Building A Part B Caseload In The LTC Setting

Editor's note: This text-based course is a transcript of the webinar, Building a Part B Caseload in the LTC Setting, presented by Elizabeth Alicea-Torres, OT, OTD, OTR, CAPS.

Please also use the handout with this text course to supplement the material.

Learning Outcomes

After this course, participants will be able to:

• Differentiate between Medicare Part A and Part B coverage for OT services in the LTC setting.
• Differentiate between client factors and performance skills that are appropriate for the development of functional maintenance programs versus traditional Part B plans of care.
• Analyze the long-term care population as it relates to OT services and plans of care that support the optimization of function across all domains of the profession.

Introduction

Thank you for joining me today. I am excited to share this content with you, and I hope that by the end of our time together, you walk away with a sense of expanded possibility in your work with long-term care residents. I am an occupational therapist, educator, and consultant with 20 years of clinical experience advancing health, wellness, and functional independence across diverse practice settings and populations. I am the owner of Hemlock Health and Wellness LLC, a female-owned practice dedicated to promoting accessibility, aging in place, and holistic well-being through individualized occupational therapy services and consultation. The motto of Hemlock Health and Wellness is "live your life your way," which encapsulates the client-centered, individualized approach to function, well-being, and independence that drives everything I do.

I also serve as a college professor, teaching occupational therapy to master's and doctoral-level students. This content is close to my heart, both clinically and academically.

Before I get into the content, I want to ask you to reflect on something. How many of you feel that there is "only so much I can do" when it comes to developing plans of care that are meaningful to the long-term care resident? In a live version of this webinar, 72% of participants shared that sentiment. And I want to say: I completely understand. At one point in my career, I felt exactly the same way. But there was a shift that I experienced — a realization of how much more was possible — and that shift is what I hope to pass along to you in this course.

We will begin with a brief refresher on the long-term care setting, then move to the core of OT's role in LTC, including how we identify resident needs and the many areas of evaluation available to us. We will then move into functional maintenance programs — what they are, where they are legally grounded, how we build them, and how we document and set goals for them. We will close with considerations for collaborating with occupational therapy assistants in the Part B LTC caseload. Throughout, I will weave in real case examples, goal writing ideas, and the evidence that grounds each area of practice.

Section 1: Refresher on Long-Term Care

What Is Long-Term Care?

Long-term care is an inpatient living environment that provides access to around-the-clock care. And when I say around-the-clock care, I specifically mean around-the-clock nursing care and around-the-clock access to a medical provider. Those who live in long-term care facilities are typically called residents — and throughout this course, you will hear me use the terms "residents" and "clients" interchangeably. But I think it is important to understand that these individuals are residents because the long-term care environment is their home. They are residing there. That framing matters enormously for how we approach our work with them.

Access to healthcare services in LTC differs from that in other home-like environments, such as assisted living facilities, independent living facilities, group homes, or other community-style settings. Primary care is available in-house: physicians, nurse practitioners, PAs, and DOs come to the site. Rehabilitation services also come to the site or work within it. Some rehabilitation providers are actual employees of the long-term care facility; others are third-party employees from outside organizations that staff rehab teams. Certain specialists — podiatry, audiology, dental, mental health, and some forms of wound care — are also available in-house. However, residents still need to access specialists in the broader community for cardiology, orthopedics, neurology, and advanced imaging. I have seen portable X-ray come into LTC settings, but something like an MRI requires an outside facility. There is no emergency department on site, and higher-level wound care or other specialty services likewise require the resident to leave the building.

The Culture of Long-Term Care

Past and current approaches to care in the LTC setting are truly medical model-focused. For anyone who has worked in a skilled nursing facility — whether it provides both short- and long-term care, or strictly long-term care — you know that these environments are structured and rigid in most aspects of the daily schedule. Certain things happen at certain times, all the time. And research has found a significant decrease in a long-term care resident's ability to engage in occupations they value. Psychosocial needs are often unmet because they are unidentified. The evidence suggests that we should move toward a more holistic model across all areas of long-term care (Mendoza et al., 2023).

I am the type of clinician who likes to use evidence to inform practice, and long-term care is no different. Research indicates that residents are at greater risk of reduced occupational engagement due to environmental structural factors. Residents report lower satisfaction across a range of occupations they consider important. I think about this in practical terms: being able to put on makeup does not always happen in LTC. Getting your nails done does not always happen. Applying lotion all over the body does not always happen. And yet these things matter enormously to the people who value them.

Here is a statistic I find particularly striking: residents spend between 85% and 92% of their time being inactive (Mitterfellner et al., 2023). For some individuals, that is not much of a change from how they lived in the community. But for others, that represents an enormous and devastating shift. Reduced occupational performance directly correlates with increased care burden, which subsequently imposes greater demands on health care systems and caregivers.

OT Service Reimbursement in LTC

There are several ways long-term care facilities can be reimbursed for OT services. These include traditional Medicare Part B, HMO Part B (Medicare Advantage plans), Medicaid, private long-term care insurance, and private funds. Understanding these distinctions is fundamental to building and sustaining a Part B caseload.

Medicare has four parts — A through D. Part A covers acute care services: hospital stays, acute rehab, and short-term rehabilitation following a hospitalization. Part B covers outpatient services and home health, including long-term care residents, because the facility is their home. For individuals who have chosen a Medicare Advantage plan — what we call HMO Part B in Massachusetts — a commercial insurance provider takes over the role of the Medicare provider, following similar guidelines but with some important distinctions I will address shortly.

The 2025 CMS State Operations Manual

The 2025 CMS State Operations Manual for LTC, Appendix PP, states that if specialized rehabilitative services — including but not limited to physical therapy, speech-language pathology, occupational therapy, and respiratory therapy — are required in a resident's comprehensive plan of care, the facility must provide those services or obtain them from an outside resource that is a provider of specialized rehabilitative services. In short, if someone in a long-term care facility has an identified need for a specialized rehabilitative service, the facility is obligated to provide it. That is a powerful statement for our profession.

Part A Versus Part B in LTC

Let me explain the distinction between Part A and Part B services in LTC, as it is nuanced and can be confusing for clinicians.

