thinking out of the box: treatment planning outside the gym
DESCRIPTION
Improve participation and functional outcomes through creativity out of the gym. Functionally based treatment will ensure patients receive medically necessary physical therapy, occupational therapy and speech services. The presentation reviews practical application to Medicare requirements. 1. Learn to identify creative treatment strategies. 2. Learn to define Medicare coverage and Medicare documentation. 3. Learn to identify the clinical benefits of Functional Based Therapies.TRANSCRIPT
Thinking Out of the Box: Treatment Planning Outside the Gym
HARMONY UNIVERSITYThe Provider Unit of
Harmony Healthcare International, Inc. (HHI)
PresentedMarianne Sherlock
Regional Consultant
OBJECTIVES
I. The learner will be able to identify creative treatment strategies.
II. The learner will be able to define Medicare coverage and Medicare Documentation requirements.
III. The learner will be able to identify the clinical benefits of Functional Based Therapies.
Regulatory Requirements
The Omnibus Budget Reconciliation Act (OBRA), also known as the Nursing Home Reform Act of 1987, supports promoting recoveryA nursing facility must provide nursing and related services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.Facilities must ensure that residents improve when possible and do not deteriorate unless the resident’s clinical condition demonstrates that the decline was unavoidable.
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Thinking Outside of the Gym
What's the value? Meeting the needs: preventing decline, falls etc, Increasing regulatory focus on quality measures.Increased scrutiny of therapy services and how these services translate into better functional outcomeLimited professional resources – need to be as efficient
Thinking Outside of the Gym
Objective Evaluation
What is the facility’s current practice? Are we meeting the needs of all the residents? What is the interdisciplinary morale? What is the level of cooperation and follow through across the disciplines? Are there limitations in professional resources? Are the available resources efficiently used?
Assessing Barriers
What types of barriers does your facility have to providing effective and efficient therapy?
Staffing PatternsEnvironmentalSiloOther….
Barriers to Providing Services
Barriers to Providing Services
Meal timesOutside AppointmentsNursing Staffing IssuesPatient direct care needs – treatments/wound careEquipment – access Dementia/Cognitive DeficitRefusals….. Why?
Do your teams work silos?
Soc Wk
Dietary
Therapy
NursingActivities
Meeting the Needs of the Resident
Nursing Shifts:
7-3 / 6-23-11/2-1011-7/10-6
Therapy Hours
PT 8-4:30OT 7-3:30 ST 8-4:30
Are therapy staff Available to teaching day, eve, night staff? Available to train/meet with family?available to assess self feeding, aspiration risk, positioning during breakfast, lunch and dinner?Is OT performing real time or simulated ADL’s? Reverse ADL’s?Home Evals: Video vs. Off siteFlexible scheduling
Where Do Patients spend Time?Consider time patient spends in room/on unit, with nursing caregivers?
Where do the patients live? Where do the patients spend most of their timeWhere might you get more cooperation with treatment?Where can you reach the most staff and families? How can you build an interdisciplinary team to increase follow through?
Things to consider….
How Many Falls Occur in The Gym?
Where do falls happen? Sitting up from bed Rolling over in bed and falling out Standing up/sitting down in wheelchair and bedReaching to answer phone, for the box of tissues, for objects on the floor, Negotiating in/around the bathroom, in and out of closet, in small spaces.In dining room
Impact of Environment
Is the environment conducive to the task? Noise –too noisy, resident can’t hearLighting- pt with glaucoma, macular degenerationDistractions- too much for patient to focusMusic- can be good, but…..
