One Step Backward, One Step Forward to Independence

By Carlos Pineda, CTO/DOR, Southland Care Center, Norwalk, CA
We are launching our “prototype” Tandem Backward Walking I-Southland Tool in a Lunch and Learn training. This maintenance series is dedicated to the person who inspired Southland to pursue greatness with maintaining the function of our beloved residents: Bertha Spaeder (pictured with Roger Pavon, PTA). Bertha has been my inspiration in pursuing greatness for our beloved patients. I named this tool after Bertha. ” B.S.MP01″ –Stands for Bertha Spaeder Maintenance Program series 01. Standardized testing and strategies are also part of the training. This evidence-based group therapy program aims to minimize fall risk.

Bertha Spaeder Maintenance Program Series 01
Walking backward is essential in our daily life: when opening a door, backing away from a kitchen sink, stepping from the curb as a swiftly-moving bus passes, during toileting, or opening the refrigerator. An effective compensatory stepping response is the first line of defense for preventing a fall during sudden large external perturbations. Falling backwards is common among our elderly population especially with comorbidities like Parkinson’s disease and CVA.

A validated standardized test, “Backward Walk Test,” assesses ability to walk backward. On the 3-meter backward walk test, if the individual completed the backward test in more than 4.5 seconds, the person is at risk for falling. Following is the procedure:

Procedure:

  1. Check Vital Signs
  2. Introduce the patients to each other
  3. Educate patients on the purpose
  4. Demonstrate the procedure
  5. Start with slow pace (60bpm on metronome) or let patient count on every step or state which leg will go first (Right…, Left…)
    a. For Progression – increase by 10 bpm every week or as needed, if safe.
    b. To add cognitive challenge, ( 1. ) Ask the patient to count backward simultaneously with the metronome beat. (2.) Instruct patient to turn head Right<>Left while walking backward.
  6. Assess for any gait deviation
  7. Repeat

Group activity should be graded and have enough stimulus/challenge to promote physiological changes. This can be effectively done using the Borg Scale. It is a skilled and billable service provided by qualified therapists that requires continuous analysis, assessment and monitoring during the intervention. Tandem Backward Walking group therapy promotes teamwork and a sense of purpose. As biopsychosocial therapists, we address not only the impairments but also the psychosocial wellbeing of the patient. We identify and take aim on what is important to the patient and on how they define quality of life.

Onboarding New Therapy Team Members

By Lisa Brook, DOR, St. Joseph Villa, Salt Lake City, Utah
Lisa Brook, DOR at St. Joseph Villa, recently shared their new therapist/new employee training and mentorship process. As COVID continues to de-escalate, their team is beginning to focus again on leadership development and believe this process starts from the very beginning of employment at St. Joe’s. They are attempting to be more intentional about onboarding and training of new therapists as their skilled census grows and they are expanding their outpatient programing as well as their LTC programing. The therapy team at St. Joe’s is being more intentional about the hiring process with improved communication with Jamie Funk, involvement of key staff in the interview process and then setting more specific plans for the onboarding and training process. In order to grow leaders we must start with growing good therapists, mindful of their treatment approaches, seeking to make the most of their time. Lisa walked us through their onboarding process:

Day 1: NetHealth email sent to the staff early in the a.m. of the first day of a new therapist’s arrival that introduces him/her so that everyone knows the person by name. On this day, the new therapist is assigned to a therapist of the same discipline just to observe. This is planned ahead of time so the therapists are aware they will have someone shadowing them that day. We encourage the new therapist to take notes as we go through the login process for NetHealth, PCC, tour the building, meet members of the leadership team, observe the pace of things, etc. The first day is usually only a half day.

Day 2-3: Again, these are usually not full days. The new employee treats two or three patients on our skilled rehab unit. Their schedule is loaded with patients who will cooperate and give them a “win” for the day. The goal is to feel comfortable with the patients and just be a therapist! At the end of those treatments, they will spend time verbally reviewing the treatment, patient response to treatment, and potential documentation with the same therapist they shadowed with on Day 1. They do their billing, write their TENs, and then the therapist reviews and they discuss necessary corrections.

Day 4 and on: As the new therapists get more comfortable, more patients are added to their caseload. They treat patients on our skilled rehab unit and start to initiate point of service documentation. Time is scheduled with their “mentoring” therapist to answer questions and review documentation and goals. This process has been helpful for new employees, and they look forward to it as it gives them an opportunity to get all their questions answered in a more in-depth manner.