The nature of the referral for services is one key differentiator. Individuals who have access to their Part A benefit must have had a three-night hospital admission. If they do not meet that threshold, they may not be able to access their Part A benefit unless they are within the window of a three-night stay. I like to use a concrete example to illustrate this. Say there is a long-term care resident — we will call her Mary — who is doing well and then falls and sustains a femur fracture requiring an open reduction internal fixation. She has a five-night hospital stay and returns to the facility. Rehab is called in, but she is not yet alert enough to participate. Five days later, she perks up, and we are still able to go in under her Part A benefit and reevaluate her, because she is still within that window from her three-night stay.

One thing residents often say is that "Medicare gives me 100 days, so I should have access to 100 days of skilled therapy." That is true in theory. However, the individual must truly require the skills of a therapist or other medical provider, and they must show consistent incremental progress. Additionally, if someone uses their 100 days, they must have a 60-day period of wellness before they are eligible for another 100 days of Part A coverage.

Part A is also associated with the term skilled, which Medicare uses in a specific way. Under Medicare's framework, if someone is receiving skilled intervention, services must be provided for at least 5 days per week. It is rare to see someone in home health or outpatient care receiving OT five days a week. In Medicare's view, that frequency level distinguishes Part A skilled services from Part B care.

Part B coverage in LTC parallels services received in the outpatient or home setting — because, again, the LTC facility is the resident's home. The frequency of traditional Part B services cannot exceed 4 times per week and can be as low as once per week. For residents with HMO Part B — Medicare Advantage plans, an authorization is typically required to continue a plan of care, and the frequency is determined by the insurance provider. In my experience, HMO Part B residents in LTC receive a maximum of three times per week, as determined by the plan.

The OT Process in LTC

The OT process in long-term care parallels the home health and outpatient settings in several important ways. We need to identify a referral source: an order must be in place from a medical provider. We verify reimbursement — sometimes handled by the director of rehabilitation or a business office staff member — but it is still a necessary step. We conduct an evaluation and develop a plan of care, using the most appropriate standardized assessments. We complete documentation—daily notes, weekly notes, or progress notes —depending on the state and the insurance. We update the plan of care at specified intervals, and ultimately, we either discontinue services or transition the resident into a functional maintenance program, which I will address in depth later in this course.

Section 2: OT's Role in the LTC Setting

Gerontological Occupational Therapy

Before I move into the specifics of screening and evaluation, I want to ground us in gerontological occupational therapy, because it shapes how we approach everything in LTC. When working with the long-term care population — particularly older adults — we must carefully consider two things: what compromises one's ability to engage in or perform activities within the context of LTC, and what will enable performance or promote engagement in priority activities to support overall well-being and quality of life.

I bring this back to the OT Practice Framework, fourth edition, and the full scope of our domains and processes. How are we optimizing quality of life and well-being across this population? How is that different from someone in short-term rehab? How is it different from someone who has lived in their own home for the past 30 years? This population has unique differences and unique needs, and our lens needs to reflect that (Barney & Perkinson, 2016).

When considering factors for this population, we want to think about how intrinsic factors are uniquely expressed among LTC residents — how function may differ now compared to the past, especially for those who are new to the setting. We want to think about the environments and contexts in which occupational options are grounded. Some individuals are accustomed to a spacious bedroom and bathroom and then find themselves sharing a small room and a bathroom with a stranger. We want to consider occupational options — what is possible in this particular LTC setting? What does this resident want or need to do? And crucially, wants and needs can be very different. We need to explore the resident's own priorities and goals before we dive into evaluating and intervening — not what nursing wants, not what the family wants, but what the resident wants (Barney & Perkinson, 2016).

Identifying Resident Needs: Screens

One of the primary mechanisms for identifying resident needs in LTC is through screens. I like to make a clear distinction between a screen and a formal evaluation. When I train level II fieldwork students, I tell them: during a screen, you are hands-off. You are not transferring anyone, you are not formally assessing anyone, you are simply inquiring, listening, and asking questions to determine whether there is a need that warrants a full evaluation.

Screens in LTC come from various sources. The MDS department — the minimum data set, typically staffed by nurses — assesses all LTC residents across a variety of functional criteria, including medications, bowel and bladder function, ADL abilities, and more. Each resident is required to have a quarterly screen from the MDS provider, an annual screen that goes a bit deeper, and a significant change screen when notable changes occur. Significant changes can include excessive unplanned weight loss or gain, the onset of a skin impairment, the use of a catheter, the addition or removal of oxygen, and similar events.

Falls are a major screening area for rehab: when someone falls, we investigate why, how, and what we can do to help. Incidents — including resident-to-resident issues, altercations, or situations involving cognitively impaired individuals — can prompt OT involvement. Skin issues, medical and nursing requests triggered by a change in status or the provision of care, dietary requests, family requests, social services, and the activities department can all generate screens.

And then there are rehab rounds, which I consider one of the most valuable and underutilized screening mechanisms available to us.

Rehab Rounds

Rehab rounds are a period of time designated for rehabilitation professionals — OT, PT, or speech therapy — to observe long-term care residents in their natural environments during the day or evening. This is the skilled eye of a rehabilitative professional applied in a non-evaluative, observational way. Rehab rounds can happen during meals in the dining room or a resident's room, during ADL care, during activities and leisure pursuits, during functional mobility, and during positioning — at the chair or bed level. Screens can even address sleep and sleep hygiene, though this requires extra planning and communication with the director of rehab to accommodate the presence outside normal working hours.

During ADL screens within rehab rounds, I assess bed-level care, seated levels at the bedside, toilet, or chair, shower-level function, the use of adaptive equipment and assistive devices, caregiver and family training needs, skin integrity, dignity, and autonomy in decision-making. Dignity is an area that sometimes gets overlooked, and I have developed entire plans of care focused on dignity and autonomy — educating caregivers on giving residents choice in what they wear, the type of soap used, and ensuring adequate privacy during care provision.

