Compliance Corner

Compliance Corner: Are You a Leader?

By Jack Rolfe, PT, MNA, CHC, RAC-CT

Lead Compliance Partner, Milestone & Endura

If your actions inspire others to dream more, learn more, do more and become more, you are a leader.” ~ John Quincy Adams

My first memory of the image of leadership was formed when I was eleven years old. I was with a group of my peers participating in a scouting activity at our church. My father was also in attendance as one of the scout group leaders. The individual in charge of the meeting was at the front of the room conducting the function. This person asked if everyone in the room would move closer to the front row. I remember looking at my buddies and we were all frozen with the thought “this would not be cool to do what the leader had asked us to do.” Then a sharp impulse came into my mind. I stood up promptly and stated “come on guys, let’s move up.” Everyone followed and the task was completed. Upon returning home that evening my father said to me “That was amazing what you did today.” I had no clue what he was talking about and stared at him like only an eleven year old could do. He repeated to me what he witnessed in the simple act of moving with my friends to the front of the class. He stated, “You are a leader.” His statement touched my soul deeply and has remained with me throughout my life.

In his book, “Executive Instinct,” Nigel Nicholson of the London Business School suggests that there may be a leadership gene — that some people are just driven to be in charge. But the University of Michigan’s Noel Tichy — in his book, “The Leadership Engine” — declares that leadership style and abilities emerge from experiences. I propose that leaders emerge from a combination of both these declarations. I add one additional idea for you to ponder. I believe that inside each one of us there is a leadership gene and it takes experiences to bring it out. Have you discovered your leadership gene?

In the movie “Facing the Giants” actor, Alex Kendrick, plays the role of high school football coach, Grant Taylor. In one scene Coach Taylor is instructing his team and specifically counsels his player, Brock, to remember he has been gifted with leadership so do not waste it! I have concluded through my life experiences that there is one sure way to develop leadership. This is accomplished by assisting others to become leaders in their own lives. When you facilitate someone finding and using their leadership gene then yours blossoms.

As we move into the year 2017, will you become a leader of your rehab team in attaining additional knowledge in regard to Compliance? Will your rehab team become the leader of Compliance in your facility? Will your facility become the leader of Compliance in your Market? Will your Market become the leader of Compliance for the Ensign organization? It can all begin with you!

As Compliance Partners go onsite when conducting the annual Medicare Systems Compliance Audit (MSCA) much of our focus on the therapy program is governed by two areas. First, is the Medicare Policies and Procedure for our organization. Second, is rule and regulation found in the Medicare Benefit Policy Manual, Chapter 8 – Coverage of Extended Care (SNF) Services. We find the successful buildings to be those who are most educated on what is expected by the Medicare Program and then they apply that education.

So, I extend to you an opportunity to express your leadership gene. Here is the challenge…Develop a creative way to present/discuss one item from the above mentioned Medicare resources each week in your rehab team meeting. Use specific policy/procedure and rule/regulation. Then create a way to spread that format to your building, your Market, and onto the Ensign organization. You can become a leader in attaining and sharing knowledge with your peers and beyond. I am eager to see the results. Will you accept the challenge?

“A leader is one who knows the way, goes the way, and shows the way.” ~ John C. Maxwell

Congratulations to Our New SPARC Winners!

Following is an essay written by our SPARC (Scholarship Program And Recognition Campaign) winner that garnered her $2,000 toward her education.

Julie Dunn, PT, Grad Date: May, 2016, Idaho State University

The making of sparks: A profession of excellent clinicians giving superior care to every patient

My lifelong passion for excellence has prepared me to be a unique agent of change, hope, and healing in the lives of the hurting and the underserved. I seek to continuously be improving inclusion, personal aspects of care, patient education, advocacy, and professional training for myself and for our profession. When my patients entrust me with the honor of helping guide them back to healing, I want to have full confidence knowing I have done everything possible to get them there.

