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Weight Training: Not Just for Kids.


Innovative rehab/strength-building program proves people at any age can benefit from a well-planned exercise program

With the advent of the Medicare Part B cap, more pressure With the Than ever was placed on rehabilitation departments and providers to help long-term care residents and short-term rehab patients get better more quickly. Even though the cap has been lifted, at least for the time being, it still makes sense to provide rehabilitation therapy in the most effective and economical way. Nursing Homes/Long Term Care Management Managing Editor Linda Zinn asked President and CEO Brian Cloch of Quality Care Management, a company that operates six nursing and rehab centers in the Chicago area, the secret to the success of their RESTORE rehabilitation program.

How has the PPS "rollercoaster ride" affected your delivery of rehab services over the past couple years?

Cloch: Actually, when we developed the RESTORE program in the fall of 1998, we did so, at least in part, as an answer to PPS. We had to come up with a way to deliver our services in less time, yet more effectively. We knew we had to find a better treatment modality than the approaches available to us at the time. The use of weight-resistance fitness equipment, the training of therapists to use it and the clinical aspects of the program enabled us to do just that.

A therapy company approached us several years before we started RESTORE to offer us a similar program, but our response was, "No way--that's a lot of money." Furthermore, we didn't think the program they offered was really adequate. When PPS arrived, however, our vice-president of reimbursement came to me and said, "You know, a program like we looked at before might be the answer to providing therapy in a PPS environment." So we decided to develop RESTORE and bought Nautilus equipment from the company that had offered us the program previously, which at the time was the exclusive national distributor for Nautilus.

I'd like to emphasize that Nautilus isn't the only brand of fitness equipment that can be used for rehab programs. Other manufacturers are also adapting--or are willing to adapt--their equipment for use in this setting.

Is this the same Nautilus equipment we see when we go to a gym or health club?

Cloch: No. The equipment we use is therapeutic in design. For instance, the seats are lower for easier transfer, and they're wider for greater stability and security for an elderly user. Even residents in their eighties and nineties can still strengthen their muscles using this type of equipment.

The weight stacks on the equipment we use are in pounds and ounces, rather than in 5- and 10-pound increments. This type of equipment isolates muscles in such a way that therapy can be geared for the muscle groups that need to be targeted.

Every piece of equipment has range-of-motion restrictors. If, for example, the rehab department gets physician's orders for using a hip-flexor machine and the doctor doesn't want the patient to move the hip more than 30 degrees, we can dial 30 degrees into the machine and know how much weight and how much motion the resident is getting.

What are some of the other advantages of the RESTORE program?

Cloch: Besides its effectiveness, it offers real benefits in terms of preventing staff injuries and preserving residents' dignity.

Here's an illustration: A very common physician's order is an assist-to-stand order, or partial weight-bearing order. Without the equipment, to carry out this type of order a therapist would have to put a resident on a table and put a gait belt around his waist, then pull him up (toward the therapist). The therapist would then ask the resident to stand on the therapist's feet, and a therapy aide or another therapist would have to help the resident stand, to keep him from moving from side to side and falling over. That's how the therapist would determine how much weight the resident was bearing.

That doesn't seem very scientific. Every therapist has a different threshold for pain! In contrast, we have a piece of equipment called the leg press machine. The resident lies flat on his back with his knees in a pushing position, and then we tell him to push the stack of weights. For a partial weight-bearing order, if a resident weighs 100 pounds, we might start by putting 50 pounds on the machine and asking the resident to push 50 pounds. Then over a period of time we'll increase the weight until he can press enough weight to indicate he has the strength and stability to stand on his own.

This regimen really takes therapy from a therapist's opinion into scientific fact. Therefore, we see better outcomes and achieve them faster. And in terms of the resident's perspective, which do you think makes a resident feel more confident--exercising on fitness equipment or being pulled onto his feet by two or even three therapy staff? It's "sexy" to work out on equipment. It's not sexy to have someone move your arms and legs for you when you can't.

What are some key components of this program, in addition to the fitness equipment?

Cloch: A huge amount of work went into the clinical program that we developed around the equipment. I'd hate for people to read this article and go out and buy exercise equipment and think they're all set. The program is much more than the equipment, which even we didn't fully realize at first. As a result we had little success in the beginning. We soon discovered we had to do a significant amount of training with the therapists and residents. We brought a physiatrist (rehabilitation physician), Dr. William Adair, on board, and he really took the program to a different level.

