Physical Mobility Scale Is an Effective Standard Test for Skilled Rehab

MP News

When it comes to our long-term care patients, many of our standard tests simply do not serve them well in regards to monitoring subtle changes over time. Standard tests such as the BERG, DGI and Tinneti are not good for patients who are wheelchair-bound. Additionally, using these tests as short-term goals can create challenges, as the patient’s overall scores will remain relatively unchanged for several weeks in most cases.

In contrast, the Physical Mobility Scale (PMS) can be used to help determine improvements and declines in function, as it measures a wider range of functional skills. The PMS measures nine basic movements using an ordinal scale of 0 to 5 for a total of 0 to 45 possible points.

Article Review

Pike and Landers (2010) studied 70 LTC residents to determine the minimal detectable change (MDC) for the PMS. The same therapist was used for all tests. Residents were tested three months apart, and a 7-point Likert Scale (very much improved to very much worsened) was used to determine how much change indicated 95 percent confidence level (MDC95).

Results

Table 1 shows the ratings of the pre- and post-tests (three months apart).

 

 

 

 

 

Data

It was found that a 5-point increase and a 4-point decrease showed a minimal clinically important difference at the 95 percent confidence level (MDC95). The scores that reflected no change were removed, and all improved scores and worsened scores were combined into two separate categories as seen in table 2.

 

 

 

Conclusion

The Physical Mobility Scale is reliable, easy to use and understand, covers all the basic skills of our patients and has high validity. This standardized test will show steady progression over time and can be used to determine increases and decreases in our long-term and short-term residents.

By Scott Langdale, PT/DPT, DOR, Beacon Hill Rehabilitation, Longview, WA

Stratifying Risk for Hospital Readmission and Assessing Safe Discharge

MP Learn

At Gateway Transitional Care Center, we’ve found that administrators and clinicians can work together to stratify residents’ risk for re-hospitalization. Below, we’ve provided some data to aid in understanding the current statistics associated with hospital readmission from skilled nursing facilities (SNF).

Hospital Readmission Rates: Why They Matter

Hospital readmission rates are regarded as a valid quality measure for SNFs:

  • CMS data show top ¾ rate < 17%
  • Bottom ¼ > 23%
  • Authors conclude the relationship between readmissions and quality of facility is not an artifact
  • High rates may damage hospital-SNF relations
  • Hospitals penalized by CMS for readmissions
  • Increased burden on U.S. healthcare ($9.41 million in Idaho alone)
  • 20% of Medicare beneficiaries discharged to SNF
  • One in four patients discharged to a SNF is readmitted within 30 days
  • Two-thirds of these readmissions may be preventable

Note: Risk stratification can occur during both admission and discharge.

Hospital Scoring Validation

  • Kim et al. validated use of the tool in 2016
  • Risk stratification
  • All cause readmission 30.9%
  • Low risk (0-4) 15.4%
  • Intermediate risk (5-6) 28.1%
  • High risk (>7) 40.9%
  • Those at high risk tend to be those who are younger (mean age 72.8), likely to be on dialysis and discharged to subspecialty service

 

Discharge Risk: Function Out-Predicts Co-Morbidities

  • Main tool of use: Functional Independence Measure
  • Motor subscale out-predicted cognitive subscale
  • Motor subscale
  • Eating, grooming, bathing, upper and lower body dressing, toileting, bowel/bladder management, bed to chair transfer, toilet transfer, shower transfer, locomotion, stairs

Prediction At Discharge Using FIM Categories

  • Patients dependent in any category of mobility — 50% increased odds (OR= 1.50)
  • Patients dependent for self-care — 36% increased odds (OR = 1.36)
  • Patients dependent for cognition — 19% increased odds (OR= 1.19)
  • All compared to 8.5% for those independent in ⅔ categories

Additional Performance Measures Useful for Prediction

  • 10 Meter Walk Test
  • Functional Reach Test
  • Six-Minute Walk Test

Using the above data, we can assess and stratify patient risk for hospital readmission, as well as predict discharge safety using valid outcome measures based on the current best evidence. By providing evidence for risk, facilities may decrease rates of hospital readmission and justify the need for ongoing services to better meet patients’ needs.

By Ian M. Campbell, SPT, Gateway Transitional Care Center, Pocatello, ID

ADL Billing Versus Self CARE Item Set Change

MP Share

At Mountain View Care Center, we questioned whether there is a correlation between the amount of activities of daily living (ADLs) the occupational therapy staff has been providing to patients with changes in their’ functional level upon discharge. We chose to compare this by analyzing the percentage of ADLs billed in the facility with the change in CARE item set from admission to discharge.

