Speech Language Pathology’s Role in COVID Recovery

The novel coronavirus and resulting pandemic have altered our lives in many ways. The combination of  isolation, physical and social distancing, as well as an economic crisis have all impacted our personal and professional lives. Juggling the ever-changing responsibilities during a healthcare emergency may be overwhelming. The lack of social connections with family and friends as well as in-person visits with your patients can lead clinicians to feelings of loneliness and isolation. Now consider the impact that continued social distancing and isolation may have on the residents and patients within our long-term care facilities. In some instances, isolation of residents has been ongoing for the entirety of the pandemic, entering nearly 6 months!

Prior to this healthcare emergency, a 2019 University of Michigan study on healthy aging noted that 34% of adults aged 50-80 years reported feeling lonely. This current period of social isolation will only exacerbate the number of adults feeling disconnected and lonely and disproportionately affect the elderly population, especially those whose primary social contacts were within their long-term care facility. Furthermore, according to the National Academics of Sciences, Engineering, and Medicine, “Seniors who are experiencing social isolation or loneliness may face a higher risk for mortality, heart disease, and depression.”

As experts on communication, SLPs know the value and need for social interaction for the mental health and well-being of our patients. We are a major factor in the identification of patient needs and educating patients and caregivers on appropriate and personalized techniques to improve and maintain cognitive, speech-language, and executive functioning. We can start by educating on the importance of social interaction and modeling how to achieve this safely during the pandemic.

In the absence of cognitive stimulation and routine, patients may have trouble maintaining prior levels of cognition. We can encourage and educate on the use of daily orientation techniques and maintaining daily routines – targeting problem solving, reasoning, memory, and sequencing during morning and evening self-care routines. Engage with each patient on a personal level and encourage all caregivers to do the same. Provide insight to caregivers on personal preferences that may enhance engagement.

Socialization and purpose play a critical role in feelings of self-worth and success in everyday life. Encourage the use of personal electronic devices. Provide education on increasing socialization through communication and social media. Encourage residents to write letters to family or “neighbors” within the facility. Foster conversation between residents and caregivers during meals and invite family or friends to “dine” with residents via videoconferencing.

Incorporate training on personalized “home” exercise programs to give purpose and focus to each resident’s day. Develop exercises that capitalize on the routines the resident has already established, such as oral motor exercises and/or breathing exercises during a TV commercial break.

As we evolve as professionals during a pandemic, we must continue to protect and advocate for our most vulnerable residents. With the continuation of the healthcare emergency there is a fine line between protecting those that are medically fragile from this virus while continuing to encourage and promote socialization that is vital to their well-being. As visitor restrictions are lessened we continue to be the lifeline that can bring awareness to the effects of social isolation on our residents in long-term care, and by supporting the facility and promoting each caregivers’ strengths as well as educating in areas of opportunity we are creating a more understanding and supportive environment for our residents.  

https://www.asha.org/Practice/Connecting-Audiologists-and-Speech-Language-Pathologists-With-Mental-Health-Resources/

https://time.com/5833681/loneliness-covid-19/

https://www.nationalacademies.org/news/2020/02/health-care-system-underused-in-addressing-social-isolation-loneliness-among-seniors-says-new-report

Occupational Therapy’s Role in COVID Recovery

As we all have become acutely aware of, COVID-19 and the response to the pandemic have resulted in adverse outcomes to residents of skilled nursing and long-term care facilities. These adverse outcomes range from reduced physical function, including decreased muscle strength and endurance, to cognitive and psychosocial impairments, including delirium, neurological dysfunction, depression, and occupational deprivation. In combination, these symptoms paint a clear picture for the need of occupational therapy (OT) intervention. As OT practitioners, we must identify and champion our unique role in not only the physical rehabilitation of our patients but also in their psychological well-being.

