Share

Heart Rate Variability (HRV) training using HeartMath devices continues across our markets. By learning how to bring your body to a state of neurological coherence, you can interrupt the stress response, and actually bring order to the nervous system. The biofeedback devices that the therapy teams are using give real-time feedback on achieving and sustaining coherence. The training has a cumulative effect on the nervous system, and can essentially “reset” our stress responses.

Our heart-brain interactions have a profound impact on overall health and vitality. With each beat, the heart transmits information to the brain and the entire body. Learning how to tap into the power of the heart can not only change our stress levels, but can impact our overall health. Our teams are using the personal devices to improve resilience, and they are also using the devices with patients to improve function, reduce pain, and increase the ability to tolerate treatment sessions. The most recent team to be trained was our HCR Plano team in Plano, Texas. Here is just one of their success stories:

Mrs. Y is a patient at HCR Plano with a recent diagnosis of cancer. One of her goals is to get stronger to be able to tolerate a chemotherapy treatment regimen. The team’s new COTA, Jay, decided to try HRV training to reduce pain and increase function. During the first session, the patient was able to briefly get into what is called neurological coherence, as indicated on the biofeedback device as the green zone. However, the pain quickly brought her out of coherence. Jay decided to try another technique. He asked her about one of her favorite places to be, and she told him it was Hawaii. Jay pulled up some Hawaiian music and talked her through the coherence steps, and she was very soon able to sustain coherence. What is really amazing is that she had been refusing physical therapy treatments due to pain, but after her session with Jay, she was able to participate in a full PT treatment, with a smile on her face. The biofeedback readings below show the spike in coherence when her favorite music and memories were introduced.

By Jennifer Wintle, Therapy Resource, Colorado

It’s easy to get caught up in the day-to-day routine in this line of work. You have new programs you want to start, financial markers you strive to hit, and all of this trickles down to your team. However, every so often, you are reminded of why you chose this profession. It’s the people, their stories, their lives, and all they share.

One of my PTAs at Sloan’s Lake, Meghan Ricketson, just shared this with me. We had a patient recently who wanted to get better so badly, but his body (his heart) just wasn’t having it. He was sent back to the hospital twice while he was a skilled resident with us. He even asked another PTA, Brent Cook, to just try to ride the bike even though his O2 sats were in the high 70% just sitting in his w/c. He asked Brent in an unsure voice, “Am I dying?”

He was one of those patients where, even though I never worked with him, it just tore at my heart to see him want to do something so badly and not be able to do so. Meghan only works 2.5 days a week but obviously had formed a bond with this patient. He had traveled all over the world, but what struck Meghan was that he had traveled to the South Pole. She is a mother of three boys and knew the boys would think that was so cool. They would talk during his PT sessions about all of his crazy feats.

He was an incredible adventurer and was able to do things that many of us in Colorado, with an obsession with mountains and thrills, would love to be able to do. He climbed 54 14,000’ers, Mt. Fuji and Mt. Kilimanjaro, and attempted to swim across the English Channel. These are only a snippet of his experiences. Unfortunately this patient ended up discharging home with hospice care on May 23, and passed peacefully on June 1.

Over the last year, Legend Oaks in New Braunfels, Texas, has implemented shadow boxes for all long-term care residents in an effort to decrease wandering, increase the patient’s ability to engage in meaningful interactions with other residents/staff/caregivers, and provide personalized, meaningful care in accordance with the patient’s Allen Cognitive Level. Residents were evaluated by a licensed therapist and determined if skilled therapy services were appropriate for the design and implementation of an FMP (Functional Maintenance Program).

Skilled therapy services’ typical duration was 2.5 weeks to complete this FMP program “shadow box.” Initial evaluations were utilized to determine the patient’s Allen Cognitive Score, which consisted of the leather lacing test and placemat test to determine baseline (ACL) Allen Cognitive levels; however, the FAST and GDS can also be utilized and converted to an Allen Cognitive Score, if the Allen test(s) are unavailable.

