Documenting Justification of Skilled Therapy Services, Part 2

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Symptomless CVAs?
By Lisa Harvey, M.S./CCC-SLP, Documentation Review Resource

A pattern that our PDPM deep diving partners have found is hospital document and/or therapy documentation that reports a history of CVA that then goes…nowhere. Despite this history, no residual speech, language, swallowing, cognitive or neuromotor findings are reported in the therapy assessments (or anywhere else). Yet according to the National Stroke Association, only 10% of people who have a stroke will make complete neurological recovery. This means that many individuals with long-term sequela are going unidentified in our setting.
According to the CDC, the most common long-term symptoms after a CVA include hemiplegia, cognitive impairments, speech and language impairments, dysphagia, incontinence and depression. Most of those symptoms, when properly identified and managed, will trigger PDPM components.

Step 1: Identify the sequela.
Obvious hemiparesis, dysphagia or aphasia will seldom be overlooked. But even minimal impairments can affect a patient’s balance, skin integrity, weight, mood and cognition. It’s critical that when a CVA history is present that the most sensitive assessments are completed to ensure that subtle impairments in symmetrical strength, righting response, complex reasoning, word retrieval, mood or swallowing are not missed.

Step 2: Identify how the patient is impacted.
It’s very unlikely that a long-term residual sequela doesn’t impact the patient’s function, the therapy treatment plan, or both. In addition to therapeutic interventions that may be need to be incorporated into the specific therapy treatment plans, the ways they impact a patient’s function should be part of the patient’s comprehensive care plan. Here are some examples:
• Hemiparesis that affects gait stability or righting response should be careplanned under fall risk management.
• Hemiparesis that affects sensation should be careplanned under skin intergrity.
• Hemiparesis that causes joint instability should be careplanned under risk for injury.
• Apraxia can affect ADL function, gait stability or speech and should be careplanned in the appropriate area.
• Aphasia or dysarthria that effects either comprehension or expression should be careplanned under risk for communication breakdown.
• Dysphagia that requires any degree of adaptation (including supervision or compensatory swallowing technique) should be careplanned under nutritional risk.

The better the assessment, the better the patient’s therapy and care plan can be customized to their needs. The more patient-focused the care, the better the patient will respond to it. And an extra bonus is that CMS recognizes the impact that long term neurologic sequela have on a patient’s care and they’ll reimburse accordingly. So we call that a win!

What’s So “Vital” About Vital Signs?

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Submitted by Tamala Sammons, M.A., CCC-SLP, Therapy Resource, Flagstone, Pennant, Sunstone, Milestone, Endura, Monument

Vital signs are the objective measurements of temperature, pulse, respirations, and blood pressure as a clinical means to assess general health. Additionally, many include Pain and Gait Speed as the fifth and sixth vital signs.

Vital signs are critical indicators of patient status, both at rest and during exercise/activity.

 

Therapists treat patients with many complicating conditions, such as:

  • Respiratory conditions — pneumonia, COPD/chronic bronchitis, emphysema, asthma, atelectasis, etc.
  • Cardiovascular conditions — CHF, hypertension, etc.
  • Metabolic conditions — renal failure, diabetes, etc.
  • Infection conditions — sepsis; Systemic Inflammatory Response Syndrome (SIRS), etc.

Taking consistent vital sign measurements will help ensure therapists have good data related to respiratory function, cardiovascular function, endurance, and a patient’s ability to tolerate functional activity.

As clinicians, it’s not only important to take vital signs, but also measure them against exercise/activity. In other words, vitals should be taken:

  • Before the exercise (to establish a baseline);
  • 6 to 8 minutes in the exercise; and
  • 5 minutes after the exercise (recovery).

This information will allow clinicians to determine if target heart rates are being attained, any changes in condition, and/or if treatment adjustments need to be made, etc.

Consistent vital sign measurements also help detect medical condition changes. For example:

Sepsis early warning signs (these changes need to be reported immediately):

  • Temperature higher than 100.4° F or lower than 96.8° F
  • Heart rate greater than 90 beats per minute
  • Respirations greater than 20 breaths per minute

Respiratory rehab considerations:

  • A resting HR > 100 bpm is a relative indicator of patient instability.
  • If lower than 90%, there is an inadequate oxygen supply, and less than 70% is life-threatening.
  • Normal resting respiratory rate is 12-20 breaths per minute. “Normal” respiratory rate for an individual with pulmonary disease may fall outside these parameters. It is important to establish what is “normal” for each patient. Respiratory rate needs to be monitored before, during and after exercise.

