Thinking Out of the Box: Treatment Planning Outside the Gym

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

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.

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

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

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?

Assessing Barriers
What types of barriers does your
facility have to providing effective
and efficient therapy?
Staffing Patterns
Environmental
Silo
Other….

Barriers to Providing Services

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?

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 8-4:30
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

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 treatment?
Where can you reach the most staff and
families?
How can you build an interdisciplinary
team to increase follow through?
Things to consider….

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

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

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

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

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

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

Efficiency
Satellites: Small office on unit with highest
rehab population
Just the basics:
Mat table/Folding Mat table
Walker- standard/rolling
Weights
Computer access

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 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…’

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.’

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

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

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

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

Functionally Based Interventions

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

Functional intervention
Improved functional outcomes
Improved participation
Improved efficiency through reduced
refusals and time used to encourage
participation

Functional…
Making it functional
Improve patient participation-
Reduce refusals
Reduce patient boredom
Reduce therapist boredom

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!)

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
#

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

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

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

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

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

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

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

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

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?

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

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

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

Questions/Answers
Harmony Healthcare International
1 (800) 530 – 4413
Ebovee@harmony-healthcare.com
www.harmony-healthcare.com
55

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

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.

Thinking Out of the Box: Treatment Planning Outside the Gym

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