My passion for excellence has been something that has driven me throughout my years of schooling, sometimes even becoming a point of resistance: While earning my bachelor’s degree, I was not content to simply obtain a common degree that would give me the most prerequisites for graduate-level education. Multiple advisors frowned on my unwillingness to major in health science, biology, kinesiology, or exercise physiology when applying for DPT and DO programs. In fact, I had to switch advisors multiple times to find someone that would work with my unique vision for my practice: I insisted on using my bachelor’s degree to obtain skills I wouldn’t learn otherwise so that I could reach the people most health care professionals can’t. Ultimately, I obtained a Bachelor of Arts in Spanish language on top of the normal prerequisites. I kept pressing onward, and by the time I started my DPT program, I was a qualified Spanish medical interpreter.

Now that I’m at the end of my formal education, my passions for excellence and inclusion still drive me to provide the best care to the underserved. My Spanish degree has proved particularly useful. One group I consider to be in underserved are non-English speaking patients: Patients with Limited English proficiency (LEP) are documented to receive not only less but also poorer-quality care, creating a disparity even greater than what exists based on ethnic and minority classifications alone.(1) Research is still being called for with regard to cost effective ways of reducing the negative effects of language barriers in health services.(2)

As an interpreter and a physical therapy student, I have personally witnessed LEP persons receiving less patient education, less examination, and overall less care during interactions with medical/therapy staff. I witnessed this despite working with outstanding physicians, nurses, and physical therapists who longed to surpass language barriers and eliminate the health disparity. Still, the quality of care remained inexorably constrained by language barriers, logistical issues with interpreter schedules, time lost during interpretation, and limited ability to communicate to build rapport. That is why, on my affiliations, I have taken on all the Spanish-speaking patients. I found myself staying multiple hours after my own shifts in order to help nurses communicate to deliver necessary medication, calm post-traumatic brain injury agitation, and figure out how to contact family members. It would make a long essay to describe all the times I have heard “I’m so glad you speak Spanish” coming from both English- and Spanish-speakers, and how many times my patients have confided in me feelings about their care, and questions they did not feel comfortable sharing with other providers. In my own practice, I will be able to communicate directly with patients without losing time or emphasis going through an interpreter. I will be able to provide more education, feedback, and understanding so that Spanish-speaking patients can confidently take charge of their own health and recovery.

Through my experience working in physical therapy from the office, technician, and now practitioner perspectives, I have added another group to my list of underserved populations: women with pelvic floor dysfunction. Disorders such as chronic pelvic pain, pelvic organ prolapse, and urinary incontinence are socially limiting and often privately debilitating problems. For example, I worked with someone who had excruciating tailbone pain so bad she could not sit, meaning she could not work, and was at risk for developing on opioid addiction. She had been to see two other PTs without success. However, thanks in large part to my post-doctorate training in pelvic floor assessment and treatment, she was able to return to full activities and sit a full day at work without symptoms.(3) This all happened after just one treatment session together! This is the kind of spark I want to be in my patients’ lives.

I am passionate about bringing high-quality, emotionally-sensitive care to these individuals who suffer privately because of shame, embarrassment, or simply not knowing what options exist for them. In school, I had the opportunity to perform qualitative and survey research with participants in one of our community health grants. I designed a survey to assess pelvic health/women’s health concerns and unmet needs in our population, who had already been involved in the grant for several years. We found that many of our participants suffered from quality-of-life-limiting pelvic floor dysfunction, and not one knew how treatable it often is! Even though each participant had biweekly interactions with a certified women’s health PT and at least yearly interactions with physicians, not one had addressed the uncomfortable subject. Neither had they received education on treatment for their other disorders within the women’s health physical therapy realm, such as osteoporosis or lymphedema. This research was presented internationally to help bring awareness of our responsibilities as PTs to at least connect these patients with the right resources. If we don’t start the conversation, it’s likely they will continue to miss valuable treatment. My passion for this excellence in PT and learning has already carried me to four continuing education courses in my last year of school. I also feel strongly about sharing that knowledge, so I sought opportunities to help make my peers better practitioners also: My school hosted me as a guest lecturer for underclassmen in the physical and occupational therapy programs on two occasions to discuss pelvic floor disorders and other physical therapy treatment options. I also got a significant piece of medical equipment donated to my school so that our students could learn about mechanical hip traction. I found it to be one more tool we can use to spark hope in those inappropriate for surgery, delay surgery, and best promote an active lifestyle until surgery best option.

