Thinking Out of the Box: Treatment
Planning Outside the Gym
HARMONY UNIVERSITY
The Provider Unit of
Harmony Healthcare Int...
OBJECTIVES
I. The learner will be able to identify
creative treatment strategies.
II. The learner will be able to define
M...
Regulatory Requirements
The Omnibus Budget Reconciliation Act (OBRA),
also known as the Nursing Home Reform Act of
1987, s...
Thinking Outside of the Gym
What's the value?
Meeting the needs: preventing decline, falls
etc,
Increasing regulatory focu...
Thinking Outside of the Gym
Objective Evaluation
What is the facility’s current practice?
Are we meeting the needs of all the residents?
What is the i...
Assessing Barriers
What types of barriers does your
facility have to providing effective
and efficient therapy?
Staffing P...
Barriers to Providing Services
Barriers to Providing Services
Meal times
Outside Appointments
Nursing Staffing Issues
Patient direct care needs – treatme...
Do your teams work silos?
Soc Wk
Dietary
Therapy
Nursing
Activities
Meeting the Needs of the Resident
Nursing Shifts:
7-3 / 6-2
3-11/2-10
11-7/10-6
Therapy Hours
PT 8-4:30
OT 7-3:30
ST 8-4:3...
Where Do Patients spend Time?
Consider time patient spends in room/on
unit, with nursing caregivers?
Where do the patients live?
Where do the patients spend most of
their time
Where might you get more cooperation
with treat...
How Many Falls Occur in The Gym?
Where do falls happen?
Sitting up from bed
Rolling over in bed and falling out
Standing u...
Impact of Environment
Is the environment conducive to the task?
Noise –too noisy, resident can’t hear
Lighting- pt with gl...
Visual Impairment
Therapists should understand the influence of
visual impairment on program participation.
Similar to wea...
Hit Them Where They Live
Therapist + Patient + Caregiver =
24 hour a day 7 days per a week impact
When you treat the patie...
Literature Support
Multi-Dimensional Challenges in
Geriatric Rehabilitation the GRAMPS
Study (Buijck, B. I. 2013)
When the...
Efficiency
Increasing efficiency by increasing on unit
presence
For facilities with space challenges and for
dementia unit...
Efficiency
Satellites: Small office on unit with highest
rehab population
Just the basics:
Mat table/Folding Mat table
Wal...
Examining Documentation
Efficiency and Accuracy
Reasonable and Necessary
Medicare Benefit Policy Manual Section
220.2
‘The services shall be of such a level of
complexity...
Reasonable and Necessary
(Medicare Benefit Policy Manual cont.)
‘Services must not only be provided by the qualified
profe...
Objective Functional Data
Standardized functional outcome measures
afford objective and inter-rater reliable data:
Gait Sp...
Developing Functional Goals
Pt will independently transfer bed to
chair I without lose of balance
Patient will Independent...
Identifying Functional Deficits
How does the patient climb the number of
stairs needed to return home? Will they be
carryi...
Resources
Resources
Resources
Resources
Resources
Resources
Resources
Implementation
Need to change the culture of the rehab
team
Need to overcome lack of knowledge.
Many resources/tools out t...
Functionally Based Interventions
Functional Interventions
Increased scrutiny of therapy services through Medicare
Reviews
Must demonstrate the skills, know...
Functional intervention
Improved functional outcomes
Improved participation
Improved efficiency through reduced
refusals a...
Functional…
Making it functional
Improve patient participation-
Reduce refusals
Reduce patient boredom
Reduce therapist bo...
Literature support
Rhythmic movement interventions such as tai chi and social
dancing can improve gait regularity and auto...
Getting started
Read the Activities and Social Work
profile
Patients occupation
Electrician, Secretary, Teacher, Homemaker...
Getting Started
Interview patient and/or family for
information:
Obtain a detailed prior level of function on
evaluation
D...
Functional
Build your treatment program from a
favorite activity
1. Identify the patient’s deficit
2. Identify a favorite,...
Functional
Think of any functional task and break
it down to its sub-task’s to design and
build your treatment session.
Ho...
Engaging the Patient
Patient requires much encouragement to participate.
Investigate why pt won’t participate.
Is the inte...
FUN in Functional
Incorporating some fun while increasing strength,
ROM, Endurance, Functional Reach, Balance
Standing/Sit...
FUN in Functional
Throwing darts while standing on a
spongy mat
Hanging up baby clothes on a clothes line
Tai chi
Modified...
Music
Enhancing Activities with Music:
If therapy must use traditional mat or
seated
Exercises or parallel bars, consider
...
Tuning In-TV Activity
Turn on the Television to the news:
Orient to Time
Functional Ambulation to locate the TV
Guide/Remo...
Mail A Letter
Mail a letter to a friend?
Problem Solving? Identify where to get Stamp?
Task complexity? (Transfer, Go to t...
Conclusion:
`:
CFR 438.25
A nursing facility must provide nursing and
related services and specialized rehabilitative
serv...
Conclusion
Functionally Evidence Based: Valid and inter-rater
reliable to more accurately identify functional
deficits, po...
References
State Operations Manual Appendix PP - Guidance to Surveyors
for Long Term Care Facilities (Rev. 70, 01-07-11)
M...
Questions/Answers
Harmony Healthcare International
1 (800) 530 – 4413
Ebovee@harmony-healthcare.com
www.harmony-healthcare...
Harmony Healthcare International
Have you Considered a Customized Complimentary
HARMONY(HHI) MEDICARE PROGRAM
EVALUATION
o...
Harmony Healthcare International
Have you Considered a Customized Complimentary
HARMONY(HHI) MEDICARE PROGRAM
EVALUATION
o...
Thinking Out of the Box: Treatment Planning Outside the Gym
Thinking Out of the Box: Treatment Planning Outside the Gym
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Thinking Out of the Box: Treatment Planning Outside the Gym

