Using Life Story Boards to Assist Residents With Dementia

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Life Story Boards Assist Dementia Residents
 
At Park View Post Acute, the use of Life Story Boards has helped caregivers promote independence, provide appropriate cueing techniques and decrease negative behaviors in residents with dementia. We’ve found these boards to be resident-centered, efficient, economical and creative communication tools in our facility.

What Do Life Story Boards Do?

Life Story Boards share information about the resident gathered in the Life History Profile with caregivers, family and visitors. Each board identifies the stage of dementia via a facility-based color-coding system. Not only do the boards communicate meaningful information about residents in an easy-to-understand format, but they also provide opportunities for residents to have quality interactions with staff throughout the day.

Modified Allen Cognitive Models
 
Modified Allen Cognitive Levels
 

Results: Improving the Quality of Care With Measurable Success

In addition to the measurable results, we’ve seen subjective success as well. Family and staff have reported decreases in negative behaviors, and front-line caregivers are problem-solving with abilities-appropriate solutions. Residents also have increased participation in out-of-room activities.

Measurable Results

Next Steps: Starting Your Own Life Story Board Program

Here’s what you’ll need in order to start your own Life Story Board Program:

  • A multidisciplinary team with different perspectives who “share the vision”
  • Administrative support and commitment
  • Passionate, visionary therapists with a minimum of specialized dementia training
  • A dedicated, organized IDT leader
  • Openness to “out of the box” ideas and intelligent risk-taking

Here are some examples of ways to use Life Story Boards throughout your facility:

  • With lower-level patients — Used to inform caregivers about what was meaningful to the resident and to paint the picture of who that person was, though he or she may not be able to interact with the board
  • With higher-level patients — Used to promote meaningful conversation and reminisce with caregivers through pictures and word prompts
  • With Abilities Care interdisciplinary teams — Used to incorporate abilities-appropriate, resident-centered information into individualized treatment strategies, behavioral approaches and interventions as part of specialized dementia care plans
  • For use as a bridge — Used with the family during care conferences, to enhance new employee orientation, as an ongoing Abilities Care training tool and to ease the care transition when staff assignments change

Implementing Life Story Boards entails training your staff to recognize the meaning of the four color-coded dementia levels. The long-term goal is for staff to understand the associated strengths, challenges and care strategies associated with those levels. From there, they are best equipped to implement that knowledge expertly in providing resident-centered, abilities-driven care.

Music & Memory at Park Manor Rehabilitation Center

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Music and Memory
 
“Music is the art which is most near to tears and memory.” — Oscar Wilde
One of the reasons the link between music and memory is so powerful is that it activates so many portions of the brain at the same time. For example:

  • Tonality processes in the pre-frontal cortex, the cerebellum and the temporal lobe.
  • Lyrics process in the Wernicke’s and Broca’s area, as well as the visual cortex and the motor cortex.
  • Rhythm processes in the left frontal cortex, the right cerebellum and the left parietal cortex.
  • The medial pre-frontal cortex is responsible for music processing and music memories. Most importantly, the prefrontal cortex is among the last regions of the brain to atrophy.

Neurological research clearly shows that the Music & Memory program provides many therapeutic benefits for individuals with cognitive impairment or physical health decline, including:

  • Boosts cognitive function by reaching into the deep recesses of memory
  • Reduces the need for anti-psychotic medications
  • Provides an enjoyable, fulfilling and individualized musical experience
  • Triggers musical memories
  • Stimulates recognition abilities
  • Enhances engagement and socialization with family, friends, staff and peers
  • Reduces falls by decreasing restlessness and agitation
  • Provides person-centered care
  • Improves the quality of life for our residents

Getting Started

This program needs a Champion, as it is time-consuming to start and maintain. The Champion in Park Manor Rehabilitation Facility is our Social Services Director and one of her SS students who is doing an internship with us. They went to the Music & Memory course and became certified in the program. However, you can do the program without being certified; you just can’t use their name and logo.

