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.

SLPs and COVID-19

By Elyse Matson, MA CCC-SLP, Clinical Resource
Cognition and Swallowing are among the common challenges persisting for many Americans after COVID-19. Speech-Language Pathologists (SLPs) can help patients regain health and quality of life.

With an estimated 10 to 30% of COVID-19 survivors experiencing a post-COVID-19 syndrome, including brain fog and swallowing difficulties, it is more important than ever to utilize the full range of services provided by SLPs.

The pandemic tested everyone as a society, but one of the persistent challenges is the daunting set of difficulties many of our residents and those in our communities are experiencing after contracting and recovering from COVID-19. Many continue to demonstrate diminished function, including with cognitive skills, communication of needs and swallowing abilities.

This is an excerpt from the new COVID-19 Clinical Pathway, available on the Portal. This tool guides SLPs through the specific treatment needs of residents at various phases of recovery from COVID-19.

Impairments SLPs can assess

● Cognition
Many residents who had COVID-19 report persistent brain fog as a debilitating symptom after recovering from the virus. This can prevent a return to home as well as impact independence with ADLs. SLPs engage with individuals to improve their memory, attention, organization and planning, problem solving, learning and social communication — such as re-learning conversational rules or understanding the intent behind a message or behind nonverbal cues. The focus is on the person’s specific challenges as well as regaining the skills that are most important to their daily life and priorities.

● Swallowing
Residents diagnosed with COVID-19 may experience swallowing problems that can put them at risk for choking, aspirating, decreased appetite and diminished sensory feedback while eating (loss of taste and smell). This may be the result of time spent on a ventilator, or it may be another side effect of the virus. SLPs are part of the team who decide on the best course of action with the patient and their family. SLPs may recommend modified textures of food and drink for patients; therapy exercises to strengthen the tongue, lips, and muscles in the mouth and throat; and strategies to make eating and drinking safer, such as modifying the pace of chewing/eating, size of food, and more.

● Communication
People diagnosed with COVID-19 are also experiencing speech and language difficulties. Some, such as those who spent a significant amount of time on a ventilator or experienced low oxygen to the brain, may have muscle weakness or reduced coordination in the muscles of the face, lips, tongue, and throat — making it difficult to talk. Others, particularly those who experienced a COVID-related stroke, may experience aphasia, which makes it hard for someone to understand, speak, read or write. SLPs intervene with patients through targeted therapy to improve their communication and understanding.

People who have severe speech and/or language difficulties may need to find other ways to answer questions or tell people what they want, such as through gesturing with their hands, pointing to letters or pictures on a paper or board, or using a computer. These are all forms of augmentative and alternative communication (AAC). SLPs help find the appropriate AAC method to meet an individual’s needs.

For questions about SLP scope of practice or program development, contact Elyse Matson, SLP Resource, at ematson@ensignservices.net.

Wound Care: A Case Study in Pueblo Springs, Tucson, AZ

Resident K is a 52-year-old man who was referred to Physical Therapy for chronic, non-healing pressure ulcers of the coccyx and ischial tuberosity and severe pain.

  • PMH: Spina Bifida, B AKA, HTN, colostomy; wounds have been present approximately 10 years. Patient underwent flap surgery five years ago; wound vac has been unsuccessful in promoting healing
  • PLOF: Modified Independent in transfers and wheelchair mobility; has resided in nursing homes for 10 years; history of being non-compliant with pressure relief and positioning

Evaluation status (4/2020):

  • Mobility: Modified I transfers and wheelchair mobility; tilt in space motorized chair with ROHO cushion
  • Strength or ROM deficits: No
  • Wound 1: Coccyx: Stage 4 pressure ulcer: 1.5L x.7W x.6D; necrotic <25%
  • Wound 2: Ischial Tuberosity: Stage 4 pressure ulcer: 3.5L x 3.0W x 3.0D
  • Pain: 7/10 with any movement, related to wounds

Wound care: Dakins solution

Patient reluctantly agrees to PT POC to initiate in-wound electrical stimulation (HVPC) five times a week to facilitate increased wound bed granulation, decrease necrotic tissue, decrease pain and facilitate wound healing. Patient states, “These wounds won’t heal; they’ve been there forever and I’ve tried it all.”
D/C plan: reside in skilled nursing facility

Discharge status (10/2020):

  • Wound 1: Coccyx: Resolved
  • Wound 2: Ischial Tuberosity: .3L x .3W x .2D
  • Pain: 0/10
  • Patient is discharging to an Assisted Living Facility

As the wounds began to improve, patient K began to be compliant with positioning and pressure relief. During the course of treatment, estim protocol changed from negative to positive polarity in wound, and then finally peri-wound as wounds became too small for in-wound electrode placement. Dressing changes occurred through IDT wound team consultation. Treatment included patient/caregiver education throughout.