According to the American Journal of Occupational Therapy’s (AJOT) OT Practice Framework, our profession, in its fullest sense, is facilitating achieved “health, well-being, and participation in life through engagement in occupation.” We identify the areas of occupation that our residents value, consider their context, and recognize the unique performance patterns and skills that affect the individual’s ability to engage and participate. This is clearly a client-centered, holistic process—one that considers physical function, cognition, and psychosocial impairments that may be impacted. Who better to address the wide range of outcomes that have resulted with our residents in skilled nursing and long-term care facilities?

As we continue to care for our residents who have been affected directly or indirectly by COVID-19, it is imperative that we implement this client-centered, holistic approach. How has the individual’s physical function been affected? Consider implementation of a cardiopulmonary program that includes respiratory strategies, postural control exercises, and exercise prescriptions. To address changes in cognition, complete a standardized cognitive assessment to identify specific processing skills for intervention during activities of daily living. Equally important, and even more important in some cases, are the psychosocial challenges that residents face during the pandemic. As patients are isolated to reduce transmission risks, unintended negative consequences present, including disruption of daily routines and restrictions to leisure and social participation. Recent studies suggest that isolation- associated loneliness has contributed to swift health declines in residents with dementia during the COVID-19 pandemic. Recognize and affirm residents in the challenges they face and use creative technological outlets to enhance participation in meaningful daily activities. Are there opportunities for virtual conferencing with friends or family? Are audio books, online games, or learning modules an option for leisure?

As OT practitioners, we are equipped to meet the tidal wave of challenges that COVID-19 has introduced to residents in skilled nursing and long-term care facilities. The tenets of our profession prepare us to respond to the physical, cognitive, and psychosocial changes that may occur. Though relaxed restrictions to nursing home visitation are on the horizon, the time is now to take hold of our unique, distinct role in facilitating health, well-being and participation in the lives of our residents.   

References:

American Occupational Therapy Association. (in press). Occupational therapy practice framework:

Domain and process (4th ed.). American Journal of Occupational Therapy, 74 (Supplement 2). Advance online publication.


De Biase, S., Cook, L., Skelton, D. A., Witham, M., & Ten Hove, R. (2020). The COVID-19 rehabilitation

pandemic1. Age and ageing, 49(5), 696–700. https://doi.org/10.1093/ageing/afaa118

Gitlow, L., PhD, ATP, FAOTA, OTR/L, Lee, S., OTR/L, Hemraj, R., OTR/L, Sheehan, L., OTD, OTR/L, & Ambroze, G., OTS. (2020). Occupational Therapy and Older Adults: Combating Social Isolation through Technology. PDF. American Occupational Therapy Association.

Lasek, A. (2020, September 18). Dementia mortality skyrockets since lockdowns; CMS loosens visitor restrictions – Clinical Daily News. Retrieved September 18, 2020, from https://www.mcknights.com/news/clinical-news/dementia-mortality-skyrockets-since-lockdowns-cms-loosens-visitor-restrictions/?utm_source=newsletter

Physical Therapy’s Role in COVID Recovery

For over 100 years, physical therapists have specialized in human movement using skilled interventions to maximize health and function.  During periods of critical illness, such as moderate to severe cases of COVID-19, it is common for patients to experience a loss of physical function which can lead to the development of new impairments or worsening of existing ones.

Long-term recovery from COVID-19 may be complicated by lasting effects due to deconditioning, restrictive lung disease, post intensive care syndrome, or neurological disorders. After 10 days of bed rest healthy older adults may lose up to 2.2 pounds of muscle mass from the legs with 2-5%/day loss of muscle strength.  Recovery of physical function may take an extended period of time with impairments that may persist up to 2 years post infection. 

As practitioners of movement, physical therapists are essential in early mobility during and following a critical illness in order to minimize the effects of immobility.  Through skilled interventions such as functional mobility, balance training, endurance activities, posture training, and strengthening, physical therapists are equipped to help residents achieve their optimal level of function as quickly and effectively as possible.

