Continuity of Care for our Long-Term Care Residents

Implementing a system that will allow us to successfully address the needs of our long-term care residents and help them achieve their goals will not only help us provide them with a good quality of life, but also allow us to develop long-term care programming successfully. Understanding the continuity of care in a long-term care setting is the first step in developing a big picture mindset. It will start when a patient is referred to therapy for a certain problem that skilled therapy intervention can address.

  1. The therapist screens the patient to identify if the patient’s problem can be resolved by therapy intervention.
  2. If the problem can be addressed by therapy intervention, an evaluation will be requested to identify the patient’s condition.
  3. Once the problems are identified, interventions are put into place.
  4. Once maximum potential is achieved, the patient is then referred to a restorative nursing program of a functional maintenance program (FMP/RNP).

Leslie is one of our long-term care residents at Cloverdale Healthcare Center.

She was initially admitted from acute care on April 12, 2016, with a diagnosis of acute CVA with left-sided weakness resulting in decreased ability to perform her functional mobility as well as her ADLs.

She has 7/10 pain on her L UE/LE because of her CVA and was aggravated by her impaired joint integrity. She required total assist with her functional mobility and ADLs using hoyer lift to transfer her from bed to the wheelchair. Because of her impairment, she was also using the bedpan for her toileting needs. Other comorbidities are her severe anxiety, depression and obesity.

Big-picture goal:I want to be able to walk again.”


Post Acute Rehabilitation Program: Therapy team worked with patient for two months, achieving multiple goals such as identifying cognitive level of the patient (high 4’s), improving her bed mobility to allow her to assist during bed mobility and toileting while using bedpan, improving her core strength to allow her to sit in her wheelchair for longer periods of time and be able to participate in activities that she enjoys, caregiver training on safe transfers, bed mobility and toileting, and UE and hand strengthened to allow her to utilize B UE for using her call light and during self feeding. Pt’s M/Care A benefit exhausted and patient was evaluated under M/Care part B benefits.

Medicare Part B Program 1: Continued with rehabilitation goals from post acute admission for one more month with improved core strength and improved UE and LE strength, allowing her to utilize B UE/LE for wheelchair mobility. Her weight shifting improved, allowing her to perform slideboard transfers with minimal assist from caregivers. Leslie was then discharged from skilled therapy intervention and was referred to functional maintenance program for slideboard transfers every day and directing patient to her activities of choice.

The maintenance program allowed her to utilize B UE/LE to continue develop her strength, improve her motor coordination and improve her core strength through repeated anterior weight shifting activities.

Medicare Part B Program 2: After three months, the patient was initially picked up by occupational therapy to work on her toileting by trialing a t-pole transfers. Pt successfully completed the program and was able to toilet for the first time for so many months in a commode.

Medicare Part B Program 3: OT referred the patient back to physical therapy to further improve her ability to stand and further improve her ability to transfer and assess if patient will be appropriate for ambulation. Leslie worked with PT for two months and was able to achieve her goal. She was able to ambulate for 125 feet while utilizing a FWW with CGA from caregivers. She was then referred to Restorative Nursing Program to further increase her B LE strength to allow her to further improve her ability to ambulate independently.

Current: Leslie continues to work with RNA, with some episodes of decline in function and a fall, which affected her progress. However, she is back on her feet and currently on physical therapy caseload to get her back to walking with RNA again.

View poster: The Big Picture Mindset (PDF format)

By Joseph Chua, PT, Cloverdale Healthcare Center. Cloverdale, CA