Methods

We gathered Optima reports from all Bandera facilities to determine service code usage of self CARE ADLs (97535) as a percentage of total billable services for a three-month time period. Functional Outcomes report containing the change in OT Self CARE item assessment was obtained for the same three-month time period. These two reports were analyzed to determine if there was a correlation between the two sets of data.

Results

The amount of billing of 97350 seemed to equate with the amount of change in CARE. However, upon closer statistical analysis, this was not found to be the case. There was no correlation found between use of ADL billing code (97535) and improvement in CARE item set. Billing of the code 97110 had a negative correlation with the improvement in ADL scores.

Data

  1. CARE item set and billing of ADL (97535) code
  2. Correlation between usage of billing codes and change in CARE item set

 

 

 

 

 

 

 

Conclusion

We concluded the following:

  1. The overuse of therapeutic exercise in OT treatment plans has a negative impact on patients’ improvement in functional levels.
  2. Occupational therapy should minimize treatments that involve purely therapeutic exercise in their daily treatment sessions.
  3. It would be more beneficial for the patients to address strength deficits through the use of ADLs and therapeutic activities than using upper body ergometry or tabletop activities.

In the future, we’d like to further our analysis by performing a study using a change in ADL levels instead of CARE to decrease concerns about CARE not being an accurate measure of improvement. Furthermore, after educating the staff on the increased use of ADLS as a modality, we’d like to perform the same analysis to determine if there was an increase in CARE item assessment as a result of increased ADL usage.

By Tonya Haynes, PT, DOR, Mountain View Care Center, Tucson, AZ

Bathing Without a Battle

MP Celebrate

It’s not uncommon for residents to resist showering, and as therapists, we work to ease their anxieties while supporting our staff. At Northbrook Healthcare Center, we’ve implemented strategies that have proved successful in encouraging residents to participate in bathing routines and even find enjoyment in the process.

Background

We had a resident exhibiting negative behaviors, i.e., slapping staff, yelling and cursing when CNAs approached her for a shower. Documented refusals resulted in a referral to our occupational therapy department for the Abilities Care Program and our Bathing Without a Battle program.

Using the Life History and Profile, OT was able to identify purposeful and meaningful activities the resident enjoyed, including:

  • Listening to classical piano music through her headphones
  • Painting her wooden birdhouses (she’s an artist)

We also implemented simple changes such as rephrasing the showering task as an opportunity to “freshen up,” language to which this Southern Belle resident responded well. Additionally, we trained nursing staff to provide an alternative to bathing. In the event the resident declined a shower, she would be offered a “Bath in a Bag.” Prior to a shower or bathing task, she was also reassured that her coffee, snack and classical piano music would be ready for her in her room.

Results

Previously, this resident refused any type of shower or bath for two to three months. Now, the resident demonstrates 100 percent active participation and no negative behaviors. Our Bathing Without a Battle program is proving effective for this resident, and undoubtedly, for the staff helping to implement her grooming routine!

 

By Tyler Johnson, OTR/L, DOR and Joni Johnson, COTA/L, TPM, Northbrook Healthcare Center, Willits, CA

A COPD Case Study

MP Share

At Northeast Nursing and Rehabilitation, we cared for a 77-year-old white male who had been recently hospitalized for acute cholecystitis. His PMH included CAD, a pacemaker, cardiac stents, HTN and COPD. The patient presented with a variety of problems, including debility, decreased ADLs, poor static/dynamic and sitting/standing balance, decreased mobility, decreased aerobic endurance and breathing abilities, and poor phonation.The patient also had decreased breath control, able to produce only three words without taking a breath. He required constant oxygen and had little diaphragmatic breathing, possibly related to the secondary effects of COPD.

Prior Level of Function

Prior to admission, the patient was ambulatory with a cane for household distances. He was I with ADLs, bed mobility and toileting, as well as I with dressing and hygiene/grooming. He consumed a regular diet, had good aerobic condition and did not require oxygen.

Interventions

We employed several strategies to help the patient, including physical, occupational and speech therapy interventions. For example:

  • PT provided family education on safety/sequencing, continual monitoring of vitals during treatment sessions, kinesio taping to address knee pain, and patellar mobilization.
  • OT addressed ADLs, LB dressing, donning/doffing shoes, UE strength, gross/fine motor UB control to manipulate objects, hygiene/grooming activities, toileting, and safe decision making.
  • ST placed the patient on a COPD program, worked on pursed lip breathing, diaphragmatic breathing, deep breathing exercises, huff cough technique, stretching and strengthening exercises, instruction in use of inspironmeter, fluency and intelligibility exercises in conversational speech.