During dining room screens, I look at self-feeding abilities, adaptive equipment needs, how the resident gets to and from the dining area, positioning at the table, food and beverage preferences, coordination and dexterity, range of motion and strength, oral motor control, levels of alertness and fatigue, caregiver and family training opportunities, dignity, and socialization. Sometimes this involves something as simple as observing that a resident cannot control a food bolus in their mouth, does not have anything to protect their clothing, and is experiencing spillage during a meal — and that a plan of care could meaningfully address that dignitary concern.

Activities and leisure screens allow me to assess the level of appropriate participation, as not all participation is appropriate for any given individual based on their unique cognitive or physical needs. I can look at cognition as it pertains to leisure participation, range of motion, and strength, positioning, behavioral interactions, areas of interest, and the distinction between passive and active participation. I did not always appreciate the value of passive participation until I began working in LTC, but it matters enormously — sometimes the best outcome for a resident is meaningful passive engagement. Research from 2023 highlighted the positive effects of leisure participation and social interaction on nursing home residents' mental health, life satisfaction, and sense of well-being (Keane et al., 2023).

Functional mobility screens can make our PT colleagues a little nervous, but functional mobility is well within our scope of practice — especially when residents mobilize to engage in important activities that they want or need to do. I look at changes in independence or further dependence, appropriateness and safety of assistive device use, footwear, and handwear for those who propel their wheelchairs, skin integrity, range of motion, manual muscle testing, vision and hearing changes, cognitive and behavioral changes, caregiver and family training opportunities, and static and dynamic balance.

Positioning screens — at the seated or bed level — require understanding that a resident's positioning can look quite different at different times of day. I have screened individuals whose positioning during breakfast looked very different at lunch and again at dinner. I look at safe positioning during ADLs and mobility, footwear and clothing, assistive devices, midline positioning, use of positioning devices, skin integrity, and airflow. When I say airflow, I mean ensuring that air can move freely throughout the body. A resident lying on their back with their posterior surface in contact with the bed surface the entire day is at a much higher risk for skin impairment. I also consider how much time a resident wants or is able to spend out of bed — and, importantly, their own desire for that.

Mental health and behavioral screens are an area I took a long time to fully appreciate in my own LTC practice. A major focus here is adjustment to the LTC setting for new residents — individuals who were living in the community and experienced a medical event or a shift in their social or health dynamics that led to a transition to long-term care. That adjustment is profound, and it warrants skilled OT screening and intervention. I also screen residents who have switched rooms, units, or transferred from another LTC environment, because even the physical orientation of a new room — where the grab bars are, whether it is a window or door bed, private or shared — can significantly impact function and comfort.

I can screen for the establishment or modification of routines and habits, identification of mental health or behavioral concerns, orientation to common areas and one's room or unit, and grieving loss in LTC. For those who have worked in long-term care for any extended period, you understand this: the friendships and relationships that residents form are meaningful. When someone passes, it genuinely affects the people who knew them. We can and should screen for grief-related needs. We also look at occupational role changes. Someone who has been living in the community with their spouse of 50 years may no longer feel connected to their identity as a husband or wife because they are no longer physically together all the time. And we can look at the prevention and mitigation of occupational deprivation — the inability to engage in an occupation due to something outside one's control. COVID-19 is the clearest recent example: when residents were sequestered to their rooms, they were stripped of mobility, leisure, and socialization through no fault of their own (Calderone et al., 2022).

A 2022 study found that a successful transition to the LTC environment was positively affected by maintaining occupational roles and an occupational identity through attention to personal objects and occupational engagement (Calderone et al., 2022). Sometimes it is as simple as calling a family member and saying, "Your father mentioned he really loved a particular pillow from home — is there any chance someone could bring it in?" And observing how that small thing changes how a person sees themselves.

Clothing, footwear, jewelry, and eyewear are additional screening areas. Every individual has the right to wear what they choose, but we can screen for wear and tear, size, and fit, as these factors impact safety and skin integrity, fall risk, and donning and doffing abilities. I have seen impaired skin from ill-fitting eyewear when someone has lost weight, and the frames no longer fit properly. We can look at adaptive equipment for these tasks, and always consider dignity and safety.

Sleep and sleep hygiene can be screened for by assessing the establishment or modification of evening and nighttime routines; sleep positioning; environmental factors such as light, sound, temperature, and fabric preferences; caregiver and family training opportunities; autonomy; and dignity. Screening for sleep and sleep hygiene may require you to be present outside your typical working hours and to communicate effectively with evening and night shift nursing staff. It also requires communication with your supervisor — especially if they are not an OT and may not automatically recognize sleep as an ADL within our scope. Being able to clearly articulate OT's role in sleep and the benefit of good sleep hygiene across this population is going to be critical for getting others on board.

OT Evaluations: Typical Referral Reasons in LTC

The most common reasons for OT evaluation referrals in LTC include changes in self-care performance; determining or facilitating the safest and most appropriate ways for the provision of care by caregivers; determining or facilitating the safest and most appropriate ways for the resident to participate in their own self-care and activities of choice; establishing or re-establishing levels of function; seating system assessment and modification; functional transfers, standing, and balance; pain management; weight loss and assessment of self-feeding; positioning needs and changes during ADLs or bed-level rest and sleep; range of motion and strength; orthotics and prosthetics; and cognition.

Some of these do not require a screen at all — for example, if a referral states that a resident who was previously completing ADLs at the toilet level is now completing them only at the bed level, that change is significant enough to move directly to evaluation.

Alternative Areas of Evaluation Focus in LTC

Now I want to move into what I call alternative areas of evaluation focus — areas that are not uncommon but are less frequently pursued in LTC, even though they are just as important as the typical referral categories. These are the areas with the greatest potential to develop the most meaningful plans of care for residents, and they are the ones I am most passionate about bringing to your attention.

Community Participation.

Community participation as an evaluation focus is appropriate for LTC residents who demonstrate certain factors: high cognitive and executive functioning, consistent communication abilities, a self-reported desire to engage in the community, goals for community-level engagement, the ability to acquire a safe transportation plan with assistance, the ability to acquire travel and community-level supports, medical stability, and a physician's order for permission to leave the building with a responsible party.