Next Steps: Next steps are really driven by the new team member. We initiate writing progress notes during week 2 for a new graduate and then add other necessary documentation as they begin to have success. As the DOR, Lisa said she checks in with them each day, but this process allows the experienced staff to take ownership of our training/onboarding process, and it seems to be working! Lisa said that even if they hired an experienced therapist rather than a new grad, there is still a lot of mentoring that we need to provide. They consider the confidence level of the therapist and tweak the process as needed. As they add more patients to their caseload, we have ongoing conversations.

Variables to Consider: New grads often require more mentoring. However, experienced therapists, part-time/PRN staff should always be provided an opportunity to receive mentorship as needed. Consideration must also be given to the confidence level of the individual. It often takes as much “coaching” for a seasoned therapist to get acclimated to treatment approaches, writing appropriate goals and skilled TENS because there are some differences in documentation in each subset of our programming (skilled rehab, skilled maintenance, outpatient, sub-acute respiratory, LTC).

Lisa said we need to allow our therapists time to grow. If we are going to create leaders, we need to be intentional about onboarding and training. We want them to be confident in their skills and critical thinking and be leaders among their peers in the building. Jamie added that Lisa has done an amazing job! St. Joseph Villa has a reputation in the community of empowering their therapists in establishing plan of care and treatment approaches to fit the needs of the community. She has heard from candidates that they know how great it is to work at St. Joseph’s, and all of the tools Lisa shared with us are having an enormous impact in growing therapists to be outstanding clinicians, leaders in St. Joe’s and then leaders beyond St. Joe’s.

Train Your Replacement? Yes, Please!

By Gary McGiven, Milestone Therapy Resource, Utah
Nicole Newberry was the DOR at Draper Rehab for the last 15 months. Early on in her experience as a DOR, she saw the value of having an ADOR and growing leaders. As a result of this realization, she identified a member of her team that she wanted to help grow as a leader. Jamie Sack, SLP, was the natural choice, as Jamie has been completely bought into the growth of the therapy program at Draper.

Over the last year, Jamie has participated in the DORiTO program, learned the daily technical, weekly skilled review, triple check process, and spent about eight weeks filling in for Nicole while she was on maternity leave. While Nicole was on leave, we learned that she would be moving her family to St. Louis so her husband could complete a medical school fellowship in pediatric ENT. While we were saddened by the news that Nicole would be leaving us, we immediately were excited by the thought that Jamie would be able to seamlessly take over the role of DOR. With some further education on the DOR role provided to Jamie and Jamie explaining some of her expectations, we were able to solidify Jamie as the DOR for Draper Rehab.

Jamie was officially named the DOR a few weeks ago as sort of a Co-DOR. The week of June 21 was her first full week as the DOR of Draper Rehab. She has hit the ground running, and the transition to date has truly been seamless.

Going through this process made me realize the benefits of growing leaders and preparing/training your potential replacement. Most obviously, this makes the process seamless, as the future leader learns the systems needed to be an effective DOR and is given an opportunity to develop relationships with members of the Therapy and interdisciplinary teams.

In addition to the obvious, this allowed Jamie to see some of the challenges of the DOR role. As Jamie saw these challenges and more of the ins and outs of being a DOR, she has been able to set boundaries for herself to ensure she enjoys a greater work/life balance. We are so thankful for Nicole and Jamie and look forward to the great things Jamie will do as she continues to learn the DOR role.

Myth Busting Medicare Part B: Training Therapists at New Acquisitions

By Dominic DeLaquil, Pennant ID/NV Therapy Resource

New acquisitions are not only a great opportunity to welcome a new facility to a market and the organization but they also give us an opportunity to provide culture and clinical training opportunities. This is really important early on as we need to understand what myths or rumors therapists from other organizations might be bringing with them. (This is also important with any new hires!)

Therapy programming on the long-term units was immediately identified as an opportunity for our residents. We saw a great opportunity to meet with the therapists, and ask questions to uncover any barriers, misunderstandings or prior trainings that they might have toward therapy interventions.