Outcomes

As as result of our interventions, the patient showed marked improvement in several areas, including functional gait distances with use of a cane, improved dexterity and fine motor control, LB dressing, toileting and more. His phonation improved, and the patient did not require oxygen at home. Ultimately, the patient was able to return home with the support of his family and thanks to the combined efforts of our therapy teams.

By Rochelle Lefton, MA, OTR; Michelle Scribner, MSLP; Heather Cox, DPT; Susan Garcia, COTA; Jesusa Herrera, PTA, Northeast Nursing and Rehabilitation, San Antonio, TX

Improving the Patient Experience Through Patient-Centered Care

MP Share

Patient Centered Care isn’t just taking good care of our patients. It is a holistic philosophy of including the patient and their family members in as many decisions and system/facility improvements as possible. It means offering choices whenever possible, thereby giving our elders more control over their lives.

This approach may include asking for their input on anything from what kind of furniture they would like to replace the old furniture in the front lobby, to what we should ask them on a discharge survey, to simply when they would like to go to bed at night. We are still in our infancy with implementing this philosophy, but here is what we have accomplished thus far:

Long-Term Care Residents

  • We invited six LTC residents to help plan our Nursing Home week in May. They offered suggestions and picked the theme for each day, the activity and the special food to be served.
  • We have added an “Activities Calendar Planning” day to our Activities calendar and have begun including LTC residents with the planning of their monthly events.
  • We have included LTC residents on our Dining Experience Performance Improvement Plan (PIP) to get their feedback on what they feel would improve their dining experience.

Rehab Patients

  • We created a PIP for the first 24 to 48 hours, as this has been an area where we either shine or fail to impress.
  • We invited a prior patient and his spouse to meet with us and get their feedback on their experience and collaborated on which areas we needed to improve.
  • Therapy is offering a choice to new patients of what time they would like to be evaluated (before lunch or after lunch).
  • Therapy is also asking each new eval if they would like to make a friend while rehabilitating. We then introduce them to another patient who also expresses an interest in meeting someone.

Through our patient-centered approach, we are able to improve the quality of life for residents and ensure they feel not only well-cared for, but also valued and significant.

By Park Manor Rehabilitation Center, Walla Walla, WA

Passport to Home: An Interdisciplinary Case Report

MP Share

We all know it’s true: There’s no place like home. That’s exactly what our 70-year-old female patient expressed upon admission at Olympia Transitional Care and Rehabilitation.

The patient experienced a cardiovascular accident at home resulting in a fall, with left distal femur shaft fracture. Upon admission, her level of function was as follows:

  • Hoyer transfer
  • NWB in LLE for eight weeks
  • 9/10 pain in LLE, TD for toileting and dressing ADLs
  • Mild-mod swallow impairment with mechanical soft and thin liquids
  • Mild dysarthria
  • Mild-mod cognitive communication deficit

The patient lived at home with her spouse with multiple myeloma in a supportive, social community. She was independent with gait in her home and over short community distances; with swallow function, motor speech, functional cognition for her living environment; and with ADLs and IADLs, including cooking and cleaning.

This patient had one simple goal: “To get back to the way it was.” More specifically, she wanted to return home to her spouse and her cats, return to ambulation at household distances, and decrease the level of caregiver assistance for ADLs.

Treatment Approach

Taking an interdisciplinary approach, we developed a treatment plan combining physical, occupational and speech therapy. COTA and PTA created a “Passport to Home” document to visually track patient goals and progress:

  • Goals are checked off as they are achieved
  • The patient has an active role in goal-setting and completion
  • Extrinsic motivator for compliance over a lengthy rehab stay

Physical Therapy

  • Pain management — manual therapy
  • Transfer training — progressive strengthening, slide board transfers
  • Gait training — parallel bars, bariatric FWW
  • Balance training
  • Stair training

Occupational Therapy

  • Toileting — Q2 hour toileting schedule, nursing staff in-service for compliance
  • Dressing — adaptive equipment education, timed trials for improved function
  • Tub transfers — tub transfer bench
  • UE resistance to fatigue

Speech Therapy

  • Oropharyngeal dysphasia — OMEX, compensatory strategy training
  • Dysarthria — OMEX, breath support training, compensatory strategy training
  • Cognitive communication deficit — external memory aid training, attention processing strategies

Additionally, we collaborated with nursing staff to ensure:

  • Safe swallow strategy and positioning training (ST, PT)
  • Compliance with toileting schedule with use of external memory aid (ST, OT)
  • Transfer recommendations set up (PT, OT)

Conclusions

Using an interdisciplinary approach with complex patients is essential to realizing the highest level of performance success. The use of standardized testing allowed us to develop a personalized plan of treatment for this patient’s needs and improve the chances of a positive outcome.