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Improve participation and functional outcomes through creativity out of the gym. Functionally based treatment will ensure patients receive medically necessary physical therapy, occupational therapy and speech services. The presentation reviews practical application to Medicare requirements.

1. Learn to identify creative treatment strategies.

2. Learn to define Medicare coverage and Medicare documentation.

3. Learn to identify the clinical benefits of Functional Based Therapies.

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Thinking Out of the Box: Treatment Planning Outside the Gym

  1. 1. Thinking Out of the Box: Treatment Planning Outside the Gym HARMONY UNIVERSITY The Provider Unit of Harmony Healthcare International, Inc. (HHI) Presented Marianne Sherlock Regional Consultant
  2. 2. OBJECTIVES I. The learner will be able to identify creative treatment strategies. II. The learner will be able to define Medicare coverage and Medicare Documentation requirements. III. The learner will be able to identify the clinical benefits of Functional Based Therapies.
  3. 3. Regulatory Requirements The Omnibus Budget Reconciliation Act (OBRA), also known as the Nursing Home Reform Act of 1987, supports promoting recovery A nursing facility must provide nursing and related services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Facilities must ensure that residents improve when possible and do not deteriorate unless the resident’s clinical condition demonstrates that the decline was unavoidable. Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 4
  4. 4. Thinking Outside of the Gym What's the value? Meeting the needs: preventing decline, falls etc, Increasing regulatory focus on quality measures. Increased scrutiny of therapy services and how these services translate into better functional outcome Limited professional resources – need to be as efficient
  5. 5. Thinking Outside of the Gym
  6. 6. Objective Evaluation What is the facility’s current practice? Are we meeting the needs of all the residents? What is the interdisciplinary morale? What is the level of cooperation and follow through across the disciplines? Are there limitations in professional resources? Are the available resources efficiently used?
  7. 7. Assessing Barriers What types of barriers does your facility have to providing effective and efficient therapy? Staffing Patterns Environmental Silo Other….
  8. 8. Barriers to Providing Services
  9. 9. Barriers to Providing Services Meal times Outside Appointments Nursing Staffing Issues Patient direct care needs – treatments/wound care Equipment – access Dementia/Cognitive Deficit Refusals….. Why?
  10. 10. Do your teams work silos? Soc Wk Dietary Therapy Nursing Activities
  11. 11. Meeting the Needs of the Resident Nursing Shifts: 7-3 / 6-2 3-11/2-10 11-7/10-6 Therapy Hours PT 8-4:30 OT 7-3:30 ST 8-4:30 Are therapy staff Available to teaching day, eve, night staff? Available to train/meet with family? available to assess self feeding, aspiration risk, positioning during breakfast, lunch and dinner? Is OT performing real time or simulated ADL’s? Reverse ADL’s? Home Evals: Video vs. Off site Flexible scheduling
  12. 12. Where Do Patients spend Time? Consider time patient spends in room/on unit, with nursing caregivers?
  13. 13. Where do the patients live? Where do the patients spend most of their time Where might you get more cooperation with treatment? Where can you reach the most staff and families? How can you build an interdisciplinary team to increase follow through? Things to consider….
  14. 14. How Many Falls Occur in The Gym? Where do falls happen? Sitting up from bed Rolling over in bed and falling out Standing up/sitting down in wheelchair and bed Reaching to answer phone, for the box of tissues, for objects on the floor, Negotiating in/around the bathroom, in and out of closet, in small spaces. In dining room
  15. 15. Impact of Environment Is the environment conducive to the task? Noise –too noisy, resident can’t hear Lighting- pt with glaucoma, macular degeneration Distractions- too much for patient to focus Music- can be good, but….. Does the environment make the patient at ease? Does the environment make sense keep the environment in the same context as the task such as ‘simulated’ADL’s
  16. 16. Visual Impairment Therapists should understand the influence of visual impairment on program participation. Similar to weakness or paralysis, a decrease in vision can significantly influence patient’s ability to engage in desired activities Diabetic Retinopathy, low vision, Macular Degeneration, Glaucoma, cataracts Impact of bright hallways and bright gyms
  17. 17. Hit Them Where They Live Therapist + Patient + Caregiver = 24 hour a day 7 days per a week impact When you treat the patient in the gym for 60 minutes you are only impacting about 4% of the patients day Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 18