To continue working for the benefit of more than just my own future patients, I have mentored numerous students in the program graduating after me. I was elected to serve multiple terms as the president for the Student Physical Therapy Association and the Director of Programming for the national Student Special Interest Group on Women’s Health. I want to find the best ways to help my patients, and share it with as many of my peers as possible. I believe when we all work together, we can increase the quality of care our patients receive.

Perhaps the best way to conclude my reflection on how I am going to be a spark in my patients’ lives would be with comments from my patients thus far. I was fortunate to work each semester to provide exercise testing and prescription to members of the community over age 55 with low socioeconomic status. I have had long conversations with several members, with them thanking me for what I helped give them: encouragement to begin taking walks again, confidence to play with grandchildren, better balance from practicing my recommended HEP while preparing dinner, and hope for a healthier and happier way of living. I want every one of my patients to leave my care with the same impression one patient described to me in a surprise thank-you note: “Thank you for being in my life. You are very special, caring, and you will be another bright star for everyone you help. You will always be a bright star in my journey.” (3) I want to continue being that “bright star,” that spark,”and I know that with this scholarship, I will be able to get even better training so that I can be.

  1. Saha S, Fernandez A, Perez-Stable E. Reducing language barriers and racial/ethnic disparities in health care: an investment in our future. J Gen Internal Med. 2007;22(Suppl 2):371-372. doi:10.1007/s11606-007-0372-4.
  1. Schwei RJ et al. Changes in research on language barriers in health care since 2003: A cross-sectional review study. Int J Nurs Studies. Feb 2016;54:36-44. doi:10.1016.injurstu.2015.03.001.
  1. Shared with permission.

Solutions for Oral Care: A Joint Project With Nursing and Speech

Solutions for Oral Care
 
Oral care in our facilities is most often thought of as a nursing measure, likely performed by the nursing assistant. Due to time constraints and other factors, oral care may be overlooked by staff. In addition, patients often do not ask for oral care in the same way they may ask for assistance with other ADLs, such as toileting or dressing.

As we sought solutions for this critical issue, we needed to consider the following factors:

  • In our skilled rehabilitation unit, the increase in short-term stays and managed care patients has meant more critically ill patients with advanced care needs. Some of these patients are admitted with tube feedings, oxygen, IVs or isolation needs.
  • Patients who are NPO have an increased risk of aspiration pneumonia due to an increase in bacteria in the oral cavity. Therefore, the CNAs were often afraid to use a wet toothbrush on these ill patients.
  • Research suggests that the patients most likely to get aspiration pneumonia are those who are dependent for oral care, dependent for feeding and missing multiple teeth.

Finding Solutions

There is a long-standing precedence of speech therapy addressing oral care as it relates to swallow safety and speech clarity. In the past, speech therapy recommended the use of a suction machine and suction toothbrushes for patients, but it was difficult to get follow-through as it was seen as a speech directive only.

As part of our sub-acute unit, our staff instituted the use of Sage Products suction toothbrush kits to help prevent VAP/HAP (ventilator/hospital-acquired pneumonia). An oral care decision tree was developed, nursing was trained and a system instituted to help nursing identify who the patients are, what the procedures are and who is responsible for the care. The decision tree is not the only solution, but it is beginning to work at Carmel Mountain Rehab.

Conclusions

In our facilities, the challenge of providing good oral care is not a new problem, but it is an important one. We do not often see the immediate results of poor oral care, but we do see the increase in infections, hospital transfers, poor patient outcomes and increased costs. A system to have nursing determine the patient’s needs gives them control and ownership over the process, which likely will lead to better compliance.

At Carmel Mountain Rehab, we are five stars because we continue to strive for better care for our patients, and we know that doing better than “good enough” has its benefits.

Submitted by Carmel Mountain Rehabilitation and Healthcare, San Diego, CA

Applying Research on Cues to Reduce Freezing of Gait to WC Propulsion

Applying Research on Cues
 
At Draper Rehabilitation & Care Center, we admitted a 79-year-old male patient with advanced Parkinson’s disease, referred to OT for wheelchair mobility. The patient recently obtained a power-assist lightweight manual wheelchair but has been unable to propel functional distances (to nursing station, dining room, activities, etc.). He demonstrates movements reminiscent of freezing of gait wherein he does not move for several seconds or minutes and appears stuck in place despite his efforts to initiate movement.