Although this patient was quite discouraged at the onset of rehabilitation and did not have high expectations for success, we were able to encourage her along the way and improve her outlook. With a team approach, were developed a detailed treatment plan that ultimately allowed her to return home near her prior level of function.

By Scott Hollander, PT, PDT; Sarah Koning, MSOT, OTR/L; and Megan Bennett, MS, CCC-SLP, Olympia Transitional Care and Rehabilitation, Olympia, WA

Group Therapy Versus Individual Therapy

MP Learn

As our payers become more complex, we as therapists need to discover ways to get better outcomes, in less time, with less reimbursement. Toward that end, we compared the functional outcomes, using the CARE item set, of our Medicaid skilled patients receiving more minutes of group therapy, as opposed to only individual minutes per our contract guidelines. We also compared the outcomes of our Medicaid patients who received group therapy to all of our patients who received all modes of therapy.

Methods

Group therapy was provided to Medicaid skilled patients following the below protocol for a two-month period:

  • Patients with a POC for five times per week received three days of group therapy (average 45 minutes) and two days of individual therapy (average 15 minutes)
  • Patients with a POC for three times per week received two days of group therapy (average of 45 minutes) and one day of individual (average of 15 minutes)
  • All groups were functional-based and were individualized per each patient’s POC
  • For all other payer types, all modes of therapy were used

Results

Results from the two-month study compared to two months prior (with no group therapy):

  • Physical Therapy functional outcomes per the CARE items improved by 30 percent for the mobility subset
  • Occupational therapy functional outcomes per the CARE items improved by 3.7 percent
  • Culture in the department improved (per staff report)
  • Patients asked to participate in group on days assigned as individual and had increased satisfaction in therapy (per resident reports/survey)
  • Family members asked for their relative to be in groups more often (per family reports)
  • Staff (CNAs) have extra time to attend to other responsibilities when multiple patients are away and patients were easier to care for with great improvement from better outcomes
  • Productivity of the department improved by 5.8 percent
  • Functional Outcomes comparing the Medicaid skilled patients receiving group therapy to all of the therapy patients: the mobility subset had 16.5 percent better outcomes, and the self-care subset had 6.3 percent better outcomes

Data

This chart shows the change in each CARE Item Set area between our control (two-month period) and our case study (two-month period), along with a comparison to the outcomes for all payers for the time period of our case study.

 

 

 

 

Conclusion

In conclusion, group therapy does improve functional outcomes versus individual therapy for Medicaid skilled patients. Additionally, outcomes were better for Medicaid patients who received group compared to all other patients (all payers) during the case study period.

In addition, group therapy provided other positive outcomes, including:

  • Increased patient satisfaction
  • Increased family satisfaction
  • Increased staff satisfaction
  • Improved culture in department
  • Improved productivity

Group therapy has shown to be a valuable mode of therapy to increase outcomes, satisfaction and productivity. Use of this mode of therapy may benefit more payer types and may be a way to continue providing great therapy services by using our resources efficiently to help with our ever-changing world of healthcare.

By The Entire Rehab Team, Led by Tracy Carrier, DOR, Chandler Post Acute & Rehabilitation, Chandler, AZ

HeartMath: Utilizing Heart Rate Variability Biofeedback

MP Share

Utilizing Heart Rate Variability Biofeedback in a Patient With CVA to Improve Psychophsyiological Coherence

By Amanda Call, MA, OTR/L, Draper Rehabilitation and Care Center, Draper, UT

At Draper Rehabilitation and Care Center, we treated a 74-year-old female patient who sustained L hemispheric hemorrhagic CVA. She presented with a host of symptoms, including R hemiplegia, dysphagia, aphasia, R neglect, malnutrition, HTN, pain, muscle spasms, constipation, depression, anxiety, neuropathy, GERD, nausea/vomiting, hyperlipidemia, and R foot and coccyx wound.

The patient spent approximately two months in a rehab hospital, followed by two months in another SNF, then came to AVR four months after her admission to the hospital. She was six months post-CVA at the time of this intervention and was reaching a plateau with therapies because of difficulty regulating her emotions, which caused increased tone and aphasia.