Along with debility, residents in nursing homes that remain quarantined during the public health emergency face another silent threat: social isolation. Even with the recent relaxation of nursing home visitor guidelines, the effects of social isolation may be long lasting.

Restricted access to family and friends may affect even those who have not contracted the virus itself and may include severe fatigue, anxiety, post-traumatic stress disorder, depression, and cognitive dysfunction. 

The effects of patients remaining in their room, the cessation of communal dining, and restricted access to common areas (i.e. the therapy gym and equipment) pose significant barriers not only to successful intervention and outcomes, but also overall resident well-being. The interdisciplinary team should assess and re-assess situations, analyze tasks, make changes, and consider a holistic plan of care to help reduce the lasting effects of social isolation and provide person-centered, specialized care which emulates Reliant’s motto of Care Matters.

References:

https://www.bsrm.org.uk/downloads/covid-19bsrmissue1-published-27-4-2020.pdf.

https://academic.oup.com/ptj/article/100/9/1458/5862054

https://www.aannet.org/initiatives/choosing-wisely/immobility-ambulation

Breast Cancer Awareness Month Activities

Most people know someone who has been diagnosed with breast cancer. This month, we remember those brave individuals we’ve lost and send lots of healing thoughts to those who still are fighting. Here are some ways you can foster a community of support to those women—and men—and their families.

Pink Pumpkins Why not!?

Organize a simple activity to have residents, patients, employees and family members paint or decorate mini-pumpkins in pink to spread awareness—and cheer—throughout residential and therapy areas.

Wear Pink

Raise awareness in the community by asking everyone to wear pink for a day or a week to remember, support and advocate for breast cancer awareness.

Host a Support Group

Work with a local oncologist and host a support group or event for women battling breast cancer to connect with each other, share their stories and offer support.

Hold a Hat & Scarf Drive

Collect or make hats or scarves to donate for women who are going through chemotherapy at a local center.

Support Prevention Programs

Host an information session with one of the community nurses, physicians or nurse practitioners to talk about how to do self exams and the importance of regular mammograms to catch breast cancer early enough for effective treatment.

Aging and Mammography

We’re living longer than ever. The median life expectancy for an 80 year old woman is nine years, so if you’re generally healthy, it can make sense to continue screening through the 70s and perhaps early 80s. As the American Cancer Society recommends, “Women should continue screening mammography as long as their overall health is good and they have a life expectancy of 10 years or longer.”

Documenting the Picture for Skilled Need During a Health Care Emergency and Beyond

​During times of pandemic and national emergency, when flexibilities or waivers are allowed by CMS, supportive documentation is crucial to justify the need for our skilled care. Throughout the public health emergency, many providers have utilized the available waivers for SNFs, including “skilling in place.”  With use of these waivers the following should be considered:

  1. Physician involvement, skilled nursing notes, and therapy evaluations and treatments should demonstrate medical necessity and skilled interventions relative to specific patient care needs. ​
  2. A signed physician certification will not suffice; the documentation needs to clearly support the order. 
  3. ​The patient assessment, physician documentation,  justification for the reason why the patient should be skilled in place versus discharged to the hospital, and hospital notes that document rationale for not admitting a patient or discharging early should all be obtained and recorded.
  4. Consistent and thorough documentation related to the care being delivered and why the particular care being provided is appropriate to the patient’s diagnosis, illness, or condition should be included.
  5. Strong facility processes, ongoing communication, and frequent medical record spot checks are the most effective ways to ensure that your records can best support the patient-centered care that is provided through the health care emergency and beyond. ​

After the emergency declaration is rescinded, it is very likely that CMS, either through the Office of the Inspector General (OIG) or contractors, will look to ensure that Medicare dollars were spent appropriately without fraud, waste or abuse. ​ When evaluating the use of the waivers, it is important to focus on CMS’ goal to take “aggressive actions and exercise regulatory flexibilities to help healthcare providers contain the spread of 2019 Novel Coronavirus Disease (COVID-19).” ​ Documentation will be critical to explain the rationale for the use of the waivers as well as clinical decision making for application.

