Outpatient On Demand

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By Kathey Perez, Therapy Resource – Keystone South Central, TX

Outpatient On Demand is a great way to look at ways to expand our delivery of outpatient services. Many of our patients are afraid to leave their home due to the pandemic, or can’t leave due to transportation issues, or maybe they are fearful to leave our facilities worried about failure when they go home. Outpatient on Demand helps us overcome some of these concerns while meeting the needs of our community. We can help those that may not be homebound by home health standards but have a need for services, and help the successful transition of patients back into their home by being able to provide education and training in the area they need to thrive. Once the patient is able to come to our facility, we can transition them to Outpatient at the facility as well. Patient identification should start with care planning upon admission to our facility. We can also identify them by doing home evaluations prior to discharge.

Home eval prior to discharge:
• What allows us to provide therapy in the home?
o Medicare specifies four locations from which a provider can provide outpatient physical therapy. Medicare Part B pays for outpatient physical therapy services when furnished by: a provider to its outpatients in the patient’s home; in the facility’s outpatient department; to inpatients of other institutions

• What is it and Why Now?
o Therapy services (PT, OT, ST) offered that meet the patients where they’re at, focusing on what matters most, being able to function in their actual home/community environment.
o COVID related shutdown, limitations, and resident declines created a shortage of therapy and a need more than ever

• What differentiates this from Home Health Services?
o Residents are not required to be certified as home-bound to participate in our services. On average, we are able to provide MORE therapy than is typically seen in HH settings. Maintenance programs are a big part of our outpatient programs

Vestibular Function

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By Evette Ramirez, DPT, DOR, Legend Oaks of Waxahachie, TX
All information taken from the Vestibular course given by Ann H. Newstead, PT, DPT, PhD, GCS, NCS, CEEAA (https://www.ahnewphysicaltherapy.com/)

As we age, there is a greater incidence of falls. Many factors play a role in these falls; some external and some internal. Some risk factors include medications and resulting side effects, cognitive impairments, lower extremity disability including loss of sensation and/or foot deformities, balance abnormalities, dizziness, orthostatic hypotension as well as increased dependence on visual cues for ability to achieve and maintain balance.

Vestibular function is an area that we as clinicians can address to help reduce potential falls. As 30% of older adults develop vestibular dysfunction, knowledge of when and how to treat as well as when to refer to a specialist is a needed skill. As we age, vestibular changes begin at age 40 with reduced number of hair cell in the inner ear as well as a decreased number of nerve fibers, which lead to decreased to increased difficulty with competing visual and somatosensory input.

Definitions to know:
Vertigo: an illusionary sensation of motion of either the self or the surroundings in absence of true motion.

Oscillopsia: a visual illusion of oscillating movements of stationary objects. This can arise with lesions of the peripheral or central vestibular systems.

Receptor: a patch of hair cells projecting into a gelatinous membrane

Otoconia: calcium carbonate crystals that rest on top of the macula and are floating on tome of the gelatinous membrane. (Gravity and shearing forces occur with acceleration and deceleration and deflection of the hairs.

Semicircular Canals (SSC): ring shaped, fluid filled canals set at 90 degree angles to each other on each side of the head as functional pairs. These work as the push / pull mechanism. Ex. Increased firing of RSSC when turning head to the right will decrease on left.

Vestibular Nuclei: There are four vestibular nuclei in the CNS. These are located in the floor of the 4th ventricle between the medulla and the pons. Visual and somatosensory inputs are integrated here with information entering bilaterally. Information is sent to the brain, cerebellum and to the spinal cord via CN VIII.

The vestibular system has three main functions: 1) Gaze stabilization which refers to ocular stability. This keeps images stable by moving eyes in response to head movements. 2) Postural control which detects position and movement of head in space; along with sensory and proprioceptive systems. 3) Perception of motion which helps to distinguish eye movements from head movements (internal) and head movements from exocentric (environmental) movements. The vestibular nuclei, cerebellum and reticular formation all receive input form visual and somatosensory systems. The output form these areas influence oculomotor control and spinal motor control. The central pathways for these systems are separate, therefore, both systems are examined and treated separately.