The patient’s Allen Cognitive Level was represented by color-coded dots on the outside of the shadow box, and the clinical staff, nurses and nurse aides received a three-week training course to increase their understanding of Allen Cognitive Levels and what each color represents. Examples of goals for the initial evaluation included:

Short-term goals:

1. “Patient will reminisce about past for a maximum duration of 30 minutes with min cues provided utilizing items from shadow box.”
2. “Patient will identify location of room utilizing shadow box visual cue in 10/10 attempts in order to decrease wandering and decrease amount of assistance required to redirect resident back to room.”
3. “Nursing/caregivers/staff will demonstrate 100% understanding of the patient’s risks/challenges/and preferences in accordance with the patient’s Allen Cognitive Level in order to provide personalized/meaningful care to the resident.”
4. “Patient will maintain topic for a maximum duration of 15 minutes in order to increase the patient’s ability to engage in meaningful interactions.”
5. “Patient will engage in conversational speech with other residents regarding content of shadow box for a maximum duration of 15 minutes in order to increase the patient’s ability to engage in social interactions.” (This is a good goal to include to be able to utilize the shadow boxes as a group treatment).
6. “Caregivers/family/staff will be able to utilize items from shadow box to engage the resident in meaningful interactions with min cues provided.”
7. “Caregivers/family/staff will demonstrate 100% understanding of the patient’s remaining abilities, risks and challenges in accordance with the patient’s Allen Cognitive Score.”

Long-term goals:

Perhaps you can utilize a “Social Validity Test” to assist with long-term goals. This test asks the resident questions such as: How often do you have difficulty locating your room? How knowledgeable are you of other resident’s lives? How much do other residents know about your own life? Options to answers were: not at all, some, extensive. These were assigned a point from 1-3, with 3 being the highest score. Long-term goals for this test:

• “Patient will increase shadow box social validity score from 1/6 to 5/6.”

Additional long-term goals can include increasing GDS and Allen Cognitive Scores.

Treatment Approaches:

During treatment, patients and family members (if able) engaged in a Life History and Questionnaire to determine memories of importance to the resident, appropriate items/pictures to reflect these memories, and patient’s preferences to provide personalized care. Timers can be set to measure how long the resident is able to reminisce about past, duration of time for topic of maintenance, and the patient’s ability to engage in conversational speech with other residents.

Additionally, if the resident exhibits difficulty in locating his/her room, measurements can be taken to determine if the resident’s ability to locate their room increases with shadow box cueing. You could also use group treatment to have residents explain their shadow box and engage in meaningful interactions with other residents. Extensive education is provided to caregivers/staff/family regarding Allen Cognitive Scores, providing the patients’ remaining abilities, risks and challenges.

Examples of Daily Treatment Encounter Notes:

1. “Min cues provided, staff was able to provide three remaining abilities, risks, challenges, and preferences for the resident in accordance with Allen Cognitive Score.”
2. “Patient was able to engage in meaningful interactions utilizing items from shadow box for a maximum duration of nine minutes.”
3. “Resident able to locate room in 8/10 attempts utilizing shadow box as a landmark.”
4. “Extensive education with patient’s family and staff regarding the resident’s remaining abilities, strengths and preferences.”

By Angela Anderson, DOR, Gateway Transitional Care, Pocatello, ID

At Gateway in Pocatello, Idaho, we are blessed to have a very cohesive team that believes in making a difference for our patients. We have been able to create a task force with Nursing, CNA staff, RNS and activities, as well as PT/OT/SLP, to identify the greatest risks and needs for our patients and implement a true IDT approach.

This collaboration has empowered the different departments to develop new ways to address a common goal. It started years ago when our nursing leadership, Travis Jacobsen (DON) and Brooke Burt (ADON) started coming to the weekly rehab meeting. It was in this setting that the Therapy and Nursing teams started building trust and working on patient impairments as a team.

Travis and Brooke have led the nursing department with IDT programs such as HeartPARC, and have pushed the education and team approach that allows the entire team from the CNAs to Social Services to Therapy and Nursing to address cardiac conditions and achieve great outcomes! The wound team was Travis’ baby even before I started at Gateway; however, he was quick to bring Therapy into that team and together we can address wounds and skin breakdown from multiple angles and several approaches.