In conclusion, a thorough interdisciplinary treatment record is crucial to support the specialized services provided during this health care emergency. ​ As we continue to provide excellent resident-centered care, we should ensure that we demonstrate the complexity, sophistication, and medical necessity of the services that we provide in our documentation. ​Documentation is paramount to fortify defensibility following this pandemic and to ensure our residents continue to have access to quality care.

Recovery and Rehabilitation Following COVID-19

As research and data collection regarding the recovery from COVID-19 grows, valuable information from research studies identifying correlations between contracting the virus and other acute medical complications, as well as the increased risk of readmission to the hospital, is clear. Current data suggests that patients hospitalized for COVID-19 are at increased risk for blood clots, strokes, heart and lung damage, speech and swallowing difficulties due to prolonged intubation, and neurological impairments.  It is our job to have a heightened awareness of potential complications associated with COVID-19 and communicate any findings to the interdisciplinary team (IDT).  With proper notification of subtle observed symptoms, the IDT can work together to minimize the side effects of COVID-19 and decrease the need for rehospitalization, consequently avoiding delayed recovery, increased potential for exposure to other contagions, and development of further complications.

Recovery is not only needed for those who have survived COVID-19; recovery, although different, is also needed for those who did not contract the virus but find themselves dealing with side effects from the modification of routines and activities in an effort to combat the spread of COVID-19. Current data shows that older adults who have not contracted the virus are seeing physical and psychosocial effects due to social distancing that result in deconditioning, increased effects of chronic disease, and reduced functional capacity. Facilities can provide ways to keep residents active while still maintaining social distancing guidelines. To thwart the effects of isolation and inability to see family, facility staff can provide technology, such as Facetime, to allow for residents to check in with their loved ones. Another consideration would be to reach out to family members and encourage them to send pictures and care packages to brighten the residents’ day.  We must ensure minimal impact to those who have made the skilled nursing facility their home by increasing opportunities for social and physical activities while maintaining precautions and social distancing during the COVID-19 pandemic.

COVID-19 has touched everyone, either directly or indirectly, and the effects of the virus may linger for an indefinite amount of time.   However, through increased communication among the IDT, we can potentially aid in speeding up the recovery process and in minimizing the risk of rehospitalization.   Additionally, through increased social and physical opportunities, our residents who have not contracted COVID-19 can explore alternative ways to stay connected and physically active.  Through the actions of a proactive interdisciplinary team, we can assist all our residents in achieving functional and quality outcomes allowing for enhanced quality of life.

The Amplifying Quality of Group Therapy

Although the concept of group therapy is not new to long-term care, the implementation of the Patient Driven Payment Model (PDPM) has ignited renewed interest in its utilization during a skilled stay. From the resource availability to expand restorative nursing programs that allow up to four skilled residents in a group, to the revised group definition under Section O of the RAI manual, it is highly likely the clinician, staff, and patient interaction throughout a stay will reflect an exciting environment of peer motivation and social engagement.  

Prior to PDPM, if a therapy clinician executed a group with skilled residents participating, the group had to be planned for no more nor less than four individuals. Now, when a skilled resident is included in a group, the clinician has the autonomy to mold the size of the group to include anywhere from two to six participants, as appropriate. The psycho-social benefits and opportunity to apply functional carryover techniques within a quality, patient-centered group have not changed.

