How Do You Measure Ownership?

By Chad Long, Therapy Resource

Recently I had the privilege of participating in a Market Meeting in IA. After great presentations about Case Mix and PDPM from our Service Center subject-matter experts (thank you, Matt Stevenson and Rob Ady), we reviewed therapy metrics. One facility, Hillcrest Healthcare Center, has been demonstrating some very interesting results. The Market Leaders asked Cassie Nielson, DOR, and CJ Rickard, ED, to present on the “secrets” of their improvements. Instead of discussing programs that were developed, or what type of accountability conversations happened with staff, Cassie simply discussed the challenge of being an “owner.”

Cassie began discussing how Hillcrest had gone through significant changes over time, from being a previous Flag flying facility to a financially struggling facility. Recently, CJ came on board as a new Operations leader (another change for the facility), and Cassie confessed to the group she was seriously considering leaving Hillcrest. Cassie then described her conversation with CJ about leaving, and how CJ, very lovingly and with compassion, asked her if she was willing to be an “owner” with him in the future of Hillcrest. He told her how being an owner was not easy and would have some sleepless nights and require tough decisions.

What struck me most about watching Cassie and CJ recall for the group their previous discussions, was how emotionally raw and real they both were as they said, “We never talked about metrics.” They just got to the very heart of what it takes to turn a person, a team and an entire facility around … true ownership.

Cassie said she really had to think, and question herself, about being an owner. Her answer did not come immediately. However, once she made the decision, she started seeing changes. She became more grateful for her team and frequently thanked them. She looked at her schedule and patient care differently and noticed opportunities. She had tough discussions with strong-opinionated therapists about patient/resident clinical care potential, and she started sharing the financial metrics with her team to include them in the overall understanding of the building operations. She also gave more control (ownership) to members of her team for clinical or operational processes.

Cassie and CJ were able to demonstrate CAPLICO in is purest form. I know they will have struggles and challenges ahead, and the metrics will not always be perfect. However, going through the challenge of being an owner will hopefully continue to define their success in the present and future.

Optima Update

By Mahta Mirhosseini, Therapy Resource

Last month, we talked about the exciting new revisions to our policy regarding Clarification orders. Facilities that are actively using Clinisign, Optima’s physician e-signature feature, do not have to write clarification orders for Part A payers when completing evals and recert if their documents are signed by the MD via Clinisign!

This can be a huge time-saving opportunity, especially since we already did not have to write clarification orders for our Part B payers. This is because Optima’s Clinisign product ensures timeliness of MD participation with therapy POCs/UPOCs. Here you will find some commonly asked questions that come when rolling out CliniSign:

Q: Can PAs/NPs sign our therapy documents via Clinisign?

A: Yes. By putting the PA/NP’s name in the “Clinisign signing Provider” area of the document, they will be alerted to sign the document. This is the signing on behalf of feature and will include the names and NPIs from both the physician and NP/PA on the document.

Q: Do I have to send the invite to a doctor who is already using Clinisign with another facility?

A: Yes, each facility needs to send out a separate invitation so the doctor can start to receive documents from your facility, but the doctor does NOT have to go through the enrollment process each time. Once enrolled, he/she will just get notifications that the facility will begin sending him documents.

Q: How often do physicians get notified?

A: Clinisign will send out a notification ONCE a day at 1 p.m. EST. This notification is sent via email and text (if mobile number has been provided). Physicians have the option to go into their account setting and change frequency and/or time of their notifications.

Q: Can the therapist edit the eval to correct a diagnosis if the doctor has already e-signed the document?

A: Yes, once the therapist goes into the document to make changes, the document will get re-sent to the physician for another e-signature.

Q: Will the MD e-signed document get sent into PCC?

A: Yes, the latest version of the document will get automatically sent over to PCC’s Therapy Clinical Document Report.

Q: Do I still have to scan these MD e-signed documents into the misc tab of PCC?

A: No, because there is an electronic time-stamped record of physician signature both in Optima and PCC.

Q: My medical records director helps monitor therapy document signatures. How will they know which documents are being electronically signed by physicians?

