Case Scenario #1, Criteria 2, Designing/Establishing a Maintenance Program Health History: Pt is 86 year old male resident of assisted living facility with underlying dx of Parkinsonism. Two months ago, patient ambulated independently in apt. with RW and with distant supervision to and from breakfast and lunch daily with RW. However pt. experienced significant functional decline after he sustained 3 falls in one week with inability to ambulate as a result and confined to wheelchair. Activity Limitations: Current status is noted as able ambulate with rolling walker 140 feet with varying amounts of assistance from stand by to minimal assist. Transfers require minimal assist. Patient has been unable to return to independent level of ambulation in facility due to balance, retropulsive tendencies during sit to stand, and decreased memory processing. Endurance has improved but is currently stable with a 2MWT of 32 feet. Walking speed is about 1 ft/sec indicating continued risk for falls with ambulation. Facility staff training has been initiated to assist with daily walking program. SLP working with patient and caregivers for recall techniques and signs of aspiration during meals. Participation Restrictions: Patient unable to safely ambulate to dining room without assistance. Plan: A daily walking program is required to maintain patient s current level of function without which patient would be at risk for skin breakdown and rapid deterioration overall if confined to a wheelchair. Will plan to educate each staff member re proper gait facilitation technique and transfer facilitation at staff change for the early morning and late afternoon shift change with a focus on safety and mitigating patient s retropulsive tendencies. Then will follow up with patient weekly with facility staff present to evaluate for maintenance of current level of function providing direction as needed. 3w2, 1w4. Goals: CG continues to demonstrate the ability to safely and independently assist with ambulation 250 feet to and from the dining room for all meals using a FWW CG able to provide appropriate cues to mitigate retropulsive tendencies during sit to stand and transfers 100% of the time Patient will maintain walking speed of 1ft/sec Patient will maintain current level of endurance with a 2MWT of 32 feet.
Case Scenario #2, Criteria 2, Designing or Establishing a Maintenance Program Health History: Patient has history of multiple exacerbations of COPD with hospitalizations and frequently on/off service for therapy for functional impairments and poor endurance with activities. Patient has severe osteoporosis due to steroid dependency and multiple recent compression fractures. Patient has reached a stable level of function after recent episode with a home exercise program established by this visit. Activity Limitations: Patient employs effective energy conservation techniques for light housekeeping, and meal making for 3 meals per day maintaining RPE between1-4. 2 MWT is 38 seconds with RPE at level 2. Risk for fracture during basic ADL s is high. Participation Restrictions: Patient unable to grocery shop/run errands without the assist from family or friends due to poor endurance and risk for fractures. Plan: Ensure patient is compliant, consistent and safe with established HEP with respect to fracture risk. 1w2, 1w every other week for 3 weeks. Goal: Maintain function and keep patient out of hospital. Patient to maintain RPE between 1-4 during light housekeeping Patient consistent and compliant with HEP and any modifications needed Criteria 2 General Goal Examples Designing or establishing a HEP or caregiver training program that requires validation of appropriate carryover and comprehension: CG continues to demonstrate the ability to safely and independently assist with ambulation 250 feet to and from the dining room for all meals using a FWW CG/Pt effectively demonstrates OTAGO exercise program at maximum level with no reports of falls Pt able to effectively perform light housekeeping and prepare all meals with a reported functional dyspnea scale of 3 or less and no weight gain Patient continues to perform HEP safely with appropriate input from caregiver Patient has effectively maintained knee ROM of in order to transfer weight over the feet during transfer so that transfers from sit to are safe and functional. Pt/CG have effectively maintained strength and activity capacity as evidence by the patient being able to maintain the ability to perform steps in 2 minute step test or reps in 30 SCST. Patient demonstrates competency in maintenance of shoulder ROM of allowing for effective UE and LE dressing
Criteria 2 General Intervention Detail Examples Instruct patient and/or caregiver in a maintenance program consisting of necessary techniques, exercises or precautions to treat the patient's illness or injury. (Document the education provided and include details about the specialized therapy skills and knowledge utilized, if the patient requires periodic reevaluation and adjustment of the program include in the assessment and plan section) Details/comments: CNA present for caregiver training in ambulation program Required instruction in techniques for effective contact guard/min assist for sit to stand transfer. Instructed caregiver in safely guarding patient on his left side and instructed caregiver in appropriate verbal cues to provide patient to assist him with improved balance and step clearance. CNA ambulated with patient for 100 feet demonstrating safe technique with minimal verbal cuing by therapist for increased fall risk due to patient listing to the left during ambulation Recommend reassessment for monitoring of effectiveness of program, techniques performed by aides and stabilization of patient status. Pt has multiple caregivers at assisted living facility and further training with caregiver remains appropriate
Case Scenario #3, Criteria 3 Performing Complex and Sophisticated Skilled Interventions This patient lives in an ALF and presents with Parkinsonism and Chronic Dysphagia (difficulty swallowing). He has had a prior hospitalization due to Pneumonia likely from aspiration. Patient has failed restorative therapy to improve signs and symptoms of aspiration during meals but continues to be at risk and on a modified diet. Patient continues on a modified diet and thickened liquids to honey consistency. The facility does not provide the thickener but the family consistently ensures the patient has a supply kept with the assisted living staff. The therapist determines the patient determines that the patient is not likely to make objective, functional improvement with swallowing but with interventions that include exercises, caregiver training and electrical stimulation for dysphagia, the patient will be able to maintain a safe swallow with precautions and avoid another hospitalization. The therapist is going to recertify the patient under Criteria 3 maintenance therapy and criteria 2 maintenance therapy. Criteria 2 to continue to provide input to assisted living staff regarding signs and symptoms of aspiration with meals and appropriately thickening fluids. Criteria 3 for application of estim during 2 meals per week to maintain the current swallowing strength. Goal: Maintain safe swallow, prevent re-hospitalization Caregivers to effectively verbalize and identify signs and symptoms of aspiration during meals Caregivers consistently thicken liquids for patient Criteria 3 General Goal Examples The skilled therapy provided is required to maintain function and involves the use of complex and sophisticated therapy procedures Due to nature of diagnosis and risk for bone fracture/tendon tears, therapist will facilitate and maintain hip external rotation and abduction ROM to allow for monthly catheter changes by RN. Lower extremity hypertonicity will be stabilized with neurodevelopmental treatment techniques by therapist allowing patient to continue to participate in ambulation and transfer tasks Patient/caregiver will demonstrate and report safe swallow during all meals with continued dysphagia electrical stimulation provided twice weekly by SLP Caregivers will verbalize and detect signs and symptoms of unsafe swallow during meals independently for 4 consecutive treatments Caregiver will accurately identify and correct unsafe swallowing during 4 consecutive meals.
Criteria 3 Intervention Detail Examples Provide maintenance therapy consisting of complex and sophisticated physical therapy procedures to treat the patient's illness or injury. (Document each of the therapeutic procedures provided and include details about the specialized therapy skills and knowledge utilized, explain why the treatment must be performed by a therapist to be safe and effective). Patient requires skilled facilitation techniques during gait training to improve right lateral weight shifting to enable stable balance effective for gait and improved left step length and clearance. Today, patient presented with increased adduction during gait and required manual stretching to (B) hip adductors and hamstrings for carryover to improved step width during gait training Because of patient s risk for fracture due to diagnosis of osteoporosis, lower extremity passive ROM is performed by a physical therapist to allow for monthly catheter changes by caregiver.