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Returning The Skills To Skilled Nursing Facility Rehabilitation

Returning The Skills To Skilled Nursing Facility Rehabilitation
Mira Rollins, OTR/L, Emily Briggs, OTR/L, RAC-CT
July 13, 2023

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Editor's note: This text-based course is a transcript of the webinar, Returning The Skills To Skilled Nursing Facility Rehabilitation, presented by Mira Rollins, OTR/L, Emily Briggs, OTR/L, RAC-CT.

Learning Outcomes

  • After this course, participants will be able to:
    • examine chief limitations of effective SNF rehabilitation.
    • analyze resources for OTs that strengthen a skill set directly pertaining to SNF rehabilitation.
    • examine specific OT interventions for skilled SNF rehabilitation


Mira: I like to begin my presentations with a warm-hearted "hey y'all," embracing my Texan heritage. With that, I extend a warm welcome to each and every one of you. Your presence here is greatly appreciated.

My professional journey has predominantly revolved around long-term care. Consequently, every facet I'll be discussing today is rooted in my personal experiences—my struggles, triumphs, and what I have learned. Often, advice and information are dispensed with the sentiment that they're easier said than done. However, I want to emphasize that I've walked the path, comprehended the challenges, and achieved success. I want you to view this endeavor as a collaborative voyage over the next few hours. 

Belief Drives Behavior: Yours

  • Critical Need for A Mindset Shift
    • Restore Value
    • Raise Expectations
    • Return to the Fundamentals

We are guided by our beliefs, shaping our actions. It is imperative for us, as therapists, to scrutinize our perceptions of our residents and our roles within the Skilled Nursing Facility (SNF) environment. I encourage a thorough self-assessment of our perceptions about our residents' worth, as even though we might hold genuine affection for the geriatric population, subconscious biases can sometimes undermine their true value.

We can overlook the unique contributions that our residents make to the world. Their presence alone, the act of breathing, serves as an anchor for someone in their life – a daughter, a husband. While they might not hold conventional jobs or partake in roles with financial compensation, their presence carries considerable significance. It's crucial that we examine our sentiments and beliefs in this regard, as these internal perspectives can inadvertently shape how we interact and care for our clients.

Furthermore, we need to elevate our expectations. Often, we see our residents through a lens of frailty and age-related vulnerability, which, to some extent, is accurate. However, it's important not to confine them within these limitations. Instead of beginning with a cautious approach that stems from a thorough evaluation of their health challenges, we should initially consider the most effective intervention for addressing a specific deficit. By taking this top-down approach – envisioning the optimal treatment plan as if no other factors were in play – and subsequently adapting it to the client's condition, we're more likely to administer the most effective and safe treatment.

A shift in mindset can also reshape our goals. Rather than merely aiming to reduce falls, a goal that holds merit, adopting a top-down approach might transform it into a broader objective like enhancing community mobility. Similarly, in the context of reducing muscle tone, approaching it from a top-down perspective could lead to a more creative and impactful strategy, optimizing client outcomes.

Returning to the foundational principles of our practice is paramount. These core techniques, often acquired in our educational journey, form the bedrock of our skills. Consider strength training – an exercise commonly approached with uniform weights for all residents. Instead, let's reevaluate and go back to the basics. Muscle growth necessitates a load of 60 to 85% of the individual's functional maximum. This requires a deliberate assessment of a client's specific functional maximum for a given muscle group. This foundational practice prompts us to tailor our interventions to the unique capabilities of each resident, going beyond assumptions.

In essence, this presentation underscores the importance of transitioning from general approaches to specific, individualized care. By reassessing our beliefs, heightening our expectations, and adhering to the foundational principles of our discipline, we can truly optimize our impact as therapists.

Belief Drives Behavior: Theirs

  • Critical Need for A Mindset Shift
    • Alliances and Agreements between others on the medical team
    • CNA – “You are our 1st and most consistent line of defense.”
    • Nursing – “We are on the same team.” 
    • Physicians – “I am knowledgeable. I am here to support your treatment plan and  make you look good.”
    • Other Therapy Disciplines – “Let’s step our game up together."
    • Family – “This will make your life easier and their life better. I won’t hurt them.”

Now that we've taken a step back to reevaluate our approach and reinforce the core principles let's look at our interactions with different members of the medical team. It's time to explore how we can bring about a shift in their perspectives.

CNAs are the unsung heroes who can truly make or break our day. Think about it. If you had a tough time with a CNA on Tuesday, you might find yourself walking into the clinic on Wednesday to see your patients still in bed, a stark contrast to the rest of the team's ready-to-go clients. The truth is CNAs spend the most time with patients, making them the frontliners in observing any changes, improvements, or declines. So, treating them like gold isn't just a nice idea—it's essential. Make them realize they are our first line of defense for our patients. Show them that we value their observations about skin integrity, eating habits, and more. By recognizing their significance, we foster a strong partnership that benefits everyone involved.

Nurses are vital colleagues who occasionally exhibit a bit of territorial behavior. It's crucial to understand their leadership role and avoid any unnecessary power struggles. They're in charge, and they need us to recognize that. Emphasize that our collaboration isn't a competition but a collective effort aimed at optimal patient care.

Physicians are the experts, but we're not far behind. When we work with doctors, it's vital to present ourselves as knowledgeable allies. Responding to their queries with efficient, precise answers highlights our expertise. This not only builds rapport but also positions us as valuable resources. The more successful we are, the better they look—building a win-win scenario.

And then there are our fellow therapists—OT, PT, and ST. Let's be candid. Being a run-of-the-mill therapist won't cut it. To truly elevate patient care, we must set higher standards within our community. By striving for excellence in our practices, we create a positive chain reaction that resonates throughout the organization. It starts with us setting the bar.

Last but not least are the families. They often yearn for their loved ones' comfort, sometimes overlooking the broader benefits of our interventions. By transparently explaining how our actions enhance their loved one's life, we can secure their support and understanding.

To wrap it all up, our transformation encompasses not just our internal mindset but also how we interact with the diverse players in our care plan. By aligning our perspectives and fostering collaborative relationships, we create a cohesive environment that truly puts patient care at the forefront.

Seating and Positioning

  • The vast majority of all wheelchairs in SNF settings are ill-fitted for:
    • Postural Support
    • Functional Mobility
    • Restraint Reduction
    • Pressure Management

I want to start with seating and positioning. We're kicking off with this topic because it's the immediate, glaring need that confronts us every time we step into a skilled nursing facility. Seating and positioning are the low-hanging fruits of challenges.

In one corner, you've got a resident perilously close to sliding right out of their chair, still somehow propelling it forward. In another corner, a resident's seat depth is so inadequate that it's practically bumping against their knees. It's a scene that's all too familiar, isn't it? You might even find yourself thinking, "I could tackle the seating and positioning needs of half this facility single-handedly."

Here's an innovative idea to add to the mix – designating a trained specialist to oversee the treatment plan's execution. A parallel can be drawn from the practices in many SNFs. They've found success in having one or two individuals responsible for managing weight measurements to ensure consistency and precision. This strategy prevents errors such as attributing a 10-pound weight loss to a patient when it was actually due to a change in equipment setup. Imagine having a specific, trained staff member who is well-versed in the intricacies of the equipment we utilize for our clients. Whenever new equipment is introduced, this designated staff member could provide guidance and training to a small group of nurses or CNAs. These trained caregivers would then be equipped to handle the equipment with expertise. To maintain the quality of our approach, a simple yet effective step could be implemented. Once a week, with approval from their nursing manager and administrator, the designated CNA could conduct equipment checks across the facility. This system not only promotes a consistent level of skill and care but also reduces the potential for errors caused by varying interpretations.

  • Residents with multiple co-morbidities:
    • Prioritize greatest needs
    • Do adjustments in phases, possibly over multiple episodes of care
    • Mindset shift from perfect to best

Another barrier is the presence of multiple comorbidities. I'm a firm believer that clients in SNFs are among the most medically intricate individuals we encounter. Despite the complexity, we should resist the notion that there's limited scope for intervention. In fact, it's quite the opposite. The extensive health considerations present in these clients provide us with numerous opportunities for meaningful impact. The key lies in strategic prioritization and phased adjustments.

Rather than feeling restricted by their multitude of health issues, we should view these as avenues for comprehensive care. The crucial strategy here is to identify and address the most pressing needs. Taking a phased approach to adjustments is paramount. This approach offers twofold benefits: it allows us to gauge the effectiveness of each change, and it enhances the resident's tolerance to adjustments. Rapid, simultaneous change risks overwhelming the resident's capacity to adapt. By introducing modifications incrementally, we promote both effective outcomes and gradual adaptability.

Embracing this approach, you may find yourself developing multiple tailored plans of care for a single issue. Imagine embarking on a seating and positioning improvement journey. What's preventing you from initially adjusting the seat depth and seat-to-floor height? After a period of adaptation, you can subsequently focus on altering the back support, transitioning away from a slingback to a more suitable alternative.