Has this program decreased the number of therapy staff needed in your facilities?

Cloch: Yes and no. In proportion to the number of residents receiving therapy, yes. But we are providing rehab services to many more residents than before the RESTORE program was implemented, so we haven't reduced our therapy staff. We haven't examined this formally, but I believe if we saw the same number of people now as we did before the program started, we could provide therapy to them with fewer therapists.

Have you ever considered marketing the RESTORE program to facilities outside those QualityCare Management operates?

Cloch: We'd love to, but the rehab program is such an integral part of a facility that it's difficult to go into one and only provide RESTORE. It's a facility-encompassing type of program, so we'd need a certain amount of leeway with the owners of the facility, to let us put the program into place the way we know it works best. Without that type of commitment, the program would fail. Some owners have the attitude of, "Put this program in my facility so my census will grow and then leave us alone," but they don't want to invest the time and energy into retraining their therapy staff.

I think one of the major failures of outside therapy companies is that they didn't have control over the operation of the facilities where they provided services, and that put them at risk. For example, if the facility took inappropriate therapy patients, there was little therapy consultants could do about it. In order to make this work, we'd have to have some say in how the therapy department would be run and have some influence with nursing, as well.

As a matter of fact, when we first tried to initiate the RESTORE program, we had an outside company providing therapy services. One reason the program failed initially was that the therapists simply refused to use the equipment; they were used to the traditional ways of providing therapy and didn't want to change. You'd think most therapists would have jumped at the chance to use state-of-the-art equipment, but most of them said, "I learned to do it this way in school. I can manually manipulate that leg better than any equipment can."

This makes no sense to me. We believe that RESTORE is the only way for a person to rehabilitate and maintain general health. I'm comfortable making such a strong statement because the old, traditional modalities are so inferior by comparison. They are slower and they are less scientific and they don't work as well.

Aside from the therapists, did you meet with resistance from other staff members when you started this program?

Cloch: Everyone, from the therapists to housekeeping, had to be educated about the program. Ironically, Dr. Adair, a highly regarded physiatrist who is now our medical director for the RESTORE program, was quite skeptical when we first showed him the program. Within a few months, he was asking, "Why doesn't the hospital [where he headed the rehabilitation department at that time] have this equipment?" What changed him from a skeptic to a huge fan and prompted him to become the medical director of this program were the results we were getting.

Do you recommend the use of this adapted fitness equipment for elderly residents who don't need rehabilitation, per se, but who could benefit from strength training?

Clochc: Absolutely. Our residents exercise on the equipment when it's not being used for therapy, and many residents who have been in rehab continue using it after their rehab is over, for maintenance.

I think one of the best uses for a program like this would be in assisted or independent living residences. If we can keep people healthier, we can delay their need for skilled nursing care.

How do your residents feel about this program?

Cloch: It makes them more self-confident, and they're seeing results quicker. Also, because we can exercise all parts of their bodies instead of just the parts that need rehab therapy, the residents who can go home after rehab are going home much more stable.

How costly was this program to get started?

Cloch: The equipment is relatively expensive--as much as $5,000 to $10,000 per piece, and we have 7 to 10 pieces in each building. Another consideration is space. The equipment requires quite a bit of room.

How can facilities justify the cost of the fitness equipment for a program such as the one you've developed?

Cloch: We're a small "mom and pop" chain of nursing homes and rehabilitation centers, but we decided we had to bite the bullet and start the program-- in hopes of having better outcomes, providing better therapy for our residents and increasing our census. It paid off on all counts.

As with any purchase decision, you have to weigh the benefits against the cost. We have hospital discharge planners who refer all their patients to us for rehabilitation, because we have the only facilities in the state that offer a program such as ours. As a result, we're seeing more rehab patients than ever before. Our company is struggling like everyone else's because of the reimbursement issues we deal with, but our rehab services under the RESTORE program are now part of the solution, rather than being part of the problem.
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Publication:Nursing Homes
Article Type:Interview
Geographic Code:1USA
Date:Oct 1, 2000
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