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Mike Johanson, MSPT for Horizon Home Health in Idaho, wrote and has trained Cornerstone and other therapists with his Stepping Stones program of fall prevention. The one-and-a-half-day course helps therapists to further their understanding of differential diagnosis regarding symptoms of dizziness, disequilibrium motion sensitivity, imbalance, gait instability resulting from BPPV, central dizziness, visual weakness, somatosensory loss, musculoskeletal imbalance and movement disorder.

Understanding the Rationale for a Balance and Falls Program

• Approximately 30 percent of community living adults fall at least once a year
• Ten to 20 percent of these community living adults have two or more falls a year
• Falls are the most common mechanism for injury in older adults
• 10 percent of those who fall will sustain a serious injury
• Approximately 300,000 hip fractures occur annually in the United States
• 25 percent of these hip fracture patients will die within one year
• Somewhere between $25 trillion to $80 trillion are spent on healthcare related to falls

Emotional impact of falls

• Falls tend to lead to fear, leading to inactivity, leading to loss of confidence, leading to decreased quality of life for patients
• It is a spiraling downward path to decreased independence and mobility
• Initial reactions to falls may be to protect, limit mobility and provide restraints — strategies that may decrease the risk of a fall in the short term but ultimately lead to declined mobility and increased risk of falls
• Forty percent of all nursing home admits are related to a fall. Falls are a major reason for moving up/down the continuum of care provided by hospitals, assisted living facilities, SNF, home health and hospice.

Home health has the ability to make one of the greatest impacts on fall reduction. Being in the patient’s home environment gives us the unique opportunity to identify specific problems, deficits and needs and tailor our approach to treatment to address those needs. Nursing has the ability to identify medical conditions, monitor effectiveness of medications, evaluate/assess vital signs, instruct when there are knowledge deficits and act as a liaison between healthcare provider and patient. Physical, occupational and speech therapists are able to address biological factors that increase the risk for falls, i.e., muscle weakness; gait and balance deficits; visual, vestibular and somatosensory deficits; and cognitive deficits. Physical and occupational therapists can also address environmental risks for falls through home assessment — identifying barriers in the home that might contribute to falls; i.e., clutter, unclear pathways, narrow doorways, throw rugs, insufficient lighting, the need for adaptive equipment, etc. They also provide instruction and training for caregivers and patients as needed to minimize the risk of falls or injury to patients.

How Stepping Stones Improves Quality of Treatment and Outcomes

Quality treatment begins with comprehensive assessment: strength, ROM, posture balance, coordination, cognition and motivation. Traditionally, therapists have been effective at assessing strength, ROM, posture and mobility. A better understanding of balance and the systems that affect it will lead to more targeted treatment plans and strategies to address deficits. Balance assessment should include assessment of sensory input from the visual, vestibular and somatosensory systems as well as strength ROM and posture.

• Visual system: the primary system for balance. Therapist will assess for conditions affecting visual acuity, contrast sensitivity, depth perception and visual field deficits.
• Somatosensory system: the ability to feel surfaces below the feet and react appropriately to maintain balance. Therapist will assess for history of peripheral neuropathy and check sensation for light touch and pressure.
• Vestibular system: provides information to central nervous system about movement of head or body, sense of rotation and acceleration. Allows us to stabilize our vision during head and body movement. Therapist will assess for peripheral and central deficits in this system which might cause dizziness, disequilibrium, sensitivity to motion, inability to focus eyes during head movement and benign paroxysmal position vertigo that is the most common cause of vertigo.
• Therapists will also assess patient’s ability to integrate these systems to perform specific balance tasks. An assessment of the central nervous system will be done through oculomotor testing, cerebellar testing and test to determine patient’s ability to multitask.

By identifying the strengths and weaknesses of each of these systems, we can develop a tailored plan of treatment that addresses the specific deficits for each patient. Specific balance, sensory integration and oculomotor tests will be performed at the beginning of treatment to establish baseline, at mid-treatment and at the end of treatment to determine the effectiveness of the treatment plan and determine outcomes.

Our experience has shown that The Stepping Stones program has the potential to improve outcomes, decrease risk of falls in the future, decrease hospitalizations due to falls, save Medicare dollars, maximize patient independence and improve quality of life for our patients in a significant way.

One of the golden opportunities for becoming the rehab facility of choice in your community is to be an extraordinary partner and a preferred provider with managed care organizations. Superior communication is the remarkable simple key to success, yet so many facilities do not implement systems and organizational strategies to keep the external case manager informed and integrated into the overall management of the patient. The external case manager can become our biggest ally, and as trust is built and outcomes are achieved, the result is nothing but extraordinary for our patients.

Some of the key factors that have proved to aid in achieving that goal include providing documentation and updates to the managed care organization’s case manager, either directly or indirectly through a case manager at the facility.

The top five ways the therapy team can help may be summarized through the following tips and ideas:

1) Provide accurate, concise, thorough and comprehensive information. It is critical that the information shared with the managed care organization’s case manager be a reflection of the patient’s current status. It is also a good idea to discuss the overall treatment plan and discharge goals at this time. This review must be supported by documentation and should reflect detailed information relevant to the current status and progression toward the discharge goals for the patient. It should also reflect our commitment to the patient achieving the outcome necessary to produce a successful and safe discharge. Assist by stressing to the team how important the process of identifying a discharge goal is and how it can eventually become warranted justification for extensions in Length of Stay (LOS). If progress has not been made, be prepared to assess if the current stated goals are still appropriate or if a change in treatment plan is required. The managed care case manager will not continue to authorize days or extend a LOS if given the same information week after week and if progress is not evident.