It's important to shift our mindset from the pursuit of perfection to the pursuit of what's best for the individual. The reality is that few, if any, clients will fit the 90-90-90 posture mold. That's not our goal. Instead, our aim is to achieve optimal seating and positioning that aligns with the unique needs of each client. This mindset shift allows us to transcend rigid expectations and embrace personalized solutions.

  • Resistive family and/or residents to trying something new
    • Pt and Family Education
    • Equipment to Trial
    • Give Options
    • Testimonials from other residents or families

Resistive family members may be another issue. They may prefer comfort-focused choices for their loved ones. For instance, they may say, "Leave Dad alone. I want him in a large chair that resembles a couch – comfort is key."

To reshape this mindset, education is a powerful tool. Begin by sharing insights on the importance of tailored seating and positioning for individuals with specific needs. This goes beyond just appearances – it's about optimizing their overall well-being. Help the family understand that optimal comfort extends beyond a superficial appearance to encompass factors like pressure relief, posture support, and functional independence.

To counter resistance, consider leveraging equipment trials. Collaborate with vendors to explore options for temporary use of various chairs, cushions, and aftermarket products. This approach allows families to experience firsthand the benefits of different options before making a commitment. Present it as an opportunity to explore and find the most suitable fit rather than settling for a singular choice.

Empower families with options rather than dictating a single solution. By offering a range of possibilities, you acknowledge their preferences while steering them toward more effective choices. Moreover, tap into the power of testimonials. When families hear from others who have experienced positive outcomes due to tailored seating and positioning, it carries more weight than what clinicians can convey.

Imagine a client or family member sharing how a specific choice improved their loved one's comfort, function, or overall well-being. These firsthand accounts carry immense credibility and can influence others to be more open to exploring alternative options.

  • Lack of Time for Evals and Fittings:
  • Bill It!
    • 97163 (high complexity) over 97162 or 97161
    • 97164 Reevaluation
    • 97542 – Wheelchair management
    • 97530 Therapeutic Activities – typically highest rate
    • 97112 Neuromuscular Reeducation
    • 97140 – Manual Therapy
    • 97110 – Therapeutic Exercise

Navigating the challenge of limited time in our busy schedules is something many of us face, given the productivity demands placed upon us. The antidote to this barrier is simple: bill your time. Remember this catchy phrase, "Bill it, bill it, bill it," perhaps reminiscent of the classic tune "Beat It." It's a lighthearted reminder to attach a revenue-generating aspect to the time invested in tasks that might seem minor or incidental.

When you find yourself thinking, "I spent 20 minutes adjusting someone's footrest in the hallway," remember that billing for your expertise is not just justified but essential.

As for how to bill, familiarize yourself with the appropriate evaluation and treatment codes that reflect the complexity of your client's needs. Recognize that the low complexity codes might not accurately capture the intricate health considerations our residents have. Instead, aim for codes like 97166 (moderate complexity) up to 97167 (high complexity) to accurately reflect the multifaceted nature of your interventions. There's also 97168 (re-evaluation code), which might be relevant based on your facility's preferences. Other codes like wheelchair management, therapeutic activity, neuromuscular re-education, manual therapy, and therapeutic exercise provide avenues for effective billing.

Understand the distinction between timed codes and unit-based codes. Vary your billing by utilizing a mix of codes, with an emphasis on timed codes when applicable. A strategy that combines your expertise with appropriate billing practices will not only align with your facility's goals but also offer you the flexibility to focus on quality care.

In essence, the onus is on you to dive into the details of coding, adapting your approach based on the services provided and the specific needs of your clients. This proactive approach ensures you maximize the revenue stream while maintaining the integrity of your practice and managing productivity expectations. Remember, it's not just about "billing it" but about doing so with precision and strategic intent.

Customizing the Chair

  • Minimizing Postural Collapse
  • Minimize Postural Asymmetry
  • Forget 90/90/90
  • Increase Attention on Back Support
  • Cushion – Use a decision tree
  • UE Positioning
  • LE Positioning
  • Edema Control
  • Use of PENS for neck, posture, and trunk control and strengthening

Our focus with customization is on mitigating postural collapse, a prevalent issue among our geriatric population. This condition often manifests as a posterior pelvic tilt coupled with increased spinal kyphosis, shown in Figure 1.

Figure 1

Figure 1. Illustration of postural changes. (BruceBlaus, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons)

These complications typically arise due to muscle imbalances in the leg muscles and abdominal area.

Our initial priority is addressing asymmetry. It's crucial to note that asymmetry, when deliberate, is not inherently negative. Deliberate asymmetry, driven by specific reasons, is perfectly acceptable. However, inadvertent asymmetry, where the client unconsciously adopts an imbalanced posture, is what we aim to avoid. Consider a scenario where one hip is more contracted than the other, prompting the need for a strategically adjusted cushion elevation on the affected side. This type of intentional asymmetry serves a purpose.

Likewise, if a client experiences a discrepancy in hamstring tightness, adjusting the leg lift on the footrests becomes a valid option. Such adjustments fall under intentional asymmetry. Furthermore, cases involving shoulder subluxations may necessitate raising or lowering an armrest, a decision that aligns with the customized approach. It's important to acknowledge that education plays a pivotal role here. Although intentional asymmetry might be misconstrued by others, consistent and clear education can dispel any misconceptions.

In instances where a resident exhibits significant kyphosis, achieving an upright posture against a flat back can be impractical. This leads us to the crucial topic of back support adjustment, which we'll delve into shortly. Instead of adhering rigidly to the 90-90-90 rule, our focus should shift toward tailoring back support. Consider the case of posterior pelvic tilt, where the upper pelvis tilts backward. A bi-angular back support proves beneficial here. This type of support accommodates the pelvis while allowing controlled trunk flexion and extension, addressing the specific needs of the individual.

On the subject of asymmetry, I'd like to address the widespread use of standard sling wheelchairs, which often fall short of accommodating various postural considerations. Our approach should challenge this norm by advocating for more personalized back support solutions.

Moving on, let's discuss cushions – an often underestimated element in the seating equation. Viewing cushions as comprehensive care plans in themselves is a mindset shift worth making. While foam cushions suffice for clients with good mobility and minimal sitting time, more specialized options are necessary for others.

Gel cushions featuring a gel pocket within a foam base provide contoured stability and effective pressure distribution. Air cushions, though highly effective in pressure relief, are contingent on consistent maintenance. Honeycomb cushions, characterized by a matrix pattern, offer shock absorption, weight distribution, and ventilation. Hybrid cushions blend these attributes for tailored comfort.

Accounting for upper extremity positioning, such as desk or arm length, and lower extremity considerations, including edema control, becomes paramount. Addressing edema control prompts a vital distinction – while elevated leg rests help alleviate fluid retention in the ankles and calf, they can inadvertently cause pooling higher up the leg. Elevating the legs above heart level remains the optimal approach for effective edema management.

Utilizing PENS (Postural, Edema, Neuromuscular, Strengthening) strategies aids in neck posture and trunk control enhancement. Combining this with strategic seating and positioning strategies assists in rectifying the postural collapse pattern.

Finally, we mustn't neglect seat-to-floor height adjustments, which play a role in facilitating proper heel strike and preventing undesirable compensations.

In conclusion, customization is the cornerstone of effective seating and positioning solutions. It's crucial to embrace adaptability, iterate as necessary, and consistently educate clients and colleagues on the rationale behind these tailored interventions. 

Dementia Considerations for Seating and Positioning 

  • Stage of dementia
    • Early
    • Middle
    • Late
  • Prior device usage
  • Purpose of the device
    • Active use
    • Passive use
  • Daily routine and habit formation

Emily: Thanks so much, Mira. When reviewing seating and positioning for individuals with dementia, it's imperative to recognize that this diagnosis shouldn't deter us from making meaningful interventions. In fact, those with dementia require our services even more as they navigate their progressive journey. Their support needs will shift, and our role is to ensure their functionality and safety remain at the forefront of care.

We can start by considering the stage of dementia. This can be assessed through various scales or simply categorized as early, middle, or late stages. While early-stage dementia cases may not often appear in skilled nursing settings, middle to late-stage individuals are more common. In the context of seating and positioning, a crucial step is to tap into their procedural memory. Have they used a wheelchair or similar device before? This prior experience can be harnessed to guide their current usage.

Also, we need to ponder the purpose of the device. Will the resident actively interact with the wheelchair? Can they self-propel, maneuver brakes, and adjust footrests? This feasibility varies with their cognitive stage. While those in the early and middle stages might be taught to utilize a wheelchair, in advanced stages, passive use might be more realistic. However, passive doesn't equate to insignificance. Even when the user isn't actively propelling, proper positioning is vital. This enables them to move from one place to another, fostering engagement and participation.