A vestibular exam will typically consist of:
• Acquiring a history
• CN testing
• Eye head coordination
• Positional testing
• Postural control
• Functional testing
• Locomotion

Other assessments include: Visual vertigo analog scale (VVAS)
Dizziness Handicap inventory/index (DHI)
Activity-specific Balance Confidence (ABC) Scale

Clinical decision-making model and differential diagnosis includes:
• Acute symptoms – Possible BPPV, labyrithinitis, stroke , fall and concussion
• Episodic – possible Meneire’s, postural hypotension
• Chronic – Possible Mal debarquement, hair cell loss, aging, long term CNS injury

Exam:
By taking our clients through various positional changes and movements of the head, we can elicit symptoms and this will help to determine where the lesion/dysfunction is originating and lead us to the best protocols to reduce symptoms. Following the steps below, one can observe ocular movements and fluidity of movements, lag in response to positional changes or presence of nystagmus (ticking of eye movements horizontally or vertically). Always take note of direction of the “beat”/tick as well as how long it lasts. Always assess the client’s perception of severity of vertigo on 0-5 scale with 5 being severe.

Visual field deficits: Normal: superior 60 deg; inferior 75 deg; tamporal 100 deg; nasal 60 deg.
Eye / head coordination: Eye range of motion – rectangular; eye coordinated, conjugate motion with head steady.
Smooth pursuit – smooth eye movement at less than 60 degrees per second; eyes tracking moving object
Saccadic eye movements – rapid eye movements between two targets
Vestibular Ocular Reflex (VOR) – gaze stability during rapid head movement
In-phase – eyes fixed on object; heading moving
Cervical Ocular reflex (COR) – rotation of body under head – keeping head stationary
Gaze Stabilization – Optokinetic system
• Combination of saccadic and smooth pursuit system
• Stimulated by repeated movements across a subject’s visual field (an object moving across the stationary visual field or by a person passing by a stationary visual field)
Nystagmus – non-voluntary rhythmic oscillation of eyes; fast and slow components beating in opposite directions; named by the fast component.
• Pathological nystagmus – appear with or without external stimulation in patients with vestibular disorders
• Spontaneous – present with head erect and gaze centered
• Positional – induced with changes in head position
• Gaze evoked – induced by change in eye position
Peripheral Vestibular lesion:
• Jerk nystagmus (named for the fast component: away from the lesion: either up or down beating) Side of lesion is opposite the quick motion (jerk)
• Pendular nystagmus (right or left beating; or up or down beating)
• Rotary nystagmus (named for direction of spin e.g. Upward and rotary)
• Result of asymmetry of right and left vestibular systems.

Head thrust test (HTT) or head impulse test (HIT) – clear neck AROM and carotid artery first
• Fixation on near target then far target ( 6 ft away)
o Slow head movements
o Fast head movements

• Watch for saccades – re-fixate on target (nose)
o Peripheral or central vestibular lesion – unable to maintain gaze
o Bilateral peripheral vestibular lesion – re-fixation to both sides

Head Shaking nystagmus test
• Eyes closed; head tilted downward to 30 deg (places horizontal canals // to ground)
• Turn head passively side to side 20x (2Hz)
• Check for nystagmus using frenzel lenses
o Unilateral peripheral lesion – asymmetrical nystagmus – slow phase toward involved (hypo-functioning) side
o Normal – no nystagmus
o Central lesion – vertical nystagmus

Clinical dynamic visual acuity test (DVAT-N)
• Measures functional VOR or ability for person to stabilize gaze during head movement
• Read visual acuity chart on wall 4 m away
o Lowest line read seated
o Lowest line read while head is passively oscillated in horizontal direction at 2Hz
*Vestibular hypofunction of >3 line change in visual acuity
Monofilament testing plantar sensation
Sensory levels 1= 1g Normal sensation
2= 10 g Protective sensation
3= 75g Loss of protective sensation
4= No perception
Motion Sensitivity quotient (MSQ) – Measures individual response to positional changes. (I.e. quickly supine to side lying R and L; supine to sit and return; wait for response
• Establish baseline of symptoms of vertigo/dizziness, nystagmus at rest
• Monitor symptoms of vertigo/nystagmus
Dix-Hallpike Maneuver
• Quick movement from sitting to sidelying with head rotated 30 deg away from downside ear
• Caution: check for neck AROM and vertebral artery prior to any quick motions of neck on older people
• Watch for nystagmus and direction
• Record duration and intensity of nystagmus and vertigo 0 (none) – 5 (severe)
o Nystagmus directional perponderance:
 Horizontal canal – nystagmus will occur with fast component toward the floor (Horizontal geotropic meaning, toward the earth) or Ageotropic – away from the earth
 Anterior canal – torsional and DB (down beat)
 Posterior canal – torsional and UB (upbeat)
The most common peripheral lesion is BPPV of the posterior canal. With testing, one will typically see and upbeating, torsional nystagmus. (There may be a 30 second delay in nystagmus). Short term is <2 minutes if BPPV. This will usually improve in one treatment. Allow rest and re-test for symptoms.

