If I Could Speak …

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As Therapists, we get into this field with aspirations of helping others. Inevitably, we come to learn that the people we are helping also touch our lives. Wellington Place had the opportunity to significantly impact the life of a new resident by providing him with a way to communicate, which he has not had the ability to do in 10 years.

Upon admission, the Wellington team learned that Clint was in an MVA 10 years prior, leaving him with quadriplegia. He had been residing in a local living center since the accident, unable to communicate his needs and wants. Medical records indicated an inability to assess him neurologically and cognitively due to the extent of his deficits. We were not satisfied with this assessment, so we attempted communication with eye blinks. He was 100% successful for 10/10 questions. We could tell from the look in his eyes that he had more to say; so we pressed on, determined to find an augmentative communication device. I brought in an alphabet communication board, and the OT made a splint for his right wrist allowing him to hold an object for pointing.

Over the next several days, the therapy team learned a lot about Clint, including his favorite sports teams. Sadly, we also learned that Clint had also been in a lot of pain over the years. In furtherance of our communication efforts, the nurse asked, “Are you in any pain?” He communicated, “y.e.s. a.r.m.” As tears rolled down his cheek, he spelled “t.h.a.n.k.y.o.u.” We fought tears as well.

His sister was overjoyed with the news that her brother could communicate and sincerely appreciated our efforts. It has been difficult for her to accept that her brother had been alone and unable to communicate for so many years. She shared that he also had a 4-year- old daughter at the time of the accident; she is now 14 years old, and has never been able to communicate with her father.

We were determined to find an augmentative communication device that would allow him to be more independent with use and reduce the amount of physical effort required to use effectively. The support and feedback from our Therapy Resources and Therapists regarding devices available on the market were overwhelming, and very much appreciated.

Ultimately, the communication word boards and the Dynavox EyeMax machine worked best for Clint. This device calibrates his eyes and allows him to find the words he wants to say. As he stares at the words, the machine speaks them.

While waiting anxiously for the new device to arrive, we spent the next eight weeks working on improving oral motor skills for saliva management, as well as speech skills. He was highly motivated and appreciative of the time spent with him. Finally, his “voice” could be heard.

From the day the EyeMax arrived, Clint worked hard with us. He showed us that he was eager to interact and had a lot to say! Clint asked about seeing his daughter, and wanted to tell his sister he loved her. He told the Dynavox Representative she was pretty, and he shared that he missed dancing, among other things. He told his SLP he loved her too.

We videotaped treatments to show his sister and physician; both were elated to see the progress made by Clint. The decision was made to allow him to reside at Wellington Place where he can continue to prosper with his newfound freedom.

It took an Ensign village to make a difference in this person’s life; Wellington’s team is thankful for the support provided by so many people. Clint tells us we changed his life for the better; and we tell him he has touched our hearts forever.

Catalina Healthcare has Patients Walking on the Moon!

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When Bruce Fraser from a company called “ALTER-G” first contacted Lori Mitchell, Physical Therapist and DOR, she was ready to hang up almost immediately, thinking it was just another sales call. But, as soon as Bruce started talking about an “antigravity treadmill, developed by NASA, which will allow patients to exercise and maintain weight bearing restrictions,” Lori started listening. What she discovered was that this newly released, FDA-approved device could have the ability to make a tremendous impact with her patient and resident population at Catalina Healthcare in Tucson, AZ.

Lori invited Bruce to meet with her Therapy Department and share more about this unique piece of equipment. She thoroughly researched the technology of the device and arranged to have a 30-day trial, with the goal of incorporating the Alter-G into the therapy program of patients who could benefit from it. Lori also wanted feedback from patients, caregivers and therapists regarding the perceived benefits and challenges of the Alter-G. This information would allow her to make an informed decision about whether or not this could be something of value for her program. With that goal in mind, Lori developed a survey to use during the trial. The Alter-G was used in treatment at Catalina 54 times over two weeks for walking or static standing exercises at 50%-65% of body weight.