Consider daily routines and habit formation. Contrary to misconceptions, the research underscores that individuals with dementia can indeed learn new habits through consistent repetition. Establishing a routine with regular reinforcement can yield positive outcomes even in this population.

Case Study

  • 85 y/o female dx with mid-stage dementia
  • Stopped feeding herself in the dining room
  • Observed at noon meal sitting in w/c with hips near the distal edge of the seat, BLEs windswept and not on footrests, head resting on top of w/c back upholstery
  • Tabletop was at the level of her forehead
  • The tray contained a plate, bowl, 2 glasses, and silverware wrapped in a napkin and tucked under the edge of the plate

Here's a real-life case study that sheds light on the impact of proper seating and positioning, particularly for individuals with dementia. This scenario is based on an actual patient encounter I had a few years back in a skilled nursing facility.

The patient, an 85-year-old woman, was diagnosed with mid-stage dementia. She had been referred to occupational therapy because she had stopped feeding herself during meals in the dining room. The occupational therapist was initially unsure of how to approach this situation, believing that the patient's advanced dementia might render her unable to learn or adapt.

Curious, I decided to assess the situation myself. When we entered the dining room during lunchtime, we found her sitting in her wheelchair, positioned with her hips near the front edge of the seat. Her legs were off the footrest, angling to the side, and her head was resting atop the back upholstery. In this posture, the dining table seemed miles away, exacerbated by the tray placed before her. The beige tray hosted a white plate with a bowl on top, two glasses, and silverware wrapped in a white napkin tucked under the plate.

It became evident that her feeding difficulties weren't solely due to her dementia. Her seating setup was incredibly impractical. The environment was visually overwhelming, and her position made it impossible for her to access the table comfortably. It was no wonder she had stopped feeding herself.

This case illustrates how the combination of proper seating, positioning, and environmental cues is pivotal for residents with dementia. Adjusting her position, ensuring a clear line of sight to her food, and simplifying the visual elements could significantly impact her ability to feed herself.

  • First Step – address w/c positioning
    • New cushion
    • Better leg rests
    • Ensure the ability to maintain an upright position
  • Next Step – address meal set up
    • Reduce visual “clutter”
    • Simplify the task
  • Final Step – address positioning and meal set up during other meals

In addressing this case, our primary concern was wheelchair positioning. We recognized that unless she was properly positioned, her ability to function, especially in feeding herself, would be severely hindered. To tackle this, we initiated several changes. First, we swapped her cushion with one that had a saddle seat design, aiding in maintaining pelvic alignment. We also replaced her leg rests with ones featuring calf pads to prevent her legs from slipping off, thereby promoting an upright posture.

However, achieving the correct position isn't enough. Maintaining it is equally essential. To address this, we moved on to adjust her meal setup, a crucial aspect of her overall positioning. While not directly related to wheelchair setup, this component significantly impacts her ability to self-feed. The initial setup was visually overwhelming, with multiple white items on a beige tray, leading to confusion. To simplify the task, we removed unnecessary clutter and presented her with just a bowl and one utensil, reducing the cognitive load.

This intervention had a transformative effect. She fed herself successfully, and when she stopped eating, it wasn't due to confusion but rather because she felt full. The relief and satisfaction she displayed were palpable, underscoring the importance of enabling her to perform this basic task.

However, our assessment wasn't complete at that point. Recognizing that all individuals, dementia or not, have good and bad days, we needed to gauge her performance across different days and meals. We needed to understand her positioning during breakfast, lunch, and dinner, acknowledging that different times of day can affect cognitive and physical functioning. Additionally, considering sundowning effects during dinner, we had to assess how her positioning and abilities might change during that period.

Sample Goals

  • Patient will achieve upright positioning in wheelchair using saddle-seat cushion and elevating leg rests with mod A from caregivers.
  • Patient will maintain upright position in wheelchair for 30 minutes without s/s of fatigue in order to eat her meals while sitting up.
  • Patient will achieve and maintain proper positioning of hemiparetic RUE on w/c elevating arm support with max A from caregivers in order to reduce contracture risk and edema in R hand.

Here are the sample goals. During our previous discussion regarding the case study, we touched upon the attainment of an upright seated position – I will refer to this as our first goal. However, a crucial question arises: Can the patient sustain this posture? This inquiry leads us to our second goal. Therefore, we are addressing two distinct objectives. It is vital to underscore that all these goals are firmly rooted in patient-centered care. Nevertheless, I wish to emphasize an important inclusion within these goals – the engagement of caregivers.

It is evident that this isn't solely about my role as an occupational therapist and the impact I can have on the patient. It revolves around establishing an unbroken continuum of care that endures even after my direct involvement ceases. If the patient can only execute the task with my immediate assistance, my mission remains unaccomplished. I must ensure the transfer of knowledge and techniques to others who can perpetuate progress and well-being. This highlights the pivotal role of caregiver training, a point Mira also stressed.

How many of us, during our time in occupational therapy school, instantly grasped a new technique or concept, feeling confident enough to apply it the very next day? I will be the first to admit that not many of us did. Acquiring new skills demands repetition, practice, and refinement – a principle that applies not only to therapists but also to caregivers. It is imperative to acknowledge that if it takes time for us to master a technique, the same principle extends to caregivers, whether they are CNAs, restorative staff, or family members. Consequently, our educational efforts must be persistent and supportive.

Similar to the patient's journey, let's consider how caregivers perform across multiple instances and various settings. Just as we meticulously observed multiple meals over several days to assess the patient's progress, we should similarly evaluate caregivers' abilities across different scenarios. This multifaceted approach ensures that the techniques and strategies remain effective over time.

Now, briefly revisiting the topic of CPT code billing, as Mira aptly mentioned, it is worth elucidating the alignment between treatment objectives and the appropriate CPT codes. The selection of these codes is not merely a matter of compliance but a reflection of the intended treatment outcomes. Proper code alignment accurately conveys the purpose of the intervention and ensures that the services provided are accurately accounted for.

To illustrate this correlation further, let's use the example of wheelchair management. The choice of CPT code depends on the underlying intent of our actions. For instance, if our aim is to improve arm strength through wheelchair propulsion, we are essentially engaging in functional therapeutic exercise – this is where code 97110 comes into play. Conversely, if our focus is on facilitating wheelchair maneuvering in confined spaces such as bathrooms or dining areas, we are delving into activities of daily living (ADLs), best represented by code 97535.

In situations where our patients contend with conditions like Parkinson's or have a history of cerebral vascular accidents (CVAs), and our goal is to enhance bilateral arm movement and coordination, code 97112, denoting neuromuscular reeducation, aligns seamlessly with our objectives. In essence, it all boils down to examining the underlying motives behind our interventions and ensuring that our coding accurately reflects these intentions.

Urinary Incontinence

  • Although aging affects the urinary tract and increases the potential for urinary incontinence, urinary incontinence itself is not a normal part of aging.” (RAI, Ch. 4, pg. 4-24)
  • “An individualized, resident-centered toileting program may decrease or prevent urinary incontinence, minimizing or avoiding the negative consequences of incontinence.” (RAI, Ch. 3, pg. H-3)
  • CMS Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual Version 1.17.1

Urinary incontinence often falls within the purview of occupational therapists. On occasion, I've been humorously accused of conducting all my treatments in the bathroom, but this matter deserves our serious attention. It's important to emphasize this point, and I'd like to start with a quote from the RAI Manual, which stands for the Resident Assessment Instrument User's Manual. This manual is what our MDS nurses use to complete the MDS assessments. The quote reads as follows: "Although aging affects the urinary tract and increases the potential for urinary incontinence, urinary incontinence itself is not a normal part of aging."

This quote underscores a critical message – we should not simply resign ourselves to the idea that urinary incontinence is an inevitable consequence of aging, using phrases like, "Oh, that's just Ms. Smith; she's always had incontinence. She's older, and it is what it is."

Another significant point made in the RAI Manual is that "An individualized, resident-centered toileting program may decrease or prevent urinary incontinence, minimizing or avoiding the negative consequences of incontinence."

I'd like to draw your attention to a couple of key elements. This ties back to what Mira previously discussed about the distinction between perfect and best. Ideally, we aim for the prevention of urinary incontinence and the avoidance of its negative consequences – that would be perfect.

However, we must acknowledge that achieving perfection is not always feasible. CMS recognizes this, which is why they specifically mention decreasing and minimizing urinary incontinence, along with mitigating the associated risks. In other words, our goal isn't always to return individuals to perfect continence; it's about improving their quality of life by reducing the impact of incontinence and its potential complications.