Research and Applications to WC Propulsion

Research on FOG reveals applications for WC mobility because freezing occurs in a variety of motor tasks, and UE kinematics have been shown to improve with the use of auditory cues.

OTs and PTs can innovate in low-tech and high-tech ways to apply this evidence to functional activities beyond gait. An example of a low-tech intervention would be attaching a laser to the wheelchair or using a bell, a metronome or music during WC propulsion. An example of a high-tech intervention would be designing a smartphone app that utilizes a smart watch or other sensor to monitor freezing and triggers visual cues or auditory cues. Therapists should also stay up to date on products that are in development and testing.

OTs and PTs can combine multiple sensory cues to increase effectiveness. OTs/PTs should also experiment with continuous and on-demand cuing.

By Amanda Call, MA, OTR/L, Draper Rehabilitation & Care Center, Draper, UT

Developing a Community Reintegration Program for Older Adults

At Magnolia Post Acute Care, there has been an increasing number of community-dwelling adults admitted to our facility with high prior level of function who are discharging back to the community. An interdisciplinary approach with both occupational therapy and physical therapy was used to identify appropriate assessment tools applicable to community reintegration and to use the indications from these tools to guide treatment interventions.

The assessment tools chosen focused on safety and fall risk as well as sit or stand balance, distance of ambulation or wheelchair mobility, safe functional reach, and overall safety awareness in the presence of high sensory demands in the community. Overall, our goal is to be able to create a comprehensive community reintegration program where patients can practice components of community re-entry in a safe environment.

Assessments Used

  • The Functional Reach Test (FRT) addresses community activities such as retrieving items during grocery outings, opening doors, operating a crosswalk push button, accessing public transportation and managing money. This assessment determines a patient’s stability by measuring the maximum distance an individual can reach forward outside a base of support while standing in a fixed position. Results of this assessment were used as an indicator of fall risk.
  • The Dynamic Gait Index (DGI) addresses more challenging aspects of balance that can be more relevant to community activities such as negotiating curb cuts, looking both ways when crossing a street, and modifying the speed of gait quickly due to changes in the environment. The Dynamic Gait Index assesses an individual’s ability to modify balance while walking in the presence of external demands.
  • The distance of ambulation is also relevant. According to Brown et al. (2010), the 200-meter, or roughly 650-foot, distance is a good starting point for older adults with the goal of returning to community independence. According to Andrews et al. (2010), full community ambulation may need to be increased to 600 meters or more.

Results

Of the seven individuals, six were taken out to the community and ambulated to a nearby 7-Eleven store, which is approximately 1,600 feet round trip from the facility. This outing addressed money management skills, navigation skills, managing intersections, item retrieval, safety education and curb cut negotiation.

Upon discharge to the community:

  • FRT — Using a cutoff score of 18.5 cm to determine fall risk (Thomas et al., 2005), six of seven patients’ scores indicated they did not have a high risk of falling.
  • DGI — Using a cutoff score of 19/24 to determine fall risk (Wrisleyand Kumar, 2010), three of seven patients’ scores indicated they did not have a high risk of falling.

 
Functional Reach Test
Dynamic Gate Index
Ambulation Distance

 

Discussion

With the use of these assessment tools, the therapists are able to examine the underlying physical requirements necessary for reintegration with the community. They establish an effective treatment plan from an evidence-based perspective with an interdisciplinary approach.

The therapists incorporated the use of compensatory strategies, alternative assistive devices, environmental supports and services, as well as referral to home health or outpatient therapy services in order to best reintegrate patients to their communities safely.

By Nicole Veniegas, MS, OTR/L, Kathryn Case, MOT, OTR/L, Harini Desai, MPT, Magnolia Post Acute Care, El Cajon, CA

The Use of Baby Dolls for Behavior Management

Baby Dolls Behavior Management
 
Our IDT Falls Committee initially discussed the implementation of baby dolls for some of our long-term care residents with a high incidence of falls and elopement and who were difficult to redirect during care. We identified four residents for a trial use of baby dolls as a means of providing the residents with a sense of purpose and to redirect positive attention during their daily routine.

Our Process

Each resident was screened with both the FAST and GDS to determine cognitive staging.