Does the environment make the patient at ease? Does the environment make sense keep the environment in the same context as the task such as ‘simulated’ ADL’s
Visual Impairment
Therapists should understand the influence of visual impairment on program participation. Similar to weakness or paralysis, a decrease in vision can significantly influence patient’s ability to engage in desired activities
Diabetic Retinopathy, low vision, Macular Degeneration, Glaucoma, cataracts Impact of bright hallways and bright gyms
Hit Them Where They Live
Therapist + Patient + Caregiver = 24 hour a day 7 days per a week
impactWhen you treat the patient in the gym for 60 minutes you are only impacting about 4% of the patients day
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Literature Support
Multi-Dimensional Challenges in Geriatric Rehabilitation the GRAMPS Study (Buijck, B. I. 2013) When therapists spend more time educating and including direct care staff in the delivery of therapeutic interventions the better their understanding and likely follow though and reinforcement
Efficiency
Increasing efficiency by increasing on unit presenceFor facilities with space challenges and for dementia unit consider Mobile Therapy Cart to carry various equipment to:
Dining RoomCommon Sitting areasQuiet HallwaysBedside
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Efficiency
Satellites: Small office on unit with highest rehab populationJust the basics:
Mat table/Folding Mat tableWalker- standard/rollingWeightsComputer access
Examining Documentation Efficiency and Accuracy
Reasonable and Necessary
Medicare Benefit Policy Manual Section 220.2‘The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist…’
Reasonable and Necessary
(Medicare Benefit Policy Manual cont.)‘Services must not only be provided by the qualified professional or qualified personnel, but they must require….the expertise, knowledge, clinical judgment, decision making and abilities of a therapist.’‘The use of scientific evidence, obtained from professional literature, and sequential measurements of the patient’s condition during treatment is encouraged to support the potential for continued improvement that may justify the patients need for therapy.’
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Objective Functional Data
Standardized functional outcome measures afford objective and inter-rater reliable data:
Gait SpeedTimed Up and GoFunctional ReachPerceived Exertion
Supports Functional reporting of G-codes
Objective assessment is critical
Developing Functional Goals
Pt will independently transfer bed to chair I without lose of balance Patient will Independently complete entire morning ADL routine with a Borg perceived exertionPatient will independently utilize safe swallow strategies through entire meal to eliminate overt aspiration
Identifying Functional Deficits
How does the patient climb the number of stairs needed to return home? Will they be carrying items?How does the patient complete complex functional home routines? Reverse ADLs? Successive transfers?How does the patient utilize compensatory strategies in real life situations?
Swallow strategies at supper?Speech strategies for emergency Phone calls?
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Resources
Resources
Resources
Resources
Resources
Resources
Resources
Implementation
Need to change the culture of the rehab team Need to overcome lack of knowledge.
Many resources/tools out there….many are freeIn-servicing—Lunch and learn session--
Make it mandatory. Choose those functional tools that make sense for your population and that make sense for the identified deficit. Choose those functional tools that are easy to useChoose those tools that can more readily reflect functional gain
Functionally Based Interventions
Functional Interventions
Increased scrutiny of therapy services through Medicare Reviews
Must demonstrate the skills, knowledge and judgment of the therapistMust demonstrate functional outcome
Assimilate traditional therapy approaches into Functional interventionsHow does the exercise/activity relate to the deficit?
Ball squeezeHow does the exercise/activity impact the restoration of function?
UBE, digi flex
Functional intervention
Improved functional outcomesImproved participationImproved efficiency through reduced refusals and time used to encourage participation
Functional…
Making it functional
Improve patient participation-Reduce refusals
Reduce patient boredomReduce therapist boredom
Literature supportRhythmic movement interventions such as tai chi and social dancing can improve gait regularity and automaticity, thereby increasing gait safety and reducing fall risk.Ref : Bridenbaugh S, A, Kressig R, W, Laboratory Review: The Role of Gait Analysis in Seniors’ Mobility and Fall Prevention. Gerontology 2011;57:256-264
Tai chi and postural stability in patients with Parkinson's disease Li F, Harmer P, Fitzgerald K, Eckstrom E, Stock R, Galver J, Maddalozzo G, Batya SS N Engl J Med 2012; 366(6): 511-519Short duration, intensive tango dancing for Parkinson disease: an uncontrolled pilot study Hackney ME, Earhart GM Complement Ther Med 2009; 17(4): 203-207
( Note: there were only about 12 subjects in this study, although not the most statistically significant study, it sounds like they had fun!)
Getting started
Read the Activities and Social Work profile
Patients occupationElectrician, Secretary, Teacher, Homemaker, etc.
Leisure activities and HobbiesWoodworker, Crafts, Sewing, Painting,
InterestsCars, Sports, Travel, Pets
#
Getting Started
Interview patient and/or family for information:
Obtain a detailed prior level of function on evaluationDaily RoutinesHome Setting challenges (stairs, shower…)Facility participation (activities etc.)Where and What they eat
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Functional
Build your treatment program from a favorite activity1. Identify the patient’s deficit2. Identify a favorite, interesting or
engaging activity3. Break down the activity into its
physical, verbal and/or cognitive components.