A: Medical records directors have access to “Physician E-Signatures Report” in Optima. Please contact Ensign Support to set up your medical records partners with an Optima user account.

Q: Whom do I contact if I have a question?

A: Please contact your local therapy resource or myself (mmirhosseini@ensignservices.net). You may also contact our Optima Support Team (support@optimahcs.com).

Designing the Facility Around Dementia Care

By Keystone Therapy

What started with a team’s desire to find a better way to treat LTC patients, morphed into a two-year ongoing journey, implementing the most recent evidence-based practice for their residents with dementia, leading them to the implementation of the Abilities Care Approach (ACA). ACA is a program that focuses on maximizing caregiver knowledge in dementia care. By doing so, it created a culture change within the facility that sparked an interest from dementia care to dementia design.

Dementia design is essentially a way to create the best environment for maximizing independence for persons living with dementia. In an Intelligent Risk, Legend Oaks-New Braunfels funded several team leaders to study dementia design at the University of Scotland, a world-renowned dementia design university where companies and facilities from all over the world have sought their accreditation and guidance in best practice for dementia design.

The training course began by presenting the increasing prevalence of dementia and the responsibility for those in the field to provide design and practice in accordance with what research has taught us about dementia. Three different models of how facilities operate when providing care to dementia residents were presented: Basic Needs, where only the basic needs of the resident are met; Social Model, where safety and security are the primary concerns; and a Bio-Psychosocial Model, which is an ambitious approach to care in dementia that takes into account individual needs and preferences, best design and care practice, along with needs and security. As they took an honest look into the approach utilized by their building, they were even more motivated to learn and implement the knowledge gained as they realized their building probably falls somewhere between a Basic Needs and a Safety/Security model.

Dementia design was introduced by an interior designer with extensive expertise in the field of dementia. The five primary dementia design principles taught during this session included: supporting individual needs, maximizing independence, reinforcing personal identity, making design orientating and understandable, and providing control and balance. Design features included: familiarity, reduction in stress and anxiety, clear visibility and multiple cues, and minimizing distractions. Design modifications and examples of other facilities were provided that achieve the five dementia design principles and design features. Color, hue and tone were explained in relation to dementia care and how to contrast design within the building to accommodate the deficits that present in dementia residents.

An extensive interactive workshop with the Legend Oaks-New Braunfels team was conducted where the team had to design a room and bathroom with the appropriate colors, hues and tones in accordance with what we had learned about vision deficits and other physical and cognitive deficits present in dementia residents. Extensive education was provided about utilizing familiar designs with dementia care and the evidence surrounding this approach. “More familiar designs mean people with dementia are less likely to need help, that they make fewer mistakes and that they are more satisfied with the process than if the designs are unfamiliar.”

The interior designer was then followed by an architect who specializes in dementia design. It was here the team learned extensive knowledge regarding appropriate lighting in the morning, afternoon and evening hours in accordance with what we know about dementia and brain function during these times. Appropriate lighting for dementia residents provides better performance throughout the day and good sleep routines, which is often difficult to accomplish in residents with dementia. Education regarding flooring consistency and knowledge on how to contrast floors with seating areas in accordance with vision deficits associated with dementia was explained in great detail to significantly decrease residents’ risk for falls and promote independence.

On the last day of training, the Legend Oaks team was able to tour educational rooms designed in accordance with the principles taught in class. These rooms included: bedrooms, bathrooms, hallways, stairs and a hospital. The team was required to inspect each room and “tag” any errors found in accordance with knowledge gained during the courses.

Legend Oaks-New Braunfels is hoping to seek a partnership with the University of Stirling as they begin their next grant that will focus on dementia design and the knowledge gained during their training courses. The team is already laser-focused on next steps and is diligently working to pave the way for dementia design in the United States, as well as provide cutting-edge research and care for residents with dementia.

Using Occupational Profiles to help with Trauma-Informed Care

By Tamala Sammons, MA CCC-SLP , Senior Therapy Resource

We have become aware of Requirements for Participation, or ROPs. An area that we might not think about from a rehab perspective is the new Phase 3 requirement of trauma-informed care. This requirement is part of Quality of care: 483.25 Quality of care.