Patients reported the following:

Hip pain went away

Legs felt better in the machine

Able to do exercises and hop on one leg, and the other leg didn’t buckle

“I am walking on the Moon”

Less pain

Entire body feels good on it

No pain in arms (due to reduced Weight Bearing on UEs)

Therapists reported the following:

The majority of the patients did much better with ambulation after using Alter-G

It is good for endurance and functional activity tolerance for ADLS/Gait/Standing

Using the Alter-G really boosted the confidence of a new amputee

There was an overall boost to the patients’ confidence

The Alter-G is much easier to use than a pool and there are similar unloading results

How Does ALTER-G Work?

Originally conceived by Dr. Robert Whalen to design effective exercise regimens for NASA’s astronauts, Differential Air Pressure (DAP) technology has been adapted by Alter-G for use in training and rehabilitation. Cleared by the FDA in 2008, the Alter-G Anti-Gravity Treadmill is a medical device that can be used for:

Rehabilitation of lower extremity injuries

Treatment of neurological conditions

Weight reduction

Aerobic conditioning

General training to combat the diseases of aging

Unweighting is achieved in the Alter-G by using air in a pressure-controlled chamber to gently lift the user. Precise calibration using patented technology allows for very specific unweighting from 100—20% of the user’s body weight in 1% increments—something no other unweighting modality can do.

Clinical studies show that the Alter-G can help decrease ground reaction forces in walking and running. The restoration of normal gait mechanics is paramount to expected recovery.

The team at Alter-G makes the statement that there are numerous benefits of implementing a senior rehabilitation and mobility program that uses this technology. It can inhibit or postpone bone loss, diabetes and heart issues. It can also reduce arthritis pain, anxiety, and depression. It also prevents functional decline which allows for independence in essential activities of daily living, such as walking, bathing, dressing, getting up from a chair, and using the toilet.

For the first time, senior rehabilitation and mobility are easily monitored and progress verified with Alter-G’s Anti-Gravity Treadmill in the most needed exercise areas:

Endurance – walking strengthens muscles and improves the health of the heart and circulatory system

Strengthening – increase muscle tissue mass and decrease age-related muscle atrophy

Range of Motion – keep the body flexible and maintain good joint health

Balance – reduces the likelihood of falls by training in a controlled environment

FUNCTIONAL REHABILITATION

Physically frail elderly persons who received supervised functional rehabilitation therapy that included strength training improved on function, strength, balance, mobility, and quality of life measures, according to studies conducted by Yale researchers reported in the October 3, 2002 issue of The New England Journal of Medicine. Researchers saw a 45 % decrease in impairment after 7 months of balance and strength training. The Alter-G treadmill has been FDA-cleared for strengthening and conditioning in older patients. FDA-cleared rehabilitative uses include any lower body disability, neurological gait training, geriatric strength training, fall prevention and weight loss program.

Lori Mitchell and her therapy team at Catalina Healthcare have taken one giant step for mankind as they have their patients walking on the moon using Alter-G.

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Managed Care for SNFs: A Growing Segment in Health Care

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The trend toward contracts with managed care agencies for the administration of health care benefits in SNFs is increasing in popularity. The high cost of caring for chronically ill patients and aging of the general population highlights LTC as the prime target for reform by the managed care industry. Managed care organizations (MCOs) will be breaking new ground in controlling and reducing costs associated with providing care to clients with prolonged needs. Payers can improve the delivery of health care and manage costs better by holding providers more accountable for the care of chronic patients. Therefore, it is important to predict the fluid nature of health care and prepare for the changes ahead. Payers and providers need to commit to a system of payment that rewards high-quality, coordinated, cost-efficient care.

The process of accepting Managed Care members into our facilities for SNF care starts with a managed care contract. When a contract is structured with rates/levels there is a contractual definition of each Level of Care, including clinical needs, therapy utilization, and what is included/excluded from the per diem rate. This information is used to negotiate the appropriate rate upon admission. Therapy requirements include how many days a week therapy is required, and the amount of therapy provided per treatment day. For example, the contract may specify that therapy is required 5/6 days a week, up to 1 hour/day or up to 2 hours/day, depending on the level authorized.

Preparing the facility to “manage” the Managed Care is just as important as the contract. It is imperative to evaluate the systems of each facility, including operational systems, clinical systems and billing systems.