Let me be direct about how I think through this. If someone did not need around-the-clock care, they would likely not be living in long-term care in the first place. So community participation is assessed on a case-by-case basis, and communication consistency matters enormously. If a resident cannot reliably tell you they are dizzy or that they need to use the bathroom, those are not the right circumstances to send someone out into the community.

I have had experiences where a family member strongly wants their loved one to attend a community event, and the resident is fully on board — and I have had experiences where the resident really did not want to go, found the idea overwhelming, and was concerned about managing in a public environment. It is always more important to honor what is appropriate for the resident and what they actually want, not what the family wants for them.

Transportation planning is a real and complex piece of this puzzle. Acquiring wheelchair-accessible van transportation on a Sunday afternoon at 3:00 PM is not necessarily going to be covered by insurance, and private pay options will likely be more expensive. I do not generally recommend Uber or Lyft for this population due to the safety and accessibility challenges. And even with appropriate transportation secured, we must consider community-level supports — the wheelchair van driver is responsible for getting the resident to and from the vehicle, not for supporting them throughout the event. Who will meet them there? Who will provide support throughout?

Goal ideas for community participation:

Within two weeks, the resident will develop a community outing plan with supervision and verbal cues to adhere to safety precautions and resource boundaries to participate in a friend's 80th birthday party.

Within four weeks, the resident's identified community caregiver will demonstrate 100% independence and safety in transferring the resident in and out of the car to engage in safe community outings.

Within three weeks, the resident will tolerate sitting out of bed in their personal manual wheelchair for 180 minutes to safely engage in an upcoming community event.

Leisure, Play, and Relaxation.

Evaluating for leisure, play, and relaxation in LTC involves identifying likes and dislikes — and I will be honest with you, I have used interest checklists, and they are limited to whatever is on the list. It has taken me time to become more creative in presenting options to residents that they could safely and realistically engage in. I look at cognitive leveling to determine the appropriateness of different leisure, play, or relaxation activities. I look at biomechanical features — what is presenting as a challenge to engaging in bingo, or sitting outside on a nice day? I look at activity tolerance, socialization skills, safety, and dignity.

I include dignity specifically around leisure because I have seen situations where a communal movie or television program in activities was not age-appropriate for the residents participating. Just because someone has a diagnosis of dementia or cognitive impairment does not mean that the only thing they would enjoy watching is cartoons. Dignity in leisure engagement deserves our attention. I also look at vitals, especially as they pertain to relaxation techniques and their effectiveness in managing or normalizing physiological responses. And I use quality-of-life assessments as both evaluative tools and outcome measures—the Quality of Life Scale (QOLS) and the QUALIDEM for individuals with dementia are two examples. I have compiled a comprehensive list of standardized assessments used in LTC practice in alphabetical order, which should be available to you in the resources section of this course.

Goal ideas for leisure, play, and relaxation:

Within two weeks, the resident's heart rate during group activities will remain between 60 and 100 BPM while integrating mindfulness techniques for anxiety management with verbal cues and/or visual prompts.

Within four weeks, the resident will appropriately engage in BINGO with three or fewer verbal cues to remain safely seated and reduce the risk of falls.

I want to tell the story behind that second goal. I had a resident who would get so excited during BINGO that he would throw himself up out of his chair — he fell twice in one week exhibiting this behavior during the game. My goal was never to exclude him from BINGO, because BINGO genuinely brought him joy. My goal was to ensure his engagement was safe and that the caregivers understood when and how to verbally cue him to remain seated. We also looked at his positioning within the room — specifically, where he sat in relation to whoever was running BINGO that day. That change in proximity made a significant difference.

Within three weeks, caregivers will accurately identify when the resident is overstimulated during group on 3/3 occasions and adjust the resident's environmental position to reduce signs and symptoms of distress and discomfort.

Within four weeks, the resident's score on the QOLS will increase by 10 points as a measure of improved satisfaction, promoting the best abilities to function.

That phrase — best abilities to function — is one I learned through dementia capable care training, and I use it across many of my goals for this population. Everything we do in LTC is working toward optimizing function and helping residents achieve their best abilities to function.

Communication and Behavior Management.

Communication and behavior management require time and intentionality. Building therapeutic rapport matters more here than almost anywhere else in LTC practice, and it cannot be rushed.

I am a firm believer that behaviors are communications of needs across the lifespan. When a resident is exhibiting challenging behavior, our job is not to manage the behavior in isolation — it is to understand what that behavior communicates. We are good at root cause analysis as OTs, and this is an area where we can really step up as advocates for our residents. Other members of the care team — nursing, social services — may not have the same training in understanding the communicative function of behavior.

In this area, I look at a resident's communication style, which is not always verbal. I cannot tell you how many times I have communicated effectively with someone solely through facial expressions and gestures. I look at methods for communication, consistency, and accuracy in communication, and what communication through behavior looks like. I look at skilled observation, therapeutic rapport and trust building, caregiver and family education and training, the assessment of vision and hearing, and how those impact communication, the management of hearing and vision devices, and biomechanical factors such as pain and its impact on communication.

One example that illustrates why this matters: a resident named Joe had hearing aids stored in a small cup on his nightstand each night by nursing. But if Joe could not put his own hearing aids in in the morning, and it was not on anyone's radar to put them in for him, they might as well not exist. It takes the skilled eye of an OT to see the small pieces of the puzzle that make the whole picture — and to meaningfully improve communication and reduce behaviors that might otherwise escalate or cause harm.

I will share a case from my practice. I had a resident who had had a laryngectomy and had great difficulty creating sound even through the tracheostomy. It was very difficult for him to communicate his pain. We created a communication board — a whiteboard — with this resident. He was cognitively intact, so he was able to track which caregivers were actually using the board and which were not. That tracking mechanism allowed me to verify whether the 100% integration goal was being met, because this resident consistently reported it to me.

Goal ideas for communication and behavior management:

Within three weeks, the resident will accurately communicate their wants and needs in 5/5 trials modified independent using their personalized communication binder to ensure needs are met and to promote best abilities to function.