Evaluation and interpretation of findings
With evaluation, Peripheral lesions/dysfunctions will present with BPPV, nystagmus, short duration vertigo, possible hearing loss and/or tinnitus. While Central dysfunctional will present with head trauma, concussion, stroke, MS. Symptoms will include nystagmus vertically, long lasting, lateropulsion and head tilt.

Mechanical Dysfunctions to look for
• Benign Proxysmal Positional Vertigo (BPPV), with typically be a result of cupulolithiasis or canalithiasis. Symptoms will typically include vertigo with changes in head position, nausea with/without vomiting, disequilibrium
• Right Posterior Cupulolithiasis will typically present with a persistent upbeat nystagmus and right torsion. Canalithiasis will typically present with transient upbeat and right torsion.
• Left anterior Cupulolithiasis will typically present with persistent downbeat and right torsion. Canalithiasis will typically present with transient downbeat and right torsion.
• Horizontal cupulolithiasis will typically present with persistent upbeat nystagmus, while canalithiasis will typically present with downbeat nystagmus

Identification of Semicircular Canal if peripheral lesion:

Canal Involvement Primary nystagmus: right Hallpike-Dix Reversal nystagmus: Right Hallpike-Dix Nystagmus: return to sitting
Right posterior Upbeat and right-ward torsion downbeat and left-ward torsion Downbeat
Right Anterior Downbeat and right torsion Upbeat and left torsion upbeat
Horizontal Horizontal opposite horizontal direction opposite horizontal direction
Left Anterior Downbeat and left-ward tornsion Upbeat and right-ward torsion upbeat

Treatment
In most instances, the techniques presented below will significantly decrease or stop symptoms within 1-2 treatments. Once, vertigo symptoms are addressed, balance, advanced gait and strengthening can be addressed as well as accommodation techniques which will become more complicated/advanced as the client accommodates. These will involve increasing eye, head and body movement as the client improves.

Canalith Repositioning Technique: CRT-Posterior SSC (Canalithesis BPPV) Treating Left side.
• Turn head left 30 deg from midline
• Maintaining 30 deg head turn, move to supine position
• While in supine, turn head to opposite side (right), 30 deg from midline
• Have client roll to onto right side while still maintaining 30 deg head turn to the right
• Transition back to upright position while maintaining 30 deg head rotation

Cupulolithesis (for posterior SSC) Treating Right side
• With client in sitting position, rotate head 30 deg right
• Move to side lying right, maintaining head rotation
• Keeping head at 30 deg rotation from midline, have client sit up and move to side lying Left
• Then move back to sitting. Head will be in original 30 deg to Right.
*once head rotation 30 deg from midline is achieved initially in sitting, this head position is maintained throughout the maneuver.

Cupulolighesis BPPV (for anterior SSC) Treating right side
• Have client in sitting position, turn head 30 deg to left
• Transition to side lying right (with head maintained in 30 deg rotation – head rotation will be up toward ceiling)
• Then move to left side lying while maintaining rotation 30 deg to left – head rotation will be toward the floor)
• Then have client move back to upright sitting, maintaining head rotation to left 30 deg.

