Today's Ancillaries, part I: PT, OT, and Speech-Language Therapy.

They're increasingly critical, but what do they do? An update.

The quality of your facility's ancillary therapies speaks worlds about your facility's overall quality of care. Excellent medical and nursing care in themselves are no longer enough. Today's residents and patients expect - and deserve - services that enhance their physical and emotional quality of life to the fullest extent possible. And that is - or should be - what ancillary services are all about.

Even so, do you really know what goes on in an occupational therapy session, or which of your patients might benefit from speech-language therapy and why? This, the first of a two-part article on today's ancillaries state-of-the-art, offers an inside look into physical, occupational, and speech-language therapy. Part II in the next issue of Nursing Homes will focus on music, art and pet therapy.

Physical and Occupational Therapy

It's common knowledge that physical and occupational therapy are central to the rehabilitation process. But what really goes on in a PT or OT session? Such knowledge is certainly important in today's marketplace.

At Ballard, a 231-bed skilled nursing and subacute facility in Des Plaines, IL, a state-of the-art rehabilitation center is staffed by two licensed physical therapists and two licensed occupational therapists, each with an assistant and student interns. In addition to their work with Ballard's short-term, and sometimes much younger, subacute patients, physical therapist Marek Zaleski, LPT and occupational therapist Dotty Karabin, OTR/L also work with the facility's long-term residents.

While not every nursing home has a simulated community environment designed specifically for geriatric rehabilitation (see "Our Town Comes to the Nursing Home," Nursing Homes, September 1994, p. 14), Ballard's program exemplifies what can be done with an updated program. Perhaps an inside look will give you some fresh ideas to help ensure that you're taking full advantage of your therapists' skills and training. Or, if you contract with an agency for your PT and/or OT services, you will see what the agency therapist should be doing in your facility.

Physical Therapy

As in all skilled nursing facilities, physical therapy screening, as mandated by OBRA, is conducted on all new admissions, readmissions, and annually on all Ballard residents. Routine ambulation and range of motion are ordered by the therapist and usually carried out by rehabilitation technicians or CNAs.

Above and beyond these basic requirements, physical therapists are trained to work with patients with any and all types of mobility-related deficits: patients recovering from stroke and other brain injuries, fractures and amputations; patients with neurologic disorders such as Parkinson's disease or multiple sclerosis; those with cognitive and perceptual deficits, such as residents with dementias; and those with weakness after illness, injury or surgery.

"The most common deficits we see are related to gait and transfers, as well as stair climbing, balance, endurance and strength," says Zaleski. He also works on tasks as basic as bed mobility (transfers and rolling), which can be especially problematic after a stroke.

The structure and content of each patient's rehab program depends, in large part, upon their individual rehab goals and expectations. For example, says Zaleski, interdisciplinary discharge planning for short-term patients, which is initiated and overseen by social services, begins immediately after admission. "I begin the PT part of the process by talking with the patient and family members, asking them what they want to accomplish in rehabilitation and where they plan to go after discharge, ie, home to live on their own, or to a family member's home, etc. If their goal is to return to their previous setting, my job is to help them achieve a physical status as close as possible to that prior to their illness or injury." Zaleski adds that the expectations of Ballard's subacute patients, some of whom are in their thirties, tend to be quite high.

The expectations and goals of long-term residents may be quite different, he says, and generally focus on enhancing quality of life: improving wheelchair mobility, increasing strength and endurance for ambulation, facilitating transfers, improving balance, improving muscle strength after hospitalization, and so on.

To achieve these goals in both patient populations, physical therapists make extensive use of a range of techniques such as low-impact aerobic exercises, gait training, high-level balance activities, transfer and bed mobility training, safety reinforcement and neuromuscular reeducation.

Because of their unique "Our Town" set-up, Ballard patients also have the luxury of being able to work on more advanced skills: getting in and out of a car, ambulating over a variety of surfaces from curbs to cobblestone, lifting bags of groceries, climbing small, narrow steps, opening and closing a storm door, etc. The open design of the rehab area allows patients just beginning the rehab process to watch as those further along in the program tackle some of these more advanced skills. Zaleski notes that this serves as a source of inspiration during what can be a long, difficult process.