Within four weeks, the resident will improve their right tripod grasp strength by 5 pounds to maintain hold of a pen to write a letter to a friend and meet communication and socialization needs.

Within two weeks, nursing caregivers will integrate the use of a communication board 100% of the time to assess and treat back pain to enhance the resident's abilities to sleep at night and sustain out-of-bed sitting during the day.

Wound Healing.

Before I address wound healing, I want to say this clearly: it is critically important to expose yourself to and acquire advanced training as it pertains to wound healing — particularly as it relates to seating systems and the use of modalities. You always want to follow your state's recommended practice policies, guidelines, and regulations. I hold OT licensure in three states — Florida, Connecticut, and Massachusetts — and the policies and regulations regarding wounds and wound management differ across all three. Know your state's rules and your facility's policies before engaging in this area.

From an OT lens, wound healing involves positioning and airflow — it is unrealistic to expect wounds on the sacrum, coccyx, heels, or back to heal when a resident is lying in supine all the time, even with an air mattress. We need to move these individuals and increase airflow to the affected areas of skin. We look at nutrition and hydration — protein intake, foods and liquids high in vitamin C, and overall hydration. We assess and modify seating systems to offload pressure from wound sites. We examine wound staging and size. I am also a certified lymphedema therapist and have taken wound care courses; I incorporate manual lymph drainage and kinesio tape to support lymphatic pathways and optimize wound healing where clinically appropriate.

Modalities for wound healing include shortwave diathermy, electrical stimulation, and ultrasound. One critical caution across all modalities: they cannot be used in or around wound beds that contain any silver — whether in the dressing or in a topical product like silver sulfadiazine. If you have a resident who would benefit from electrical stimulation around a wound and they have a silver dressing in place, the nurse would need to remove the dressing prior to treatment and replace it afterward. That coordination is your responsibility to facilitate.

I want to share an experience that brought the dignity piece of wound care vividly into focus for me. I was working with a resident on bed-level positioning during wound care — the nurse's treatment took about 30 to 40 minutes. Throughout, this resident's fists were clenched, and her eyes were tightly closed. She was not communicating during the treatment, which was unlike her. After the treatment, I asked her what was happening for her during that time. She said, "The nurse who comes in does a wonderful job with my wound. But she never closes the curtain. Every time someone walks by or comes into the room, I feel like my whole bottom is exposed, and I am just too scared to say something." I was genuinely shocked. And that experience brought the dignity piece into the sharpest possible focus for me. I now address this in every wound-related plan of care.

Goal ideas for wound healing:

Within two weeks, the resident's sacral wound will reduce in depth, length, and width by at least 1 cm, as a measure of wound healing, with the integration of shortwave diathermy.

Within three weeks, nursing caregivers will return and demonstrate the ability to reposition the resident on their side, integrating the recommended positioning devices, modified independently through the use of a photograph, to reduce the risk of further skin impairment and promote the best abilities to function.

That goal — using a de-identified photograph — came from a practice I found enormously effective. When I get a resident positioned optimally using positioning devices, I take a photograph (de-identified, not including the face) and post it in a visible place so nursing staff can replicate the positioning when I am not there. I have done this successfully enough times that I include it as a formal goal component.

Within four weeks, the resident will maintain supervised out-of-bed sitting using a loaner tilt-in-space seating system with a ROHO cushion to offload sacral wound pressure in three-hour increments to engage in activities and lunch in the dining room.

Spirituality, Religion, and Culture.

As a college professor who teaches OT to graduate students, I cover spirituality, religion, and culture as a dedicated area of practice — and it is one that gets lost in translation in LTC settings more often than it should, through no one person's fault. It simply is not always on the radar, and it matters.

We can identify spiritual preferences, religious affiliations, and cultural associations as a standard part of our intake process. We can honor spirituality, religion, and culture in someone's daily routine as a valued instrumental activity of daily living. We can look at quality of life and life satisfaction as they relate to spiritual and cultural identity, work to maintain a sense of belonging through adaptive strategy development, support cultural expression and participation, and engage in advanced care planning with spiritual, religious, and cultural considerations in mind.

I will share an experience that crystallized this for me. I was walking past a common room in an LTC setting where a weekly Christian church service was being held. The nursing assistants had placed several residents in the hallway into that room. When I looked more closely, I recognized that four of those residents — all wheelchair-bound and unable to independently mobilize out of the room — were of Jewish and Muslim faith. They had been placed into a Christian service because it was convenient, and they could not communicate or physically remove themselves from the situation. That experience reinforced for me how important it is to identify someone's spiritual and religious preferences before making assumptions — and to incorporate them into the plan of care and the facility's care culture.

I have also learned from a previous course I taught here on terminal illness and end-of-life care that advanced care planning is deeply interwoven with spiritual, religious, and cultural identity — and that OTs have a meaningful role to play in supporting residents through that process.

Goal ideas for spirituality, religion, and culture:

Within four weeks, the resident will increase their right shoulder active flexion to 165 degrees to make contact with the mezuzah upon entering their room as a mechanism of religious self-expression, promoting their best ability to function.

I want to tell the story behind that goal. I had a resident in South Florida who moved into a private room in LTC. Her daughter found a magnetic mezuzah — a scroll with Hebrew prayers, placed within the frame of a doorway as a practice of Jewish religious observance — and was able to mount it on the doorpost. But the resident, who was ambulatory, could not reach it due to shoulder weakness. We worked on building shoulder flexion range specifically to enable her to make contact with the mezuzah upon entering and leaving her room. It was one of the most meaningful goals I have written, and achieving it mattered enormously to her.

Within two weeks, the resident's daughter will demonstrate independent, safe abilities to feed the resident cleared foods of choice to honoring culture and ensuring adequate nutrition and hydration, with no signs or symptoms of aspiration at the bed or chair level.

That goal came from a resident who was originally from Thailand and would not eat anything offered in the facility's standard menu. She also had dysphagia. Once there was a cleared food list and the daughter knew what was safe, I worked on ensuring the daughter could feed her parent safely — understanding appropriate bite and sip sizes and the signs and symptoms of aspiration — so that culturally meaningful meals could occur.

