MP

In our facility, we wanted to restart the Restorative Nursing Program to keep our patients at their highest practical level, to be proactive with declines and to capture appropriate resources being provided to patients. Due to high turnover on the nursing team, as well as nursing leadership, it became a challenge to keep the program alive at our facility. With a new Director of Nurses hired, it created an opportunity for us to cultivate a partnership with the nursing team and revamp the program to the benefit of our residents.

We identified the following problem areas:

• The therapy department did not have a specific system to identify appropriate residents to refer to this program.
• The RNP was not properly trained in how to carry out the program.
• The therapists were uneducated on how to create recommendations for clinically appropriate patients to the nursing team.
• There was a lack of communication between nursing and therapy about who was on the program and who might need a referral.

We then implemented several solutions:

• Identify significant changes in function through reports in PCC and review weekly.
• Meet with the MDS Coordinator weekly to determine referrals through MDS reports.
• Meet with facility staff weekly to discuss any changes, including declines or improvements.
• Implement therapy discipline-specific quarterly screens and ROM screens.
• Train each patient we refer to this program through one-on-one restorative training and additional trainings throughout the year.
• Train therapy team in how to appropriately screen patients and make referrals to the Restorative Nursing Program.
• Create a culture of therapy, Functional Maintenance Program, Restorative Nursing Program or activities, involving all patients at our facility in at least one of these programs.
• Get behind the program and drive the bus, not allowing others to get complacent and quickly fixing issues that arise. Instill confidence in those who provide the program and those who refer to it.

Outcomes

Once our facility put systems in place to identify appropriate patients to refer to this program, we added two full-time restorative aides to provide restorative nursing six days per week. Since then, our residents have increased socialization through this program and have experienced shorter length of stays on therapy services. Due to continual staff education, nursing is more aware of how therapy can help. When there is a decline or an improvement, the therapy department receives more timely notifications.

Additionally, we have an increased Medicaid rate due to the facility being able to capture the additional resources being provided to the patients through the robust utilization of this program. This has allowed the facility to pay for the additional full-time restorative nurse aides and helped shift burden off the primary caregivers (certified nurse aides).

By Stephany Kozeny M.A. CCC/SLP and Mandi Kelly LVN RAC, Wellington Rehabilitation and Healthcare, Temple, TX

Lake Village Nursing & Rehabilitation is known for its high quality of care and success rate. Many patients continue to return to this innovative facility for all of their rehab needs. What is it about Lake Village that allows us to generate consistently high success rates as well as quantifiable profit margins?

We believe it comes down to a multifaceted approach to patient care involving teamwork, staffing and equipment, and patient-directed treatment. Combined, these components result in a thriving platform year after year.

Teamwork, Staffing and Equipment

At Lake Village, we have found that a collaboration of disciplines may enhance patients’ compliance, satisfaction and overall generalization/carryover of skills. For example, physical and occupational therapy work together to develop strength, balance and teaching skills needed for ADLs. While PT works on W/C transfers, OT might incorporate these instructions while practicing toilet transfers, as well as self-care and dressing.

Meanwhile, the speech therapist may communicate with the team regarding patients’ communication needs, including levels of cuing when learning an activity, appropriate complexity of language and the maximum number of directions patients can follow, in order to increase overall retention of coaching and treatment.

In order to maximize teamwork and communication between disciplines for overall quality of care, it is important to recognize the role of team-building, led by the DOR, using techniques such as lunch and learns for therapy staff, off-site departmental lunches, group mentoring, one-on-one feedback and a generalized focus on employee satisfaction.

An Employee Satisfaction Survey was administered to all full-time therapists in order to measure overall happiness at work and its effects on patient care:

Patient-Directed Care

Disability may relate to several body systems and affect many aspects of life. Therefore, rehabilitation should address all needs of the individual patient. The delivery of care should be tailored to the patient’s needs.

At Lake Village, team members are problem-oriented rather than status-minded. The therapists treat the patients, instead of treating the diagnosis. Upon leaving the facility and/or upon discharge, patients feel a sense of completion and success, as well as a full understanding of techniques to assist in maintaining their achieved level of function.

Catering to the specific needs of each patient, along with creating an individualized plan of care, leads to a higher rate of goal-met status as well as positive results/reviews for the therapy team and the facility as a whole. Below is a testimonial from a satisfied patient:

“When I first arrived, I was helpless. I could barely roll over or move around in my bed, let alone sit up in a chair without having severe anxiety and tremors. After months of therapy, with therapists I trusted, I gained confidence enough to make progress. I can now transfer much easier; I walk 190 feet at a time with a walker, with just one standing rest break! I really appreciate the therapists, who in the end, turned out more like friends, because of how much they care.”