It is also the physical therapist who assesses the need for and makes recommendations with respect to ambulation devices (canes and walkers) and wheelchairs, makes certain that patients are matched with the correct device and trained in its use and, along with occupational therapy, fits wheelchairs with equipment to enhance safety and comfort.

Zaleski stresses that this is a critical, and sometimes underutilized, aspect of physical therapy. "Canes, walkers and wheelchairs are not one-size-fits-all devices. There is an increasingly wide variety of ambulation and mobility devices on the market, and finding the device that best suits a patient's needs, abilities and limitations is critical to the rehabilitation process and to that patient's quality of life."

Of course, state-of-the-art or not, all these services must be provided within the limitations imposed by reimbursement criteria. For example, Ballard residents who don't qualify for skilled physical therapy services, such as those with a mobility deficit who have not been hospitalized for the required three days, those who experience a slight decline or weakness, or those whom Zaleski determines have the potential for decline, might be placed on a nonskilled physical rehabilitation program. The licensed therapist performs the evaluation and designs the program, which is then carried out by a rehab technician under the supervision of the skilled therapist.

Ballard is also dealing with a growing number of patients covered by managed care entities, primarily HMOs. Interestingly, while he acknowledges having a certain amount of apprehension at first, Zaleski now often finds managed care easier to work with and more efficient than Medicare, primarily because of the payer-provider communication which allows him to discuss problems and needed changes with a "real person."

"With Medicare, it's a matter of documenting, more documenting, and hoping that needed services won't be denied," says Zaleski. "On the other hand, we have weekly communication with the HMO case manager by phone and by fax and I find out about approval right then and there." Zaleski adds that, in his experience, approval is obtained "99% of the time."

Occupational Therapy

Despite the occupational therapist's critical and unique role in the rehabilitation process, their discipline remains somewhat of a mystery, even to some health care professionals outside the rehab field, who may consider them an offshoot of physical therapy.

While there appears to be some overlap between OT and PT, as they complement one another in order to achieve common outcome goals - to restore function to a level as close as possible to that prior to injury or illness - occupational therapy is a distinct and separate discipline. OT focuses on functional skills that enhance independence in activities of daily living. Those activities can include anything from buttoning a shirt to writing checks.

"Our emphasis in OT is primarily on upper body conditioning, coordination, standing, balance, and so on," says Ballard occupational therapist Dotty Karabin, OTR/L. "When we work on areas that fall within the physical therapy spectrum - balance, gait and transfers - the emphasis is on the functional aspects of self-care needs: a resident who can't dress himself because of a balance deficit, or a hip fracture patient who needs to increase his range of motion in order to be able to bathe himself."

To this end, explains Karabin, "occupational therapists are trained to analyze muscle movement and design and direct activities to improve strength, coordination and range of motion." For example, a stroke patient with one-sided weakness might be given exercises in which they use wrist weights and reach for objects placed at differing heights to increase strength and improve range of motion. Specially designed clothes pins with differing resistance levels might be used to improve coordination, pinch strength and dexterity, and putty might be used to build hand strength.

"Occupational therapy activities are never randomly assigned," stresses Karabin. "Each activity is purposeful and related to a specific functional activities of daily living goal."

Occupational and physical therapists work closely together, frequently consulting and sometimes "co-treating" in basic areas such as balance. The OT and PT may also share information or collaboratively evaluate a particular aspect of care.

Because Medicare and MCOs reimburse only for OT services that address functional areas of living, goals and progress have to be set and documented very carefully, says Karabin. "Reimbursement criteria are much more stringent than when I started in this profession," she says. "We can't simply write a goal of improving strength or coordination. Instead, we need to justify our services in a functional context, ie, 'coordination exercises with pegs to enable the patient to button his shirt.' We then have to be able to document that patient's functional improvement with respect to that specific task."

This concept, says Karabin, is one that families may understandably find difficult to comprehend. "It's sometimes hard to explain to a resident's daughter or son that I can't simply work with their mother for four weeks to improve her strength or dexterity, if she is able to do everything for herself. The plateau that the payer defines as the end-point of needed services can be a difficult concept to grasp and to accept, even for the health care professional."