Within four weeks, activities staff will independently identify signs and symptoms of the resident being overstimulated and/or dysregulated during church services and redirect the resident appropriately to maintain health and well-being.

Sleep and Sleep Hygiene.

The LTC setting is now home, and home is a place of rest. That is the framing I come back to when thinking about sleep and sleep hygiene as an area of OT practice in LTC.

We can evaluate and identify sleep and rest preferences and patterns, and the effectiveness of the current sleep routine. If a resident was accustomed to going to bed at 10:00 PM and the CNA is coming in at 5:00 in the afternoon to get them into bed for the night, that is a significant occupational mismatch. Just because nursing or anyone else has an idea of when residents should be in bed does not mean it honors what that resident wants or supports their well-being. This is where we step in as advocates — help me understand this resident's preferences, can we find a compromise?

We can also examine the impact of medications on sleep. In my experience, there is typically a window of about one hour in either direction for medication administration in LTC settings. If someone is prescribed a strong sleep medication like Trazodone at 8:00 PM and it is consistently given at 7:00 on the dot, they may be waking at 3:00 AM and not getting enough sleep. We can work toward figuring out the optimal timing for maximum sleep duration.

Environmental factors — light, sound, temperature, and even fabric — all influence sleep quality. I have worked with residents in LTC who brought in their own sheets and linens from home, laundered by a family member, because that was what they needed to achieve a good night's sleep. Sometimes sensory regulation is the key piece. Personally, I know that if my room is not dark, cool, with a fan running, and soft sheets, I am not sleeping well. If that is true for me, it is true for others too — and we can assess and address it.

Sleep screening and intervention may require working outside your typical hours. I have flexed my schedule specifically to observe a resident's nighttime functional mobility in real time — arriving at 1:00 PM instead of 7:00 AM, and having the CNAs text me when the resident began to move toward the bathroom so I could observe the functional mobility sequence in natural conditions. Beyond that, simulation is our primary tool, and it works well when paired with strong communication with night shift staff.

Goal ideas for sleep and rest:

Within three weeks, nursing caregivers will consistently provide setup of the resident's bedtime routine supplies within the desired parameters of 8:00 PM–9:30 PM to allow for engagement in nightly ADL routines to optimize rest, sleep, and function.

The resident will complete a sleep diary nightly, modified independently using a phone reminder to track their sleep and rest, promoting their best abilities to function, within four weeks.

The resident will engage in simulated nighttime functional mobility from the edge of the bed to the bathroom and back, modified independent at the rolling walker level, safely in 5/5 attempts to promote independent nighttime toileting in two weeks.

The resident will sequence the steps of their desired sleep routine under supervision, with intermittent verbal cues to pace, to optimize rest and well-being.

End-of-Life and Advanced Care Planning.

I want to preface this section by acknowledging that every OT may have different personal feelings about addressing end-of-life care in practice, and that is completely understandable. Continuing education in this area — including exploring your own relationship to mortality and end-of-life conversations — is helpful before diving in. I have taught a webinar here on terminal illness and end-of-life care that goes into much greater depth.

What I want to convey here is that there is a meaningful OT role in this space. We can facilitate participation in end-of-life and advanced care planning and preparation. I have seen this area be particularly meaningful for residents who have no nearby family — their children live across the country, or everyone else has passed away. They may not feel comfortable talking with their children about end-of-life wishes because they fear upsetting them. We can step in and provide a skilled, compassionate space for those conversations.

We can consider redefining occupational roles at this stage of life. We can foster ongoing engagement in self-care and activities of choice — just because someone is in the end-of-life stage does not mean they have no desire to continue doing things for themselves. We can look at anxiety and pain assessment and management, coping strategies, caregiver and family education and training, and education about body systems and disease processes as they relate to function. Integrating energy conservation strategies becomes especially important at this stage.

Legacy projects are one of the most meaningful interventions I have engaged in with residents approaching end of life. A legacy project can take many forms — a binder, a box, a voice recording, a video — and it is something the resident creates to leave for someone they care about. It is a testament to who they are. I will be honest: these can be emotionally weighty for the OT, too. But they are deeply rewarding, and I have received enormous gratitude from family members for facilitating this work with their loved ones.

Goal ideas for end-of-life and advanced care planning:

The resident will engage in strategies to reduce anxiety with supervision using a list during repositioning and bed-level toileting in 4/4 trials in three weeks.

The resident will assume the role of grandmother to her grandchildren by participating in the development of a legacy project with moderate assistance from OT caregivers within four weeks.

The resident will actively participate in advanced care planning arrangements — including identifying preferences, completing advance directives, and communicating decisions with family or providers — with minimal verbal cues during structured therapy sessions in order to support autonomy in future healthcare decision-making within four weeks.

Section 3: Functional Maintenance Programs in LTC

Background: Jimmo v. Sebelius

Functional maintenance programs have a specific legal history that every OT working in LTC should know. In 2013, the U.S. District Court for the District of Vermont ruled on a case known as Jimmo v. Sebelius. This settlement agreement concerned the improper application of an improvement standard. Prior to this case, Medicare claims for rehabilitation services could be summarily denied if a beneficiary lacked restoration potential—even when that beneficiary required a covered level of skilled care to prevent or slow further deterioration of their clinical condition.

What was happening in practice was that claims were being denied because the beneficiary was not showing progress, not advancing to lesser levels of assistance. But skilled care to prevent deterioration was also being denied, even when the deterioration itself was avoidable. That was the problem this case addressed (CMS, n.d.).

Following the settlement, CMS now states that a beneficiary's lack of restoration potential cannot in itself serve as the basis for denying coverage, without regard to an individualized assessment of the beneficiary's medical condition and the reasonableness and necessity of the treatment, care, or services in question. However — and this is critical — coverage would not be available if the beneficiary's care needs can be addressed safely and effectively by non-skilled personnel. Coverage is based in part on whether the skills of a therapist are required.

CMS defines a maintenance program (MP) as "a program established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness" (CMS, 2014; Novak et al., 2023). This definition opened significant doors for long-term care residents who could benefit from skilled intervention to prevent functional decline or to slow the progression of an illness, disease, or condition.