  18. 18. Literature Support Multi-Dimensional Challenges in Geriatric Rehabilitation the GRAMPS Study (Buijck, B. I. 2013) When therapists spend more time educating and including direct care staff in the delivery of therapeutic interventions the better their understanding and likely follow though and reinforcement
  19. 19. Efficiency Increasing efficiency by increasing on unit presence For facilities with space challenges and for dementia unit consider Mobile Therapy Cart to carry various equipment to: Dining Room Common Sitting areas Quiet Hallways Bedside Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 20
  20. 20. Efficiency Satellites: Small office on unit with highest rehab population Just the basics: Mat table/Folding Mat table Walker- standard/rolling Weights Computer access
  21. 21. Examining Documentation Efficiency and Accuracy
  22. 22. Reasonable and Necessary Medicare Benefit Policy Manual Section 220.2 ‘The services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a therapist…’
  23. 23. Reasonable and Necessary (Medicare Benefit Policy Manual cont.) ‘Services must not only be provided by the qualified professional or qualified personnel, but they must require….the expertise, knowledge, clinical judgment, decision making and abilities of a therapist.’ ‘The use of scientific evidence, obtained from professional literature, and sequential measurements of the patient’s condition during treatment is encouraged to support the potential for continued improvement that may justify the patients need for therapy.’ Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 24
  24. 24. Objective Functional Data Standardized functional outcome measures afford objective and inter-rater reliable data: Gait Speed Timed Up and Go Functional Reach Perceived Exertion Supports Functional reporting of G-codes Objective assessment is critical
  25. 25. Developing Functional Goals Pt will independently transfer bed to chair I without lose of balance Patient will Independently complete entire morning ADL routine with a Borg perceived exertion Patient will independently utilize safe swallow strategies through entire meal to eliminate overt aspiration
  26. 26. Identifying Functional Deficits How does the patient climb the number of stairs needed to return home? Will they be carrying items? How does the patient complete complex functional home routines? Reverse ADLs? Successive transfers? How does the patient utilize compensatory strategies in real life situations? Swallow strategies at supper? Speech strategies for emergency Phone calls?Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 27
  27. 27. Resources
  28. 28. Resources
  29. 29. Resources
  30. 30. Resources
  31. 31. Resources
  32. 32. Resources
  33. 33. Resources
  34. 34. Implementation Need to change the culture of the rehab team Need to overcome lack of knowledge. Many resources/tools out there….many are free In-servicing—Lunch and learn session-- Make it mandatory. Choose those functional tools that make sense for your population and that make sense for the identified deficit. Choose those functional tools that are easy to use Choose those tools that can more readily reflect functional gain
  35. 35. Functionally Based Interventions
  36. 36. Functional Interventions Increased scrutiny of therapy services through Medicare Reviews Must demonstrate the skills, knowledge and judgment of the therapist Must demonstrate functional outcome Assimilate traditional therapy approaches into Functional interventions How does the exercise/activity relate to the deficit? Ball squeeze How does the exercise/activity impact the restoration of function? UBE, digi flex
  37. 37. Functional intervention Improved functional outcomes Improved participation Improved efficiency through reduced refusals and time used to encourage participation
  38. 38. Functional… Making it functional Improve patient participation- Reduce refusals Reduce patient boredom Reduce therapist boredom
  39. 39. Literature support Rhythmic movement interventions such as tai chi and social dancing can improve gait regularity and automaticity, thereby increasing gait safety and reducing fall risk. Ref : Bridenbaugh S, A, Kressig R, W, Laboratory Review: The Role of Gait Analysis in Seniors’ Mobility and Fall Prevention. Gerontology 2011;57:256-264 Tai chi and postural stability in patients with Parkinson's disease Li F, Harmer P, Fitzgerald K, Eckstrom E, Stock R, Galver J, Maddalozzo G, Batya SS N Engl J Med 2012; 366(6): 511-519 Short duration, intensive tango dancing for Parkinson disease: an uncontrolled pilot study Hackney ME, Earhart GM Complement Ther Med 2009; 17(4): 203-207 ( Note: there were only about 12 subjects in this study, although not the most statistically significant study, it sounds like they had fun!)
  40. 40. Getting started Read the Activities and Social Work profile Patients occupation Electrician, Secretary, Teacher, Homemaker, etc. Leisure activities and Hobbies Woodworker, Crafts, Sewing, Painting, Interests Cars, Sports, Travel, Pets #
  41. 41. Getting Started Interview patient and/or family for information: Obtain a detailed prior level of function on evaluation Daily Routines Home Setting challenges (stairs, shower…) Facility participation (activities etc.) Where and What they eat Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 42