You can start with your most agitated residents first to get the program up and running slower, so it won’t be so daunting. The SS student did an iPod (new or used), headphone and iTunes card drive at the university where she was a student and helped with all the initial setup. Park Manor employees also donated, as well as brought in CDs or flash drives with music to download. Our SSD orders used iPods, headphones and iTunes cards from Amazon periodically.

We also sent out letters to our family members letting them know that we were implementing the Music & Memory program. We asked them to let us know what their loved ones’ favorite music was and/or bring in any music they thought they would like.

To help prepare our staff, we had a facility viewing of the movie “Alive Inside,” a documentary about music and its effects on dementia (the start of the Music & Memory foundation), currently available on Netflix or at Amazon.com.

With the program up and running, we use the following process to personalize the experience for each resident:

  • Each iPod is assigned a number for each resident.
  • The iPods are then personalized with the resident’s playlist.
  • The staff check the iPods in and out for the residents (to help prevent them from getting lost or stolen).
  • When any staff member notices a resident appears restless or agitated, is yelling (but has no care needs), or even just appears bored or lonely, we ask them if they would like to listen to music.

Results

The Music & Memory program has enhanced the lives of our residents. Park Manor has one of the lowest rates in the state of Washington for psychotropic medication use. We have decreased our falls, and the program has decreased the noise level by reducing yelling and agitation.

Meanwhile, it has provided our staff with a powerful tool to care for our residents holistically. It has freed up staff time to assist with resident cares. Undoubtedly, the Music & Memory program is an essential tool to provide compassionate, patient care to our residents with dementia.

Abilities Care in Action

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Person-Centered Dementia Management, a Montessori-Inspired Program

At Legacy Rehab and Living, the protocol is a referral to therapy for any patient with a dementia diagnosis, a decline in function, and/or increased adverse behaviors with a goal to reduce psychotropic medications.

With these patients, we complete a comprehensive Life History Profile to develop personalized activities that tie in to the resident’s interests. We also administer the Allen Cognitive Level Screen/Allen Diagnostic Module to determine the resident’s cognitive levels and cognitive capabilities.

Motivating Patients

We value and appreciate each individual with dementia at Legacy Rehab and Living. We design interventions to facilitate the highest level of independence and to reduce adverse behaviors.

We begin by discovering activities that each resident enjoys to help motivate them to participate. By examining a resident’s preferred activities, cognitive capabilities, past experiences and remaining abilities, we are able to design meaningful activities that are appropriately adapted to the individual. Activities are:

  • Modified to be the just right challenge for the resident’s cognitive ability
  • Designed to engage all five senses
  • Designed to be meaningful and to provide the individual with dementia a purpose for an improved quality of life

Outcomes

Using this approach with dementia patients, we have seen a decrease in psychotropic medications, a decrease in behaviors, an improved quality of life and patient/family satisfaction, and improved quality measures. Above all, we strive to understand each person’s past in order to connect to their present and set them up for success at our facility.

By Marisa Parker, MS, CCC/SLP/DOR, Legacy Rehab and Living, Amarillo, TX

 

 

Building your own Elevated Garden Box

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Gardening is one of the most popular pastimes for Americans. And creating a meaningful treatment incorporating a purposeful treatment activity such as Gardening can leave our patients feeling good in spite of their health conditions, which may limit movement (such as arthritis) or cause fatigue. With a few strategies, gardening can be a great reinforcement for patient’s to practice their modifications within the context of a pleasurable and safe activity. According to the AOTA, occupational therapy professionals take a holistic approach and develop strategies to help people do the things they want and need to do no matter their limitations, disability, disease, or condition. Using Gardening as the therapeutic modality can make a treatment very meaningful to a patient.