As the therapists involved with the case brainstormed ideas to address the barriers preventing the patient’s progress, the patient’s ability to self-regulate emotions and physiological states came up as a common barrier that was limiting progress and functioning. At this time, OT learned about heart rate variability biofeedback and theorized that the patient might benefit from this intervention to facilitate self-regulation skills. She suspected that teaching the patient to control heart rate and breathing would help with emotional regulation as well as improving tone and aphasia, which would allow her to progress with her therapy goals and become more independent.

Literature Review

“Heart rate variability is a measure of the naturally occurring beat-to-beat changes in heart rate.” (McCraty et al 2004). When an individual’s respirations and heart rate are at an optimal frequency, this is referred to as coherence. Coherence is “the maintenance of a physiologically efficient and highly regenerative inner state, characterized by reduced nervous system chaos and increased synchronization and harmony in system wide dynamics” and “is conducive to healing and rehabilitation, emotional stability, and optimal performance” (McCraty et al 2004).

Research studies suggest that “individuals with brain injury and impaired self-regulation often display HRV patterns with reduced HRV” and speculate that interventions which address HRV “could directly enhance the ability to self-regulate.” (Kim et al 2015).

A study of individuals with severe brain injury found that there was an association observed between HRV coherence and improved emotional control, attention, life satisfaction, self-esteem and self-awareness and concluded that “HRV biofeedback has promise as an effective, cost-efficient method for improving self-regulation in individuals with severe brain injury” (Kim et al 2015).

An additional study of individuals with chronic brain injury found that there was an association between HRV training and the regulation of emotion and cognition and that “individuals with severe, chronic brain injury can modify HRV through biofeedback” (Kim et al 2013).

Intervention

OT facilitated seven treatments utilizing heart rate variability biofeedback training during a period of three weeks. Interventions were completed using a computer-based system that tracked heart rate using a pulse oximeter and created a visual representation of heart rate variability on the computer screen. The visual representation was in the form of a line graph and a bar graph, but the system also allowed for the feedback to be given in the form of a variety of games. This patient preferred to receive feedback through the games.

This intervention was used as a preparatory activity for ADL tasks such as toileting. At the beginning of this intervention period, intervention focused on discussion of toileting because toileting was a task that caused significant fear for the patient, resulting in increased tone, difficulty communicating and difficulty problem solving to complete the task.

As the patient improved her ability to modify her heart rate variability, intervention progressed to toileting in the therapy gym, then in the patient room and with her CNAs. Furthermore, as the patient became better at regulating her physiological states while using the program, therapists began encouraging her to apply the strategies during ADL tasks. For example, if the patient became upset or frustrated during toileting, the patient was encouraged to close her eyes and picture the biofeedback games.

Example of game available in emWave Pro™ program. As patient coherence improves, the rainbow extends to the pot of gold and gold coins can be earned.

Results

During the three week period after initiating the intervention, the patient showed improvement in the following areas of OT functioning: View here: HeartMath – Draper

 

Alexa and TBI Helps Patient Following Brain Injury

MP Learn

Consider the following patient profile: A 19-year-old with traumatic brain injury secondary to assault presented with moderate deficits in immediate and short-term memory as well as temporal and spatial orientation. He was also legally blind as a result of his injury.

The patient has been receiving skilled Speech Therapy at Rock Canyon since March 2017 to address oropharyngeal dysphagia and communication/cognitive deficits. Additionally, our team employed the use of an Alexa device and TBI services for therapeutic interventions, plus an improved quality of life for the patient.

 

Intervention Components

Caregiver Coaching

  • Educating the patient’s mother on programming the device and its features
  • Encouraging caregivers to cue the patient to use the device for temporal orientation and checking or adding events to the schedule

Script Therapy and Drill

  • Rehearsing with the patient before having the patient activate the device for adding events to the schedule, checking the date and daily schedule, and solving math problems with drill exercises

Education on Device

  • New skills, entertainment features (music, books on tape)
  • Shift in ownership — allowing the client to take the initiative to use and experiment with the device independently

Quality of Life

  • Music (Spotify, Amazon Prime)
  • Books on tape (Audible)
  • News (NPR)
  • General information (Wikipedia)
  • Weather
  • Horoscopes
  • Alarms
  • Games (Jeopardy)

Data

At the baseline, the patient was able to answer 0 percent of temporal orientation questions (day of the week, date, year) or his daily schedule. Currently, the patient shows significant improvements in regards to temporal orientation and personal scheduling when verbally cued to use the device. Goals include having the patient answer temporal orientation questions, add events to his schedule and check his schedule without being cued to use the device.

By Rock Canyon Rehabilitation, Pueblo, CO