  42. 42. Functional Build your treatment program from a favorite activity 1. Identify the patient’s deficit 2. Identify a favorite, interesting or engaging activity 3. Break down the activity into its physical, verbal and/or cognitive components. 4. Analyze the components and determine which component will make most impact the deficit/impairment
  43. 43. Functional Think of any functional task and break it down to its sub-task’s to design and build your treatment session. Home making tasks; cooking, cleaning, Taking care of a pet Mailing a letter Making a photo album Wrapping gifts
  44. 44. Engaging the Patient Patient requires much encouragement to participate. Investigate why pt won’t participate. Is the intervention appropriate for the deficit? Is it fun? Is it painful? Cognitive deficit? Is it boring ? Is it embarrassing? Can they see? Can they hear? What environment have I tried? What interventions have I tried? What are the goals? Are they appropriate? Do they need to be revised? Are our goals the same as the patient’s goals? The patient may want to walk, but is too fearful, too weak to accomplish
  45. 45. FUN in Functional Incorporating some fun while increasing strength, ROM, Endurance, Functional Reach, Balance Standing/Sitting on high stool Making cookies, making a sandwich. Wrap gifts, Making a photo album Board (revised) Game, Card Games Video game (golfing in Scotland?) ‘Mock’ baseball, basketball, golf, bowling, tennis/badminton /boxing
  46. 46. FUN in Functional Throwing darts while standing on a spongy mat Hanging up baby clothes on a clothes line Tai chi Modified yoga Dancing Walking ‘invisible’ pet Calling distance family members Ordering out for lunch Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 47
  47. 47. Music Enhancing Activities with Music: If therapy must use traditional mat or seated Exercises or parallel bars, consider movement to music to make the activity more interesting and fun Make sure music fits activity and resident Singing to improve breath support and/or voice
  48. 48. Tuning In-TV Activity Turn on the Television to the news: Orient to Time Functional Ambulation to locate the TV Guide/Remote control Item retrieval from Floor Sequencing Tasks (What Do I do first?) Problem Solving (How do I find out?) Fine motor control (knobs and buttons) Activity Tolerance Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 49
  49. 49. Mail A Letter Mail a letter to a friend? Problem Solving? Identify where to get Stamp? Task complexity? (Transfer, Go to the bathroom before heading out, get coat on) Locating and ambulating to mailbox? Outside? Terrain? Curbs? Asking for help? Fine motor (writing, placing stamp..) Functional assessment with turns, opening doors, carrying items? Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 50
  50. 50. Conclusion: `: CFR 438.25 A nursing facility must provide nursing and related services and specialized rehabilitative services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident Facilities must ensure that residents improve when possible and do not deteriorate unless the resident’s clinical condition demonstrates that the decline was unavoidable
  51. 51. Conclusion Functionally Evidence Based: Valid and inter-rater reliable to more accurately identify functional deficits, potential barriers to progress and risks Quality of Care: Improved outcome and carryover through increased on unit presence/interdisciplinary Increased interdisciplinary cooperation Reduced refusals(?) Limited time to serve all residents that need to be served. Increase efficient use of limited resources-Time management with limited staffing
  52. 52. References State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities (Rev. 70, 01-07-11) Medicare Benefit Policy Manual Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance (Rev. 161, 10-26-12) Effectiveness of Occupational Therapy Interventions for Older Adults Living With Low Vision Am J Occup Ther May 1, 2013 67:263-265 Buijck, B. I. (2013). Multi-Dimensional Challenges in Geriatric Rehabilitation the GRAMPS-Study (Doctoral dissertation, Radbound University, Nijmegen, Netherlands). Retrieved fromhttp://repository.ubn.kun.nl/bitstream/2066/107678/1/107678.pdf #page=76 Radboud Universiteit Nijmegen, 8 mei 2013 Copyright © 2013 All Rights Reserved Harmony Healthcare International, Inc. 54
  53. 53. Questions/Answers Harmony Healthcare International 1 (800) 530 – 4413 Ebovee@harmony-healthcare.com www.harmony-healthcare.com 55
  54. 54. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Assess your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free 56
  55. 55. Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Benchmark your facility against key indicators and national norms Email us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free Harmony Healthcare International, Inc.Copyright © 2013 All Rights Reserved 57Harmony Healthcare International, Inc.

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