Risks Associated With Incontinence

  • Skin breakdown
  • Infections
  • UTIs
  • Falls/injuries related to rushing to the bathroom
  • Social isolation/embarrassment
  • Sleep disruption
  • Interference with the ability to participate in activities
  • Increased burden of care

Addressing urinary incontinence isn't just about improving one's quality of life; it's about mitigating a spectrum of associated risks. These risks encompass skin breakdown, infections, including urinary tract infections, and falls or injuries resulting from hurried bathroom visits. We've all encountered patients who've taken a tumble while trying to reach the restroom during an incontinent episode.

Moreover, incontinence can lead to social isolation and embarrassment. Many residents are acutely aware of their incontinence issues, opting to forgo communal dining and activities due to feelings of shame. This withdrawal has a direct impact on their emotional well-being and social engagement.

Sleep disruption is another significant consequence. Frequent nighttime bathroom visits disrupt sleep patterns, undermining overall health and well-being.

In addition, incontinence interferes with an individual's ability to participate fully in activities. They may attend but have to leave multiple times, detracting from their overall enjoyment and engagement.

These multifaceted risks not only affect the individuals themselves but also increase the overall burden of care. Incontinent individuals require heightened levels of assistance, often depending on caregivers for bathroom trips and changes. This places additional strain on healthcare resources and can impede the individual's sense of independence.

Steps Required for Continence

  • Sense the need to urinate
  • Find a bathroom or bedside commode
  • Physically get to the bathroom/bedside commode
  • Manage clothing while maintaining control of the bladder
  • Relieve themselves when it is appropriate
  • Deficits can occur at any step (or multiple steps) along this process!

When evaluating continence, it's imperative to consider all the elements that contribute to an individual's ability to maintain control. This comprehensive assessment starts with the basics: Can they perceive the need to urinate? Do they possess an awareness of when they need to use the restroom?

Furthermore, the amount of warning they receive is crucial. Are they granted sufficient time to locate a bathroom or a bedside commode, a suitable and accessible place for relief? Equally important is their physical capability to reach these facilities independently. Can they navigate to the bathroom or commode unassisted?

The next critical aspect involves their capacity to manage their clothing while simultaneously maintaining control over their bladder. This can become increasingly challenging as one ages. Additionally, can they effectively relieve themselves when it is appropriate? This entails the ability to hold it when necessary and relax when it's time to empty their bladder.

It's essential to recognize that deficits can manifest at any point within this process, and in some cases, multiple deficits may be present simultaneously. Our role as therapists is to assess and pinpoint these deficits accurately, tailoring our treatment strategies accordingly. While Kegel exercises are often a go-to option when addressing incontinence, a thorough assessment allows us to develop a more comprehensive and effective treatment plan that addresses the specific needs and deficits of each individual.

Treatment for Incontinence

  • Barrier reduction/elimination (i.e., mobility, assistive devices, transfer training, balance reeducation, etc.)
  • Pelvic floor muscle exercises (Kegel exercises)
  • Faciliatory pelvic muscle exercises
    • Abdominal muscles
    • Abductor/obturator internus
    • Hip adductor
    • Gluteal muscles
    • Transverse abdominis

Mira: When examining the entire sequence of steps involved in achieving continence, it becomes apparent that a range of interventions can be applied. An initial consideration is barrier reduction or elimination – identifying and addressing any obstacles that hinder a person's ability to reach the bathroom. This might encompass mobility issues, difficulties with assistive devices, transfer challenges, or problems related to balance and clothing management. Each of these aspects requires a tailored approach.

While Kegel exercises are commonly associated with addressing incontinence, it's essential to recognize that not everyone can perform them effectively due to cognitive or physical limitations. However, there are alternative exercises targeting various muscle groups that can contribute to improved continence. These include exercises for abdominal muscles, abductors and obturator internus, hip abductors, gluteal muscles, and the transverse abdominus. These exercises offer a broader range of options to work with patients, even if they cannot perform Kegels.

Transitioning from general to specific goals is key. Specific muscle groups can become the focus of treatment goals, allowing therapists to tailor interventions more precisely. Whether it's strengthening targeted muscles or addressing postural issues, setting specific goals enhances the effectiveness of treatment plans.

Moreover, it's important to approach these interventions with a mindset of improvement rather than aiming to fix or correct everything. This mentality opens up opportunities for more comprehensive and effective care, acknowledging that progress is achievable even if complete resolution may not be possible in every case.

Shoulder Rehabilitation

  • From Gross/General to Specific
    • Main DX
      • Osteoarthritis
      • Muscle Sprains
      • Rotator Cuff Tears
      • Frozen Shoulder
      • CVA Effects

Shoulder rehabilitation is an area where occupational therapists can truly excel. We'll transition from a broad overview to more specific considerations. There are numerous shoulder diagnoses that we encounter, and while I'll touch on three or four of the most common ones, it's important to recognize that many more exist.

Shoulder Rehabilitation: Osteoarthritis   

  • Occurs when the cartilage lining of the GH or AV  joint is worm or torn away
  • Humerus rubs against the joints
  • Symptoms:
    • Shoulder pain felt deep and posteriorly
    • Pain felt in the middle of range and decreases at beginning and ending of range *
    • “Catching” and “Crunching”
    • Atrophy, Swelling and Stiffness

In osteoarthritis, the cartilage lining the glenohumeral (GH) or acromioclavicular (AC) joint deteriorates, resulting in the humerus rubbing directly against the joint. This friction is what causes pain and discomfort.

Symptoms of osteoarthritis in the shoulder include pain that is felt deeper within the joint and toward the posterior aspect. This pain is typically most pronounced in the middle range of motion and tends to decrease at the beginning and end of the range. This corresponds to the mechanics of the shoulder, where there is still some space between the humeral head and the joint at the beginning and end of the range. However, in the middle range, when the humeral head is not properly accommodated within the joint space, the patient experiences the most pain. This discomfort is often described as a sensation of catching or crunching.

Physical signs associated with osteoarthritis include muscle atrophy, swelling, and stiffness in the affected shoulder. It's crucial for occupational therapists to recognize these symptoms to accurately diagnose and develop tailored treatment plans for individuals with osteoarthritis of the shoulder.

  • Specific Treatments:
    • Strengthen Rotator Cuff Muscles
    • Strengthen Muscles of the Upper Back
    • Strengthen Scapular Muscles
    • ROM activities
    • Joint Mobilization
    • Pendulum, shoulder elevation, External Rotation and Postural Strengthening
    • TENS for pain

Here is a more nuanced approach to shoulder rehabilitation, one that moves beyond generic exercises and addresses specific muscle groups and movements. In the quest for genuine shoulder rehab, we'll delve into the following tailored treatments.

First and foremost, we target the rotator cuff muscles - the supraspinatus, subscapularis, teres minor, and infraspinatus. Our aim is to strengthen these critical players in shoulder function. We emphasize both internal and external rotation exercises. To enhance muscle isolation during these movements, we often employ a helpful trick: placing a towel roll strategically under the shoulder. This technique encourages patients to focus on precise muscle engagement without straying into unnecessary shoulder abduction or elbow extension.

Next up are scaption exercises. Scaption involves lifting the arm at approximately 30 degrees in the frontal plane. This particular angle aligns the scapular muscles and effectively reduces the potential for impingement. It's a valuable addition to our arsenal of specific shoulder rehab techniques.

But we don't stop at the rotator cuff alone. Our approach extends to include the upper back and scapular muscles. We target muscles such as the latissimus dorsi, levator scapulae, and rhomboids. By broadening our focus to encompass these muscle groups, we create a more comprehensive and effective treatment plan.

Furthermore, our approach incorporates both range of motion exercises and joint mobilization. While these terms are often used interchangeably, they hold distinct meaning in the context of specific shoulder rehabilitation. Joint mobilization, in particular, involves careful consideration of the pressure and speed at which we manipulate the joint. It's a technique that allows us to mimic the natural glide between the joint's bones. This can be graded on a scale from one to five, with higher grades involving oscillations and faster thrusts. It's a nuanced approach that sets specific shoulder rehab apart from routine range of motion exercises.

To round off our comprehensive treatment plan, we incorporate pendulum exercises, shoulder elevation routines, external rotation exercises, and postural strengthening exercises. Moreover, we address pain management using TENS (Transcutaneous Electrical Nerve Stimulation) settings, which can be a valuable tool in the rehabilitation process.

In summary, specific shoulder rehabilitation goes beyond the standard exercises often used in generic treatment plans. By targeting specific muscles and movements, incorporating joint mobilization techniques, and addressing pain with precision, we create tailored rehab strategies that offer patients a more focused and effective path to recovery.

Shoulder Rehabilitation: Frozen Shoulder

  • Shoulder Adhesive Capsulitis
  • Shoulder Capsule thickens and tightens around shoulder joint
  • Three Phases
    • Freezing
    • Frozen
    • Thawing

It's essential to recognize that specific shoulder rehabilitation plans can vary significantly based on the underlying diagnosis. Osteoarthritis and frozen shoulder, also known as shoulder adhesive capsulitis, present distinct challenges and require tailored approaches.