  • Resident #1: Stage 6 on the FAST, Level 6 GDS. She had frequent episodes of crying out for family and attempts to get out of bed, and she was combative during care.
  • Resident #2: Stage 5 on the FAST, Level 5 GDS. She was often trying to elope, constantly looking for family, combative with staff and resistant to care.
  • Resident #3: Stage 5 on the FAST, Level 5 GDS. She was depressed, looking for family and trying to get up on her own.
  • Resident #4: Stage 6 on the FAST, Level 6 GDS. She was often looking for her deceased husband and waiting at the door for her children, and she often expressed wanting to die because she was a burden.

We determined it would be appropriate for these residents to take place in our trial use of baby dolls in the facility. Residents’ families were informed of our plan.

Our residents were all provided with ethnicity-specific baby dolls to increase the likelihood that they would relate to the doll they were provided. We monitored their ability to relate, their interaction with the baby dolls and their overall behaviors.

Findings

  • Resident #1 was more easily re-directed, had decreased episodes of crying, decreased attempts to get out of bed, and decreased conflict and anger associated with her family.
  • Resident #2 was interactive with her baby doll, but she continues to attempt to elope from the facility and look for family.
  • Resident #3 experienced an effective dose reduction with psychotropic medications, fewer attempts to get up on her own and decreased verbalization of being sad.
  • Resident #4 had decreased episodes of wanting to find her family and a decreased incidence of verbalizing wanting to die.

Plan

Daily Activities programming revolved around care for the baby dolls. The Activities Director provided diapers, wipes, clothing and blankets, and residents cared for their baby dolls during morning activities. Residents gained an extreme sense of satisfaction, care and purpose during this care.

We will continue to work with our psychiatrist on gradual dose reduction of psychotropic medications when appropriate. We also will continue to trial the use of baby dolls with other residents who may benefit from this programming.

Conclusions

The use of baby dolls has proved to be an asset in our skilled nursing facility. Our residents have a sense of purpose, are brought back to a nurturing time in their lives and are distracted with a positive outlet. We will continue to use baby dolls as a valuable part of our programming with residents who fit our criteria.

By Aimee Bhatia MSOTR/L, PAM, Glenwood Care Center, Oxnard, CA

Dementia Care Programming: A Person-Centered Approach

Dementia Care Programming Person Centered Approach
 
“Too often we underestimate the power of a touch, a smile, a kind word, a listening ear, an honest compliment, or the smallest act of caring, all of which have the potential to turn a life around.” — Leo Buscaglia

Our Dementia Care Program was established to improve the quality of life of each person living with dementia entrusted to our care at Oceanview Healthcare & Rehabilitation. Our goal is to steadily increase the well-being of those we affect directly, while becoming an influential model within the community for a widespread shift in how we view dementia as a culture. Program objectives include the following:

  • Preserve autonomy
  • Ensure safety
  • Promote dignity
  • Maintain ability
  • Facilitate active participation
  • Encourage resident friendships

Programming Process

To meet the above objectives, we have a multi-step process designed to uncover each resident’s unique background, needs, wants and abilities. Our process includes:

  1. Interviews to discover each person’s life story, unique experiences, hobbies and interests.
  2. An assessment of physical and cognitive abilities as well as personal needs and desires.
  3. Development of person-centered programs that preserve each resident’s abilities and enhance their quality of life.
  4. Education and training for caregivers to ensure competency when implementing each program.
  5. Completion of quarterly or biannual screens to re-assess abilities. If necessary, programs are revised and staff is retrained accordingly.

Research-Inspired Environmental Modifications

At Oceanview, the above process enables evidence-based integration of our dementia patients into environments alongside like-ability peers. We call these environments “neighborhoods.”

These neighborhoods enable us to customize care. Whether it be through activity planning or caregiver training, we emphasize preservation of ability, dignity and independence. By improving caregiver education, we are able to better prevent communal conflict, implement beneficial activities, encourage meaningful relationships and strategically modify environments.

Caregiver training, specific to each neighborhood, includes the following:

  • Communication strategies
  • Cuing techniques
  • Behavioral strategies
  • Estimated assistance necessary

At Oceanview, we pride ourselves on an “outside of the box” philosophy that enables us to maintain a person-centered approach while enhancing the well-being of all. Beyond this, we aspire to be a catalyst for cultural change by encouraging others to abandon the negative stigmas attached to dementia and emphasize the value and uniqueness of each distinctive life.