Understanding the benefits of maintenance therapy to keep residents at their highest practicable level of function was an identified area of educational opportunities. The training focused on the three things that are required to be in place to support the need for therapy services:

  1. Services must require the skills of a therapist
  2. Services must be reasonable and necessary for the patient’s condition
  3. Services must be rehabilitative in nature OR require the skills of a therapist to maintain function or prevent decline

It’s important to provide training on maintenance programs, including preventing decline, training aides and caregivers, and how we might attempt to transition to a maintenance program that can be carried out by our CNAs or RNAs. For example, training included how to adjust frequency to measure if therapy can discharge altogether without decline setting in and documenting those changes to the POC as evidence of the need for ongoing therapy skill if that’s the case. Training was also tied into the importance of QMs and survey tags related to failure to prevent a decline in function.”

Here are the key areas that constitute material impact other than progress:
• Assessment and analysis (Vitals, standardized tests)
• Preventing decline or deterioration
• Decreasing medical risk (Vitals)
• Training others to facilitation improvement or prevent decline

The training then focused on examples of what to capture in the documentation to support therapy services. Overall the response was a collective sigh of relief knowing that they, the therapists, could build a LTC program using their clinical judgment and knowing that they had the resources and support to ensure services were supported in the documentation.

Urinary Incontinence Program

By Danielle Banman, OT/DOR, The Healthcare Resort of Leawood, KS
Here at The Healthcare Resort of Leawood, we have the privilege of serving our LTC and ALF residents, rehab patients, and community outpatients with our urinary incontinence program. We provide training on exercises to improve pelvic floor muscle strength and education on bladder emptying strategies, adequate water intake, and bladder irritant avoidance during the first 30 days. If the patient has not made significant improvement within 30 days, we are able to initiate PENS during weeks five and six per Medicare guidelines. We are then able to provide continued training and PENS with the addition of MFAC during weeks six to 10 to help the patient make as much progress as possible.

I have been helping people with this program for over 20 years and keep seeing great results! Patients tell us how much it has changed their lives time and time again. They are often able to attend activities and events they love, travel, and have improved quality of sleep, to name just a few benefits. If your team would like to know more about this great program, we would love to help you get started!

Contact dbanman@ensignservices.net, livewellatleawood.com, or 913-484-5234.

Oral Infection Control at City Creek

By Gary McGiven, Therapy Resource, Milestone, UT
Since converting to a COVID-designated facility, City Creek has seen a more acutely ill patient population with an increased reliance on staff support for oral infection control. As COVID-19 patients are significantly more likely to experience complications if they also have poor oral health, City Creek’s SLPs have implemented a system to better track data on how frequently oral infection control support is being offered.

Even for patients who are cognitively and physically capable of performing it for themselves, staff support in the form of set-up assistance or verbal reminders has been valuable. Each patient has a laminated chart displayed in their room. It shows which staff member performed oral care and when. We note patterns of support being offered and frequently refused, or observing patients completing oral care independently.

For patients on the free water protocol, for example, the use of this chart has been extremely valuable. This system has increased patient and staff awareness of the importance of frequent oral care, and individual accountability in staff members. When we can identify patterns, for example, the frequency with which oral care is offered during AM versus PM shifts, we can better target staff education. We’re striving to move the perception of oral care toward an oral infection control program.

Recognizing St. Joseph SLPs for their Outstanding Clinical Outcomes

Submitted by Lisa Brook, PT/DOR, St. Joseph Villa, Salt Lake City, UT
Susan Roubian, Hannah Allen, Katie Paulsen and Taylor Schweitzer comprise the St. Joseph Villa Speech Therapy team. This program has grown significantly, going from 1 1/2 SLPs to four full-time SLPs over the last two years! These SLPs have made an effort to collaborate with interdisciplinary teams in our facility to change the way we care for our residents and improve their therapy and quality of life. We have been developing programs in the areas of AmpCare, Think Thin!, Oral Care, Speak Out!, Abilities Care, and high-level cognitive groups for our residents with mild cognitive impairment.

L to R: Taylor Schweitzer, Hannah Allen, Susan Roubian, Katie Paulsen

During our COVID outbreaks, our SLPs played a crucial role in managing change in condition and aspiration risk and significantly changed our outcomes. They are now utilizing The Breather with our Respiratory Muscle Strength Training program to meet the growing needs of post-COVID respiratory insufficiency impacting communication and swallowing.

We have also been developing programs to improve outreach to our ALF, ILF and outpatients from the community! Beginning in June, we will begin FEES training in preparation for an in-house FEES program, increasing access to instrumental evaluations by the treating therapists. Our trained SLPs will be facilitating mentorship of others seeking to be FEES certified in our market.

