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  Geriatrics and Speech Therapy 


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Collaborative Care Evolutions


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Collaborative Care Evolutions
Emphasizing wellness and prevention with holistic senior care
By Kate DeBevois
05.01.07

Article available online at: http://www.therapytimes.com/050107GERIATRICS


When it comes to seniors, therapists are transitioning from reactive to proactive patient care. Therapists at centers such as Lincolnshire, Ill.,-based Pond’s Rehabilitation and Wealshire Skilled Nursing Care Center are bringing the wellness trend to rehabilitation and long-term care, emphasizing prevention and a holistic approach.
 
From joint replacement recoveries to hospital de-conditioning, the center’s “rehabilitation pavilion” uses individualized short- and long-term care programs to help patients (including Medicare Part B patients) “maximize therapeutic potential, address their emotional outlook and improve their quality of life,” says Jennifer Loughney-Bebinger, MPA, LNHA, administrator and COO.

The center provides rehabilitation and Medicare services, all levels of therapy and nursing services for Alzheimer’s, dementia and non-dementia residents and special care programs for individuals with Parkinson’s.

At the center, physicians, therapists and nurses receive additional training to serve special needs, including Alzheimer’s, post-stroke therapy and dementia. “We pride ourselves on offering a knowledgeable staff, safe and proven procedures and the latest advances in medical technology,” says president Arnold Goldberg, “The greatest testament to our success is the fact that our short-term rehabilitation residents recover – and leave – so soon.”

Collaboration

According to Loughney-Bebinger, administrator and COO, therapists at the center regularly combine physical, occupational and speech therapy with nutrition and music therapy.

Therapists collaborate on a daily basis performing co-treats regularly based on patient needs. For patients who receive elective knee replacements, the center’s rapid rehab for the active geriatric population, provides care for patients between ages 40 to 80, depending on their activity level.

Loughney-Bebinger says collaboration enhances patient care through improved communication. “When one therapist understands what the other therapist is doing, they can aid each other in providing success for the resident,” she says.

When therapists meet with patients and their other clinicians each week, “they know which person is treating who and for what reason, the patient knows everyone is on the same page and each therapist understands the entire treatment plan,” she says. “This makes the patient feel more comfortable, opens the lines of communications and gets them home as soon as possible. Patients come back for the second knee surgery because this is their rehab home.”

The rapid rehab short-term care program is part of the larger living community, with private kitchen suites, bathrooms, living rooms and courtyards within a “household” of 16 patients. Therapists in the program work with physiotherapist Tamara Gurevich, MD, the physical medicine and rehabilitation director, to ensure each patient is working the correct muscle groups to recover quickly.

Music therapist Patricia Little, RMT, has created a comprehensive music therapy program that helps patients adjust to daily transitions. She ensures relaxing music is played during therapy sessions, mealtimes and at the end of the day to facilitate a relaxing enviroment. She also visits the rapid rehab program four times a week to help residents “have fun and express themselves musically.”

According to assistant administrator Shari Floss, “In order for the body to heal and get better faster, we have to recognize that the emotional and spiritual aspects of the human being [needs] to be nurtured; music therapy provides that support.”

A Personal Touch

According to Floss, the center has three times the average staff-to-patient ratio; enabling staff to spend more time with each patient. Because the center specializes in person-centered therapy, “something as simple as ‘this individual loves country western music’ can be used [in] care planning to help speed up recovery,” Floss says.

Emphasizing the center’s holistic approach, she says, “When you don’t just look at the knee, you look at the whole person, what they enjoy, the music they love and their spiritual needs, they feel fulfilled and ready to work harder at therapy on Monday.” Floss says this philosophy “really does filter down into an expedited recovery, we look at the entire person and it does show up in our recovery success rates.”

Virginia Garberding, RN, director of restorative nursing and education, says therapists and clinicians who notice details, such as tactile defensiveness in a non-verbal dementia or stroke patient, is what makes Wealshire unique. For example, if a person with dementia has tactile defensiveness and is sensitive to showering, “it is just a matter of making sure the staff is aware. If the person with dementia cannot tolerate the feel of the water on their skin, other options can be offered, such as bed baths,” Garberding says. “You have to communicate that information to each and every person who cares for the patient,” to ensure a continuity of care.

Holistic Patient Care

The center approaches short-term rehabilitation holistically, combining physical, emotional and cognitive therapy. Michael Edquiban, PT, heads the center’s therapy department and works closely with Tamara Gurevich, MD, physical medicine and rehabilitation director.

“Our goal is to make exercise both fun and functional,” Edquiban says. “We work in small groups to maximize individualized care and encourage residents to motivate each other. Most of all, we strive to offer comfort, compassion and care when it comes to treating each person’s needs. Regular team meetings with caregivers and therapists across all involved disciplines allow us to adjust and adapt to changing conditions. Our integrated approach can make the difference between a resident going home next week or going home next month,” Edquiban, says.

The center collaborates with Gurevich, who maintains an independent practice in Buffalo Grove, Ill., specializing in pain management, arthritis, sports injuries, workers compensation and other musculoskeletal conditions. 
 
Gurevich provides portable vestibular testing device for the diagnosis and treatment of vertigo, a common condition in the elderly that often contributes to falls. First, residents are screened to assess and isolate potential causes of vertigo; then, therapists work to pinpoint and treat the underlying cause, such as a sensory disturbance, inner ear condition, muscle weakness or neurological disorder.