Things to look at:

Operational Systems

Admissions process and communication systems

Assessment systems

MCOs want quick acceptance of the referral: Is there staff in the facility or out in the hospitals with clinical expertise to quickly assess clinical documentation and make the decision on whether to accept the patient?

Clinical Systems

Evaluate the communication system between departments.

Quality care and coordination: Are all departments obtaining the information they need?

Outcome Data: Are you utilizing data to show patient outcomes?

Physician involvement: is your Medical Director involved in patient care? Does your facility have a Physiatrist? Specialty Wound care physician/ nurse?

Case Management

Whether your facility has a designated Case Manager or not, it is important to utilize the Case Management process to manage patients effectively. Case Managers or a Case Management designee will:

Assess patient needs

Obtain Authorization for admission to facility

Negotiate level of care/rate, per facility contract

Understand contractual exclusions

Therapy utilization: Negotiate higher rates when additional therapy is appropriate.

Utilization Review: Provide clinical updates needed for continued stay

Monitor progress

Evaluate alternative options and services to meet an individual’s health needs

Promote quality cost-effective outcomes.

Assist in fostering a positive relationship between facility and health plan. This process results in appropriate admissions, better assessment of needs, and better initial treatment and discharge planning.

Billing Systems

Does the BOM understand the exclusions and how to bill them? Is the correct rate/revenue code being billed?

Does your BOM have a provider manual from each health plan providing detailed information for billing and appeals?

Marketing

Educate the hospital about contracts. Ask questions about MCO needs (services needed/difficult placements)

Understand the goal is reduced LOS with quality outcomes

Share success stories with the hospital

Understand which physicians have these patients and communicate with them regarding innovative treatments and successful outcomes.

Establish a relationship of trust with Insurance CM’s so they will think of you when assisting in the placement of the patient.

MCO Expectations:

Decreased Length of Stay

Quality outcomes with supportive data

One knowledgeable contact who is easily reached

Good surveys; they review all CMS surveys during the initial credentialing process prior to a contract and during re-credentialing (every 3 years or greater).

Things to consider:

Provide staff with Managed Care training

Dedicate a unit for short-term rehab providing sub-acute services, including medical director involvement, physiatrist and wound care physicians

Develop a Case Management process utilizing a Case Manager or clinical designee

Increase communication between all departments

Sounds complicated. Why would we want to embrace Managed Care at all?

There are several reasons:

The number of Medicare beneficiaries is growing every year

Census growth

Revenue enhancement

Growth of overall number of referrals. Admissions of sometimes difficult to place managed care patients can lead to the referral of less complicated patients.

Intelligent Risk-Taking

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Kelly Schwarz, DOR at North Mountain, and her CEO, Brian Newberry, have been working together for the past few years in one of our organization’s most successful subacute programs. Located in Phoenix, AZ, North Mountain serves the inpatient ventilator patient, as well as inpatient and outpatient renal dialysis patient. The success at North Mountain comes from having the right people—people who are committed and disciplined to care for this highly specialized population. In addition, Brian recognized the high degree of specialization, as well as the time that goes into caring for the subacute patient. He partnered with the payer sources to develop reimbursement programs that were more in line with the level of care required to run a subacute. His success in this market is directly related to his comprehensive understanding of the environmental, clinical and financial demands of this population. Because there are so many details required to run a successful subacute business, less and less skilled nursing facilities have been willing to take the risk. Yet, the needs are continuing to grow.

This fall, Brian, with the support of the Ensign Group, took a giant step and started a new company, Subacute Facility Services. Subacute Facility Services is focused first and foremost on supporting the facilities within our organization, operating in markets where there is an interest and demand with development of subacute service delivery.

Brian is currently working with four facilities in the focused stages of development: Catalina Healthcare Center, Sunview Healthcare and Rehab, Provo Healthcare and Rehab, and Victoria Ventura Health and Rehab. Aside from these four, SFS is currently considering a subacute up in Northern California as well. Brian recognizes the importance of clinical training and has been partnering with Kelly Schwarz to provide support in the initial stages of training with the therapy programs. This allows Kelly and her team to share their hands-on experiences of what approaches are working, what equipment is helpful, as well as some of the varying needs for additional support personnel and scheduling considerations.