Trauma-informed care: Trauma survivors must receive culturally-competent, trauma-informed care in accordance with professional standards of practice, accounting for residents’ experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization.

Currently, trauma is defined as singular or cumulative experiences that result in adverse effects on functioning and mental, physical, emotional or spiritual well-being. Trauma contributes to mental health and functional difficulties. Individuals with multiple adverse experiences are more likely to engage in health-risk behaviors and are more likely to be obese, and have higher rates of heart disease, stroke, liver disease, lung cancer, chronic obstructive pulmonary disease, and autoimmune disorders than the general population (Oral et al., 2016).

There are five primary principles for trauma-informed care.

  • This includes creating spaces where people feel culturally, emotionally and physically safe as well as an awareness of an individual’s discomfort or unease
  • Transparency and trustworthiness
  • Choice
  • Collaboration and mutuality
  • Empowerment

It is important for us to be aware of any adverse experiences our patients may have encountered and awareness of any triggers so we can work with them in an environment where they feel safe, can make choices and are empowered with their plan of care.

Our Occupational Therapists are essential partners as they can complete an occupational profile as part of their evaluation. According to AOTA, “The occupational profile is a summary of a client’s occupational history and experiences, patterns of daily living, interests, values and needs. The information is obtained from the client’s perspective through both formal interview techniques and casual conversation and leads to an individualized, client-centered approach to intervention.” The profile demonstrates occupational therapy practitioners’ commitment to clients as collaborators in the occupational therapy process and facilitates client-centered practice.

A copy of an occupational profile can be found on AOTA’s site: https://www.aota.org/~/media/Corporate/Files/Practice/Manage/Documentation/AOTA-Occupational-Profile-Template.pdf

Additionally, taking time to obtain the occupational profile is essential to allow care providers to deeply connect and align with the principles of trauma-informed care. Occupational profiles allow therapists to build trust, collaborate with and empower clients, and get to personal issues that are unique to each person they work with.

Occupational therapists are not expected to do this alone, however, as trauma-informed care is an IDT approach. Even though standard occupational therapy interventions that focus on improving function, well-being and health can support individuals with intensive needs, it is essential that practitioners know the limits of their personal knowledge and skills and be ready to refer when needed by maintaining collaborative relationships with colleagues who have advanced trauma-specific skills. Sharing this information with the IDT will help with effective care planning strategies, especially if that means bringing in other professionals to help.

Additional Resources

  • For a complete description of each component and examples of each, refer to the Occupational Therapy Practice Framework: Domain and Process, 3rd Edition.
  • American Occupational Therapy Association (2014). Occupational therapy practice framework: Domain and process (3rd ed.).
  • American Journal of Occupational Therapy, 68, S1–S48. https://doi.org/10.5014/ajot.2014.682006
  • aota.org

What is IDDSI?

By Elyse Matson, MA CCC-SLP, SLP Therapy Resource

IDDSI stands for International Dysphagia Diet Standardization Initiative. The purpose of the initiative was to create standards across all environments so that the foods and liquids have the same texture or viscosity.

For example, when a patient arrives to your facility on nectar liquids, how do we determine if the hospital’s version of nectar is the same as ours?

The IDDSI framework consists of a continuum of 8 levels (0-7), where drinks are measured from Levels 0–4, while foods are measured from Levels 3–7.

There are specific testing methods to determine the levels, including a flow test with use of a 10 ml syringe and a fork test to determine food particle size and food softness.

Implementation

So should you implement IDDSI at your facility? There are several factors to consider. The first is, who is your menu vendor? The vendor supplies the menus to the kitchen and provides instructions/wording on which diets your facility uses and how to prepare the meals. It is up to this vendor to adopt IDDSI and provide the new language/instructions to the kitchen.

The next question is whether your local hospitals/referral sources are adopting IDDSI. This may create a need to address the diets sooner rather than later. We have created a conversion chart below to provide to your admitting nurses so they can convert the IDDSI diets back to your current diets.

Finally, you will need to work closely with your SLP, Dietary Department and IDT to determine if your facility is ready for this change. For further questions, please go to www.iddsi.org or reach out to Elyse Matson, SLP Resource (ematson@ensignservices.net).

