Third Quarter 2014

FlagPOST Archives
Preparation is Key as the IMPACT Act Becomes Law

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act signed by President Barack Obama on Monday, October 6, 2014, directs the US Department of Health and Human Services (HHS) to standardize patient assessment data, quality, and resource use measures for PAC providers including home health agencies (HHAs), skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), and long-term care hospitals (LTCHs).


It is believed that the standardization of patient data across Post-Acute Care settings will allow HHS to compare quality across PAC settings, improve hospital and PAC discharge planning, and use this standardized data to reform PAC payments in the future.

The new law will:

    • Require PAC providers to begin reporting standardized patient assessment data at times of admission and discharge by October 1, 2018, for SNFs, IRFs, and LTCHs and by January 1, 2019, for HHAs.
    • Require new quality measures on domains beginning October 1, 2016, through January 1, 2019, including functional status, skin integrity, medication reconciliation, incidence of major falls, and patient preference regarding treatment and discharge.
    • Require resource use measures by October 1, 2016, including Medicare spending per beneficiary, discharge to community, and hospitalization rates of potentially preventable readmissions.
    • Require the Secretary of HHS to provide confidential feedback reports to providers. The Secretary will make PAC performance available to the public in future years.
    • Require MedPAC and HHS to study alternative PAC payment models, with reports due to Congress in 2016 for MedPAC and 2021-2022 for HHS.
    • Require the Secretary to develop processes using data to assist providers and beneficiaries with discharge planning from inpatient or PAC settings...Read On.  

The Power of Music: Connecting with Non Verbal Patients   


With the right tools and training to tap into the abilities of our residents with dementia, tremendous results can happen - something that Jennifer Yocum has seen firsthand as our Speech Language Pathologist at Oceanview in Texas City, Texas. Consider, for instance, one case study involving a patient named Janice who resides on the secure unit.


Prior to Jennifer treating her,    Janice was nonverbal, and according to staff, she only occasionally made small noises but would smile when you made eye contact with her and spoke to her. Jennifer began her assessment with olfactory stimulation and immediately got encouraging results through nonverbal expressions of excitement. The following day, Jennifer completed an auditory stimulation assessment. She began with simple songs on the computer, and she could see instantly that Janice was engaged in the music. She then tried some other common songs to tap into Janice's long-term memory, and lo and behold, she began to SING - audibly, accurately, intelligibly and best of all ... HAPPILY!


Jennifer eagerly began to work with Janice daily, trying various techniques to carry over the singing to everyday language.. Jennifer then learned from Janice's husband that he used to be in a band and that she loved to sing and dance to his guitar playing. The connection with Janice's husband was powerful, and he was moved and overwhelmed with joy that Jennifer was taking the time and was caring enough to find the beauty that was always there behind this previously nonverbal resident.


The joy of giving goes both ways. Jennifer describes the impact this experience had on her as well: "Helping Janice did not just help Janice. It gave her husband peace that someone was caring for her, and not just caregiver caring. It gave me an overwhelming sense of satisfaction and intrinsic reward no money can buy."

The momentum and expertise in caring for this special population is growing. Gina Tucker-Roghi leads our charge with Abilities Care Approach. This evidence-based approach builds on remaining abilities to compensate for impairment, and outcomes include enhanced functional performance and reduction in negative behaviors. Gina recently trained over 60 therapists, nurses and members of the IDT in Milestone so that our Utah facilities can begin or enhance their dementia care. Gina also presented at the Occupational Therapy Association of California (OTAC) Conference in Pasadena, Calif., in October on the Abilities Care Approach. Kelly Alvord, Milestone Therapy Resource, will also be finishing his certification from Dementia Care Specialists so that he can continue the excitement in Utah.

A Simple Activity That Made a Big Difference at Cloverdale Healthcare


Polly Hendrix, RN, Director of Nursing at Cloverdale Healthcare Center in Cloverdale, Calif., had the pleasure of witnessing an incredible interaction between Occupational Therapist Amanda Grace and Charles, a patient with dementia. Here, she shares her experience with the FlagPOST.


I would like to show Ensign what a wonderful OT we have in Amanda Grace. I witnessed her interacting with a patient today while he was in the middle of a meltdown. He was yelling, agitated and distressed. Amanda stepped in and provided not just comfort and reassurance (as we all do), but she was also able to redirect Charlie and engage him in looking at rings he was wearing, and an activity. 