Horizontal Canals – Roll Test
• With pt in supine, to test right side, have client rotate head to the right
• To test left side, have client rotate head to the left
*Alternative position can be performed with client’s head on a pillow or wedge

Canalith repositioning technique: CRT – Horizontal SSC
• Start with client in side lying with “bad” ear down
• Roll to supine
• Then move to opposite side lying position with “bad” ear up
• Then move to quadruped position with head // to the floor

Habituation Techniques:
• General habituation technique for posterior SSC BPPV. In sitting position, rotate head 30 deg Left, move to side lying left, then back to sitting, repeat on opposite side. Remain in position 30 sec or until vertigo stops. Perform 10-20 x TID.
• Gaze stability – looking at a fixed object and turning the head slowly from side to side.
o Turning body under the head with head fixed
o Body/head fixed looking at a central object, moving eyes only look to objects above, below, laterally and diagonal to central object/point
o Balance activities – stepping over objects, around objects.
o Gait activities with head movement

The activities outlined above are just a starting point. Be creative and always create an individualized program for each client based on symptoms, persistence of symptoms and each client’s specific deficits, their specific goals and activities and hobbies each client wants to return to.

Congratulations, Jacob Barnes, Bandera’s Newest CTO

MP Celebrate

By Shelby Donahoo, Therapy Resource, Tucson, AZ
We are proud to honor Jacob Barnes, PTA, TPM, at Park Avenue Health and Rehab in Tucson, AZ!
Jacob has been with Ensign at Park Avenue since 2013 and truly exemplifies CAPLICO culture. Jacob’s ED, Jordan Monson, says Jacob “is like salt: He’s sprinkled into every nook and cranny that is Park Avenue.” In other words, while Jacob leads a large rehab team with strong outcomes clinically and operationally, his ownership over the years is way beyond the Rehab department.

2020 led to some exceptionally tough times for all, but Jacob’s leadership shined through in this pandemic. In between serving meals, moving beds, and working all hours to support the facility, he quadrupled long-term care revenue, increasing margin by 8%. This was accomplished by concerted and thoughtful implementation of holistic programming to meet the growing needs of Park’s residents. He developed leaders in his team, such as our Bandera Abilities TEACHA, and created a designated long-term care lead and team. He helped facilitate support and communication with market DORs as challenges arose during COVID.

So here’s a perfect example of why Jacob is CTO: December 18 was his surprise CTO celebration. While facility staff, folks from all over the market, and even DORs from Phoenix (who drove two hours) congregated outside, Jacob’s co-worker was to distract him and then bring him out to “go to lunch” once he was texted that all was ready. The text to come went out, and we waited, poised with confetti — and waited some more. Finally we got a text back — Jacob was busy giving a resident a haircut! After another 15 minutes, the text came that he was done and they were headed outside. And we waited. Another text came from the co-worker: Jacob was stopping to answer call lights on the way. True and awesome story.

Thank you for all you do for your residents, facility, Bandera and the full organization, Jacob! And for your unwavering wit and humor along the way.

Transitioning Our STOP AND WATCH Program into a True Conversation

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By Kari Rhodes, MS, CCC-SLP, Therapy Resource – Keystone – West, TX
At Legend Oaks of Fort Worth, there have been a fair share of ups and downs in communication. As with most skilled nursing facilities, there are some struggles to get nursing and therapy on the same page, especially regarding changes in a patient’s condition. However, a recent change in structure for daily morning meetings has made a significant impact on both communication and patient care.
Initially, staff were encouraged to complete paper STOP AND WATCH forms that were turned in to the charge nurse. This was helpful in reporting noted changes, but it did leave room for improvement. Papers were misplaced, the change was forgotten, or multiple forms may be completed on one resident.

Staff were then trained in entering the STOP AND WATCH forms on the clinical dashboard in PCC. This improved the chance that the alert was seen by more people and addressed by a clinician. Unfortunately, the electronic alerts also were, at times, inadvertently left unaddressed by a busy nurse or well-meaning staff member.

Fortunately, what has been an amazing change for the team at Legend Oaks Fort Worth was a very simple addition to the morning meeting. In addition to reviewing metrics and culture topics, our ED implemented a review of the daily STOP AND WATCH alerts for the whole team to address. Each alert is discussed by the team. What condition or behavior caused the alert? What was done to address the change? How is the resident doing on a daily basis? This has significantly increased the topic of conversation regarding change in condition.

Here at Legend Oaks of Fort Worth, we are continuing to strive for improved care and communication. This simple change in a system that was already in place has opened the door for more conversation, increased discussion regarding change of condition, and decreased discharges back to the hospital.