Travis has been instrumental in developing interdisciplinary management of ESRD patients in conjunction with a local nephrologist. With his help, we have developed programs addressing fall risk and quality of life in addition to excellent medical management. Because of the team approach and leadership of our DON/ADON, we have been able to approach all patients from a patient-centered perspective and treat the “whole person.”

Heart Math Variability, By Casey Murphy, Therapy Resource

I was at our Legend Greenville facility to assist with Mock survey, and I ended up (organically and unplanned) doing an impromptu in-service with the therapy team on HeartMath. I demoed the Bluetooth device on one of the therapists who told me she was “stressed,” and we saw amazing results just with a three- to five-minute session (in front of a bunch of therapists!). She felt more relaxed afterward and was smiling a lot more for the duration of the day.

The team was so impressed, they wanted to try it on one of their patients. I sat with a speech therapy student with a patient who had dementia (and a pacemaker). I was able to sit and talk to her, taking her through the breathing exercises and talking about her family for a total of 6.5 minutes. She was only in high coherence for 12% of the time, but was in medium coherence for a whopping 41% of the time. We ended things with her smiling and thanking me for taking the time to talk to her about her family. The supervising SLP told me that she normally is not able to hold her attention; in fact, they had a goal for holding attention span for five minutes. She also told me she is usually very anxious.

Later that afternoon, I walked back into the gym and noticed the patient on the bike working with a PT, smiling and waving at me as I walked by. The PTA (who I demoed the unit on) pulled me into the charting office elated! She informed me that the patient hasn’t been able to ride the bike previously because she would scream out in pain. The staff couldn’t believe she was participating and enjoying working with everyone! The team was convinced it was the HRV session. Who knows, maybe we got lucky, but it was really cool to see that therapist and patient benefit from just one short session each!

So, needless to say, the Greenville therapy team is very interested in learning more. I loaned them my device so they can practice on their patients and themselves.

We are only just beginning. We started with a vision about wanting to share the best practices that we are seeing in our facilities throughout the organization. With a centered focus on long-term care, we turned our vision into reality with the creation of the LTC Think Tanks. Below you will read a brief recap about a few of our LTC Think Tanks, and we hope to continue to bring you innovative, inspiring, passion-driven ideas to help keep your long-term care residents performing at their highest level of potential with the ultimate goal to decrease their risk of further decline.

If you or members of your team would like support in program development, patient care identification strategies, and/or feedback on questions regarding long-term care, please reach out to LTC_TaskForce@ensignservices.net. Our mission is to provide a centralized hub to facilitate the dissemination of ideas.

Renew Purpose and Restore Peace

The rehab team at the Garrison facility, led by Christa Keesee, is inspiring us all. By identifying the needs of their patients, they created a specialized program to “Renew Purpose and Restore Peace” for their ever-deserving long-term care residents. Molly Setliff, occupational therapist from Garrison, provided a thorough presentation to help walk you through the mission and implementation process of the program. Molly also takes you through challenges you may experience and helpful alternatives.

Reach out to Christa Keesee to learn more.

Benefits of Using Therapy Animals in LTC

We had great contributors such as Michelle Wang, Jon Anderson, Barbara Mohrle and Ciara Cox who centered on the benefits of using therapy animals in LTC. Each has had great experience with using therapy animals in their facilities, and it provided great joy to many of the patients during their treatment sessions. We have a detailed presentation that bullets the ADL and musculoskeletal benefits of using therapy animals during patient care.

If considering a pet therapy program, consult with your state to ensure you have all requisite elements in place and also that the facility has a policy in place, as the state will look for this on survey.

Below are some helpful sites to visit if you are interested in learning more about therapy animals or getting your animal trained:

• Take a look at the Good Dog Citizen program at https://www.akc.org/ to learn more about the specialized training program.
• Contact your local zoo. Many are available to come on site and visit your facilities with a variety of animals.
• Search Google under Therapy Animals along with the name of your city. This search will populate contacts for therapy animals in your area.