Acknowledging that full- or even part-time occupational therapists may be somewhat of a luxury to many nursing homes, Karabin notes that, as with physical therapy, nursing homes can contract with a rehab agency for the services of an OT as-needed. Under these types of contracts, resident evaluations are performed by a registered OT (trained in a four-year college program and nine-month internship) and treatment is carried out by an OT assistant (trained in a two-year program) under the supervision of a registered occupational therapist.

Speech-Language Therapy

It may surprise you to know that speech-language pathologists (SLPs) are among the most highly trained ancillary therapy professionals. Certification is awarded only after completion of a two-year master's degree program, a national exam, a nine-month clinical fellowship and recommendation to the American Speech Language Hearing Association. Licensure and continuing education credits are required in all states.

Why all the training and education? Some examples of the work of two Cleveland, Ohio-area speech-language pathologists, one a contract therapist for a county facility, and the other a full-time therapist in a not-for-profit senior living community, will give you an idea of the scope and depth of their discipline, as well as the benefits nursing home residents derive from their services.

Speech-Language

Cuyahoga County Nursing Home contracts with the Cleveland Hearing and Speech Center for speech-language pathology services for their primarily Medicaid resident population. Speech-language pathologist Angela Richardson, MS,CCC-SLP, notes that the Hearing and Speech Center therapists spend approximately two half days per week at the facility, as required by the contract, primarily to do evaluations.

In addition to OBRA-mandated annual, new admission, readmission and change of status screenings, the Center fields a range of speech-language referrals for evaluations. Cases include residents with diagnosed dementias, brain injury due to conditions such as stroke and trauma and, occasionally, conditions such as cerebral palsy, which may adversely affect speech production while language skills may remain intact.

"Most of these referrals are related to a change in status - after hospitalization or stroke, and for dementia, which is a common reason for referral," says Richardson. "When we do an evaluation, we conduct a number of tests to try to determine the etiology and characteristics of the deficit. We attempt to assess each resident's cognitive, linguistic and overall communication behaviors in order to identify existing strengths and weaknesses." For example, a speech-language evaluation on a resident recovering from a stroke might include the following:

* Cognitive tests (ie, thinking skills, memory skills) to differentiate between cognitive deficits and communication problems.

* Analysis of spontaneous language and communication behaviors and naming tests to determine if the resident is aphasic. During naming tests, the resident is asked to identify pictures or objects and the level of cueing required, and the types of errors made are documented.

* Repetition tests. Residents are asked to repeat high-frequency sentences (commonly heard expressions such as, 'there are no ifs, ands or buts about it') and low-frequency sentences (long, complex sentences that require good memory skills and recall to produce). The same type of test is also carried out with single words, numbers and letters.

* Articulation tests. Speech production skills are assessed, especially if speech clarity is poor.

* Reading and writing tests to help characterize the deficit. Once the evaluation is complete, Richardson explains, a number of factors are taken into consideration when deciding whether or not to enroll the resident in a therapeutic program. "We try to look at the big picture with respect to where the person is in his life and what skills he'll need: is this a person who may return home; a resident who will be staying in the facility; if the deficit primarily affects reading skills, was reading important to this person before their admission?"

Another consideration is the prospect for improvement. Richardson notes that a particular resident might not be a candidate for therapy at the time of the evaluation for reasons such as extreme weakness or severe dementia that preclude participation and minimize the potential benefits of the therapy. In these cases, Richardson talks with the nursing staff about things they can do to improve communication with the resident, the aim being to improve quality of life.

Jennifer Brush, MA, CCC-SLP, full-time speech-language pathologist at Cleveland's Menorah Park Center For The Aging, explains that, especially for residents with dementias, speech-language therapy seeks to improve communication in whatever form best suits the resident. "We work as a team with nursing, activities and social services to ensure that all staff members communicate with the resident in the most effective way possible." For some, this may amount to simplifying what's said to the resident and, for others, it may mean developing memory books or aids that facilitate communication with the resident's family and the staff.