As noted by CMS and in multiple research studies, the psycho-social benefits of group are varied and include enhanced learning, increased sense of support, decreased depression, and improved motivation. Consider the story of a skilled patient who planned to return home alone. Prior to the event that led to the skilled stay, she participated in social outings once a week and depended heavily on loved ones to drop by for social interaction. Her family and friends encouraged her to “get out more”, but due to a self-perceived burden and a touch of embarrassment over her functional changes, she frequently declined the invitations. Eventually, this unintentional social isolation led to depression, sadness, and declining functional health. In her weakened functional state, she fell and although no fractures or breaks resulted, she did admit to the hospital due to altered mental status, dehydration, and mild malnutrition. Once stabilized, she admitted to a skilled nursing facility with the hope her weakened state could be reasonably reversed for a safe return home. During her stay, she participated in a physical therapy group once a week in addition to her daily individual therapy. Knowing her history, the clinician formulated a peer group identifying patients with similar goals targeting gait and balance, with the knowledge that this patient needed the peer motivation and example for attaining and maintaining her functional gains once she discharged home. During those sessions, the patient was encouraged by the evidence that her story was not unique and allowed her to self-identify the functional and emotional effects of isolation all while achieving her physical therapy goals.

Group therapy presents the unique opportunity for the therapy practitioner or restorative nursing staff to engage the patient during their care journey in novel ways. As a result, success is often amplified due to the underlying qualities inherent within group formats that simply cannot be mirrored in individual treatment sessions.  Whether delivered by restorative aides as part of a nursing program or by therapy clinicians as part of a rehabilitation stay, there is magic in the makeup of a group that is created with patient-centered intention and guided by staff who recognize the benefits of community and teamwork.

Password Hygiene

Do you have good password hygiene?  Good password hygiene helps keep your work and personal information safe. 

You have healthy password hygiene if you:

  1. Create strong passwords by establishing passwords minimally 8 characters in length and containing upper case, lower case, and symbols.  A password of more than 8 characters is even better because more guesses will be needed by hackers to get it right.  Even with frequent warnings regarding cyber security, the two most common passwords people use are “password” and “12345678”!
  2. Use a different password for every account or online profile.  Should the system you are using be compromised that password could be published for the world to see.  There are almost 2.7 billion rows of data in the “Have I Been Pwned?” website of account information that has been compromised in data breaches.  This is a respected site that aggregates data breaches in order to make it easy for people to find out if they have been impacted by a breach.  You can check it yourself by going to https://haveibeenpwned.com.  
  3. Use two-factor authentication (2FA) whenever available.  This requires a second code be entered that will be provided through text, email or token in addition to your User ID and Password.
  4. Never write down your User ID or password and particularly never write it down and post it to your computer.

Maintain healthy security by maintaining healthy password hygiene.

Initiating Conversations Beyond the Facility

Ninety-five days, three months, or one quarter to go until the hard transition from RUG-IV to PDPM. However you prefer to frame it, there’s no denying the next few weeks will demonstrate a shift from theoretical planning of the facility processes to practical application. Within the current planning process Reliant has been privileged to be included in many of your conversations regarding facility education opportunities, interdepartmental communication strategies, and service delivery execution under PDPM.

The preparation and planning strategies have circulated around accurate MDS coding to ensure appropriate resource provision for the patient’s care needs while a resident in our facilities. We are actively educating all levels of nursing staff, therapy staff, administration, and admissions coordinators in expected conversation changes, but have we considered education needs beyond the facility? 

Under PDPM, facilities will be asking more detailed questions of the hospital discharge coordinators and specialists’ offices. We’ll be seeking clarification, coding specificity, and asking probing questions to ensure the patient’s assessment reflects all active comorbidities and conditions. As such, our community partners may begin to ask, “Where is this coming from?” Providing these partners with a big picture snapshot of PDPM and potential conversation changes will help to ease questions and prepare our partners for their own best practice referral strategy.

Team work and collaboration should start before a resident’s admission to the SNF and continue throughout the entire stay.  If you haven’t already, now is the time to reach out to your partners to initiate conversations regarding any process changes required for this transition.  By working together and proactively engaging our referral sources, we can identify education targets now, and avoid pitfalls in the future. 