Conclusion

Lake Village provides skilled therapeutic intervention aimed at increasing overall quality of care. We focus on teamwork, staffing and equipment, and patient-directed treatment in order to provide a thriving environment for all. This year, we have improved in many areas, including employee satisfaction and decreased use of contract labor. In the future, we aim to create an outpatient setting, in order to transition our patients in the continuum of care with personalized and trustworthy care.

At Hurricane Health and Rehabilitation, we have seen time and again that collaboration improves patient outcomes. Take, for example, the case of Phil, a 50-year-old resident who arrived at our facility after sustaining a bilateral anterior cerebral artery infarction (ACA CVA). Phil sustained damage to both hemispheres of his frontal lobe with corpus callosum involvement.

Having been discharged from our local hospital’s acute rehab unit due to failure to comply with the required therapy regime, Phil came to Hurricane Health with unique requirements. With such a rare stroke, Phil needed a therapy team willing to collaborate not only amongst ourselves, but also with the healthcare community to create and execute a successful plan of care.

The Problem

Phil was alert and pleasant, but he also was described as apathetic and unwilling to cooperate by the neuro specialty rehab unit at the local hospital. His deficits included difficulty following simple commands, incontinence, minimal response when asked questions, occasional volitional speech, poor initiation of gross motor movements, and an inability to communicate with staff to express wants and needs.

Finding Solutions

Phil’s condition did not improve after two weeks of traditional therapy approaches. Preliminary research revealed that Phil’s behaviors were common sequelae of bilateral ACA CVA, rather than therapy avoidance behaviors. Therapists shared findings from treatment sessions to create a clear picture of Phil’s deficits and preserved skills. Together, we discovered he presented with symptoms characteristic of akinetic mutism.

The Opportunity

Now that Phil was communicating effectively with staff and family and initiating ADL routines, he was able to participate in more rigorous physical and occupational therapy. He began to make progress with gross motor movements as well.

Meanwhile, speech therapists collaborated with OT Asa Gardine to address bowel and bladder care. Using Phil’s own cell phone, we programmed alarms every three hours and trained him to request assistance to the restroom at these scheduled times. Input from both therapies was critical to implement such an effective bowel and bladder program.

Collaboration

Evidence-based therapy approaches for Phil’s akinetic mutism were not readily available. Phil’s speech therapists, Karen Straw and Maggie Maxfield, reached out to experts in this field of research to learn about effective techniques.

We were contacted by Danielle Erdman, a speech therapist with Brooks Rehabilitation in Jacksonville, Florida. She studies a phenomenon called the “telephone effect,” or the transient improvement of communication skills when patients with akinetic mutism speak over the telephone, rather than face-to-face.

Through our collaboration, we crafted a unique therapy plan that relied on the telephone effect to improve Phil’s communication skills. We saw rapid improvement in all of Phil’s communication deficits, with sufficient carryover away from the telephone — a novel finding that is being prepared for publication by Erdman, et al.

Outcomes

Undoubtedly, collaboration proved to be the key to identifying the best therapy approaches for Phil. His akinetic mutism symptoms improved significantly once we were able to identify a neurological etiology for observed behaviors, to determine appropriate goals and to use evidence-based practice for effective therapy.

As a four-month resident of our facility, Phil continues to progress toward independence in execution of ADLs. He has graduated from requiring two-person transfer assist to the independent use of a walker and improved independence in bowel and bladder care so he can return home.

 

Managing wounds is one of the most critical components of helping patients to heal after surgery and get back to living their lives. With the Post-Myocutaneous Flap Rehabilitation Program at Englewood Post Acute Rehab, we have experienced positive outcomes with patients in need of post-surgery wound care.

The program took root through a relationship established between an ED (who is an RN) and a local reconstructive surgeon. As a result of discussions about the growth potential of a program geared toward post-myocutaneous flap rehabilitation, we determined that there was a great need in the community for a program addressing this type of therapy.

After obtaining physician protocols, we were able to train therapy and nursing staff in the use of MIST^® Therapy to heal sutures post-surgery. MIST Therapy is a painless, noncontact, low-frequency ultrasound delivered through a saline mist to the wound bed. Unlike most wound therapies that are limited to treating the wound surface, the gentle sound waves of MIST Therapy stimulate the cells within and below the wound bed to accelerate the normal healing process.

With additional training provided to staff regarding the care, turning and sitting tolerance schedules, the program has welcomed seven patients thus far and continues to grow. Our positive outcomes have led the surgeon to refer additional patients with surgical closures and severe wounds.

MIST Therapy recommended by the surgeon can be done by an RN, thereby decreasing therapy minutes while patients build sitting tolerance. We are seeing a greater need for nursing staff due to MIST treatments and sitting schedules. We also see extreme variations in patient abilities and PLOF.

As we continue to fine-tune the program, we will be actively assessing the power mobility of this population, including the potential for re-integration activities. We look forward to seeing the program grow and potentially serve as a benchmark for facilities wishing to implement such a program.

By Deming Haugland DPT, DOR, Englewood Post Acute Rehab, Englewood, CO