– See more at: http://www.aota.org/about-occupational-therapy/patients-clients/health-and-wellness/gardening.aspx#sthash.2kWoDUAw.dpuf

One of the environmental modifications which helps make gardening a more accessible modality for our patients is the Elevated Garden Box, such as the one shown in the picture below. Therapy Resource, Curtis Hoagland, hand-crafted this gardening box for the Occupational Therapy Department at Richland Hills Rehabilitation and Healthcare in Fort Worth. By combining his love of building with wanting to help fill this need for the therapy team, Curtis brought a smile to the face of Jaclynn Stolfus, our OTR at Richland Hills pictured below standing with her newly delivered Elevated Gardening Box.

Elevated Garden Box – adapted from Ana White, Pinterest post.

Shopping List:

2 – 4×4 fir or cedar post (fir is cheaper and lasts nearly as long) I actually used pre-treated lumbar after researching that it is EPA approved for humans and food boxes.
3 – 6×8 cedar boards
3 – 1x3x6 cedar fence pickets (cheaper than cedar board)
1 – roll of 1/4″ hardware cloth 50×24″ (make sure to get hardware cloth with 1/4″ holes, 1/2 inch is too large and all your dirt will fall through)
16 – 3/8 inch x 3 inch lag screws
16 – 3/8 inch flat washers
Box of 1 1/4 inch exterior wood screws

Cut List:

Legs: cut the 4×4’s into 4 – 32 inch legs
Sides: cut 2 of the 6×8 cedar boards into 4 – 48 inch lengths
Ends: Cut 1 of the 6×8 cedar boards into 4 – 24 inch lengths
Bottom slats: cut the 3 – 1x3x6 into 6 24 inch lengths
Bottom hardware cloth: cut the hardware cloth into a 24×50 inch rectangle.

Pre-drill all holes to attach ends, sides and bottom support slats

Attach the 24” ends to the 4×4 post using the 3/8 x 3 inch lag screws (be sure to add a washer to the lag screw prior to driving it into the post). Allow the ends to extend beyond each 4×4 post by 5/8 of inch. This will allow the sides to butt up against the ends and keep the width of the box 24 inches (important to ensure the hardware cloth fits)

Attach the 48” sides (pre-drill holes) using remaining lag screws and washers.

To prevent cracking of the side and end boards, only drive the lag screws in about 2.5 inches and then hand tighten with a 9/16 inch socket until snug.

Cut the hardware cloth to about 50 inches long. Below is a picture showing how to wrap it around the legs. I tucked mine in on the inside of the end boards. Once it is aligned to the edges and tucked in on the ends, use ½ inch staples to secure it to the box on the post, the end board and the side boards (takes lots of staples).

 

 

 

 

 

Align the 1x3x24 inch cedar slats to the bottom of the box (equal distance apart) and fasten to the bottom of the sides using the 1 ¼ inch exterior wood screws (Pre-drill holes through the slats and sides to prevent cracking).

Alternate option (which I did): Add a 1×2 inch furring strip to the inside of each side about 5/8 of an inch from the bottom. Attach the hardware cloth to these furring strips and then align and attach the 1x3x24 inch cedar slats to the furring strips instead of the sides. This way the bottom slats are not visible on the finished project and anchor the hardware cloth more securely.

 

 

Lightly sand all edges. And then add a layer of compost or coconut cloth on the inside bottom of the box and then fill with potting soil or other planting soil of choice. The compost / coconut cloth helps prevent the planting soil from sifting through the bottom hardware cloth.

 

http://www.ana-white.com/2012/11/plans/counter-height-garden-boxes-2-feet-x-4-feet

Total Hip/Total Knee Arthroplasty Clinical Outcomes

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As you may know, treatment for a total hip arthroplasty and/or total knee arthroplasty involves surgical repair, stabilization and post-acute rehabilitation. While costly, these procedures often improve quality of life for patients.

At the same time, the costs of rehabilitation have been on the rise, and the Centers for Medicare and Medicaid Services has developed policies to ensure rehabilitation treatment is given in an appropriate setting.