Frozen shoulder occurs when the capsule surrounding the shoulder joint thickens and tightens. It's a different ballgame compared to osteoarthritis, where there's more of a rubbing sensation. In the case of a frozen shoulder, it's almost like the joint is being constricted or smothered, lacking the freedom to move smoothly throughout the complete range of motion.

What further complicates the scenario is that the frozen shoulder progresses through three distinct phases: freezing, frozen, and thawing. Each phase demands a different approach and intervention strategy. So, as we navigate these phases, we need to adapt our treatment plan accordingly to provide the most effective care for patients dealing with this challenging condition.

  • Freezing Phase:
  • Duration – 2 to 9 months
  • Gradual onset of pain
  • Intense pain at night
  • Prescribe gentle ROM shoulder, PAIN-FREE RANGE
  • Alternating heat and ice

During the freezing phase of a frozen shoulder, which typically occurs between two to nine months after onset, patients experience a gradual onset of pain. One key distinguishing characteristic that patients often describe is that the pain tends to intensify at night and decrease during the day. This is because the shoulder joint hasn't yet completely lost its range of motion, and movement throughout the day helps alleviate some of the discomfort. However, immobility exacerbates the pain.

In this phase, our treatment approach focuses on gentle range of motion exercises within the pain-free range. It's crucial to empower the patient to communicate their pain-free range, as we aim to avoid increasing inflammation within the joint capsule. Unlike the typical instruction to hold a position for 15 seconds, during the freezing phase, we advocate for shorter durations of holding, around five to seven seconds, but with more repetitions.

Additionally, we pay attention to the neck and scapular muscles. Manual tension-releasing exercises in these areas become integral during this phase. These manual techniques help alleviate tension, which, if left unaddressed, can lead to associated and referred pain. Thus, addressing tension is a crucial component of the treatment plan during the freezing phase of a frozen shoulder.

  • Frozen Shoulder: Alternating Heat Vs. Ice Debate
  • Cryotherapy:
  1. Vasoconstriction
  2. Decrease inflammation
  3. Decrease pain signals
  • Heat
  1. Vasodilator
  2. Increase circulation, increase nutrient-rich blood flow, increase healing
  3. Decrease pain

The use of alternating heat and ice during frozen shoulder treatment is a technique that's subject to some debate. However, research suggests that when applied intentionally, purposefully monitored, and with consideration for the patient's response, it can be a valuable and safe approach within our modalities toolkit.

Both heat and ice offer distinct benefits that we are well aware of. Cold therapy primarily serves to decrease inflammation and reduce pain signals sent by the body and brain. This makes it a valuable tool, especially during the stages of a frozen shoulder when inflammation and pain are prominent. On the other hand, heat promotes increased circulation, delivering nutrient-rich blood to the affected area, facilitating the healing process, and further reducing pain.

The choice between heat and ice may not be a one-size-fits-all decision. Depending on how an individual responds to each modality, you may intentionally opt for one over the other in specific treatment sessions. This approach is distinct from a standardized practice where one modality is consistently chosen. The key is to assess and adapt based on your patient's unique needs and responses, and in some cases, you might even alternate between heat and ice to optimize the therapeutic benefits.

  • Acute Injuries – ICE for the first approx. 48 hours
  • Specific Contrast Bath
    • 1:3 ratio for cold:heat
    • Start and end with Ice – focus on decreasing inflammation
  • Watch Outs:
    • Skin integrity
    • Stretch during the hot stages, not cold
    • Localize as much as possible

As a general guideline, when dealing with acute injuries, it's common practice to apply ice for the initial 48 hours. If you're employing a contrast bath, the recommended ratio is one part cold to three parts heat. What sets this approach apart is the crucial consideration of starting and ending with ice. The intention here is to ensure that the beginning and conclusion of the treatment are geared toward reducing inflammation. This diverges from the conventional practice of providing heat at the start of a session and ice at the end, underscoring the importance of tailored, condition-specific choices.

However, when working with both heat and ice, it's essential to monitor skin integrity and the level of stretch applied. Stretching should occur during the warm phases, preferably while or immediately after the client comes off the heat. Furthermore, to optimize the effectiveness of heat and ice therapy, localization is key. Using appropriately sized pads or modalities to target the specific area is of utmost importance in achieving the desired therapeutic outcomes and ensuring patient comfort and safety.

  • Frozen Phase:
    • Duration – 4 - 12 months
    • Decrease pain but decrease ROM
    • Continue gentle shoulder ROM, but add chest and back
    • Rotation before elevation
    • Add strengthening, focusing on isometrics
    • Short hold times
    • Alternating heat and ice
    • Alternating NMES, Channel 1 on Cervical Region and Channel 2 on Trapezius, Channel 3 to the Deltoid
    • TENS for pain

The frozen phase typically occurs around four to 12 months after the initial incident. During this stage, you'll likely observe decreased pain in your client, but they haven't yet experienced a significant reduction in their range of motion. It's a crucial juncture where the joint is frozen but not entirely immobile, as it will be in the later stages if the cycle remains uninterrupted.

In the frozen phase, your approach should encompass gentle shoulder range of motion exercises. Here, you'll start to notice an increase in pain associated with range of motion, but the joint isn't completely immobile yet. Passive or active-assisted range of motion exercises are appropriate in this context. Additionally, consider incorporating chest and back exercises within the range of motion routines.

One key principle to follow during this stage is "rotation before elevation." This means that you prioritize rotational movements over elevational ones. The rationale behind this is that rotation can be performed with less associated pain, allowing you to move the joint within the capsule, thereby breaking up some of the adhesions and maintaining some degree of joint mobility. Rotation exercises become valuable tools in this phase.

Another significant addition in the frozen phase is the introduction of strengthening exercises. While we didn't focus on strengthening during the initial stage, it becomes relevant here. However, the emphasis should be on isometric exercises, and you should still adhere to short hold times. Alternating heat and ice therapy continues to play a role in managing pain.

Moreover, in this phase, you should consider incorporating neuromuscular reeducation exercises, particularly targeting the cervical region, trapezius muscles, and deltoid. These specific interventions reflect the intricacies of addressing frozen shoulder, highlighting how the treatment approach must adapt to the patient's stage within the condition.

  • Thawing Phase:
    • Duration: 5-26 months
    • Decrease pain and increase ROM
    • Increase limits of shoulder ROM exercises
    • Continue Isometrics but also add resistance of chest, back, and rotator cuff
    • Increase hold times
    • Alternating heat and ice

In the thawing phase, which typically occurs between five to 26 months post-onset, you'll observe decreased pain and increased range of motion. This phase represents the culmination of effective treatment, as the joint is starting to regain mobility, and discomfort is on the decline.

During this stage, it's appropriate to expand the limits of the shoulder range of motion further. The progress made in the previous phases has set the stage for this advancement. Continue with isometric exercises, as they have proven effective, but now, due to the decreased pain, you can introduce resistive exercises targeting the chest, back, and rotator cuff muscles. With the reduction in pain, your patient can tolerate longer hold times, perhaps in the realm of a 15-second duration. However, it's crucial to adapt these hold times according to the individual's tolerance, as there's no rigid rule that universally applies.

You can also choose to maintain the practice of alternating between heat and ice therapy based on the patient's comfort and response. This phase represents a significant achievement in the rehabilitation journey, reflecting how a tailored approach can yield remarkable results in restoring both range of motion and comfort to the patient.

Shoulder Rehabilitation: CVA

  • Hemiplegia or Hemiparalysis
  • Subluxation – GH joint slips out of Glenoid Fossa
    • Focus on Supraspinatus and Deltoid
    • Use slings sparingly
    • Use other positioning devices for support
    • Longitudinal strapping method
    • Circumferential strapping method
    • TENS and NMES

A subluxation can occur following a CVA (Cerebrovascular Accident). Subluxation refers to the condition where the shoulder joint, known as the GH (Glenohumeral) joint, slips out of the glenoid fossa. This condition is depicted in Figures 2 and 3.

Figure 2

Figure 2. Example of a subluxation on the outside of a person's arm.

Figure 3

Figure 3. Example of a subluxation shown on x-ray.

Our focus here will be on specific details regarding the supraspinatus and deltoid muscles.

In terms of strengthening and exercises, our primary target will be these specific muscles. We should use slings sparingly. Slings can be employed when patients are upright and walking or in situations where gravity plays a role. However, it's not a one-size-fits-all solution for every subluxation case. We want to avoid encouraging the posture characterized by inward rotation of the shoulder and flexion of the elbow whenever possible.

Instead of slings, we can utilize positioning devices for support. Another technique to consider is a longitudinal strapping method. Here's a brief explanation of this method:

- Begin with a piece of tape.
- Cut the tape up the middle, leaving about one to two inches uncut at the top.
- This will yield a strip with two flaps, which can be used for strapping.
- Place the bottom of the tape at the tip of the deltoid tuberosity.
- The two flaps should wrap around the shoulder, with one going around the anterior deltoid area and the other around the posterior side.