Kudos to the Pueblo team for being willing to tackle the “impossible” wounds and having the perseverance to hang in there! They understood that chronic healing takes time. Meeting requirements of documenting progress every 30 days, changing protocols when healing began to plateau, and using skilled assessment allowed them to continue the POC to closure/near closure of the wounds.

Submitted by Shelby Donahoo, M.S., OTR/L, Therapy Resource, Bandera

The Power of Therapy and Nursing Partnerships

By Kelly Alvord, Therapy Resource, Sunstone UT
The Sunstone DONs and DORs recently participated in a combined meeting. This meeting of minds was designed to make sure we understand the challenges and initiatives of each other’s departments and to really collaborate where we could to help each other meet goals and obtain great clinical results.

Key partnership topics discussed:

  • We first pulled the “Rehab Screen Consultation F TAGs” POSTette from the portal. Each DOR presented on an F-tag from the POSTette and how the Therapy team will support and take the ownership of these tags for survey. For example, F Tags F684, F676, F677, and F810 all have to do with Activities of Daily Living (ADLs). The teams addressed their strategies for therapy partnership with ADLs for this group of F Tags. We discussed specific actions and roles Therapy has to support the DONs to prepare for survey. The DONs learned how their DORs are truly their clinical partners. This discussion was very interactive. The DONs were excited to know we “have their back” when it comes to involvement with patients to prevent decline and help with survey results.
  • Deb Bielek introduced our Excellence in Programming and Clinical Care (EPIC) Programs. EPIC programs. The DONs and DORs all committed to collaborating and establishing an EPIC program for each of their facilities based on clinical needs and trends.
  • Clay Christensen presented on the 5 Dysfunctions of a Team, which focused on establishing trust, being vulnerable, and not fearing conflict. This information was further validation of power of a strong DON and DOR partnership.
  • We also had fun together and had cluster competitions with an offsite activity.

With these dynamic partnerships with DONs and DORs, Sunstone is unstoppable!

Do Your Patients Need Better Grooming and Hygiene?


I think most of us would answer yes to this question!

I wanted to share a cool program that Adina Gray, SLP/DOR, and her team at Lake Village have started to meet the needs of their residents and see great improvements in this area:

At Lake Village in Lewisville, Texas, the therapy department saw a need for residents who either: didn’t enjoy showers, refused showers, had a decline in personal hygiene, and/or could benefit from some modifications and adaptations to their daily wash routine.

The OTs started by identifying the residents, and then we went about finding inexpensive but functional shower caddies (the Target College Essentials ones were perfect). They then talked to the residents and their families, and obtained the items that the patients would utilize and enjoy specific to them. For example, some families brought nice-smelling body wash, specific hair products for different hair textures,, good shavers and shaving cream for the men, etc. Items were labeled as necessary to help with carryover and ease of use.

We also established grooming and hygiene routines with laminated visual schedules for those who could follow them for doing things such as daily teeth brushing, washing their face and combing hair. And when OTs have established the routines and a patient is demonstrating good independence with the program, we then refer to ST in order to continue with carryover and use of visual aids and daily schedule to complete tasks as independently as possible.

Feel free to reach out to Adina (adhill@ensignservices.net) or your therapy resource with any questions!

Submitted by Barbara Mohrle, OTR, Therapy Resource, Keystone North

Sensory Integration Coding

By Brian del Poso, OTR/L, CHC, RAC-CT and Tamala Sammons, MA, CCC-SLP, Therapy Resources
Sensory Integration (SI) Therapy was originally invented by OT, Jean Ayres, in the 1970s to help children with sensory processing problems. Although less prevalent, SI techniques and theory used to modulate the sensory and proprioceptive systems can also be used with the adult population.

We’ve had a few questions recently around the appropriate use of the 97533 Sensory Integration CPT code. In general, this is an allowable code and covered by our MACs. However, since we know SI is predominantly used with the pediatric population, if utilizing this code as part of therapy intervention with the adult population, it is important that we use evidence-based practice, research, and have clear supportive documentation to demonstrate that sensory processing/modulation is a cause of functional deficits and that the interventions being billed truly fall within SI intervention strategies.