At Palm Terrace Skilled Nursing Facility, we have undertaken a project that focuses on clinical outcomes for THA and TKA patients who choose to recover at a skilled nursing facility. We strive to inform patients and medical stakeholders of the potential clinical outcomes when SNFs are used to provide rehabilitation at a reduced cost and with positive results.

Through careful literature review, quantitative coding, data collection and analysis, we are able to observe the following results:

  • The outcome measures display a significant improvement from baseline records to discharge.
  • The option for post-acute rehab at an SNF will reduce costs while providing optimal care and recovery for THA and TKA patients.
  • Patients show improvements in all the outcome measures with the exception of maintaining a baseline for negotiating stairs during their stay at an SNF.
  • Providing both occupational therapy and physical therapy enables post-acute patients to have a longer stay in a facility that offers rehabilitation at a lesser cost compared with a hospital stay.
  • This study revels that a THA or TKA patient can return home with significant improvements.

Continued research is needed to determine which setting would be the most appropriate for THA and TKA patient rehabilitation. However, we are encouraged by the results of our study thus far. We have seen patients undergo rehabilitation at our SNF and return as close as possible to their prior level of function for ADLS in the least restrictive environment.

Submitted by Palm Terrace Skilled Nursing Facility, Laguna Hills, CA

An IDT Approach to Therapy

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Time and again, we see the benefits of an interdisciplinary approach to therapy with our patients at Rosewood Rehabilitation Center. Take, for instance, the case of our patient who was hospitalized due to Guillan-Barre Syndrome with symptoms of progressive weakness and impaired coordination. Our combination of physical and occupational therapy created a pathway for success with this patient.

Prior to the hospitalization, the patient was living with a spouse in a country home and was independent with all ADLs, IADLs and functional mobility without an assistive device. We recognized the following factors as being critical to the patient’s success at our facility.

Keys to Success With Physical Therapy

  • Neuro PENS three times per week with electrodes on the hip flexors and vastus medialis, and another line from just distal to the ischial tuberosities to the belly of the hamstring group.
  • HEP exercises for completion outside of therapy from the SOT.
  • Lateral and anterior/posterior weight shifting to increase proprioception at the ankles.
  • Use of the spectrum of assistive devices for ambulation fluidly during progression, from the parallel bars to a single point cane. With progress, we would constantly revisit more restrictive devices to refine a specific aspect of the gait pattern.
  • High and appropriate family involvement.

Keys to Success With Occupational Therapy

  • High cognitive function, active/fit before onset and motivated
  • CNA and family training to ensure carryover with OOB schedule and HEP for fine motor and UE strengthening
  • High and appropriate family involvement
  • Knowing your tools: E-stim versus therex versus fine motor activities, such as theraputty, to address deficits
  • Continuous evaluation of deficits and active grading up and down for the Just Right Challenge

This is just one example of a success story at our facility. We continue to explore the best ways to provide rehabilitation services for each individual using this interdisciplinary approach to care.

By Craig Chang OTR, Scott Judd PT, & Kristen Weaver OTR, Rosewood Rehabilitation Center, Reno, NV

Celebrating Our Team!

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Celebrating Our Team
 
At Somerset Subacute Nursing and Rehab, it’s not just a job for our rehab team; we also enjoy each other’s company. We always find time to eat and celebrate!

At the same time, our therapists are always working diligently to find the best ways to support our patients through rehab. Below are some of the highlights of our rehab team’s efforts.

Physical Therapy

Our PTs work with all types of patients, including those who are developmentally disabled, deaf or mute. Our staff learned to communicate via sign language, and patients have progressed from total assist and unable to ambulate to Modified Indep without AD upon discharge.

In addition, our DOR, together with other PTs from various facilities, collaborated on PT Day of Service for Alzheimer’s and Brain Awareness Month and was featured on the APTA website.