Brian describes his vision for Subacute Facility Services as being more than just a consulting company. “My focus is to partner with the facility directly in setting up subacute/respiratory services in their buildings from start to finish. I’m committed to being engaged in the process over the first five years of the new venture in an effort to transfer any knowledge and experience I’ve gained over the years at North Mountain to the EDs so they are successful in their endeavor.” Brian’s ownership in helping to achieve success with our organization’s subacute ventures is the core of the anticipated success.

Kudos to our Teams

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The following was submitted via The Ensign Group, Inc. website:

To The Chairman of the Board & Respective Members:

Aloha. Who would ever dream that a once fit and healthy rugby player like me would end up in a healthcare facility at such a young, ripe and prime age like me. Well, I did, and here I am now at Orem Rehabilitation & Nursing Center. I wanted to inform you that I have been very impressed with our new Director Wes, and the way he operates and manages this facility. He leads with excellent guidance and management skills. As for our other team members here in management—like the Assisant DON Leslie; the office administrators Tina, Tenielle, Justyn, Whitney; in Physical Therapy Sam & Crew; in Recreation Sally and Crew; the CNA Coordinator Noa; to Brandon in Maintenance—all play a major role to my well-being. The Team here is all part of my healing process. They are in my book of life. I am here to heal and to rise up again to enter the workforce. I also stayed at Arlington Hills in SLC right after my surgery. I enjoyed my stay there as well. I will be sad when I will have to leave here soon, when I walk out on my own without a wheel chair or walker. Thanks one again for an awesome facility and a fine bunch of managers. I wish your company all the best for the future.

Mahalo,

BP

p.s. I will relay my experience to the people of Polynesia and others, and recommend that they stay and heal at one of your facilities.

Therapy Can Be a Walk in the Garden

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by Jill Schuette, OT –

It’s a hodgepodge of plant life: petunias, tomatoes, squash, rosemary, ferns. To the casual observer, it may seem like landscaping with a lack of direction. But to the therapy team at Pocatello Care and Rehab, it is a garden with a clear sense of purpose. In the facility’s small courtyard, a very special program is in full bloom. This is where patients practice therapeutic gardening as part of an interdisciplinary array of therapy techniques.

Working with plants is helpful to patients with emotional and physical challenges. For example, stroke victims can work on upper extremity function as they turn soil in a planter or water flowers. Gardening helps strengthen muscles, improve fine motor skills, increase endurance and enhance dexterity. Patients with depression or other mood disorders can increase their activity level and self-esteem.

The courtyard garden has a wide path for patients to practice safe maneuvering with walkers or wheelchairs, and features sitting and standing-height planters. Future plans for expansion include benches and conversational seating areas for therapeutic rest breaks and socialization.

Our Simple Garden Recipe:

1) Cement blocks: we stacked ours at different heights to allow both standing and seated therapy

2) Sturdy wood frames with bottom supports

3) Garden box inserts: ours are heavy black plastic, but we would recommend you choose something deep enough to allow for root expansion. We are limited to shallow root plants such as strawberries and culinary herbs

4) Wine casks or whiskey barrels: we bought ours from the local nursery. Be sure to drill holes in the bottoms to allow for proper drainage of soil.

5) Gourds: we selected these because they allow for a longer cultivating/harvesting season

6) Sensory plants: herbs are great for the senses –touch, smell and taste

7) Multi-pick plants: strawberries and tomatoes allow multiple harvests for patients

8) Visual stimulation: low maintenance flowers like petunias and sunflowers pack a visual punch

9) Water: Be sure to include watering your garden when doing daily planning. Patients manage our watering six days a week, nursing staff handles the seventh day.

Your garden project doesn’t need to be expensive or fancy. Sometimes simple really is best. Our garden setup changes each season, based on what works and what doesn’t.

Be sure to get the most out of your therapy garden by choosing plants that have multiple uses. Have your patients harvest fresh herbs for cooking activities, cut flowers for a dining table arrangement,and paint gourds for fall and winter table decorations. Use your imagination to get your patients actively involved in their garden. Give them ownership and see what blooms!