Submitted by Oceanview Healthcare & Rehabilitation, Texas City, TX

 

Rehabilitation and Focused Dementia Care Survey

Rehabilitation and Focused Dementia Care Survey
The Courtyard Rehabilitation & Healthcare Center is a 56-bed facility that has been selected to participate in pilot of a Focused Dementia Care Survey, which examined dementia care in nursing homes. The survey examined the processes for prescribing antipsychotic medications and was later expanded to look at standards of care along with over utilizations of antipsychotic medications.

The Courtyard was selected for this pilot program due to a high census of people with dementia diagnoses. A survey was conducted in March 2016, and it was determined that 49 out of 51 residents had a dementia diagnosis.

 

Method

We selected five residents who had a diagnosis of dementia (Alzheimer’s, Lewy body, vascular disease and other dementias) and required different levels of assistance with ADLs. The residents were screened by Physical Therapy, Occupational Therapy and Speech Therapy. Our method included the following steps:

  • The involvement of and conversations between facility leaders, including the DON, unit managers, medical directors and administrators, were examined for appropriate individualized approaches to initiate care.
  • Interdisciplinary and intra-disciplinary conversations about specific triggers of distress as well as desired outcomes were monitored among disciplines and across shifts.
  • Staff consistently communicated about the plan of care during IDT meetings.
  • Residents were examined for any sudden change in condition and medical causes of behavior (delirium or infection).
  • Alternatives to psychopharmacological medications were discussed. These included family/caregiver involvement, rehab, activities, and the Music and Memory program.
  • Therapy established a plan of care for residents having deficits in safety awareness, poor static/dynamic balance with ADLs, difficulty with bed mobility, sequencing with dressing/hygiene/grooming, orientation to facility, and poor phases of gait.
  • Residents participated with rehab services for an average of 27 days. Nursing, family/caregivers, physicians, activities and restorative aides worked closely with the rehabilitation department, reporting positive and/or negative changes in behavior.
  • Specific preventive measures to undesired behaviors were also determined to each individual, such as time of day.
  • We integrated treatments with morning ADLs (getting out of bed, grooming, dressing, hygiene, transfers, toileting, walk to dine, etc.).
  • We worked closely with the Activities Department and also encouraged family involvement.

Conclusions

Patients who were at a higher level of function, by requiring the least amount of assistance outside therapy services, showed the most significant improvement physically with rehab services. We saw success with nursing staff examining alternatives to psychopharmacological medications, family and caregiver involvement, and individualized activities determined by the Activities Department.

Lower-functioning residents showed improvement with alertness, engagement with activities and family members, decreased anxiety/agitation, and responsiveness to nursing with Music and Memory. As part of the Music and Memory program, iPods were loaded with specific songs to trigger memories of past events such as weddings and anniversaries.

Residents continue to work with restorative, Activities Department and nursing for the most effect non-psychopharmacological treatments. Ultimately, the goal is to maintain highest level of function and improve residents’ quality of life.

Submitted by The Courtyard Rehabilitation & Healthcare Center, Victoria, TX

Progressing a Bilateral BKA Patient to Ambulation

Mark (name changed), a 66-year-old male, presented at Coral Desert Rehab with pneumonia, COPD, diabetes mellitus, hypertension, and most notably, bilateral BKA. He had previously been admitted to an acute hospital following surgery resulting in L BKA, but he checked back into the hospital after coming down with pneumonia, after which he came to Coral Desert.

In his initial evaluation, physical therapists noted the patient’s goal to return to living independently with functional transfers and household ambulation and noted his “good rehab potential.” The task ahead was monumental, as the patient had fallen twice in the last year, was unable to complete any functional tests or measures, and was Max-to-Mod Assist on all transfers.

Treatment

Initial treatment focused on regaining ROM and strength in the patient’s LEs, transfer training, UE strengthening and core stability. While the patient was highly involved and motivated in his rehabilitation, at one week of treatment, he was unable to make any progress on any short-term goals.