PDPM Corner: ARDs and Section GGs

By Lori O’Hara, MA, CCC-SLP, Therapy Resource ADR/Appeals/Clinical Review

Setting the ARD

The purpose of the lookback period is to capture those conditions and characteristics that impact the patient’s treatment plan in such a way that they can 1) be reported to oversight agencies and 2) calculate a reimbursement rate.

Under PDPM, since the whole premise of the rate is that it is commensurate with how complex the patient is, it’s then essential that the lookback period capture as many of those things as possible. And it may be that capturing hospital activity is important!

If a patient received IV hydration or nutrition while in the hospital, it can impact our Nursing case mix. This makes sense — patients who were dependent on an enteral delivery of fluid or calories are quite fragile in the period after this treatment concludes. The lookback on this item is seven days and includes delivery while in the hospital.

So the IDT’s job is to decide what the right ARD is to capture all the important info. We may choose to set the ARD on day one, knowing that capturing the hospital intervention paints the most accurate picture of the patient’s complexity. Or, if an IV medication starts after admission on day 7, that might be the right date for a lookback to capture the clinical picture. Or, if the patient had fluids through the day of discharge and has wound treatments ordered on day five, then a lookback that captures part of the hospital activity and part of the post-admission activity may be what’s best.

The good news is that up through day eight, the ARD can be moved forward and backward as needed to make sure that we’ve captured all the complexities of the patient we’re taking care of.

Section GG Reconciliation

Mythbuster time! Therapy should not be the only source of data for Section GG. One of the sources, sure! But not the only one.

Data sources should include therapy evaluations, nursing documentation and the MDS Coordinator’s observation of CNA care. All of this data should be recorded in the record, and then the IDT’s job is to reconcile this through the Section GG UDA.

So what does “reconciliation” mean? It means looking at all the available data and deciding what really represents the “usual and baseline” performance through analysis and discussion.

Say you’re looking at toilet transfers. The Occupational Therapy evaluation says Mod Assist, the nurses’ notes say Partial/Moderate Assistance, and the MDS Nurse documents Partial/Moderate Assistance in her entry. Then Partial/Moderate Assistance seems like the perfect answer.

But what if the OT says Moderate Assist, one nursing entry says Moderate/Partial but one says Substantial/Maximal — and the MDS Coordinator’s note also says Substantial/Maximal? What’s the right answer?

That’s the reconciliation part. And there’s no CMS mandated formula — it’s your IDT looking at the data and the overall performance of the patient and deciding. Do you suspect the patient performs a little more independently with therapy, but that really they’re requiring more help? Then landing on the more dependent score is probably the right answer. Do you know that later in the day they become a lot heavier? Then again, their usual performance is probably the more dependent one.

The critical element is having as much data as you can (and sometimes that will be a very small amount, if therapy is starting the day of admission!) and making a reasoned decision based on the information you have. You want to be able to point to the data you had available and your IDT’s decision-making process to support your coding should you need to defend it later.

Therapist Profile: Andy Miyyapuram

Meet Andy! Satyanand Miyyapuram, better known as “Andy,” is an amazing PT at our Golden Acres building in Dallas.

Andy has been a Physical Therapist for 16 years and has spent the last four of them with Ensign. Golden Acres is an older, sprawling campus with primarily long-term care residents, including a locked dementia unit.

Andy spends each day truly living our core values and fulfilling our goal of dignifying long-term care in the eyes of the world. He spends every day finding what will help make the residents’ quality of life better. He uses his clinical skills to find the abilities of the residents, and he builds on those, creating a successful and elevating experience. He keeps them smiling and laughing, and many patients will agree to therapy “to only work with Andy.”

“To say that Andy is hard-working is an understatement,” states DOR Cara Koepsel. “He is always looking to learn new techniques and programming to better himself in caring for his patients. He makes our patients’ lives better every day, and in this setting, that is the most important thing we do. As an employee, Andy makes my life easy. He goes above and beyond his daily job duties, looking for patients to evaluate that may need his expertise, and constantly asking what he can do to keep Golden Acres patients happy.”