Here are some important tips for this strapping method:

- Measure the tape length from the AC joint to the tip of the deltoid tuberosity.
- When applying the front strap, ensure the client is in external rotation.
- For the back strap, bring the client into a little internal rotation.
- Tension should be applied primarily to the strap that provides support, which runs from the pectoral area around to the scapula.
- Apply approximately 80% tension as you come around the back and then loosen to about 60% when adhering the tape.

This strapping technique aims to provide support and can alleviate pain associated with subluxation. It's essential to follow proper procedures and maintain the right tension to achieve the desired effect.

Additionally, techniques like TENS (Transcutaneous Electrical Nerve Stimulation) and neuromuscular re-education can complement the taping method to address pain and support muscle function effectively.

Lastly, it's worth noting that some of the taping methods mentioned here can also be applied to address pain in the rotator cuff, making these techniques versatile tools in rehabilitation.

Fall Management & Mitigation

  • Root Cause Analysis
    • Where, when, why, how?
    • Witnessed or unwitnessed?
    • Correlation of time of fall with medication administration
    • Internal and eternal risk factors
  • Address identified issues
  • Look at patient/client, environment, support provided, and tasks/activities

Emily: Thanks, Mira. The primary goal is to manage and mitigate the risks associated with falls, as achieving complete prevention may not always be realistic. To address falls effectively, we need to start with a thorough root-cause analysis. When a patient experiences a fall, we must gather essential information: where the fall occurred, the time of day, the reasons behind it, and whether it was witnessed or not. Additionally, we should consider the timing of the fall concerning medication administration, as certain medications can increase fall risk. Both internal factors (such as safety awareness, leg strength, and balance) and external factors (like wet floors or tripping hazards) need to be assessed.

Once we have a comprehensive understanding of the fall's circumstances, we can proceed to address the identified issues. This approach should prioritize the patient's needs and preferences, taking into account their environment, available support (both from people and assistive devices), and the specific tasks or activities they are trying to perform. It's important to recognize that there may be situations where we can't change the patient themselves, in which case our focus should shift towards modifying their environment or adapting the tasks they engage in.

Falls and Dementia

  • Increased risk of falls
    • Impaired judgment
    • Gait deficits
    • Impaired visual and spatial perception
    • Decreased hazard recognition
  • May have difficulty reporting what happened if the fall is unwitnessed

What can we do in cases of dementia to manage and mitigate the risk of falls? Even when dealing with patients who have advanced dementia or impulsive behavior due to psychiatric conditions, there are still aspects we can address. We may not be able to change their underlying conditions or cognitive abilities, but we can modify other factors to enhance their safety and function. For example, in the case of the patient with wheelchair seating and positioning issues, the focus was on optimizing her posture and the task itself. We didn't attempt to change her cognitive or physical limitations directly.

Falls are a significant concern, especially for patients with dementia, and many residents in skilled nursing facilities are at an increased risk. Factors contributing to this risk may include impaired judgment, reduced awareness of physical limitations, impaired visual and spatial perception, and diminished hazard recognition. While it may seem challenging to improve cognitive deficits associated with dementia, we can still take measures to reduce fall risk. We should look beyond changing the patient's cognitive abilities and consider environmental modifications, task adaptation, and the use of assistive devices to enhance safety and function.

  • Look at modifiable risk factors
    • Cognition and safety awareness may not be modifiable
    • Strength and balance can be modified
    • Environment can be modified
    • Physical supports can be modified
    • Social/caregiver support can be modified
    • Tasks/activities can be modified

When dealing with residents who have dementia and are at risk of falls, it's crucial to focus on what we can modify to reduce the risk. While we may not be able to change their cognitive deficits or safety awareness directly, there are several factors we can address.

First, we can work on their strength and balance. Muscles don't get dementia, which means we can still improve their physical condition. Creative activities like dancing or modified exercises can help enhance their strength and balance, reducing the risk of falls.

Second, we should consider modifying the environment. Rearranging the living space to ensure stable support can make a significant difference. This may involve rearranging furniture or placing mobility aids within easy reach to encourage residents to use them.

Third, we need to ensure that physical supports are readily available and properly positioned. Wheelchairs, walkers, or other mobility aids should be accessible and correctly placed to encourage their use when needed.

Fourth, social and caregiver support play a vital role. Training staff to leave equipment accessible and properly position it is crucial. Staff should also be educated on providing appropriate assistance to residents to help them avoid falls.

Lastly, we can adapt tasks and activities to minimize fall risks. This might involve encouraging residents to use a chair instead of standing or making other modifications based on their capabilities.

The ultimate goal is not necessarily to eliminate all falls, which may be unrealistic, but to manage and mitigate the risk factors that can lead to them, thereby improving residents' safety and quality of life.

Case Study

Let's dive into a case study to illustrate this further. 

  • Residents placed near the nurse’s station
  • Monitoring due to frequent attempts to stand or get out of their wheelchair
  • Nurses and CNAs repeatedly telling them to “sit down”
  • Vicious cycle increases frustration for both the nurse/CNA and the resident
  • “Behaviors” will often escalate

If you've worked in a nursing home, you're probably well-acquainted with the scenario of residents positioned near the nurses' station due to their persistent attempts to stand up and move independently. Picture a cluster of residents seated close to the nurses' station, and each one determined to rise from their chair. The nurses and CNAs continuously pass by, repeatedly instructing them to sit down, a constant chorus of "Sit down, Mr. Jones. Sit down, Ms. Smith." This situation can humorously be likened to a game of nursing whack-a-mole, but it ultimately creates a frustrating cycle for both the care staff and the residents. Consequently, these residents may persist in their attempts to stand, growing increasingly agitated, which can manifest as what we often label as challenging behaviors. It's important to recognize that these behaviors often serve as a means of communication when verbal communication is limited or ineffective.

  • Root cause analysis – why are they trying to get up?
    • Discomfort?
    • Unmet need? (i.e., hot/cold, hungry/thirsty, etc.)
    • Other needs/wants? (i.e., bored, overstimulated)
  • Address the root cause
    • Help the resident stand and weight shift for a few seconds for pressure relief
    • Take a short walk with the resident
    • Allow them to rest in bed for a brief time if needed
    • Involve the resident in an activity

What's the next step? We go back to conducting a thorough root cause analysis. Why are these residents persistently attempting to stand up from their chairs? Is it due to discomfort, which might necessitate a seating and positioning program, as we discussed earlier? Could they have unmet needs like feeling too hot, too cold, hungry, thirsty, or needing a bathroom break? Are they trying to fulfill these unmet needs through their actions? Alternatively, are there other needs or desires at play? Perhaps they're bored and seeking something to do, or maybe they're overstimulated by their proximity to the nurse's station, especially during shift changes.

As occupational therapists, our role is to perform this root cause analysis and work towards identifying and addressing these needs. It may require some trial and error, but that's part of our process of understanding and meeting the residents' needs.

Consider the analogy of a family car trip. When you're on a long journey, how often do you make stops? You likely need to stretch your legs and relieve the discomfort of sitting for extended periods. Similarly, residents can't endure prolonged sitting either. You can assist them in standing and shifting their weight for pressure relief, take short walks with them, or allow them a brief rest in bed if necessary. If they can't manage sitting from lunch until dinner, they might benefit from an afternoon nap or engaging in activities to stave off boredom. Moreover, it's crucial to train the staff to implement these strategies effectively. Your role extends beyond personal interactions; you must ensure that the facility staff can carry out these measures to address the root causes.

Sample Goals

  • Patient will reduce fall risk as evidenced by increase in Functional Reach/Modified Functional Reach score from 16cm to 19cm.
  • Patient will participate in standing weight-shift activity with min A from caregivers to reduce attempts to stand unassisted.
  • Patient will tolerate upright sitting in w/c for 90 minutes without attempts to stand unassisted to reduce fall risk.

Let's explore a selection of sample goals aimed at addressing fall risk and enhancing the efficacy of interventions for nursing home residents. These goals are crafted with a focus on specificity, measurability, and alignment with the unique needs of each resident, ensuring personalized and effective care.

One primary goal centers on the reduction of fall risk. To evaluate progress, it's advisable to employ standardized assessments specifically designed for assessing fall risk. The Functional Reach or Modified Functional Reach test, as illustrated, is one such tool that can be utilized. However, therapists retain the flexibility to select the assessment that best aligns with the resident's individual situation. The use of standardized assessments provides an objective metric for monitoring the resident's advancement in mitigating fall risk throughout their care journey.