Using vital signs to determine exercise termination:

  • Significant blood pressure changes
    • o BP>200/110
    • Lightheadedness; BP drops >20 mmHg
    • No more than an increase of 20mm Hg with activity
    • Oxygen saturation <90%
  • Severe shortness of breath
  • Noticeable change in heart rhythm

It’s important to know the normal ranges for each vital sign along with considerations for an aging population. Additionally, it’s also important to know what medications patients are taking and if those medications may interfere with vital sign measurements.

For example:

  • The medicine digoxin used for heart failure and blood pressure medicines called beta-blockers may cause the pulse to slow.
  • Diuretics (water pills) can cause low blood pressure, most often when changing body position too quickly.

Take time to ensure every member of the Therapy team is taking vital signs consistently and throughout treatment sessions as recommended. Consider hosting a training lab if any skills need to be refreshed. Ensure team members have access to vital sign equipment (consider vital sign kits for each team member).

For more information on the details of vital signs, please refer to the Vital Signs POSTette, Pain Management POSTette, and Clincally Complex POSTette.

For training tools, check out these resources:

• Training video on taking blood pressure: https://www.youtube.com/watch?v=UGOoeqSo_ws
• Training video on all vital signs: https://www.youtube.com/watch?v=JpGuSxDQ8js
• LMS video available on Vital Signs: How to Measure Vital Signs REL-PAC-0-HMVS 1 hour

Therapy to ED Leadership

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Submitted by Brian del Poso, OTR/L, CHC, RAC-CT, Therapy Resource

As you all know and have heard, our organization considers itself a “leadership development company that happens to be in healthcare,” and we are always looking to develop the best and right leaders. On previous Therapy Leadership calls, we’ve had guest speakers who were former DORs who took on the challenge of becoming EDs, quite successfully we might add! Our organization recognizes how special our therapists and therapy leadership are and the potential that many of you possess.
In a continuing effort to tap into that potential and to foster and grow any thoughts you may have or have had about becoming an ED, we are starting a series of interviews with our former therapists/DORs turned ED, to get some further perspective. Here’s the first of the series from Stephanie Anderson out of Rock Creek of Ottawa in Kansas.

Thanks for taking the time to check out this interview, and if you want to talk further or have questions about becoming an ED or the AIT program, we encourage you to take the next step and start talking to folks. There are many ways to get more information and insight, such as your ED, Market, therapy resources, Clay Christensen, and/or any of the former DORs who are now successful EDs. If you’d like to talk further with Stephanie or any of our other former DORs, let us know and we’ll get you their contact info!

Question: What is your favorite part about being an ED?
Stephanie: I love that I am able to really take the time to focus on staff and residents. I get to spend my day “people-ing,” as I like to call it. Being on the floor, problem solving, getting to know the staff and residents on another level, and really driving the culture and vision I have for the building all make my day so enjoyable. The impact I can have as an ED in taking our building to the next level is what motivates me each and every day.

Question: As a DOR, you were in a good place in your career. What kinds of things were you thinking about when the thought of being an ED came up?
Stephanie: Can I really do this? Do I want to do this? How will my relationships change with my peers and team if I make this switch? I love this building, as it is in my hometown and I’ve seen the changes that have happened over the years. I joined Rock Creek of Ottawa during the acquisition in November 2018. Prior to the acquisition, the building didn’t have the best reputation, so I love that I can be part of fixing that. I took the DOR job with every intention to change the reputation here. As the ED, I feel I have more impact and push to continue to change. Me stepping into this role allows the community to continue to build trust in us.

Question: How did you come to the decision to push forward into the AIT/CIT program?
Stephanie: Our market lead actually approached me about the idea. My ED at the time had been telling me for a while that I would make a great ED someday, but that day came faster than I was anticipating! It was a little unconventional as I still served as the DOR while I was going through the AIT and I was able to complete the AIT in my home building. There were long days, but I was able to make my AIT experience a positive one. You really are the one responsible for making your AIT program great. My therapy department was operating well and I felt like I needed more. I was also able to connect with other EDs within Ensign that were DORs previously and went through AIT.

Question: You’ve been transitioning to this role during this rough time of the pandemic. Are there qualities or characteristics you took from being a DOR that have helped you with your transition during this time?
Stephanie: How to enhance culture across departments, clinical skillset as far as infection control and isolation room practices, implementing strategies to enhance residents’ quality of life and functional abilities, LTC programming, creative ways to drive revenue, seeing the business side of how the operation works, building a strong team and having the right people on your team to be successful, driving culture.