Oxygen saturation, dyspnea upon exertion and overall weakness remained serious barriers to progress, and the patient still required Mod-Max Assists for most transfers. After having been treated for just over a month, while a few of his transfer levels had gone from Mod to Min Assist, the patient’s inability to ambulate limited any further progression and visibly frustrated the patient.

Turning Point

Four weeks after being admitted to Coral Desert, the patient’s lead physical therapist brainstormed an idea to get the patient spending more time upright and headed toward ambulation. The patient stood in parallel bars upright on his RLE and his LLE on a stool. This was progressed to having the patient ambulate within the bars, sliding the stool along with him. Then, the stool was replaced by a knee caddy placed backward to support the LLE.

Once the patient adjusted to this new setup, he progressed to ambulating outside of the parallel bars with the knee caddy facing forward and therapists guarding both sides. The patient loved being upright and the feeling of walking again, and it seemed to lift his spirits greatly.

Carpe Ambulation

After six weeks at Coral Desert, the patient’s doctor had expressed that the patient just wasn’t strong enough and that plans for a second prosthesis should not be followed as the patient wouldn’t be able to walk.

However, the patient was dedicated during rehab sessions and even put in extra time after-hours. Soon, he was able to show off his progress while ambulating with the knee caddy while representatives from a prosthetics company observed. He impressed them enough that plans to get his second prosthesis were put in place. Within several days, a temporary prosthetic was being fitted.

Conclusion

Throughout treatment, clinical expertise and results implied that the patient would struggle given the opportunity to not only perform a sit-to-stand transfer, but also ambulate with both prosthetics. However, once the prosthetic was on, Mark not only stood up with only CGA, but also proceeded to walk on both prosthetics much better than expected for 50 feet, with a therapist only occasionally giving a Min-Assist and mostly just Contact-Guard Assist.

In the following sessions, Mark also began training to step up one step, weight-shift between his legs, and continue increasing his ambulation distance. Although Mark still has impairments to overcome, his progression increased exponentially upon spending more time upright. This has not only allowed his strength and functional mobility to greatly increase, but has led to his prognosis to eventually return home as well. Mark’s story is an amazing example of the power of both physical therapy and of giving people a chance.

[include graphic of the timeline for patient]
Submitted by Coral Desert Rehabilitation, St. George, UT

Creating Client-Centered Functional Tasks

Research indicates that older adults treated with a “client-centered” focus and approach show positive results in meaningful engagement, socialization, activity tolerance, UB/LB strength, ADLs, IADLs, balance, emotional well-being, motivation, participation and overall quality of life (Law, 2002). Our goal is to improve the overall quality of life for Carrollton Health and Rehab residents by including meaningful functional activities of choice in our clients’ treatment plans.

Process

We began our research by meeting as a rehab team and reviewing our current treatment approaches. Through our discussion, the Carrollton Health and Rehab team identified the following process to better assist our clients:

  1. Identify clients’ occupational needs
  2. Provide active and meaningful tasks that engage our clients
  3. Evaluate their occupational performance based on functional activities provided

Evaluations

In order to assess client needs, our therapists used the following standardized assessments to assist in addressing occupational performance:

  • Physical Therapy: Tinetti, Timed Up and Go, 30-second sit to stand, Berg balance
  • Occupational Therapy: Canadian Occupational Performance Measure, BaFPE, Kels, Activity Index & Meaningfulness of Activity, Florey Occupational Role and screen interview, Leisure Profile for Adults/Seniors
  • Speech Therapy: MOCA, SLUMS

Interventions

  • PT: Treatments to improving gait and balance included walking outdoors on uneven surfaces, playing sports, dancing, and cultural group with activities that were fun and challenging
  • OT: Treatments included cooking, decorating during holidays, crafts, planting, flower arranging and any meaningful client-oriented functional task
  • ST: Treatments included medication management, menu reading, playing fun cognitive games and tasks to assist with cognition

Results

Therapists evaluated their interventions by answering an informal yes/no survey and program evaluation. The overall findings were that the therapists at Carrollton Health and Rehab were successful in providing fun, functional tasks to help their clients achieve their overall goals and to improve quality of life.

By Julie Hebert, OTR, OTD, Carrollton Health and Rehabilitation Center, Carrollton, TX