amber Thompson, Market Leader, Keystone – Texas
Reaching the Highest Peak Is What Drives Us, But Reaching It Together Is What Matters
We would like to cordially invite you to be a part of the APEX challenge. Our focus over the past year has been on building leaders and transforming the way we serve our staff and residents. How do we create strong relationships within our IDT that are built on trust, accountability and love for one another? Performing physical challenges together as a team will create bonds between people that last a lifetime. The post COVID world has been a struggle for a lot of our operations. Employees are tired, some feel hopeless and some are lost in a spiral and can’t find their footing.

As a market, the team decided to change our name in January 2022 to APEX. The context behind this was…how will we inspire our teams to get to the top of the mountain even when we are tired and feel as if we have no more to give? We are struggling with agency usage, retention, lower reimbursement rates and the cluster rigor. The market has refocused and recommitted to growing leaders and inspiring their teams to turn their visions into reality.

On April 22, 2022 a team of our leaders rented a passenger van and drove 8hrs to Guadalupe Peak National Park. Guadalupe Peak is a rewarding, although strenuous, 8.5 mile round trip hike with a 3,000 foot elevation gain. It took a total of 8 hours to complete and was much more difficult than we anticipated. The following day we piled back up into the van and drove 8 hours back to New Braunfels. Squeezing into a passenger van after completing a grueling hike seems like it would be horrible but it was one of the best rides ever! We had fun blasting music, reminiscing about the death march we completed and just bonding in general.

This trip was one of the most amazing and transformational experiences I have ever had. Each of us came with a set of strengths and weaknesses and a varying ability to hike the course. We had some that could have run up the mountain (well, maybe just one clinical resource), some who walked at decent pace and some who had a very difficult time making it to the summit. The part that inspired me the most was how everyone helped each other out. We had stronger hikers in the back helping the ones who were struggling a bit. We had hikers leading the pack to encourage everyone to keep going and letting them know it was possible to make it to the top. Not one team member was left behind. The bonds and true friendships that were built that day are irreplaceable.

This experience can be tied to all of our goals as a market. The stronger operations help the struggling operations. The struggling operations are not scared to admit they are struggling and reach out to ask others for help. They are able to do this because they have relationships with each other that are built on trust. Every leader knows they will not be left behind. An activity we have decided to do as a market involves climbing peaks/hiking trails in Texas as a team. In essence, each climb is designed to challenge personal growth and ultimately help transform the way we serve our staff and residents.

Our question to you is…. What will your market’s challenge be? What “mountain” will you climb? If you come to TX and hike Guadalupe Peak, we will send you a medal. If you would like, we will come hike it with you!

If every market creates a challenge and a medal for those who complete it, we can motivate the clusters and teams to seek the medals together. Every adventure trip is priceless time with your team members having fun and hyper-focused to accomplish something extremely difficult. When they come back they are never the same again—what could this do for your buildings? Unity, loyalty, humility, perseverance, sacrifice…the list is endless in applications. Remember…the joy is in the journey!

APEX CHALLENGE:

  1. Pick your challenge (it has to be physical) and create excitement around it
  2. Create a medal
  3. Send pics of your challenge
  4. Update us on how your team responded (did this strengthen relationships? Etc)
    Move those mountains!! Conquer your challenges!! Build your teams!!
    CONTEST: Teams who submit a picture and a summary of how this impacted your team will be put into a raffle to win a prize!!

New Hire Coffee Connection

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By Denny Davis, Therapy Resource – Bandera – Arizona
Bandera East had its first New Hire Coffee Connection Meeting to help with retention, education, communication and culture. DOR Kathleen “Katie” Deichert, OT from Mission Palms, started this on the east side on April 29. We had three new hires (all new grads) and two current students (hopefully new hires in the future!) who attended, and it was a great success! They were very excited to meet other therapists and form relationships and connections with others within the organization.

We made it fun by playing two games to get to know each other, such as Left, Right, Center (which had a $15 grand prize!) and a Kahootz quiz covering a little bit of everything, including some background on Bandera, CAPLICO, billing, documentation and some general PDPM information to help introduce some different topics. The things they love about our company are the culture, the support and the feeling of belonging! We are doing a great job loving on our new staff and students!

I am very excited to be a part of the growth these new hires (and hopefully the students if they come back to us after they graduate) will go thru and see the great things they will bring to the company in the future as they learn, continue to develop their skill set, and become more confident therapists and leaders! I see great things coming!

Our next meeting in May will be with Matt Pecora at Chandler Post-Acute. 😊

Educational Nugget: Association Physical Activity and Risk of Depression

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Submitted by Jessica Foster, Therapy Resource, Bandera, Arizona
What are they saying? (**Definition of PA – Physical Activity)
The Message
The connection between physical activity and a lower risk of depression is well-known, but less is understood about the extent to which higher amounts of PA result in lower risks for depression. Researchers who analyzed the results of 15 studies involving more than 190,000 participants believe they’ve come closer to an answer: Yes, there is a dose-response relationship, they write, but it’s most significant (and predictable) at the lower end of the PA spectrum. Overall, they assert, if less-active adults in the studies had met current PA recommendations, one in nine cases of depression could’ve been prevented.

Why It Matters
Authors believe that establishing the dose-response relationship between PA and depression could be an important tool for health care providers and others in sharing the benefits of even modest amounts of PA, “especially to inactive individuals who may perceive the current recommended target as unrealistic,” they write.

More from the Study
Pinpointing the reasons for PA’s effects on depression were outside the scope of the study, but authors speculate that they could include neuro-endocrine and inflammatory responses, improved physical self-perceptions and more social interactions, and the effects of greater time spent in green spaces. The interplay of these factors needs more study, they add, particularly when considering how individuals with less access to green spaces and greater exposure to noise pollution may experience reduced mental health benefits.

Keep in Mind …
The study is not without its limitations, according to authors. Among them: PA levels were self-reported, data was limited at higher levels of PA, and data was lacking for analysis of demographic subgroups, including those from lower- and middle-income countries.