Question: What advice would you give to a therapist if they are thinking about becoming an ED or even just about the ED role in general?
Stephanie: I’ve been told that DORs who transition to EDs are the most successful. ☺ If you’re considering making the jump, I encourage you to reach out to people who have done it and gain perspective. The beauty about Ensign is that our culture and processes allow awesome things like this to happen!

Therapist Profile - Avenlea Gamble, DOR/SLP, Northbrook Healthcare

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Submitted by Jamie Funk, Therapy Recruiting Resource

Meet Avenlea Gamble (pictured Left), a second-generation Ensignista who is the Director of Rehabilitation at Northbrook Healthcare Center in Willits, California. Avenlea has been coming to Northbrook since she was three days old, which may sound strange unless you know that her mom, Shawndee Gamble (pictured Right), is the facility administrator there.

This story is about Avenlea, but it is woven tightly with the story of her mother. Shawndee began working at both our Ukiah and Willits locations when she was 17 years old, first as a CNA, then in medical records, and then as an activities director. Avenlea would help out with bingo and one-on-one activities with the residents and developed a lasting love for the long-term care setting. Shawndee later entered the AIT program and has been the facility administrator at Northbrook for 13 years.

Avenlea began her healthcare career at 16 when she became a care partner for Northbrook residents under the Department of Social Services. She also served as a dietary aide, helped with HR, and basically filled in on any odd job that was needed. She loved helping her small, tight-knit community. Willits has a population of approximately 5,000, so Avenlea cared for many of her friend’s parents and grandparents over the years.

Avenlea loved growing up in a small town, and her graduating high school class had only 18 students! She knew from early on that she wanted a career in therapy and wanted to return to Willits to help alleviate the ongoing shortage of qualified medical professionals there. She ultimately chose speech therapy because it allowed her to support communication and give people a voice.

The University of Pacific is where Avenlea obtained her undergraduate and graduate degrees in Speech Language Pathology, and also where she met her now husband, Jan. An interesting fact is that UOP had the same number of students as the entire town of Willits. Despite the crowd, Avenlea loved her experience there and had great clinical exposure with patients beginning in her junior year.

Jan took Avenlea’s last name when they married since the family history meant so much to her (and she is the namesake for her family). Jan is an opera singer as well as an audiologist and works in a clinic in Santa Rosa. He has a passion for music but also for science, so audiology was a perfect combination of the two. You can find his music and online choir on YouTube. Avenlea says their home is filled with a variety of instruments and full of music most of the time. Her two cats, Belle and Jasper, are happy residents and can be found enjoying a view of the beautiful foothills through a sunny picture window in the Gambles’ house.

After graduating with her Master’s Degree in Speech Language Pathology, Avenlea worked in an acute care hospital setting in Stockton to complete her clinical fellowship year and earn her CCCs. It wasn’t long before a speech therapist position became available back home and she convinced Jan to join her in moving back.

Let’s Keep Doing the Important Work

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By Cara Koepsel, M.S., CCC-SLP, DOR, Golden Acres Health and Rehabilitation, Dallas, TX

Here at Golden Acres in Dallas, Texas, we love our long-term care residents. They are the heart and soul of our facility, and we wouldn’t have it any other way. One of our residents passed away recently, and it never gets easier. The family reached out to myself, the DOR, and the social worker in hopes of getting a copy of her grandmother’s life storyboard that was created during therapy with one of our amazing speech therapists. Her granddaughter wanted to utilize this resident’s life storyboard to aid in writing her obituary. To think that the Abilities Care Approach Program could, in such a trying and upsetting time, bring joy and meaning to a grieving family is truly amazing.

What an important program this is, and what a reminder that what we are doing in therapy every day matters maybe more than it ever has before. The Abilities Care Approach Program is a program widely utilized across our Ensign facilities that is evidenced-based, and essentially allows the therapists to work with family members and residents to develop a life storyboard that paints a picture of our residents’ likes, dislikes, family history, and abilities they have within their communication and self-care activities through their changing stages of dementia.

For our family members to be involved in their loved one’s care through the stages of dementia is so important, especially right now as they cannot see their loved ones as they are used to. Our therapists, through this program, can work with our families to give them peace of mind that during a pandemic, their loved ones are being loved and cared for so well. Our long-term care programming continues to be so important right now! Let’s remind ourselves that we continue to make a huge difference in our residents’ lives!