Celebrating Success at Beacon Harbor

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By April Trammell, SLP, DOR, Beacon Harbor Health & Rehabilitation, Rowlett, TX
Jimmy arrived at Beacon Harbor on April 13, 2020. He was in a very devastated state following a spinal fusion, which was compromised, leaving him with hemiparesis from the chest down. Because he was unable to feel his legs and feet, he was having frequent falls, required a hospital bed with assist rails in order to maneuver in and out of bed, and was wheelchair-bound. “I was brought to Beacon Harbor for my last days on earth to be comfortable and to give my wife Dianne a respite.”

Plans for Jimmy were to transition here to Beacon Harbor long-term care. But Jimmy had other plans in mind. He was successfully determined to wean off of all pain medication. “Then I started doing therapy — that wore me out — but I had it in my head that I wanted to recover.” Jimmy and his team of therapists were determined to help him gain his independence. “Day after day, week after week, I started improving not just a little bit — a lot! No explanation ‘why’ except my therapy and my willingness to do what is asked of me. They have challenged me on so many things, and they are holding me up, allowing me to improve.” He progressed to being able to transfer independently in and out of bed, and to be able to complete basic self-care such as dressing, bathing and toileting independently. “I feel like I am being rebuilt. There’s something about this place that draws it out of you.”

Jimmy and his therapists continued to focus on neuro re-education, and he slowly began to regain full sensation in his body. “I am able to feel hot water and take a hot shower for the first time in over 35 years!” He did not give up; Jimmy continued to thrive in therapy and began walking with a walker for the first time in 10 years. “I started taking control of my life slow, but every day it was a very hard road to walk down — for myself, for my wife and family. I would say Beacon Harbor is just one of the best rehab centers that I’ve ever been in in this nation, and I have been in quite a few from state to state over the years. The bottom line, Beacon Harbor: You have an amazing PT, OT, ST and Nursing staff. I’m getting ready for my second phase of taking my life back. I’m going to move into assisted living, and from there, back home. Thank you for a second chance at life.”

Happy News from EPAR

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By Paula Voorhis, PTA, DOR, Englewood Post Acute & Rehabilitation, Englewood, CO

In recent weeks, Englewood Post-Acute and Rehab has been handling the COVID outbreak with as much grace as possible. I just wanted to take a moment to share some photos of our celebrations of success.

This is our first group treatment since October, which is when we went into full lock-down, outbreak mode. It was organized by two of the most compassionate therapists I know, Emily White, PTA, and Wendy Garrison, OTA. The residents had a blast!

This is Ron; he was in a catastrophic car accident in 2019, which brought him to us. He received prosthetic training and was set to go home in early November, when he tested positive for COVID. Plans to DC home were postponed, but he made it, and has made it back home to Nebraska.

This is Jessica, the Clinical lead and head cheerleader for team Ron. We all cried like babies when he finally went home.

 

 

 

As a compromised patient, Glenna should not have survived, according to all our knowledge of the virus, but she did. What a happy day it was to move her off of the COVID wing back to her own room.

This was our very first survivor. She didn’t even know she was sick and was happily confused about all the fuss we were making over her. We are all truly thankful for the opportunity to celebrate with her. (photo of thankful I beat COVID)

While we all have the heartbreaking stories we carry in our hearts about those who didn’t make it, and the effects of long-term isolation and burnout as we care for our people, it remains good practice to reflect on joy and the many successes we all share to move forward. It is powerful medicine for the wounded and heart-sick amongst us.

Therapist Profile - Dennis Baloy

MP Celebrate

By Jamie Funk, Therapy Recruiting Resource
Dennis Baloy is one of our more recent additions to the Ensign affiliated therapy leadership team. As the Director of Rehabilitation at St. Elizabeth Healthcare & Rehabilitation Center, Dennis immediately recognized our unique culture: “I just want everyone to know how lucky I feel to be part of this wonderful organization that truly embodies the value of Customer Second, where we as therapists and employees are celebrated, valued and appreciated. I am even more humbled to be surrounded by really bright, talented and passionate leaders. Everyone is so inspiring in their unique ways. Collectively, this is what truly sets us apart!”

Dennis has been a therapist for 15 years and a Director of Rehabilitation for the past eight years. He graduated with his Bachelor of Science in Occupational Therapy in the Philippines and later completed his Clinical Doctorate in Occupational Therapy with Geriatric Certification in the United States. As a child, Dennis always wanted to become a doctor and thought therapy might be a stepping stone to that career. However, as he immersed himself in his first OT internship, Dennis realized that OT was it for him — a career that would allow him to care for others, be creative and be human. Dennis has two brothers who are his biggest inspiration and mentors: Paul and Kirby. “They are the biggest reasons why I am where I am with my career,” Dennis says.