…But How Should I Document

We usually receive tons of questions regarding how to best document our skilled maintenance services that are provided to our LTC patients. A special thank-you to Lori O’Hara for debunking some documentation myths surrounding Skilled Maintenance Therapy and for also giving us clear breakdowns of what this type of service should look like. We offer a skilled Maintenance POSTette, located on the portal, which includes documentation examples.

During the Think Tank, we also shared a really cool therapy tracking tool. The creator, Shaun Baldwin, was unable to join us, so I hope I did it justice with my explanation. We viewed the spreadsheet, which has a ton of information; he uses it during his Medicaid meetings to keep track of patients during the week. To make sure that he does not overlook any of his LTC residents, he built a section that lets him know how long it has been since a discipline last treated a patient. If the patient has not been on a discipline for longer than 75 days, the cell will turn yellow, and if it has been greater than 150 days, the cell will turn red. He uses the spreadsheet as a visual reminder of who may need to receive a follow-up by therapy. Shaun is very open and available to answer any of your questions regarding the tracking tool. Shaun Baldwin is the DOR at our San Marcos facility in Texas.

Functional Jobs Program

Program development is not always about structured exercise programs and textbook balance training. There are a variety of programs that may not sound like therapy in the traditional sense, but they are oftentimes the most beneficial to our patients’ physical and psychological well-being. Do your residents need a “job”? Barbara Mohrle, DOR/Therapy Resource, and Marisa Parker, DOR/Therapy Resource, reminded us all about living a purposeful life and why that is so important to our residents.

What is the Functional Jobs Program? It is a LTC program designed to allow residents an opportunity to serve and take part in daily activities that keep them fulfilled.

• The therapy team realized that many of their residents had a passion to serve, and they wanted to take part in daily activities that allow them to improve/maintain their level of functional mobility and decrease the risk of injury.
• As therapists/assistants, we have an opportunity to provide skilled care to our patients and help prepare/engage them in their “job.”

Reach out to Barbara Mohrle and Marisa Parker for more information on implementing the Functional Job Program in your facility.

PTNM and NMES

Marci Williams, PT, DPT, and Katie Kellagher, CCC-SLP, discussed two types of modalities that can significantly impact a patient’s quality of life.

Here are some key takeaways:

Percutaneous Tibial Neuromodulation (PTNM)

• Geared toward patients suffering from urinary incontinence
• Huge opportunity for the therapy and nursing partnership
• Email LTC_Taskforce for assistance with implementation
• This is a service-based billing code with opportunity to provide care to more than one patient at a time

Neuromuscular Electrical Stimulation (NMES)

• Certification in Vital Stim or NMES is a great adjunct to traditional interventions
• Referral sources are always excited to hear about therapists who are certified in NMES
• Please reach out to Elyse Matson, SLP Educational Resource, for additional support in modality implementation and/or documentation

Figuring Out LTC

Jennifer Kuehn, DOR from the Endura Market, led an excellent presentation on how to effectively navigate the area of LTC. Jenny dove into the clinical decision-making and patient identification process with great strategy and clinical reasoning. Reach out to Jenny to get your hands on her PowerPoint presentation. We received tons of great questions on the call; one question in particular stood out regarding patient weight loss. Elsye Matson, MA CCC-SLP, serves as our SLP educational resource. Elyse, with great detail, answered the posed question below. Please feel free to follow up with Elsye directly for further clarification.

What is the desired weight loss that a patient must have to warrant speech to evaluate?

SLPs should either be a part of the weight-loss committee or get updates from the RD in their facility on a weekly basis. The MDS triggers issues with weight loss at 5.0, 7.5, or 10.0% weight loss over a period such as a week or a month. There are a multitude of reasons one loses weight, including issues with self-feeding (refer to OT), medical complications affecting appetite and desired weight loss. A small amount of weight loss may indicate a serious issue if the patient was admitted weighing 80 pounds. Alternatively, a large weight loss from a 300-pound patient may be desired.