Occupational Therapy

We celebrated OT month together with Earth Day through the use of fine motor movements. We incorporated psychosocial stimulation of planting their own flowers and personalized it with their own pot painting.

Speech Therapy

Speech-language pathologists make a difference by making effective communication, a human right, accessible and achievable for all.

Our STs also work with trach/vent patients to address dysphagia and to improve overall quality of life.

By reaching out to one another and finding ways to connect as a team, we have built a supportive, interconnected culture at Somerset Subacute Nursing and Rehab. Even as we celebrate each other’s company, our therapists continually work together for the benefit of patients.

By Michelle Worth, PT, DOR, Somerset Subacute Nursing and Rehab, El Cajon, CA

Using Bundled Payments for Care

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Using Bundled Payments for Care
 
Sabino Canyon Rehabilitation & Care Center is always working to create a sense of community. Our dedicated, compassionate staff strives to exceed expectations and make a difference in the lives of those we serve by providing exceptional care and service and remembering they are the reason we are here. As part of this commitment to our community, we opted to participate in the Bundled Payments for Care program on Oct. 1, 2015.

Methods

The BPCI initiative is comprised of four broadly defined models of care, which link payments for the multiple services that beneficiaries receive during an episode of care. For example, Sabino Canyon’s focus is on medical non-infectious orthopedic and major joint replacement of the lower extremity. Under the initiative, organizations enter into payment arrangements that include financial and performance accountability for episodes of care. These models may lead to higher quality and more coordinated care at a lower cost to Medicare.

Results

By participating in the BPCI program, we were able to reduce the average length of stay by five days for all payers. We also implemented 90-day tracking for participants to reduce re-hospitalization. These participants became rehab candidates versus hospice patients.

Our goal is threefold with this program:

  1. To manage the length of stay with a continuum of care.
  2. To reintegrate participants back into the community.
  3. To track participants for 90 days, by ensuring they have follow-up appointments and continue to function in the community with participant education.

By providing these services, we help to reduce the cost of healthcare, improve the patient experience and better the lives of those we serve.

By Dora Alvarez, COTA/L Therapy Program Manager, Sabino Canyon Rehabilitation & Care Center, Tucson, AZ

 

 

Tai Chi at Holladay Healthcare

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Holladay Healthcare has been developing programs to assist people with Parkinson’s disease. We currently provide both the LSVT BIG and LSVT LOUD therapy treatment approaches by licensed and certified PTs, PTA and SLP. These approaches focus on improving amplitude of motor movements and voice projections, due to the decrease of these processes associated with Parkinson’s disease.

To go along with our LSVT therapy, Holladay Healthcare started providing tai chi classes to the community last year. We have been working with the Mountain West Parkinson Initiative (formerly known as the Utah Parkinson Association) to help increase awareness of these classes.

Tai chi involves a series of slow, rhythmic, meditative body movements that were originally designed to promote inner peace and calm. There are many benefits of performing tai chi, including balance/fall prevention, strength, flexibility, endurance, coordination, gait and decreased stress.

There are quite a few research studies being published about the benefits of tai chi as a viable exercise routine for people with Parkinson’s disease. For example, a randomized control trial published in The New England Journal of Medicine in 2012 researched the use of tai chi to improve postural stability for fall prevention. This study performed tai chi twice a week for 24 weeks and compared it with two other groups who performed a resistance training program or a stretching program.

Their results showed that the tai chi group performed better than the other two groups in their primary outcomes of maximum excursion and directional control. Tai chi outperformed the resistance group in stride length and functional reach; it also outperformed the stretching group in all secondary outcomes, which included stride length, knee extension/flexion strength, functional reach, and timed up and go test. Patients who participated in the tai chi group also had fewer reported falls during the study compared to the other groups. The gains made during the 24-week study were maintained three months following the study.