Here is the Sensory Integration 97533 code descriptor:
This activity focuses on sensory integrative techniques to enhance sensory processing and to promote adaptive responses to environmental demands, with direct one-on-one contact by the qualified professional, each 15 minutes.
From AOTA:
“Occupational performance difficulties due to sensory modulation challenges or poor integration of sensation can result from difficulties in how the nervous system receives, organizes, and uses sensory information from the body and the physical environment for self-regulation, motor planning, and skill development. These problems impact self-concept, emotional regulation, attention, problem solving, behavior control, skill performance, and the capacity to develop and maintain interpersonal relationships. In adults, they may negatively impact the ability to parent, work, or engage in home management, social, and leisure activities.”
From the AOTA article: Sensory Integration Use with Elders with Advanced Dementia
“Research of current approaches in treating older adults with dementia to decrease negative symptoms and increase quality of life, revealed the trend of using a multi-sensory protocol designed for this population (Chitsey, Haight, & Jones, 2002; Knight, Adkison, & Kovach, 2010; Kverno et al., 2009; Lape, 2009; Letts et al., 2011; Padilla, 2011). Kverno et al. (2009) noted in their literature review of non-pharmacological treatment of individuals with dementia that “individuals with advanced levels of dementia benefited to a greater extent from nonverbal patterned multisensory stimulation” (p. 840). Multisensory stimulation incorporates the use of tactile, visual, auditory, olfactory, and gustatory sensory pathways, along with movement, to help the individual interpret his or her environment (Lape, 2009).”
The occupational therapy evaluation and treatment plan is designed to “structure, modify, or adapt the environment and to enhance and support performance” (American Occupational Therapy Association, 2015, p. 6913410050p1), in order to re-engage patients.

Adding sensory integration as a treatment approach starts with assessing any comfort or discomfort when a patient is participating in: ADLs (grooming, dressing, bathing, etc.); Meals; Upper extremity movement; Functional transfers; Seating and positioning.
Goals can be developed around any identified areas of discomfort by creating situations to increase episodes of comfort with those tasks.

What do the MACs say? Here is the language from the Novitas as an example:
Sensory Integration 97533
This activity focuses on sensory integrative techniques to enhance sensory processing and to promote adaptive responses to environmental demands, with direct one-on-one contact by the qualified professional, each 15 minutes.

The patient must have the capacity to learn from instructions. Utilization of sensory integrative techniques should be infrequent for Medicare patients.

For more resources, documents, and tools to help provide information to you and your staff, please see the Sensory Integration section under Therapy > Clinical Programming on the Portal.

Local Community Children Spreading the Love

By John Patrick Diaz, DPT, DOR, Magnolia Post Acute Care, El Cajon, CA
We all know that the mental health of our residents has been directly (through a specific medical condition) or indirectly (via communal isolation or psychological stresses) affected by this pandemic. Any type of interaction, whether it be through Facetime, window visits, regular phone calls, or even texting our loved ones, makes a huge difference in getting them through their day.

As part of Celebration and Loving One Another, Caitlin Dablow, SLP, and Jacalyn Leigh, COTA, guided a group of local community kids in creating Valentine’s Day cards for our residents at Magnolia Post Acute. The parents of the kids were so supportive in getting them together and designing simple but meaningful cards.

The cards were distributed to each resident with the assistance of our kitchen staff during their lunch meal. As each resident read their card, it was such a great sight to see that everyone had a smile on their faces while others became teary-eyed. Everyone appreciated the gesture knowing that the community cares. We may not be able to celebrate together as a group, but we for sure have felt the love and positive vibes within the facility.

Thinking Outside the Box: Modified Diets That Are Tasty and Appealing!

Submitted by Shelby Donahoo, Therapy Resource, Tucson, AZ
When Sara Mohr, CFY at Sabino Canyon in Tucson, Arizona, was a SLP graduate student at the University of Arizona, the reality for those on modified diets became clear. Often a diagnosis of dysphagia brings confusion and worry. Getting modified diets right seems obvious, but actually can be quite hard. Options seemed few: mashed potatoes, blended meat and yogurt. She found few resources out there for patients in terms of appealing and tasty recipes with easy instructions for cooking and modifying.

She and her colleague, Louisa Williams, had an idea. What if they created a food blog to improve accessibility to quality information on modified diets?

So they established realmealsmodified.com and began creating recipes and posting foods that meet texture requirements of the International Dysphagia Diet Standardization Initiative (IDDSI) while looking appetizing and tasting flavorful!

Sara says her goal with modified diet recipes is that “it should be good enough to bring to a potluck, share with the group, and not be embarrassed.” They do the cooking, test the recipes in various consistencies, and essentially take the guesswork out of modified diets.
If a recipe doesn’t work well modified, they don’t post it. Last year, Sara was working on a potato salad recipe using cauliflower (potatoes would just end up mashed) but reported it was “too soupy, too vinegary.” She’s recently perfected it and it will post the recipe soon.
Recipes include items such as Chicken Pot Pie Puree, Sopa Azteca, Chocolate Chip Banana Bread, Minced Pancakes and Salmon! Portions can be made for individuals or the whole family.