During the Ensign transition at St. Elizabeth, Dennis saw that culture was a top priority. “It was refreshing to see how involved all employees are in the facility. No longer does each department feel separate from one another. Every staff member is valued equally and has a voice. The support from our resources and Service Center is always present when you need it — this was definitely a big change in mindset for me coming from a corporate hierarchical structure,” Dennis remembers.

Dennis says that his biggest challenge has been being new in our company, new in his role and then having relentless COVID outbreaks in the community to deal with. “It has been stressful at times, but for the most part it is just a big challenge that I am willing to face. I feel like I don’t know a lot of things and that I still need to learn a lot of technical items, but I am excited to listen and grow. There is a huge sense of fulfillment if you know you can be of service to others and spread positive and enriching influence.”

Dennis has shown himself to be a wonderful leader. He loves being able to see his colleagues go out on their own and feel like they can do their jobs well because they feel valued, appreciated, empowered and loved. “Nothing beats the feeling of knowing that they love coming to work, they love their patients and their profession, and they can provide for their families and be themselves,” Dennis explains, “My favorite core value is Love One Another. Love at its core is selfless — the moment we think less of ourselves and more of the betterment of others. This allows us to build a community of trust, and this trust allows us to better serve our facility, our patients and our community.”

Dennis finds mentors throughout his facility. “I see everyone in my facility as my mentor,” he says. “I learn so much from each of the department heads and especially my administrator and DON — they all have strong attributes that complement each other and the whole facility.” Dennis also loves his nursing team and treats them like family. He has been able to build strong relationships with nursing through honest and genuine communication.

In his off-work hours, Dennis is passionate about photography and videography. He owns his own company, and pre-COVID, was very busy providing those services at weddings and other events. He still spends a lot of time taking photos and creating videos for fun. Dennis has also fallen in love with the world of triathlons and has set a goal to complete an Ironman competition in 2021. Favorite movies include “Braveheart,” “50 First Dates,” “Memento,” “Crash,” “Into the Wild” and a variety of Disney movies that he watches with his family.

As for the future, Dennis is focused on both family and work. “I would just love to see my daughter grow to be a nice kid — a good, smiling and happy kid. I want her to get to be who she wants to be and be happy doing that and being helpful to others. I have a goal to spend more quality time with my wife at home and hopefully some future trips together.” Dennis is looking forward to seeing his facility GROW. His goal is to serve more residents with inpatient and outpatient services and be recognized in the community as a skilled nursing facility that provides excellent clinical care that is warm, loving and inviting. He would also love to help spread this to the other Ensign affiliates in his area.

It always seems like something magical and wonderful has happened when a great therapist finds a great place to work and grow. Magic is definitely happening at St. Elizabeth!

Think Thin! Collaboration in Flagstone

MP Learn
Morgan Nebo
Aggie Smith

Morgan Nebo, Dietary Supervisor at Victoria Post-Acute, and Aggie Smith, Flagstone Dietitian, provided a great presentation to the Flagstone DORs and SLPs on best practices for therapy and dietary collaboration with emphasis on ThinkThin!

Key takeaways from this presentation:
1. CMS — Quality of Care Intent: “To the extent possible, MAINTAIN or IMPROVE before complications arise.”

● Resident HYDRATION is the key (and the challenge) with thickened liquids.
● F692, Quality of Care Nutrition and Hydration, requires that a resident is offered sufficient fluid intake to maintain proper hydration and health.
● As a general rule, most residents will require 1500–2000 cc daily under “normal” circumstances — SLP collaboration.

2. Nutritional Assessment and Risk Identification: Collaboration with SLP and Food/Nutrition to assess a variety of areas.
3. Become familiar with using the information in PCC: i.e., Nutritional Assessment UDA along with CNA input/output reporting.
4. Collaboration is super important during quarterly assessments
5. Become familiar with the facility menu system in the affiliate you are servicing. Review the diet manual standards and follow facility nomenclature. If a facility-wide change is needed, collaborate!

The training was so successful, the LMS team is working on a recording so everyone in the organization can benefit from the great information and have continued collaboration for Think Thin!