I remember practicing in 2013 when this case came to be and how it shifted things in the field. And I will be honest — I was not fully aware of its implications at the time. But through years of long-term care practice, you learn how to build and justify maintenance programs, and the Jimmo settlement is the foundation of that justification.

OT Considerations for Functional Maintenance Programs

From the OT perspective, developing a functional maintenance program requires a careful risk-benefit analysis: what is the risk if we do not engage this resident in a maintenance program, and what are the benefits if we do? A central question is: what can be successfully taught to a non-skilled caregiver, versus what are the actual skills of the occupational therapist?

This leads to another question: Is it realistic to ask non-skilled personnel to assess a resident? That depends on what is being assessed and the required response. Assessing pain is generally appropriate for a CNA in most scenarios — though assessing pain during functional mobility or self-care may not be, depending on the resident's unique needs. Assessing dizziness through simple conversation is generally okay for a non-skilled person. But if that assessment requires checking vitals, or if the clinician needs to watch for nystagmus or signs of vertigo, a CNA is not the right person to make that clinical judgment. Tone management, in my opinion, should not be delegated to non-skilled personnel. The different presentations of tone — hypotonic versus hypertonic, variations across different extremities — require skilled clinical observation and response. A general balance assessment might be okay, but managing balance during activity with skilled verbal, tactile, or visual cues is not something we should be teaching non-skilled caregivers. That is part of why we went to school for as long as we did.

Examples of Functional Maintenance Programs in LTC

In the LTC setting, functional maintenance programs may be appropriate for:

Functional mobility within the facility for a resident who requires skilled cues — verbal, visual, or tactile. If someone needs to walk to the dining room or to visit a friend's room and they require skilled cueing to do so safely, that is grounds for a functional maintenance program.

Skilled tone management followed by or preceding passive range of motion, to allow for safe and thorough ADL care or the application of an orthotic.

Skilled range of motion to assess and maintain skin integrity.

Skilled range of motion and tone management to prevent the formation or worsening of contractures.

Skilled use of modalities.

Skilled establishment and facilitation of habits and routines to prevent or slow functional decline. This requires a clinical decision-maker — someone who can determine that a resident is regulated and appropriate to engage in a routine or activity. A non-skilled person cannot always make that determination safely.

Skilled transfer techniques that allow a resident to engage in their environment. I have had residents who could not transfer into a shower chair safely with CNA staff, who refused the shower bed, and for whom OT had to be present for every shower transfer — both into and out of the shower chair. This required coordinating the resident's shower schedule around OT availability, which meant shifting their shower hours to the 7:00–3:00 shift. That is the kind of coordination that skilled functional maintenance programs require.

Skilled assessment of client factors and contexts for safety — including vitals, pain, skin integrity, areas of pressure, regulation, and the creation of the just-right challenge. I truly believe OTs are the best-positioned professionals to create the just-right challenge for a patient, and if you find yourself thinking "this is only successful and safe when I am here," that is the signal that a functional maintenance program is clinically appropriate.

Documentation for Functional Maintenance Programs

Documentation for functional maintenance programs must include a clear identification of the resident's condition or conditions — including the prognosis — to support the need for skilled intervention to prevent or slow further deterioration despite the lack of restoration potential (Center for Medicare and Medicaid Services, n.d.). We must verbalize and document that the restoration potential is absent or unachievable. And we need to be specific about why. This person has multiple sclerosis, and it is progressive. This person has dementia, and it is progressive. This person has Parkinson's disease, and it is progressive. Whatever the rationale, it must be stated clearly in the documentation, along with a clinical picture that depicts what is happening and why this maintenance program is going to be effective and necessary.

Goal Writing for Functional Maintenance Programs

When a typical or traditional Part B plan of care transitions into a functional maintenance program, the goals need to shift accordingly. Consider integrating the following verbs and verb phrases into your maintenance program goals:

- "Continue to tolerate…"
- "Consistently perform / integrate / tolerate…"
- "Demonstrate the ability to maintain…"
- "Maintain…"

And the following endings:

- "…to optimize functional potential / safety / autonomy / dignity"
- "…prevent the formation / reduction / deterioration of…"

If you are providing a skilled service so that a resident can maintain something they currently do for themselves, that language looks one way. If you are providing a skilled service so that they can maintain something as a result of the skilled intervention itself — for example, providing passive range of motion to maintain skin integrity — that calls for slightly different phrasing. Think carefully about what it is you are maintaining, and who is doing what, and write the goal to reflect that precision.

Section 4: Functional Maintenance Case Studies

Case Study: Mallory

Mallory was a female in her mid-70s with middle-stage dementia. She was independently ambulatory — this woman could sprint across her locked unit without any assistive device, which was something else to see. She required assist of one for ADLs except for self-feeding, which she managed with setup. She had minimal assist for most self-care tasks and required cues for sequencing and pacing.

Then COVID happened. Mallory was sequestered to her room, and the change in her routine was dramatic. Very quickly, she became bedbound and contracted. Her upper and lower extremities were flexed at all major joints. Her hips were wind-swept to the left, her ankles were plantarflexed — she had significant foot drop — and bathing, dressing, and toileting became very difficult for nursing staff. An OT evaluation was ordered.

Using her traditional Part B services, I began working on tone management and passive range of motion of her upper extremities — primarily the shoulders and elbows, with some work at the wrists and hands — as well as her hips for toileting and bathing. Her hips were adducted and wind-swept, her knees were flexed, and her heels were nearly in contact with her posterior. It was very difficult to clean her, bathe her, or manage perineal care. I integrated shortwave diathermy to the elbows and shoulders prior to skilled passive range-of-motion and tone management. We were eventually able to achieve an adequate range of motion to allow caregivers to complete ADL care and toileting at the bed level.

After four weeks, I began a de-escalation process — moving to three times per week for two weeks, then two times per week for two weeks. With the de-escalation, Mallory's condition regressed quickly. It became clear that she needed to transition to a maintenance program at four to five times per week. At my facility, there is no frequency cap for functional maintenance programs — the four-times-per-week Part B limit does not apply. We were able to build a maintenance program at up to 5 times per week, eventually regaining the range lost during de-escalation and maintaining it over a long period.