2) Review all documentation/updates before sharing the information with the managed care organization. It is important to review this information before it is presented so you can justify what may be your eventual request for additional days or a higher level of care. For example, if the overall status of the patient has declined since last week, be prepared with an explanation as to why and what occurred prior to anyone calling the managed care organization’s case manager. These are just some of the questions to be considered and answered prior to submitting documentation/updates:

• Has there been a change in the patient’s overall health status that has impacted the treatment plan for therapy? If yes, make sure it is documented appropriately.
• Is the patient refusing therapy? If yes, why and how many times has therapy been refused and how has the patient’s progress been affected?
• If the patient does not seem to be progressing at all, does the documentation/update reflect why? Are we targeting realistic, achievable goals for the patient?
• Is the current discharge plan achievable? Do we need to revise the plan? Make sure the revisions are communicated with detail as to why. In most situations, sending therapy notes is not sufficient in itself and will probably be sent back with a request for more information. A clear understanding of the content of the entire documentation/update (nursing and therapy) can prove to be a timesaver. Read it before you send it!

3) Ensure timely reporting. Make sure documentation/updates are submitted on the date they are requested. Most managed care organizations will stipulate a deadline for review, but if possible, it is good practice to tell the managed care case manager when the facility team meetings/conferences are held and suggest that updates are scheduled on those days, thereby providing the most current and accurate information. It is good practice to make sure a definitive date for the next review is agreed upon.

4) Anticipate the managed care case manager’s questions/concerns. It is always good practice to try to anticipate what the managed care organization’s case manager will need in order to authorize additional days or bump a patient to a higher level of care. The obvious question is, “Did the patient make appropriate progress?” If the patient has not made appropriate progress, we must be prepared to answer why and give them clinical justification as to why the patient’s inpatient stay should be extended (e.g., strengthening, safety issues, cognition). In any event, the managed care case manager will almost always want to discuss the current treatment and discharge plan’s viability — for example, when the discharge plan is for the patient to return home, but treatment progression has clearly defined the patient unable to gain enough function to manage at home. At this point, the managed care case manager will expect that we identify a new discharge plan. The Ensign Team should recommend to the managed care organization’s case manager the new most appropriate discharge plan. Also, if we are asking for additional services to be covered, we will need to be prepared to explain why that service is needed and how it will impact the agreed-upon discharge goal. For example, if you are requesting more units, be prepared to defend the rationale as to what value the extra units of therapy bring to the outcomes of the patient’s stay.

5) Be able to discuss progress toward desired outcomes/discharge plan and estimated LOS. When giving an update, focus the discussion on the desired result of care and the resultant discharge plan. Concurrent reviews of the patient’s status during the stay should evaluate the appropriateness of the current treatment plan and its success at achieving the final discharge result. For example, let’s say you have an 85-year old man who just suffered a massive stroke. His deficits are significant. Upon admission, he requires maximum assistance with all ADLs and transfers and is only able to take a few steps on the parallel bars. He suffers from significant swallowing problems and currently has a feeding tube. He is also incontinent of both bowel and bladder. His wife is 81 and very small in stature. The team agrees that an appropriate discharge plan must include, but not be limited to, her husband being able to toilet independently, transfer on his own and manage three steps to enter the home in order for the wife to be able to care for him alone. Every time this patient’s progress is reviewed, the focus should be on progression toward the discharge goals. If at some point it is clear that the patient is making minimal progress, the team must re-evaluate and design a more appropriate discharge goal and plan. For instance, it becomes clear that the patient will not reach his goals and be able to go home; you should be able to document that a different option has been identified. Finally, always be prepared to give the managed care organization’s case manager an estimate of how much longer the patient needs to achieve the agreed-upon goals/desired outcomes.

By Dawn Webster, Managed Care Resource

Curtis Merring, OTR/L, MOT developed a seating and positioning course for our therapy programs, and piloted the training at Panorama Gardens on March 21, 2013. Staff from Panorama, Glenwood, and Mission Care learned about the most recent research and seating and positioning solutions specifically for our population. Curtis will hold the course for more to attend at the Service Center on March 27, 2013. This is an excellent opportunity to develop positioning strategies for both our short-term rehab patients and our long-term residents. We will be offering this course across the organization, so check with your therapy resource for when the training will be in your area.

Ensign Services is the proud sponsor of the Dementia Capable Care Foundations Course to be held November 10, 2012. This Foundation course will be held in Santa Rosa, California at the Courtyard Marriott and provides participants with a common framework about Alzheimer’s disease and related dementias (ADRD), a best-abilities perspective, dementia stages, behavior management, and care techniques to promote the best ability to function and person-centered care. Material is presented in a lecture format with small group activities to apply principles learned. Gina Tucker-Roghi, MHS, OTR/L and Therapy Resource for Northern Pioneers, will be the lecturer for this course. Gina is a certified Dementia Care Specialist Instructor for the Dementia Capable Care Foundations Course. She received her B.S in Occupational Therapy from San Jose State University in 1992 and later earned a Masters of Health Science degree from the University of Indianapolis in 2004. In her many years of experience, Gina has specialized in geriatric practice and has extensive experience in the evaluation and treatment of persons with dementia. As a Therapy Resource, she now uses this experience to train other therapists in assessments and treatment approaches to facilitate the best ability to function in persons with dementia.