Another pivotal goal revolves around encouraging residents to actively engage in a standing weight shift activity. To ensure this goal encompasses various facets, it's imperative to actively involve caregivers. The ultimate objective is to attain a level of assistance that is minimal (min assist) from caregivers during the standing weight shift activity. This goal underscores the importance of collaboration between therapists and caregivers to empower residents effectively. It emphasizes the need to equip caregivers with the knowledge and skills necessary to provide residents with the support they require.

For residents undergoing a seating and positioning program, it is essential to establish a goal related to their capacity to endure upright sitting. This goal seeks to determine the duration for which a resident can comfortably maintain an upright seated posture before experiencing discomfort or fatigue. This threshold is crucial for devising interventions effectively. It informs therapists when it becomes necessary to implement strategies like a standing weight shift activity or transition the resident to an alternative position, such as reclining or participating in an alternative activity. This goal underscores the importance of precise monitoring and responsiveness to the resident's comfort and well-being during seating and positioning interventions.

These sample goals provide templates that therapists can adapt and tailor to align with the unique needs and objectives of individual residents. Furthermore, electronic medical records (EMRs) offer a valuable tool for documenting and tracking these goals. EMRs often offer the flexibility to create customized goals tailored to each resident's individual care plan, ensuring that care remains centered on the resident and focused on achieving positive outcomes.

Mira: Thank you for clarifying the taping protocol for rotator cuff pain versus subluxation. To recap and provide a clear distinction, when addressing rotator cuff pain, the taping protocol involves starting at the pectoral region (pecs) and proceeding around the AC joint, with the strap going up towards the scapula. This approach is focused on providing support and relief for rotator cuff-related discomfort.

Conversely, when dealing with subluxation, a similar method is employed, commencing from the same point at the pectoral region. However, the key difference lies in the direction of pressure application. For subluxation, the strap is positioned along the anterior deltoid and directed upward and posteriorly. This technique aims to assist in lifting the humerus back into place within the glenoid fossa, addressing the subluxation issue.

These nuanced variations in taping protocols underscore the importance of precise and targeted interventions based on the specific clinical presentation of each patient, whether they are experiencing rotator cuff pain or subluxation. Your clarification helps ensure that therapists can apply the appropriate techniques effectively, promoting optimal patient outcomes.

Keys to Long-Term Success With LTC Residents

  • 25% of LTC residents on therapy caseload
  • Expand life beyond the 4 walls
  • Increasing goals to include IADL activities
    • Gardening Groups
    • Create Walking Groups
  • Wellness Programs
  • Use New Technology

Here are some fundamental principles for achieving long-term success in occupational therapy within skilled nursing facilities.

Firstly, it's essential to maintain a balance in caseloads. While there's no rigid rule, aiming for around 25% of residents receiving therapy services is a practical guideline. This approach acknowledges the diverse range of challenges that residents face in long-term care. Occupational therapists should remain open to assessing residents for potential therapy needs. Striking this balance not only enhances individual well-being but also contributes to the facility's revenue.

Another critical aspect is expanding life beyond the facility's walls. Encouraging residents to engage with the community can significantly enhance their overall quality of life. Occupational therapists can facilitate outings, community events, or other activities that promote social interaction and well-being, creating a more fulfilling life for residents.

Furthermore, occupational therapy goals should extend beyond basic Activities of Daily Living (ADLs). Therapists should consider incorporating Instrumental Activities of Daily Living (IADLs) into their interventions. These can include tasks like gardening and participating in walking groups. Additionally, it's important to explore wellness programs and embrace technology to enhance therapy outcomes. Innovative software solutions, such as Restore Skills, offer engaging exercises, data storage, progress tracking, and valuable insights for improving therapy results. Collaborating with administrators and Directors of Rehabilitation (DORs) to introduce such technology can significantly benefit residents and the facility.

In summary, these principles emphasize a holistic and forward-thinking approach to occupational therapy within skilled nursing facilities, ultimately benefiting both residents and the facility's overall success.

  • Get Them Up
  • Get Them Out
  • Get Them Active

And then we also need to get them up, get them out, and get them active. You can make a goal just by thinking of get 'em up up out of the bed, up in their chair, getting them out out of their room, out of the building. How can you look at whatever for this particular resident? Because for some resident, it might not be out the building, it might just be out of the bed for two hours. So looking at get them up, out, and active can help you not only help your residents but expand your treatment roster. And I'm going to have Emily help us out with these.

It's also essential to focus on getting residents up, out, and active as a core component of their care plan. Establishing goals that encourage residents to become more mobile and engaged can significantly improve their overall well-being.

A valuable approach is to create specific goals for each resident. This might involve setting objectives for getting them out of bed, ensuring they spend time in their chairs, encouraging outings from their rooms, or even venturing outside the building. The key is tailoring these objectives to the unique needs and capabilities of each resident.

  • Weekly LOC meetings (therapist with best LTC eye attends)
  • Effective Utilization of PCC and Matrix flags
  • Falls Program 
  • “Team Leads” within therapy department

Emily: Another crucial aspect of achieving long-term success in skilled nursing facilities is ensuring that therapists with a strong focus on long-term care participate in weekly level-of-care meetings. These meetings, often known as level of care or care plan meetings, provide a platform to stay informed about changes in residents' conditions. It doesn't necessarily have to be the director of rehab attending but rather the individual with a keen understanding of the nuances of long-term care.

Listening for keywords in these meetings, such as falls, changes in self-feeding abilities, increased pain complaints, or alterations in medications, is vital. Recognizing these cues allows the occupational therapist to step in and assess how they can help residents adapt to these changes effectively.

Effective utilization of flags in your facility's EMR system, like PointClickCare or Matrix, is essential. These flags draw information from nursing documentation and can serve as valuable indicators for when therapy services may be needed. By reviewing these flags, therapists can promptly address emerging issues and ensure residents receive the necessary care and support.

Implementing a fall program is a critical component of long-term care success. While preventing falls entirely may not always be feasible, focusing on fall management and mitigation can significantly enhance resident safety. Identifying modifiable risk factors and proactively addressing them is paramount to reducing the likelihood of falls.

Lastly, consider designating team leads within your therapy department. Each team lead can specialize in different areas, such as seating and positioning or fall prevention, leveraging their expertise to drive specialized programs forward. This approach encourages ownership, collaboration, and innovation within the therapy team, ultimately benefiting residents and the facility's overall success.

Keys to Long-Term Success With Part A and Private Insurance

  • Shorter but more Intense sessions
  • Utilize Rehab Tech
  • Determine “priority” discipline(s)
  • Maximize 25% of allotted group time

In the context of Part A and private insurance patients, several strategies can contribute to long-term success, even though the therapy duration is shorter and more intense:

Shorter but Intense Sessions: Recognize the need for shorter yet highly focused therapy sessions. Prioritize high-impact interventions to maximize progress during the limited therapy timeframe.

Leverage Rehab Tech Support: While rehab techs cannot bill for services, their assistance can be valuable. They can help set up treatment areas, arrange equipment, and ensure smooth therapy sessions. Make efficient use of their support to streamline therapy processes.

Identify Priority Discipline: Determine which discipline is most critical for addressing the patient's immediate needs. Concentrate your efforts on this priority discipline to optimize the patient's progress.

Utilize Group Time: Under Part A, there is an allowance for group and concurrent therapy. Make sure to maximize this opportunity, as it can be an effective way to address multiple patients simultaneously. Rehab techs can assist in setting up group sessions, enhancing efficiency in managing group therapy.

Incorporate interdisciplinary collaboration: Foster collaboration with other healthcare disciplines involved in the patient's care, such as nursing and social work. This teamwork can help address the patient's holistic needs and provide a more comprehensive approach to rehabilitation.

By implementing these strategies, therapists can provide effective care to Part A and private insurance patients, even within the constraints of shorter therapy periods, ultimately contributing to long-term success and improved patient outcomes.

Watch Outs

  • Usual Performance Score completed by all appropriate disciplines
  • Overutilization of 97110
  • Part B episode greater than 60 days
  • Medicaid will begin using GG codes
  • Covid Waivers expiring

Here are some important considerations to keep in mind as we navigate Section GG, which plays a crucial role in assessing patient performance across various disciplines within our healthcare facility.

Firstly, it's essential to emphasize that Section GG should be completed by all appropriate disciplines. While in many cases, nurses tend to defer to therapy professionals as these assessments often pertain to therapy-related activities, it's imperative that we broaden our perspective. We should not only focus on how a patient performs during therapy sessions but also consider their performance in everyday situations, such as interactions with Certified Nursing Assistants (CNAs) in the hallway.

A common issue to be cautious of is the overutilization of CPT code 97110, which corresponds to therapeutic exercise. While we briefly discussed this in relation to CPT code usage, it's worth highlighting that the same activity, like propelling a wheelchair, can fall under different codes based on its context. For instance, it could be coded as 97110 if it's part of a therapeutic exercise session, 97535 if it involves Activities of Daily Living (ADLs), or 97112 if it pertains to bilateral integration and coordination. Similarly, if a patient is new to using a wheelchair, the focus might be on wheelchair management, encompassing tasks like locking/unlocking brakes, adjusting armrests for transfers, and handling footrests. It's crucial to accurately code these activities to reflect the care provided.