It was the activity that really caught my attention. She had a Halloween bucket of "Witches Stew," made of rice, pastas, and small toys such as erasers and rings that Charlie could dig through to find. It provided him with a calming sensory experience, a distraction, and he was able to get a reward in the eraser or a ring. Within a couple of minutes, Charlie went from yelling and distressed to quiet, happily showing me the rings he had found previously. I left the area with Amanda engaging Charlie in digging through the "Witches Stew"; he was chatting away, not distressed. It was so wonderful to see, it brought tears to your eyes - to see what could be done to decrease the distress some residents have and improve their quality of life. We are so fortunate to have Amanda, and I hope to continue to see the work she does and learn from her.



From Tragedy to Triumph: "Someone who did so much makes me want to do more"

We are pleased to share this inspiring story written by Trevor Pettigrew, recent recipient of our quarterly SPARC scholarship for students. Trevor, a physical therapy student at the University of Washington, shared the following thoughts with our committee of therapy resources that votes on the winner of the award.


Staring at the run-down "single-wide" in the middle of nowhere, I could barely believe my parents as they told my siblings and me that this would be our home for awhile. We had just moved from a pleasant neighborhood in a suburb of Los Angeles. The move itself had been stressful - caravanning up north, with merely the hope of a job and a home, and our pared-down belongings left in storage.

My dad's company had been bought out and the employees laid off while I was in elementary school. While not extravagant, our comfortable lifestyle disappeared as my family was caught in the country's economic downturn. After thousands of resumes, several low-paying jobs, and depleted savings, my parents decided to take a leap of faith and move to an area where my dad had often dreamed of living: southern Oregon....Read On

Story of Recovery Sets Benchmark for Future Treatments

Park Manor Rehabilitation Center, Walla Walla, WA

When 42-year-old Heather entered Park Manor Rehabilitation Center, she had already experienced more struggles than many people twice her age. With a medical history of diabetes mellitus and lower-back pain, Heather had visited the emergency room due to pain in her right lower extremity - at the time, thought to be sciatic pain. An MRI was negative for a herniated disc; however, an X-ray confirmed she had necrotizing fasciitis.  


Heather's diagnosis led to her transfer to Kadlec Medical Center, where the wound was debrided and a wound vac put in place. After receiving antibiotic treatment, she was life-lighted to Harborview Medical Center in Seattle for further care, which included debridement of the right thigh, calf and gluteal area, perineum and groin through four separate incisions. Admitted to the ICU, intubated and placed in a coma for four weeks, Heather underwent a total of 12 debridement surgeries.


During this time, Heather also developed VRE. Her family was told she had less than a 15 percent chance of survival. Despite the odds, Heather persevered and stayed at Harborview for a total of seven weeks. From there, her journey began with Park Manor Rehab for post-acute care...

Read On

Are Your Patients "Motivated to Move?"
Fall-Reduction Programming Ideas

 By Tamala Sammons, Therapy Resource


We spend a lot of hours trying to stop our patients from moving. We stop them from getting up, picking things up off of the floor, leaving the facility and so on. What if we shifted our focus from the physical aspects of fall prevention and started looking at our patients' social aspects of life? To put it simply, what if we stop trying to stop them?


As humans, we are motivated by behaviors like meeting an unmet need or wanting to move. Residents who struggle with self-care and mobility might experience feelings of loneliness, helplessness and boredom if they are continually prevented from addressing their intrinsic desire to get moving. In fact, these three emotions account for the primary suffering among our elders! By utilizing social interventions, however, we can not only reduce the frequency of these feelings, but also help to reduce falls, medications, restraints, skin issues, weight loss, etc.


Some of our residents are able to sit for longer periods of time, engage in activities longer, etc., but others are not. We need to identify those residents. In other words, it's more than a fall risk score to determine who is really at risk to fall. Two residents can have the exact same fall risk score, but one may be at a higher actual risk to fall because of his "motivation to move" behaviors. Our treatment interventions need to include the social aspects for these residents to develop individualized plans...Read On


Developing a Post-Acute Cardiac Wellness Specialty Program

 By Deb Bielek, Therapy Resource


As we are all well aware, CMS has begun penalizing hospitals for unplanned readmission of certain diagnoses, including acute myocardial infarction (AMI), heart failure (HF) and pneumonia (PN). This new rule brought into focus specialty areas where the post-acute care settings could partner with the hospitals for improved outcomes. Many skilled nursing and rehabilitation programs have always accepted patients with cardiac conditions, but they are now talking about their role in relation to reducing hospital readmissions. In many cases, the SNF, HH and outpatient programs are providing therapy to these patients under the general rehabilitation program.