Here at Holladay Healthcare, we have been able to offer tai chi once a week for eight weeks. We are finishing our fifth class and have been able to help several people in our area with Parkinson’s disease. The community is starting to recognize us as a center to provide Parkinson’s treatment. Holladay Healthcare presented tai chi on Oct. 22 at the Mountain West Parkinson Initiative’s annual Parkinson Symposium.

References:
  1. http://www.medicinenet.com/tai_chi/article.htm
  2. Li F, Harmer P, Fitzgerald K, et al. Tai Chi and Postural Stability in Patients with Parkinson’s disease. N Engl J Med 2012;366:511-9
By Jeremy McCorristin, PT/DPT and DOR, Holladay Healthcare, Salt Lake City, UT

Community and IADL Reintegration Toolbox

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In the post-acute rehabilitation setting, we see many different types of patients from different socioeconomic backgrounds, ethnicities and cultures, as well as different prior levels of function. As occupational therapy professionals, it is our job to identify the needs of our different patient populations and address a treatment plan that allows for a safe return to prior levels of function. Oftentimes, this includes our independent activities of daily living in our community-dwelling older adult population. I strongly feel that while basic ADLs definitely have a role in the SNF setting, with insurance companies constantly looking for progress in these areas, IADLs have been largely overlooked in this setting.

At my facility, I have been working diligently to expand our role with IADL retraining. I believe that IADLs are not only important for a successful return to a prior level of function, but also as a treatment modality to be implemented according to our occupation-based principles. In my experience, many patients demonstrate improved standing activity tolerance, functional reach and dynamic balance when engaged in valued IADL tasks.

As such, my goal with this article is to encourage and provide resources for occupational therapy departments in developing IADL programs. Of importance to note is that the majority of the items for these programs were purchased from dollar stores or using items already around the rehab department. If you have additional questions, feel free to contact our department.

Meal Preparation/Cooking

When addressing meal preparation or cooking, we first identify the patient’s prior level of cooking. In order to best assess safety with these different aspects, we obtained a hot plate to simulate a stovetop and a toaster oven to simulate an oven, in addition to the microwave we already had available in our kitchen. Besides the standard safety assessment with cooking (can the patient turn off the hot plate/stove, reach all necessary items and handle hot items with caution?), it is also important to assess the ability to follow multi-step directions. Challenge the patient or adapt/grade the task accordingly from a three-step meal to a five-step meal and vice versa.

Grocery Shopping

For grocery shopping, I created a simple activity using items purchased from the dollar store or found around my home. With the help of our rehab aide, we affixed labels as price tags to the food items and created various shopping lists. Each shopping list incorporates different levels of difficulty. With the task, the patient can also practice money management and organizational skills, as well as identify potential issues related to item retrieval tasks with a new AD.

Community Reintegration

Depending on the socioeconomic status of the patient, both the physical therapist and the occupational therapist can be important in addressing community mobility options for the patient. Community mobility can be important in the patient’s ability to attend future medical or outpatient therapy appointments. As such, we developed a public transportation program to enhance our community reintegration services. The patient can practice identifying bus routes and estimating times and can even participate in an actual bus outing.

Medication Management

One of the first steps we try to address with new patients with a high PLOF is to assess their ability to manage new medications using an assessment tool. We can also practice using the patient’s own medication regimen and

beads to improve the patient’s ability to manage medications upon discharge. Furthermore, we are able to provide necessary recommendations regarding the type of pillbox (one time per day, two times per day, four times per day, etc.) and potential need for assistance or reminders via a phone or an alarm.

Other IADLs

In addition, other IADLs and leisure tasks can also be important to address in improving functional outcomes for our community-dwelling population as well as improving motivation with participation in therapy programs. Other programs that we have expanded upon at our facility are gardening, laundry and item retrieval tasks. My next project and goal is to develop a simulated pet care program to include feeding, washing and grooming, as many patients state this as one of their main goals and prior activities.

By Kathryn Case, OTR/L, Magnolia Post Acute Care, El Cajon, CA