Skilled Nursing Facility Provider Review Reports

Skilled Nursing Facility (SNF) Provider Preview Reports have been updated and are now available. Providers have until March 4, 2019 to review their performance data prior to the April 2019 Nursing Home Compare site refresh, during which this data will be publicly displayed. Corrections to the underlying data will not be permitted during this time; however, providers can request CMS review of their data during the preview period if they believe the quality measure scores that are displayed within their Preview Reports are inaccurate. 

To view the full memo and data contained within the report click here.

Targeted Prove and Educate Trends

As we move into 2019, our focus is honed on the new payment model going into effect in October, PDPM. However, CMS continues to review current trends and initiate audits without a break in sight. With the continuation of Targeted Probe and Education (TPE) audits on the rise, strong supporting documentation, accurate billing practices and managing patient stays appropriately must be the focus of our treatment each and every day.
Read article here .

Honoring President Bush’s Influence on the Americans with Disabilities Act (ADA)

by Connie Welcome, OT

As America mourns the passing of our 41 st President, Mr. George H. W. Bush, what has become almost palpable is how his influence is intertwined within the fabric of our society. There are so many contributions he made that continue to penetrate our current democracy; foremost in my mind is the passage of the landmark civil rights law, the Americans with Disabilities Act (ADA) of 1990. On the day President Bush signed the bill into law, he remarked, “Every man, woman, and child with a disability can now pass through once-closed doors into a bright new era of equality, independence, and freedom.” He went on to say, “Today’s legislation brings us closer to that day when no American will ever again be deprived of their basic guarantee of ‘life, liberty, and the pursuit of happiness’. Together, we must remove the physical barriers we have created and the social barriers that we have accepted. For ours will never be a truly prosperous nation until all within it prosper.”

The ADA was passed my freshman year in college, so I well remember how it impacted society, from the grumblings of business owners who had to comply with the demands of the law, to the excitement of those with disabilities who could access previously unknown worlds. For the first time in my life, I became more keenly aware that there was a large population of society who did not have access to many things that I took for granted. I began to look at the world differently, seeing it from their eyes. When I would enter a small restroom stall, I wondered what someone in a wheelchair did when they needed to go to the bathroom. Did they just stay home because it was too much trouble? I surmised that staying home was probably what I would have done. This was a time of change, change for the better, and it intrigued me to the point that I eventually went to graduate school and became an occupational therapist, with the goal of making my world a more accessible place.

Today, nearly 29 years later, society often takes for granted the sweeping changes this law made. As therapists, it means that the patients we serve can access public transportation without having to leave their wheelchairs behind, shop at grocery stores without fear of being turned away and bravely enter a restaurant without fear of being refused service. There is access to public restrooms, ramps to access federal buildings and shopping centers, handicap parking spaces and doors that open with the push of a button, crosswalk signs and sounds, braille signs for those with visual impairments, and telephones and television access for the hearing impaired. From the perspective of an occupational therapist, possibly one of the most important changes was employers had to accommodate those with disabilities without discrimination. It meant our patients could and continue to be able to be gainfully employed, becoming active members of society, enjoying the benefits that work and interaction within the environment afford. For our elderly, it meant they no longer had to be “shut-ins”, but could freely access society and be accepted, not shunned.

The ADA not only opened doors for patients, but for therapists alike. It provided a way for me personally to channel my desire to help others and created opportunities for therapists to implement their skills and advocate for their patients like never before. It opened a world of possibilities for successes for many in our society who had experienced few, allowing them to demonstrate their abilities. Without its passage, I would truly not be the therapist I am today, and our world would be a vastly different place!

So today, as we honor the legacy of Mr. George H. W. Bush, let us continue to carry the torch and be “points of light” for the patients we serve. In his words, “Our success with this act proves that we are keeping faith with the spirit of our courageous forefathers who wrote in the Declaration of Independence, ‘We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable rights.'”
Connie is an Occupational Therapist and Clinical Services Specialist with Reliant Rehabilitation.