For Medicare Part B, it's important to monitor episodes of care that extend beyond 60 days. While it's not to say that such episodes are always inappropriate, they do raise concerns for CMS. Therefore, it's vital that our documentation effectively justifies the necessity for patients to remain on caseload for an extended duration. This is a crucial step in maintaining compliance and avoiding red flags with CMS.

Additionally, be aware that Medicaid is transitioning from Section G to GG codes for ADL scoring, which impacts states that employ a case-mix system like Texas and several others. Keep yourself informed about how your specific state is adapting to these changes, as they may shift toward the Patient-Driven Payment Model (PDPM).

Lastly, stay attuned to COVID waivers. Some of these waivers have already expired, while others lapsed when the public health emergency concluded. Some have been granted extensions. An example is telehealth for therapy, which remains available but with an expiration date. To ensure we provide the best care while staying compliant with regulations, it's essential to stay vigilant and well-informed regarding these evolving policies and guidelines.


  • It’s Hard
  • It’s Possible
  • It’s Complex
  • It’s Strategy
  • You Got This!

Mira: First and foremost, we acknowledge that the challenges we face in our roles are far from easy or straightforward. Our intention in offering these suggestions is not to imply that success comes effortlessly. On the contrary, we recognize the complexity of our patients' conditions, and it's essential to approach them with the mindset that meaningful interventions are not only possible but crucial.

In skilled nursing facility rehab, there's often a perception that we are generalists, and to some extent, that may be accurate. However, it's important to understand that we possess a unique depth of knowledge. We work with patients who present with a wide array of complex needs, making us some of the most specialized and knowledgeable therapists in our field. This diversity of experiences equips us to handle the intricacies of each case effectively.

Furthermore, our approach is not one-size-fits-all. We don't apply the same methods, routines, or structures universally. Instead, we are deliberate in tailoring our strategies to the unique needs of each individual. This individualized approach is a cornerstone of our practice, allowing us to provide the most effective care possible.

Lastly, we want to offer a virtual cheer to all of you who, like us, work in the challenging and rewarding field of geriatric care. We understand the difficulties, but we also firmly believe in your abilities. Together, as dedicated therapists in this specialized realm, we can continue to make a meaningful difference in the lives of our patients. Keep up the incredible work you do!

Questions and Answers

Regarding taping, when is it usually removed?

Typically, tape is removed after about five to seven days. However, if it's a patient's first time being taped or if there are concerns about their skin integrity, it might be advisable to remove it sooner, perhaps after two to three days. The timing of removal should be based on individual patient needs and skin response.

Could you clarify the one-to-three ratio in contrast baths?

The one-to-three ratio, in contrast, baths pertains to the duration of time, not repetitions. For instance, if you perform the contrast bath for one minute in hot water followed by three minutes in cold water, the ratio refers to the one-minute hot water segment compared to the three-minute cold water segment.

Is training essential for using physical agent modalities (PAMs)?

While PAMs are typically within the scope of practice for therapists, it's highly recommended to seek additional training, especially on specific equipment provided by vendors. Each PAM device may operate differently, and additional training can enhance your proficiency and ensure safe and effective use. Some states may even require specific certificates and training beyond what is covered in your education.

Have you ever seen facilities implement routines like offering drinks, bathroom breaks, or standing up at set intervals?

Yes, such routines can be effective in addressing the needs of residents in a facility. When CNAs establish regular check-in intervals for residents, it can help fulfill their needs without causing disruptions or behaviors. This approach also allows residents to participate in activities away from the nurses' station and maintain a consistent routine.

Do you agree that implementing short naps after lunch can be beneficial for residents?

Yes, implementing short naps after lunch can indeed be beneficial for residents. While it may require some effort to get residents into bed and back up, the potential benefits, such as increased alertness and improved mood, can outweigh the initial effort. It can also be part of a collaborative effort with other healthcare professionals to meet individualized resident needs.

Can elevated leg rests help with knee joint pain, arthritis, and vascular pain or edema?

Yes, elevated leg rests can be helpful for addressing knee joint pain, arthritis, and vascular issues like edema. However, it's crucial to use leg rests as part of a comprehensive program that may include other interventions like compression sleeves. Leg elevation should not be the sole method for edema control; it should be integrated into a broader plan for managing these conditions effectively.


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Centers for Medicare & Medicaid Services Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.17.1. (October 2019). https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment Instruments/NursingHomeQualityInits/MDS30RAIManual 

Demurtas, J., Schoene, D., Torbahn, G., Marengoni, A., Grande, G., Zou, L., Petrovic, M., Maggi, S., Cesari, M., Lamb, S., Soysal, P., Kemmler, W., Sieber, C., Mueller, C., Shenkin, S. D., Schwingshackl, L., Smith, L., Veronese, N., & European Society of Geriatric Medicine Special Interest Group in Systematic Reviews and Meta-Analyses, Frailty, Sarcopenia, and Dementia (2020). Physical activity and exercise in mild cognitive impairment and dementia: An umbrella review of intervention and observational studies. Journal of the American Medical Directors Association21(10), 1415–1422.e6. https://doi.org/10.1016/j.jamda.2020.08.031

Djade, C. D., Porgo, T. V., Zomahoun, H. T. V., Perrault-Sullivan, G., & Dionne, C. E. (2020). Incidence of shoulder pain in 40 years old and over and associated factors: A systematic review. European journal of pain (London, England)24(1), 39–50. https://doi.org/10.1002/ejp.1482

Falah-Hassani, K., Reeves, J., Shiri, R., Hickling, D., & McLean, L. (2021). The pathophysiology of  stress urinary incontinence: a systematic review and meta-analysis. Int Urogynecol J., 32(3):501-552. doi: 10.1007/s00192-020-04622-9. 

Jensen, L. E., & Padilla, R. (2011). Effectiveness of interventions to prevent falls in  people with Alzheimer’s disease and related dementias. American Journal of  Occupational Therapy, 65, 532–540. doi: 10.5014/ajot.2011.002626 

Sondell, A., Rosendahl, E., Gustafson, Y., Lindelöf, N., & Littbrand, H. (2019). The applicability of a high-intensity functional exercise program among older people with dementia living in nursing homes. J Geriatr Phys Ther., 42(4):E16-E24. doi:  10.1519/JPT.0000000000000199. PMID: 29851748; PMCID: PMC6791515. 

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Tricco, A. C., Thomas, S. M., Veroniki, A. A., Hamid, J. S., Cogo, E., Strifler, L., Khan, P. A., Robson, R., Sibley, K. M., MacDonald, H., Riva, J. J., Thavorn, K., Wilson, C., Holroyd-Leduc, J., Kerr, G. D., Feldman, F., Majumdar, S. R., Jaglal, S. B., Hui, W., & Straus, S. E. (2017). Comparisons of interventions for preventing falls in older adults: A systematic review and meta-analysis. JAMA318(17), 1687–1699. https://doi.org/10.1001/jama.2017.15006


Rollins, M., & Briggs, E. (2023). Returning the skills to skilled nursing facility rehabilitation. OccupationalTherapy.com, Article 5623. Available at www.OccupationalTherapy.com

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mira rollins

Mira Rollins, OTR/L

Mira Rollins has been an occupational therapist for over 20 years. The majority of her career has been spent treating geriatrics in rehabilitation skilled nursing facilities. Her clinical experience also includes spinal cord injury and acute care hospital settings. Mira has also had the honor of leading successful rehab teams in her role as director of rehab and regional manager. She now uses her 20 years of experience as an adjunct professor for OTA programs and as the owner of Mira j. Rollins Engagement Programs, a training and consulting company.

emily briggs

Emily Briggs, OTR/L, RAC-CT

Emily Briggs has been an occupational therapist for over 20 years and has spent the majority of her career in the skilled nursing facility (SNF) setting, serving in roles from staff therapist to Director of Rehab to Director of Clinical Compliance for a multi-site chain.  Throughout her roles, Emily has supervised multiple OT and OTA students during fieldwork rotations.  In 2020, Emily obtained her Resident Assessment Coordinator certification (RAC-CT), and in 2022 she became a Certified Independent Trainer under Teepa Snow’s Positive Approach to Care (PAC).  Emily is passionate about functional treatment, enhancing the quality of life of people living with dementia, and training future generations of therapists.

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Returning The Skills To Skilled Nursing Facility Rehabilitation
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Successful outcomes and sustained health and wellness for patients depend on the compliance and performance of caregivers. This presentation identifies specific symptoms of caregiver burnout as well as interventions and goals to incorporate into the plan of care.

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