We have seen the opportunity in some of our markets to further develop well-defined cardiac specialty programs with quality outcome measures in place (such as the CARE Item Set and NOMS), for the primary purpose of enhancing the transition of care for this highly specialized population. By implementing this type of specialty program, we believe that hospital readmissions, greater patient satisfaction and higher success with transitions of care will be achieved. When we add in the fact that we will be able to provide measurable outcomes using standardized tools such as CARE and NOMS, measuring the overall effectiveness of the program and evaluating opportunities for further development will be more distinguishable.


In 2012, your therapy resource team developed a tool that could be used to help facilitate the steps for developing a specialty program. In 2014, we refined it using the specialty of cardiac wellness as an example, sharing it through leadership meetings and the Therapy Portal..Read On
Sharing a Passion for Learning 
Park View Post Acute, Santa Rosa, CA


At Park View Post Acute, our education didn't stop when we donned caps and gowns and earned our degrees. In fact, we have a clinical education commitment that allows us to complete an annual in-service training for our rehab partners that highlights an "innovative treatment option. We continually strive to enthusiastically seek out new or better ways of providing skilled interventions and share them with the team. Below, we have highlighted some of our recent trainings and how they have expanded our horizons.


Topic: Therapeutic Clothespin Activities Kit

Using a portable kit containing clothespins, this therapy approach encourages interventions to address pincer grasp and release, sequencing, upper-extremity range of motion and decreased visual field neglect. Use of this kit has enabled functional gains in hygiene and grooming activities, instrumental activities of daily living, upper-body dressing and handwriting skills.


Topic: Supported Conversation for Adults with Aphasia (SCA)

In this training, we discovered ways to acknowledge and reveal competence for adults with aphasia. For example, we can acknowledge the shared experience of being frustrated by saying phrases such as, "I know that you know" at appropriate times. To reveal competence, we focus on using short, simple sentence and an expressive voice; writing down key words or main ideas; and eliminating distractions such as noises, other people and multiple visual materials.


Topic: Low Vision Experience and Treatment Techniques

In this simulation and intervention training, we experienced how the world looks through the eyes of those with macular degeneration, diabetic retinopathy, glaucoma and cataracts. Interventions included large-print materials, glare reduction, color contrasts and use of clock patterns for ADLs.


In the near future, we'll be undergoing training for therapeutic massage, osteoporosis and spinal precautions techniques, evidence-supported use of games in occupational therapy, benign paroxysmal positioning vertigo and multidirectional weight shifting training using the Wii (who says learning can't be fun?). We look forward to sharing our newfound innovations with our partners and continuing to open our minds to new ideas! 

Finding Relief with the Kinesio Tape Protocol

San Marcos Rehabilitation & Health Care, San Marcos, TX


When Patient B. came to us at San Marcos Rehabilitation & Health Care with persistent shoulder pain, he was experiencing reduced activity tolerance and participation, a decreased upper-extremity range of motion and a need for assistance with ADLs. His shoulder pain measured 8 out of 10 on his B shoulders; his muscle strength was at 3+ out of 5 for his shoulder flexors, abductors and extensors; and his Shoulder Pain and Disability Index (SPADI) score was 90 out of 100. Needless to say, B. had a lot of work ahead of him, as did our therapists.


Through the collaborative efforts of Physical Therapy and Nursing, we designed a treatment program for B. that would allow us to help the patient progress while also m onitoring his pain levels. Using the SPADI score allowed for an objective measure of pain relief as we set to work with various therapies, including a kinesio taping technique, therapeutic exercises to strengthen the shoulders, and scapular mobilization and gentle Grade 3 joint oscillation (inferior glide) of the humerus for two minutes at a time. For the first intervention, we incorporated kinesio taping of the B shoulders based on protocol developed by Kase, Wallis & Kase (2003). The second intervention included preheating the shoulders with a hot pack for 15 minutes, followed by various shoulder and scapular mobilization techniques...Read On


With Perseverance, Patients and Therapists Find Success at Veranda

Veranda Rehabilitation and Healthcare, Harlingen, TX

At Veranda, there is no greater incentive for our therapists to persevere through difficult cases than to see patients returning home to carry on with their lives. In the example of one client, admitted to Veranda with a gunshot wound to the mouth and presenting with ETOH abuse, B nephrolithiasis, malnutrition, liver cirrhosis and other symptoms, it was clear from the start that this patient would require extensive therapy. However, our therapists were up for the task, and his story is just one of many that demonstrates how our commitment to a positive outcome allows us to create a partnership for healing with even the most challenging patients...Read On