4. Analyze the components and determine which component will make most impact the deficit/impairment
Functional
Think of any functional task and break it down to its sub-task’s to design and build your treatment session.
Home making tasks; cooking, cleaning, Taking care of a petMailing a letterMaking a photo albumWrapping gifts
Engaging the Patient
Patient requires much encouragement to participate. Investigate why pt won’t participate.
Is the intervention appropriate for the deficit? Is it fun? Is it painful? Cognitive deficit? Is it boring ?Is it embarrassing? Can they see? Can they hear? What environment have I tried? What interventions have I tried? What are the goals? Are they appropriate? Do they need to be revised? Are our goals the same as the patient’s goals? The patient may want to walk, but is too fearful, too weak to accomplish
FUN in Functional
Incorporating some fun while increasing strength, ROM, Endurance, Functional Reach, Balance
Standing/Sitting on high stool
Making cookies, making a sandwich.Wrap gifts, Making a photo albumBoard (revised) Game, Card GamesVideo game (golfing in Scotland?)‘Mock’ baseball, basketball, golf, bowling, tennis/badminton /boxing
FUN in Functional
Throwing darts while standing on a spongy matHanging up baby clothes on a clothes lineTai chiModified yoga DancingWalking ‘invisible’ petCalling distance family membersOrdering out for lunch
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Music
Enhancing Activities with Music: If therapy must use traditional mat or seatedExercises or parallel bars, consider movement to music to make the activity more interesting and funMake sure music fits activity and residentSinging to improve breath support and/or voice
Tuning In-TV Activity
Turn on the Television to the news:Orient to TimeFunctional Ambulation to locate the TV Guide/Remote controlItem retrieval from Floor Sequencing Tasks (What Do I do first?)Problem Solving (How do I find out?)Fine motor control (knobs and buttons)Activity Tolerance
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Mail A Letter
Mail a letter to a friend?Problem Solving? Identify where to get Stamp?Task complexity? (Transfer, Go to the bathroom before heading out, get coat on)Locating and ambulating to mailbox? Outside? Terrain? Curbs?Asking for help?Fine motor (writing, placing stamp..)Functional assessment with turns, opening doors, carrying items?
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Conclusion: `:
CFR 438.25A nursing facility must provide nursing and related services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each residentFacilities must ensure that residents improve when possible and do not deteriorate unless the resident’s clinical condition demonstrates that the decline was unavoidable
Conclusion
Functionally Evidence Based: Valid and inter-rater reliable to more accurately identify functional deficits, potential barriers to progress and risksQuality of Care: Improved outcome and carryover through increased on unit presence/interdisciplinary
Increased interdisciplinary cooperationReduced refusals(?) Limited time to serve all residents that need to be served. Increase efficient use of limited resources-Time management with limited staffing
References
State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev. 70, 01-07-11) Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance (Rev. 161, 10-26-12) Effectiveness of Occupational Therapy Interventions for Older Adults Living With Low Vision Am J Occup Ther May 1, 2013 67:263-265Buijck, B. I. (2013). Multi-Dimensional Challenges in Geriatric Rehabilitation the GRAMPS-Study (Doctoral dissertation, Radbound University, Nijmegen, Netherlands). Retrieved fromhttp://repository.ubn.kun.nl/bitstream/2066/107678/1/107678.pdf#page=76 Radboud Universiteit Nijmegen, 8 mei 2013Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 54
Harmony Healthcare InternationalHave you Considered a Customized Complimentary
HARMONY(HHI) MEDICARE PROGRAM EVALUATION
or CASE MIX ANALYSIS
for your Facility?Perhaps your facility has potential for additional
revenue Assess your facility against key indicators and national
norms
Email us at for more [email protected]
Analysis is cost & obligation free 56
Harmony Healthcare InternationalHave you Considered a Customized Complimentary
HARMONY(HHI) MEDICARE PROGRAM EVALUATION
or CASE MIX ANALYSIS
for your Facility?Perhaps your facility has potential for additional
revenue Benchmark your facility against key indicators and
national norms
Email us at for more [email protected]
Analysis is cost & obligation freeHarmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved 57Harmony Healthcare International, Inc.