When he is not changing lives at Golden Acres, Andy loves to spend time with his children, taking them on long drives and out for ice cream! He loves to cook, dance and volunteer at his church. He believes it is important to also better your mind, and he enjoys going to the library on the weekends. He is currently working on his GCS and OCS certifications and hopes to finish by March 2020.

Andy’s work ethic and smile are contagious. You cannot help but be motivated after even the briefest of interactions with him, and we are truly grateful for all that he does for our residents at Golden Acres!

WELL (We Embrace Living|Loving Life!) — It’s Time to Get Outside!

Meet Angela Ambrose. Angela is our latest partner contributing to our WELL Project and is a freelance writer with more than 30 years of writing experience. She is also an ACE-certified group fitness instructor and yoga teacher. When she’s not writing or teaching classes, Angela enjoys hiking, running and cooking up healthy Mediterranean-style meals for her family. Born and raised in Chicago, Angela moved to Phoenix 20 years ago and has settled comfortably into her home in the sunny Southwest. For the latest health and fitness news, visit AngelaAmbrose.com or follow Angela on Facebook (@AmbroseHealthyLiving).

Outdoor Exercise Heals the Mind and Body

With the arrival of cooler fall temperatures, you’ll have more reason to get out and enjoy the fresh air and sunshine. Here are a few health benefits of taking your workout outside:

 

Release more feel-good hormones. Outdoor exercise is a natural anti-depressant. Exposure to sunlight increases the hormone serotonin, which can elevate your mood and lessen anxiety. Exercise, by itself, can lift your spirits by releasing brain chemicals called endorphins. When you combine the powerful effects of exercising with time spent outdoors, you multiply these feel-good hormones, which increases your sense of well-being and helps ward off depression.

Improve sleep. Daily exposure to sunlight naturally regulates circadian rhythms — your body’s internal clock — for a better night’s sleep. Regular exercise can further improve sleep quality by helping you get to sleep sooner and increasing deep sleep.

Increase vitamin D production. When your skin is exposed to direct sunlight, it produces vitamin D3. This vitamin stimulates the absorption of calcium, which is essential in maintaining strong bones. Vitamin D also helps fight off infections. Deficiencies in vitamin D can increase the risk of developing heart disease, diabetes, autoimmune diseases and some cancers.

Burn more calories. The constantly changing outdoor environment creates more challenges and stress on the body. Wind resistance can make you burn more calories, especially when you’re running or cycling into a headwind. Walking or jogging on an uneven, changing terrain also requires more muscle engagement than a flat, uniform surface. Your body must also work harder to regulate your internal temperature when exercising outdoors in hot or cold temperatures.

Exercise longer. Running in place on a treadmill and staring at one spot on the wall breeds boredom. But when you’re outdoors, you’re more engaged and stimulated by the sights and sounds of nature around you. A 2012 University of California, San Diego, study of older adults showed that those who exercised outdoors were significantly more active — working out longer and more often than those who exercised indoors.

Save time and money – Instead of fighting rush hour traffic to get to the gym, go on an early-morning bike ride or take an after-dinner walk — with the added benefit of greeting neighbors you see along the way. Plus, save money on expensive gym memberships and gas.

The benefits of exercising and spending time outdoors are well-established, and when you combine the two, they have the potential to dramatically improve your physical and mental health by elevating your mood, strengthening your immune system, improving your sleep and increasing production of the essential vitamin D3.

Sunshine is one of the keys to these health benefits, but like exercise, moderation is important. If you will be out in the sun for extended periods, protect your skin from UV rays by using a natural chemical-free sunscreen.

WELL Challenge! Here are two simple ways to share your own stories about getting into the great outdoors. Choose the one that is easiest for you:

  1. From your Instagram account, share a picture and caption and remember to hashtag both #CAPLICOwell and #CAPLICOnation.
  1. From your smartphone, visit EnsignTherapy.com, click “WELL” at the top of the page, then click “Share Your Story” from the top of the WELL Site. There you’ll find room to share a short story and upload a picture from your phone.

We look forward to seeing your inspiring stories as a collaborator to our WELL Project.

Add Heart to Your Teams!

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.