Providing a Treatment Plan for

Pannus Support

Wellington Place Living & Rehab, Temple, TX


For patients with excessive pannus, whereby the skin on the lower abdomen hangs down due to rapid weight loss, there are multiple complications that can arise. The condition increases the risk for excessive external hip rotation contracture, skin breakdown due to trapped moisture and decreased lower-extremity strength and range of motion.


Patients with no medical complications might choose to have the excess skin surgically removed. However, for some patients, such as Patient G.D. at Wellington Place Living & Rehab, surgery is not an option and we must find alternative treatments.


G.D. is an older woman who had lost a significant amount of weight, resulting in a pannus that would sit in between her legs. She was scheduled to have surgery to have the pannus removed, but due to some co-morbidities, she was unable to proceed with the surgical procedure. The patient's health declined, and she was no longer able to transfer herself. That's when she joined us at Wellington....Read On


Barihab Table Case Study

Mountain View Rehabilitation  and Care Center, Marysville, WA


Sometimes, one new piece of equipment makes all the difference for a patient. Take, for instance, the case of one resident at Mountain View Rehabilitation and Care Center (MVR) who was admitted following a right middle cerebral artery aneurism, with coil embolization of aneurism, aneurism perforation and resultant subarachnoid hemorrhage. hospitalized for three and a half months prior to admission at MVR, Patient R. entered our facility with multiple challenges preventing her from living a more independent life. However, with our therapists' patient and caring approach, plus the addition of a Barihab table to her treatment routine, R. has made incredible strides in her recovery...

Read On


Improving Quality of Life for Terminal Patients

Northeast Rehabilitation Center, San Antonio, TX


For patients with a terminal illness such as cancer, hospice is not the only answer - and certainly not the best one in many cases. That's something we learned firsthand in working with Patient P., a woman who presented with stage III lung cancer and whose chemotherapy treatment had proved ineffective. When told by her doctors that she needed to consider hospice, P. refused - and those of us at Northeast Rehabilitation and Healthcare Center stepped in to provide rehabilitation services.


P. entered our facility with multiple confounding factors, including aspiration pneumonia, neuropathy, COPD, poor trunk control, Hx of hip fx with resultant leg discrepancy, a peg tube and oxygen dependency. Moreover, she weighed just 80 pounds and was both emotionally and financially devastated by her diagnosis. To make matters worse, her husband needed to work and was therefore unavailable to assist her during the day. P. simply was overwhelmed and wanted to be at home.

Doing our best to create a home away from home for P., the team at Northeast Rehab took an interdisciplinary approach that included occupational, physical and speech therapy...Read On


At Willow Bend, We Are All in This Together!

Willow Bend Nursing & Rehabilitation Center, Mesquite, TX



When Patient W. entered the doors of Willow Bend in February 2014, it was likely the last place he wanted to be. His life of living independently, working, driving and enjoying time with his wife had been turned upside down due to a right-knee replacement. Now nonambulatory, unable to dress his lower body and requiring help with toileting, W. had some work to do before he could return to his normal routine - and Willow Bend's caring and dedicated staff was eager to help him get where he wanted to be.


Upon admission, W. had been under the care of orthopedist Dr. Doe, who referred his patient for physical therapy. This was Dr. Doe's first referral to Willow Bend, and our therapists did not disappoint him! Six times a week, they worked with W. to address his right-knee AROM and PROM, step length, weight bearing, weight shifting and proprioception as well as provide creative approaches to pain management and increasing range of motion. In addition, with occupational therapy six times weekly to focus on lower-body dressing, toileting, energy conservation techniques and compensatory strategies, W. had a full therapy schedule tailored to his unique needs.


During his stay, W. saw Dr. Doe twice, and after each visit, Dr. Doe sent a note to therapy stating what an awesome job the therapists had done with his patient! He was so pleased with W.'s progress, in fact, that he has started referring his other patients to Willow Bend. With so many different facilities from which to choose, why does Dr. Doe, along with other healthcare professionals like him, send his patients to Willow Bend? The facility's staff, or "Benders," takes a collaborative approach to patient care that results in positive outcomes for patients such as W. "We are all in this together" is our motto that we live daily, and everyone from nursing, OT and PT to social workers works closely with one another to ensure successful treatment.