Finally, it is important to know information about meds, labs and conditions to differentiate a patient losing weight from diuresis/CHF issues versus true weight loss. So the circuitous answer re: weight loss and dysphagia is that it depends on each individual situation. We must always look at the whole patient and assess what is needed. There really is no correct answer, as weight loss is one symptom of many problems. We need to know our residents, stay in contact with our IDT and re-assess tube feedings and modified diets on a regular basis.

How Culture and Clinical Meet Financial

We had a great speaker by the name of Karlena (Valerie) Brooks, COTA. Karlena joined the Legend North Austin team as the Therapy Program Manager almost a year ago. Through her focus on revamping the culture and implementation of clinical programs, Karlena has tremendously grown her financial results in the area of LTC. It was wonderful to have her ED, Jocelyn, contribute to the discussion by sharing the effectiveness of what the development of a true partnership with the IDT can lead to. Reach out to Karlena to learn more; it will be well worth your time.

By Kai Williams, Therapy Resource

At Glenwood Care Center in Oxnard, CA, Cherryll Santos (L) and Aimee Bhatia (R) have a unique close relationship. Cherryll’s 18 years of leadership are evident in the culture of the nursing department, as this is a happy, cohesive team with strong clinical systems in place. Aimee, DOR, has been at Glenwood as a treating OT for five years, and a DOR for almost three. The relationship between these two leaders has a big impact on how nursing and therapy work closely together.

Cherryll and Aimee collaborate on clinical decision making and utilize each other’s strengths to collaborate with physicians, build programs, nurture relationships with families, and ensure excellence in patient care. The therapy team has a Culture Committee to partner with nursing in spreading love, celebration and appreciation to the CNAs and nursing staff. It’s amazing what a little bit of recognition and gratefulness does to boost morale!

The department head team also initiated a “random acts of appreciation” task force where the department heads pass out small gift cards when someone on the floor is noted to go above and beyond with their job assignments or to assist co-workers — once again, a simple gesture that goes a long way. For nurses week this year, a few department heads teamed up to plan daily dress-ups and games/events to appreciate staff and make them feel loved.

On a daily basis, therapy assists with CNA training and in-services to ensure quality of care and reduce workplace injury. We work closely with nursing to establish appropriate fall precautions for high-risk residents. We advocate for needed services for our long-term residents while working hand in hand on identifying appropriate residents, and we work closely with RNA to ensure a continuum of care and no loss of function that is preventable. Our Glenwood Care Center nursing and therapy partnership is a powerful team of dedicated clinicians with the common goal of providing quality care, a safe environment and opportunities for residents and staff to flourish.

The Emerald Market has been focusing on building a partnership with the Heartland PD Foundation in an effort to enhance and grow our facility programs. Initially we met with the Foundation’s Community Program Manager, Kim Nitz, to inquire if they had any unmet needs and to discuss how we could possibly meet those needs. Her first response was sponsorship of their fundraising and awareness events like The Moving Day PD Walk and secondly providing meals after their weekly exercise class to both participants and their caregivers.

As a Market, we became a Bronze Sponsor — as shared in a previous FlagPOST. Beginning in May, the Healthcare Resort of Kansas City, Riverbend PARC, the Healthcare Resort of Leawood, and the Healthcare Resort of Olathe started providing lunch for 25 participants and their caregivers on a monthly basis. The focus was more on building relationships rather than heavily marketing our programs/facilities per the request of the Foundation.

We had great dialog at the initial meet-and-greet lunch and were able to provide educational pieces based on their feedback at the subsequent lunches. We discussed safe transfer training techniques, how to cope with “freezing” during transfers, car transfers, balance deficits and balance exercises. The initial four months were such a success that the Foundation has invited us to continue to hold lunch and learns until the end of the year. I strongly believe our partnership has been so successful because the participants see and feel our sincere compassion for the PD community.

As a Market, our goal is to establish and offer a PD Support Group by the first of the year in the northern part of the city at the Healthcare Resort of Kansas City and the southern part of the city at the Healthcare Resort of Olathe. We are diligently working to increase our relationships with Movement Disorder Physicians and vendors to have as possible guest speakers at our support groups.

I look forward to sharing the next chapter in our PD program development successes after the first of the year.

By Madeana Galler, Therapy Resource – Emerald Market, Kansas