Gurevich works to tailor each therapy regimen to address the source of the problem and prevent falls, which, in turn, may prevent surgeries to repair or replace fractured hip or knee bones. “Vestibular testing and rehabilitation is a critical part of patient recovery,” Gurevich says. “It has been highly successful in not only identifying the underlying conditions of vertigo, but [also] in teaching patients how to overcome balance issues, retrain muscle groups and even perform simple tasks differently to avoid injury.”

Garberding says the facility has four different payment plans and works with Medicare and Medicaid for people who come in with a dementia diagnosis. With this patient population, noticing the smallest details is key in creating a comfortable therapy experience. Therapists work more gently with these patients. “Because we know they are only able to follow one-step instruction [and] their progress will be slower, we give them ongoing guidance in these tasks so they can have a sense of accomplishment,” Loughney-Bebinger says.

Staff Stability and Care Continuity
 
President Arnold Goldberg says staff stability is key in providing care continuity. More than one-third of nurses working at Wealshire have been there for a minimum of six and a half years, while 23 of its certified nursing assistants (CNAs) have been employed for seven years. In addition, approximately 75 percent of the activities staff has been at the facility for five years, with one activities department employee topping 11 years.
 
Wealshire also hired additional educators, activity therapists, physical therapists, physical therapist assistants, rehabilitation aids, occupational therapists, speech therapists, dieticians, wound care specialists and neurophysiologists to meet the demand for elective joint replacement surgeries.

Working with Medicare Part B

According to Leslie Fried, director of the Alzheimer’s Association Medicare advocacy project, many Medicare contractors follow the “improvement standard” under Part B, which will only cover rehabilitation services, including physical, occupational or speech therapies, if the service is expected to improve the health or function of the beneficiary.

Fried says, “For Alzheimer’s beneficiaries, these Medicare policies fail to recognize the benefit of occupational, physical and speech therapies to maximize functioning or slow deterioration for individuals with Alzheimer's disease.”

Fried says since the close of several class action lawsuit Medicare Part A coverage of rehabilitation services (i.e., services through home health agencies or skilled nursing facilities), the improvement standard is no longer required for Medicare coverage.

The Alzheimer's Association is working to convince the Centers for Medicare and Medicaid Services (CMS) and its contractors “to reevaluate local coverage policies and develop new policies that are fair, reasonable and consistent with current clinical standards, best practices and research,” according to the association. 

According to Fried, the association’s efforts to enhance access to services include “advocating for the revision of the ‘improvement’ standard included in the Medicare manuals, commenting on local coverage policies and working with a Medicare contractor medical director on an initiative to enhance access to home health services.”

Therapy Caps

According to the Alzheimer’s Association, in January 2006, CMS began implementing an annual dollar cap on rehabilitative therapies for Medicare beneficiaries. The annual cap for 2007 is $1,780 for occupational therapy services and $1,780 for physical and speech therapy services. Fried says, “If a beneficiary exceeds the dollar amount for therapy services during the year, Medicare will no longer cover the services.”

There are exceptions to the cap; however, this only applies when additional therapy services are determined medically necessary. For example, an exception “should be provided when an individual has a complex or coexisting condition, such as Alzheimer’s disease, that may affect the pace of progress in treatment,” Fried says.

In those circumstances, the patient may need therapy services that exceed the cap. The association plans to continue monitoring the exceptions process “to ensure Alzheimer’s beneficiaries have access to medically necessary therapy,” according to the association.  

The association supports a repeal or moratorium of the therapy cap and has urged Congress to repeal the cap. “However, if the cap continues to be implemented, the exceptions process must be maintained in order to ensure access to these important medical services,” association representatives say.

Senior Care – Back to Basics for Enhanced Care

“Ultimately, it all goes back to really the basics,” Floss says. “With all the new terms and fancy slogans, I think great, innovative care is nothing more than basic loving care. Know the person you are caring for inside and out, know that perhaps water on skin coming from a showerhead hurts them and share that information with every person that needs to know it. Know that grainy foods bother a resident and then share that; it simply means communicating.”

Floss says the household centric format at Wealshire helps therapists to enhance collaboration efforts. “Delivering loving, compassionate, kind care is not something you will get out of a new gizmo. You will get people sharing information doing everything possible to make a day pleasant and free of irritations; you’ve got to care enough to communicate,” Floss says. Loughney-Bebinger adds, “It’s understanding the [patient as a] person, their mind, their body and their spirit and treating them with dignity.”

Transitioning from complete independence to assisted living is often a devastating move for many patients. A facility with a visiting RN who meets with patients in their home to discuss concerns ahead of time helps to ease the transition.

From the admission process to home placement, Loughney-Bebinger recommends gathering as much information as possible from patients entering senior care facilities. “We want to know what nickname they like, that they love bridge and [enjoy] bowling and really love spaghetti, in addition to their communication and therapy abilities.”
 
Kate DeBevois is the staff writer for Therapy Times. Questions or comments can be directed to kdebevois@valleyforgepress.com.

Click on the play button below to view an exclusive Webcast about a unique facility centered around the geriatric community.



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AccuMed Technology Solutions at CSM 2010
Bill Cummins, MS, CCC-SLP, discusses the Cypress Therapy software from AccuMed Technology Solutions, which provides a library of documentation templates, including daily notes, weekly summaries, initial and monthly plans of progress, and discipline-specific evaluations, as well as Cypress Mobile software in which therapists enter treatment data as they work with patients, running on any handheld device using the Windows Mobile® operating system Cypress Therapy software integrates, manages, and displays information for therapists, managers, and business office staff.
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