"When working with stroke or head trauma patients," says Brush, "we address speech intelligibility, voice, pragmatics, verbal and written expression and reading and auditory comprehension."

Swallowing Disorders 

Referrals to speech therapy for swallowing evaluations are quite common in the nursing home population, and take precedence over all other types of referrals because of safety issues and quality of life, says Richardson.

"Our main concern is the possibility of overt and/or silent aspiration. Silent aspiration refers to residents who appear to be eating well without coughing or choking, but who are actually aspirating oral secretions, foods and/or liquids. Chronic aspiration can lead to respiratory difficulties such as aspiration pneumonia. We also frequently see people without any history suggesting a swallowing difficulty who turn out to have a severe underlying condition, such as an undiagnosed malignancy."

At Cuyahoga County Nursing Home, swallowing evaluations are done at the bedside, preferably during mealtime. Richardson explains that "what we really want to know in the nursing home is how the resident is doing with the current diet and what we can do to ensure safety and enhance enjoyment." For example, if a resident seems to be having trouble with foods or liquids of a thin consistency, the therapist may add a small amount of thickener to see if there's an improvement. In all cases, the resident's positioning while eating is assessed thoroughly and changed when needed, with input from occupational therapy.

Because bedside evaluations are limited to clinical observations, Richardson always refers residents for further testing (modified barium swallow or endoscopy) when she suspects an underlying problem. "Bedside evaluations allow us to assess the oral phase of swallowing (chewing, oral sensitivity, preparing for the swallow), but only allow us to make educated inferences about the pharyngeal phase of swallowing through analysis of laryngeal function.

"In addition to observing for obvious signs like choking and coughing, we also listen for vocal quality changes after the swallow (i.e., does the voice sound wet or gurgly)." When serious underlying conditions are ruled out and the problem can't be taken care of with simple dietary consistency changes, Richardson often recommends swallow therapy.

Jennifer Brush explains that the goal of swallow therapy is to enable residents to eat the highest consistency (and therefore, most enjoyable) diet that can be safely tolerated.

Menorah Park therapists teach residents a number of techniques to that end, such as exercises designed to strengthen oral motor musculature. "We see a number of residents with weak muscles in the mouth and tongue, and weak muscles around the lips, for example, that make it difficult to place the lips around a glass and keep fluid from spilling out of the mouth," Brush explains.

She also teaches residents different ways of swallowing, called compensatory swallowing techniques, each geared to a particular deficit. Residents are taught how to chew more effectively, to be aware of food that becomes lodged in the sides of their mouths and to use the tongue to clear the food to prevent choking.

Because positioning is so critical, Brush also works very closely with occupational therapy to determine each resident's optimal positioning for the safest possible swallowing. "Sometimes," she explains, "merely tilting the head in one direction or another can produce the anatomical change needed to ensure safe swallowing."

Brush and Richardson both rely strongly on the nursing and dietary staff to carry out their recommendations and monitor progress. "This kind of teamwork with the nursing staff is especially important when the SLP isn't in the facility full-time," says Richardson, who is often expected to design functional maintenance programs for the nursing staff to carry out. "Without their support and follow-up, nothing we're trying to accomplish stands a chance of succeeding."

Brush adds that she also relies heavily on nursing to initiate change of status referrals which, she notes, may include positive changes in which a resident previously unable to undergo therapy becomes sufficiently strong or alert to proceed with treatment. In all cases, referrals need to be made by a physician in order to be reimbursed.

In both Menorah Park and Cuyahoga County Nursing Home, reimbursement criteria for SLP services are the same as those for the other skilled services described in this article and, like physical and occupational therapy, documentation must focus on specific functional goals and outcomes. While the duration of therapy varies greatly, on average, skilled SLP services are provided in one-hour sessions three times a week for six to eight weeks. While Richardson notes that reimbursement denials have been relatively rare over the ten months she has been working at the county facility, Brush says she frequently receives requests for additional information before payment decisions are made. "We're not sure why," she says, "but they seem to come in cycles of relatively 'quiet' periods followed by requests for more information on almost all our reimbursement documentation."