Short-term goals:

Resident will maintain 60 degrees of passive bilateral shoulder abduction to allow for the provision of ADL care in two weeks.

Resident will maintain -45 degrees of passive bilateral elbow extension to allow for the provision of ADL care in two weeks.

Mallory lacked 45 degrees of elbow extension to neutral, and those short-term goals carried over every time I updated her plan of care, because the skilled intervention was always what sustained them.

Long-term goal:

Nursing caregivers will demonstrate 100% competency in safe resident handling and repositioning techniques during bed-level ADL care to maintain their current functional status in four weeks.

To measure that long-term goal, I would randomly pop in during care across different shifts and different caregivers — because staff rotate daily — and observe. I would intervene when needed and document what I saw.

Case Study: Kim

Kim was in her mid-40s with a spinal cord injury and embolic CVAs. She was dependent for all ADLs and related mobility — bed-level care, mechanical lift, all of it. She presented with bilateral wrist drop and demonstrated significant clonus with attempts to position her wrists in neutral. Her skin was becoming impaired at the volar wrist creases. She told nursing: I want to make my wrists straight, I want to be able to get my nails done, I want someone to wash my hands, I do not like the smell.

An OT evaluation and treatment order was placed. I established a traditional Part B plan of care for three to four times per week, addressing ROM concerns and investigating orthotics for daytime wear. Throughout this plan of care, we identified appropriate orthotics and a wear schedule that was successfully implemented with OT support. We were able to work Kim up to approximately eight hours per day of orthotic tolerance.

When it came time to train nursing staff to apply the orthotics independently, we learned that Kim required the skills of a therapist to prepare the wrists adequately — managing her clonus sufficiently to allow safe orthotic application — before the orthotics could be placed. It was not a lengthy process, but it was a skilled one. Nursing neither had the skill nor the time, even if the skill could theoretically have been taught. It was determined that Kim needed a functional maintenance program, with OT performing the skilled preparation and application of the orthotics five times per week.

At that time, I worked a Sunday-through-Thursday schedule, and Kim agreed to a Sunday-through-Thursday orthotic schedule for hand hygiene and nail care. That schedule aligned with OT coverage to maintain compliance with the plan of care.

Short-term goal:

Resident will consistently tolerate the skilled application of bilateral wrist orthotics five times per week to optimize skin integrity and participation in hand hygiene and nail care in two weeks.

Long-term goal:

Resident will maintain tolerance of bilateral wrist orthotics for up to eight hours per day when applied with no signs or symptoms of skin impairment or further contracture development to maximize functional potential in four weeks.

Section 5: Working With OTAs and the LTC Part B Caseload

Collaboration with occupational therapy assistants in the LTC Part B caseload is an important area that deserves thoughtful attention. I want to share several considerations from my perspective as both a practicing OT and an educator.

First and foremost, education between OTRs and OTAs should be collaborative—not hierarchical in one direction only. A registered therapist educating assistants is important and appropriate, but so is remaining open to learning from assistants who may have more LTC-specific experience than you do. I have worked with OTAs who had been in the same LTC facility for 25, 27, or even 30 years. They know that building — and its residents — in ways that a newer OTR simply cannot match. They can walk the hallways blindfolded. Their observations are invaluable for building a Part B caseload, even though they cannot independently evaluate.

There should be a clear, shared understanding of the differences in payer sources for LTC residents: why a resident might be seen one time per week versus four times per week, or why an HMO Part B plan limits frequency to three times per week. The scope of OT practice in the LTC setting — including the less common areas of evaluation and intervention I discussed today — should be collaboratively explored. And the different areas of focus for OT intervention in this setting — restoration, adaptation, compensation, and maintenance — should all be clearly understood and distinguished.

OTAs may have received differing primary education about LTC as a niche area of practice, and they may require guidance. At the same time, so might a newer OTR who did not have a fieldwork experience in LTC. Being open to that mutuality is important.

OTAs can also be powerful sources of referrals through their own skilled observation of residents in the facility. While they cannot evaluate independently, they can screen, observe, and communicate findings — and that is enormously valuable for building and sustaining a Part B caseload.

There may be hesitation or confusion among OTAs regarding functional maintenance programs and their implications to Medicare billing policies. Myth-busting around functional maintenance programs — what they are, how they are justified, what the Jimmo settlement established — is part of collaborative education in the LTC setting.

Finally, OTAs may need deeper insight into the results and interpretations of standardized assessments for this population, as well as their meaning and impact on the plan of care. Making space for those conversations and building a practice culture where questions are welcome to support better outcomes for residents and a stronger, more cohesive team.

Summary

Long-term care is one of the most complex and multidimensional practice settings in occupational therapy, and I believe it is often undersupported in our professional education and culture. I hope this course has expanded your sense of what is possible in LTC — both for the residents you serve and for your own professional practice.

Part B services in the long-term care setting parallel home health and outpatient in fundamental ways, and understanding the distinctions between Part A and Part B — and between traditional Medicare and HMO Part B — allows you to advocate for appropriate frequency and duration of services. The long-term care population deserves plans of care that go well beyond ADL retraining: they deserve plans of care that address community participation, leisure and play, communication, spirituality and culture, sleep, and end-of-life care with the same rigor and intentionality as any other referral.

Functional maintenance programs, grounded in the Jimmo v. Sebelius settlement, provide a legitimate and clinically appropriate mechanism for sustaining skilled OT services with residents who have no restoration potential but require our skills to prevent further deterioration. Knowing how to build these programs, document them, and write goals for them is foundational to practicing effectively in LTC.

Collaboration with OTAs in this setting is not just about supervision — it is about building shared knowledge, shared purpose, and shared advocacy for the residents in your care.

I want to close with the framing that drives everything I do in long-term care: these residents are at home. They are living their lives in these facilities, and what they want from their lives there deserves the full weight of our clinical attention, creativity, and advocacy. Every screen conducted, every evaluation opened, every functional maintenance program built is an opportunity to help a resident live their life their way.

References

See additional handout.