Our SLP team is recognized by our IDT team for their outstanding clinical outcomes, their care of our residents, and their outstanding communication with providers. This team of exceptional therapists are dedicated to providing high-quality care to our residents and are excited to keep expanding and optimizing care for those we serve!

SLP Helps Resident Find Purpose and Decrease Behaviors

By Dominic DeLaquil, PT, CEEAA, Therapy Resource, ID/NV
Steve is a LTC resident at McCall Rehab being treated by Speech Therapy for cognitive/communication deficits. He has a history of alcohol abuse and dementia. With winter in the mountains and COVID restrictions, his behaviors had become a real problem. He was initially refusing to get OOB and staying in a dark room, but as the weather began to turn to spring, he began excessive wandering, wanting to get out of the facility. He was agitated and confused and began urinating in sinks and trash cans.

Using the ACA approach, SLP Cassie Johnson took him outside and listened. He was remarking on all of the things around that building that might need repair or upkeep after the long winter. She asked him what he would do, and one thing led to another, and she got some sandpaper and he started working on refinishing a wooden patio table at the facility. Another resident became interested, and they worked on the table together. They have since formed a friendship and seek each other out. All of Steve’s behaviors have ceased and he is more motivated to improve his abilities and hopes to discharge to an ALF. As an additional benefit, other residents became interested and the furniture sanding became a group activity!

In addition, his SLUMS score in February, when he was depressed and his confusion was worse, was a 13/30. Tested recently, after finding some purpose and satisfaction, his cognition actually shows improvement and he scored a 22/30!

Millennium Post Acute Rehab’s SLP Superstar Team

By Heather Bjernudd, Therapy Resource, South Carolina
Our speech therapists at Millennium Post Acute Rehab in West Columbia, South Carolina, are incredible! When this facility started taking ventilator-dependent patients this year, these ladies jumped in and have had incredible results.

Here is a highlight on a current patient: 32-year-old male admitted with severe trauma, left hemi craniotomy that affected all function and ventilator-dependent. Swallow response was absent; silently aspirating, NPO, PEG; mild/moderate aphasia with decreased ability to communicate via trach. Cognition impaired, BIMS score of 7. Forty days since admission. Patient able to tolerate Passy Muir Valve up to five hours at a time. Swallow trials with ice chips showing improvement, improved swallow initiation and laryngeal function. Patient is able to follow multi-step directions for swallowing maneuvers and functional tasks. Able to complete diaphragmatic breathing exercises with min assists. Patient has been weaned off of the ventilator and has a real possibility of being weaned off of the trach.

Growing SLP Programs

By Jeremy Osmond, DOR, Provo Rehabilitation and Nursing, Provo, UT
Dot Stuart, SLP at Provo Rehabilitation and Nursing, decided to focus on education related to growing SLP programs for her Director of Rehab in Training Ops (DORiTO) capstone project. The information was so impressive that I asked her to present at a Sunstone DOR meeting to help other therapy leaders really understand all the things SLPs can do in our setting.

She highlighted that the SLP needs to be committed beyond the patients that they receive orders for on admits and really focus on all residents in their facility to make sure their highest level of function is being attained. Her training focused on SLP support for PDPM, including completing the BIMs; identifying NTAs such as malnutrition and SLPs’ role in intervention; and ensuring SLP swallow assessments are reviewed for accurate Section K reporting.

She focused on the importance of really knowing each payer plan and what that means for intervention. SLPs need to manage their program efficiently based on payers and authorizations along with clinical presentations. They need to be a partner to the DOR to ensure clinical outcomes even with reimbursement challenges.

She addressed how SLPs can help so many LTC patients, including what tools we have in place to help quickly identify any changes of condition; long-term modified diets; etc. Many SLPs and DORs are not as familiar with the available reports in PCC to help with patient identification. She also trained on the importance of being present in the facility and making sure the IDT members, clinical team and other therapy disciplines really understand how they can help with patient care. Click below for a summary of helpful reports in PCC for SLPs.

Dot also emphasized the importance of strong student programs to help future SLPs really understand their value and how they can make a difference in a patient’s life in the Post-Acute and LTC setting.

Provo has trended increased treatment hours and need for more SLP staff with the help of Dot’s focus and drive to ensure every patient’s needs are met.