After several weeks of hard work, W. was discharged from Willow Bend in April 2014 to return home to his wife, fully independent with ambulation, transfers, dressing and toileting. He has continued outpatient treatment with physical therapy three times per week and also works toward improved right-knee range of motion and step length during ambulation. Thanks to the combined commitment of W. and his team of therapists, he got his life back!


Issue: 8

In This Issue
The Power of Music: Connecting with Non Verbal Patients
A Simple Activity that Made a Big Difference at Cloverdale
From Tragedy to Triumph
Story of Recovery Sets Benchmark for Future Treatments
Are Your Patients Motivated to Move?
Developing a Post Acute Cardiac Wellness Specialty Program
Sharing a Passion for Learning
Finding Relief with Kinesio Tape Protocol
With Perseverance, Patients and Therapists Find Success at Veranda
Providing a Treatment Plan for Pannus Support
Barihab Table Case Study
Improving Quality of Life for Terminal Patients
At Willow Bend, We are All in This Together!

The Compliance Corner 


By Brian del Poso, OTR/L 

Senior Compliance Partner for Signum


From IRO-No

to IRO-Yes!

The IRO onsite visits for year one of our Corporate Integrity Agreement (CIA) have come and gone and, as an organization, we've accomplished something unbelievable, scoring in the high 90s to 100 percent for all eight of our facilities audited!

It was an arduous task preparing for the IRO, and much kudos goes to the resources and compliance partners involved, but the biggest hand has to go the therapy teams at each facility that stepped up their game and knocked it out of the park! One may think with such great scores, how can we possibly improve, and what can be learned? The answer is, plenty. Like everything else in healthcare, the learning doesn't end, and there are always ways to improve ourselves and our systems.


One of the biggest lessons we've learned, or better yet, confirmed, was that the IRO looked at things in a similar fashion to how our compliance team looks at things. So, in the ever-changing world of healthcare, have confidence that our organization is doing everything we can to do things the right way and get us through the IRO process. Here are some other things the IRO focused on and we learned during the IRO onsite visits:


Therapy treatment observations:


Keyed in on diverse and dynamic treatment interventions.

Also emphasized whether the therapists were assessing and monitoring their patients during treatment.


The IRO mentioned several times how the use of standardized testing would help with the justification of our therapy documentation and support need for continued therapy services. 

 The key point is that although a functional level (i.e., Min (A), SBA, (S), etc.) may show that a resident is performing well, there may be underlying factors that can prevent a safe discharge and we may be able to show through standardized testing.

Inconsistencies were being looked at with billing of therapy services. 

The IRO was looking at fluctuating delivery of minutes (i.e., 75 min. one day, 30 min. the next day, and then 70 min. another day, etc.) and checking to see if there was a daily note to help explain the inconsistencies.

We can strengthen our justification and/or explanation of missed treatment visits.


Evaluations billed for 15 min. or less were questioned.

A couple of thoughts arose for you to think about: 1) Was an effective evaluation really done in such a short amount of time when there is so much information on the therapy POC? 2) Were minutes that were actually evaluation minutes being charged as treatment minutes instead?


The IRO loved the use of projection screens/TV monitors during the PPS Daily Technical Meeting and the Weekly Medicare Meeting. She liked how the entire IDT could see what was being tracked, check for accuracy, and how the information could be shared and edited on the spot after being discussed.


The practice questions we developed and trained the chosen facilities on were pretty much the questions that were asked by the IRO. Most of the questions were about things we do on a normal basis (how we track minutes, what is concurrent treatment, how is the communication between DOR and staff, etc.), but one of the big questions that we may not think about all the time was, "What do you remember or what stood out to you from the CIA education you received?"


The Risk Matrix that the compliance team uses was a good predictor of risk for IRO selection.

Remember, the key factors that impact the Risk Matrix are: RU and RV RUG Utilization, ADL Index Scores, Total Medicare Days, and Avg. Length of Stay.


The last takeaway that I'd like to leave you all with is, let's take what this year's chosen facilities went through and changed as a learning experience across our organization. Let's move forward and instead of being scared or taking a negative outlook to our CIA, look at it as an opportunity to improve ourselves as an organization and as professionals. Let's NOT go back to the way things used to be, and let's embrace all the "new standards" we've learned this year as our now "everyday" practices.

Mary Spaeder, Editor 

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