Sara and Louisa are planning a “puree road trip” this summer, with the goal of finding options for those on modified diets to eat when traveling.

What a great resource for our SLPs to share with clients and families!

A Trio of Wellness: Oral Health, Overall Health and Quality of Life

By Razan Malkawi, M.S., CF-SLP, Rose Villa Healthcare Center, Bellflower, CA
Research indicates a clear link between oral hygiene and the overall health of patients. Poor oral hygiene can contribute to new arising medical conditions, and it may worsen the existing disease and interfere with the outcomes of treatment. Continuous education and awareness in oral hygiene are essential in our facility. We hold weekly, if not daily, in-services to discuss preventative measures collaboratively. Members of the interdisciplinary team, including but not limited to the speech therapist, occupational and physical therapists, CNAs, nurses, and the administrators, are all involved in providing evidence-based resources to assure a high quality of life for our patients here at Rose Villa Healthcare Center.

Causes of poor oral hygiene may be related to genetic, developmental and environmental factors. Most of our patients receive medications that may have side effects. For example, Xerostomia (i.e., extremely dry mouth) is a common problem that contributes to poor oral hygiene; causes include drugs, smoking, radiation therapy, diabetes Mellitus, etc. (Kapoor et al., 2014). Our role is to assist with and provide instructions and education regarding the different mouth care approaches for our patients. Mouth cleaning and care, including brushing teeth, mouth wash, and the use of sponge sticks, are all vital behaviors to prevent the existing disease’s escalation and the emergence of new ones. A speech therapist often works with patients who suffer from swallowing problems (i.e., dysphagia), as swallowing dysfunction may cause the entry of food or drink particles into the airways, and bacteria from the mouth may reach the patient’s lungs and cause aspiration pneumonia (Shun-Te HUANG, 2020). Safe swallowing strategies like posture adjustment, proper oral care, and motor-exercises contribute to treating dysphagia and reduce the prevalence of aspiration pneumonia (Shun-Te HUANG, 2020).

In a recent in-service, we discussed the necessity of providing oral care to NPO patients as a preventative measure. Education in this area is essential; one may think that if patients do not eat or drink, mouth cleaning is not a priority! Well, this is not true; NPO patients are at risk for infections, aspiration pneumonia, Xerostomia, and dehydration if oral care is neglected (Liddle, 2014). The state of NPO, along with the presence of dysphagia, may cause aspiration or pulmonary pneumonia if appropriate oral hygiene regimens are not in place. The patient may still aspirate on his/her own saliva; commonly, such incidences occur at nighttime when HOB (i.e., head of bed) is minimally elevated. As healthcare providers, let us all take the initiative to provide our patients with the highest quality of life by spreading awareness.

Refer to our SLP Dehydration Risk Free Water Protocol, for additional information including an Oral Health Assessment Tool (OHAT) for non-dental professionals.

Temple View Transitional Care Improves their Self-Care GG Scores

By Cory Robertson, Therapy Resource, Idaho

Temple View Transitional Care Center in Rexburg, Idaho, Therapy led by Susie Swetter, DPT, DOR, joined the organization in the fall of 2019 during the transition from PPS to PDPM. One area in particular they have been focused on is improving their Self-Care GG scores. The challenge to improve was brought to the team, and their new OT, Neil Marion, stepped up to own it.

The team met to review their GG scores and their coding process. Neil looked at the metrics and said, “I want Temple View to lead the market in the self-care increase score.” At the time, Temple View was behind several other buildings in the Market in self-care. However, within several weeks of continued improvement in self-care scores, Temple View grabbed the top spot in percentage improvement in self-care scores for the ID/NV market.

When asked how Neil did it, his response to getting the top spot was amazing:

“Thanks for all the congratulations! I appreciate that, and when Susie asked me to respond about what I did to increase self-care scores, I simply said, ‘I’m just doing my job as an OT. Don’t hide your skills as an OT or COTA; we can offer so much to the people we care for, from the core self-care tasks with adaptations or full restoration of their skills, positioning in bed or w/c, home assessments, splinting/orthotics, neuro-rehab, cognitive rehab as it relates to ADLs, IADLs, fine/gross motor training, power w/c assessment, and strengthening of the specific muscles to increase independence and so much more! Don’t lose who you are as an OT; that identity is important … what makes us different than PT or ST? My answer: so, so much, and it’s our job to proudly proclaim who we are and show our facilities what we can do.”

Thank you, Team Temple View and Neil, for your ownership of this important measure and ensuring your patients get the very best care!