While there is a great deal of focus on the management of post-acute patients in the SNF population, many of whom will return to the community, management of long term care patients is equally essential to the provision of services along the continuum of care. According to CMS regulations, long term care patients have a right to function at their highest practicable level, including the delivery of services to slow the progression of decline, as long as these services meet the definition of skilled criteria. In order for these services to be skilled, they must be considered reasonable and necessary and require the skills, knowledge, and judgment of a licensed qualified professional based on their inherent complexity.
There are essentially three levels of care in the SNF population, which could be viewed as a triangle. The bottom or widest part of the triangle represents the “restorative” patient, who typically has a brief stay in the SNF, and whose plan is to return to the community. The center of the triangle represents the “compensatory” level of care, which depicts the patient who is unable to return to the community, but who is taught to compensate overall for their deficits in order to enable them to function at as high a level as possible during their stay in the SNF.
The very top of the triangle represents the “adaptive” level of care. At this level rests the end-stage patient, who may require palliative care, such as wound care for pain management, positioning, or swallowing interventions. In order to meet the needs of these segments of the patient population, interdisciplinary teamwork is essential to achieve ADL independence, decrease pain and decrease staff injury during the provision of care. Enabling a patient to assist in the ADL task can improve quality of life, and much more.
In order for Rehabilitation to identify declining functional components timely, accurate nursing documentation is key for several reasons. Nursing documentation forms the basis for identifying the actual onset date of the patient’s change in condition. While the “three day rule” is not required to establish a patient has had a change of condition, multiple entries help to establish that skilled nursing observation, assessment and monitoring are ongoing, and that there is a pattern or chain of circumstances occurring with the patient which warrant a closer look. The scope of these changes is broad, and covers multiple areas and systems. Areas of patient decline to note include postural changes, skin redness, decreased mobility, the need for increased staff assistance to complete ADL’s, increased pain, decreased appetite, weight loss, and increased lethargy, to name a few. Through the daily skilled observations of CNAs and Nurses, subtle changes in patient performance may be identified, signifying the need for skilled assessment by the Rehabilitation professional. Identifying change in these areas should be documented, and should generate a referral to Therapy for a closer look.
Referrals to Physical Therapy should occur based upon the following symptoms:
- Decreased mobility; including bed mobility or overall functional mobility.
- Increased pain with movement; either active or passive.
- Joint changes; contractures and decreased range of motion.
- Changes in muscle tone; either increased rigidity or flaccidity.
- Onset of increased tremors, shakiness, or knees buckling.
- Increased assistance with transfers.
- Gait changes; such as unsteadiness, shuffling gait.
- Balance changes; such as loss of balance.
- Furniture walking (holding on to furniture during attempts to walk).
- Falls or unintentional changes in plane.
- Pressure areas; stage 3 or 4 including non-healing wounds of greater than 30 days.
- Changes in sequencing movements; such as decreased ability to use assistive devices for ambulation.
Referrals to Occupational Therapy should occur based upon the following symptoms:
- Decline in ADL independence; including the need for increased assistance toileting, self feeding, dressing, bathing.
- Decreased trunk control or strength.
- Postural changes; leaning in wheelchair, anteriorly, laterally or posteriorly.
- Muscular tone changes; i.e. increased rigidity or flaccidity.
- Decreased wheelchair mobility.
- Skin redness to bony prominences or other areas with prolonged wheelchair sitting.
- Increased pain in upper extremities and joints; including shoulders, hands, wrists, etc.
- Contracture of upper extremity joints, including fingers, hands, etc.
- Decreased ability sequencing activities of daily living, i.e. dressing, functional problem solving.
- Positioning changes; i.e. inability to hold head up in wheelchair.
- Decreased functional activity tolerance for ADL’s.
- Increases in shortness of breath while completing ADL’s.
- Decreased ability to reach for items in immediate environment.
- Declining cognition.
- Decreased safety awareness.
- Decreased visual discrimination or acuity.
- Decreased continence.
Referrals to Speech-Language Pathology should occur based upon the following symptoms:
- Decreased ability to communicate basic wants/needs.
- Slurred or garbled speech that is difficult to understand.
- Inability to name objects.
- Increased lethargy.
- Declining cognition.
- Increased confusion.
- Decreased problem solving of simple daily functional situations.
- Inability to recognize familiar faces.
- Weight loss.
- Prolonged chewing or swallowing during meals.
- Residual food remaining in the mouth after meals.
- Coughing, choking, runny nose, or watery eyes during meals.
- Decreased PO intake.
- Decreased safety awareness.
- Facial asymmetry.
- Incidence of drooling; difficulty managing own secretions or saliva
- Wet, gurgly vocal quality.
- Decreased audible voice.
- Uncoordinated respiration and swallowing during meals.
- Decreased visual scanning.
- Recurrent URI’s, particularly Right Lower Lobe pneumonia.
The above lists represent only the starting points for which the patient should be referred to Therapy for additional screening and/or evaluation. In order to support the initiation of Therapy Services for a long term care patient, it is essential that there are nursing notes describing when the changes occurred, under what circumstances they were identified, the frequency with which the symptoms are noted, any interventions attempted by nursing to address the concerns, who was notified of the changes, any pertinent nursing assessments performed, etc. Therapy will review the nursing notes as part of the screening and evaluation process, and this will become the basis for medical necessity of the Therapy intervention, as well as the onset date on the Skilled Therapy Evaluation.
Below are a few examples of nursing documentation in support of the initiation of Rehabilitation services:
- Patient noted with increased left leaning over the side of the wheelchair every evening after meals.
- Attempts to reposition the patient were not successful.
- Patient noted with knees buckling daily when CNA staff ambulate patient to the toilet.
- Patient complains of increased shoulder pain during dressing.
- Patient noted with excessive chewing prior to swallowing during meals.
- Patient no longer propels self to meals.
- Patient with unsteady gait during walk to dine restorative nursing program.
- Patient with increased confusion regarding recognition of family members or previously familiar objects in environment.
- Patient noted with decreased ability to control saliva throughout the day for several days.
- Patient with decreased task attention; no longer able to watch movies during activities.
- Patient with recurrent respiratory infections.
These represent many of the areas that skilled Rehabilitation is able to assess and manage. The goal of the Therapy intervention is to progress the patient to the highest practicable level, slow the decline of their disease process, develop systems to maintain them at as high a level as possible for as long as possible, train the staff and family regarding how to elicit optimal performance from the patient, and ultimately transition the patient back to the Nursing staff. Clinical objectivity by all disciplines involved is highly valuable in these processes, in order to ensure that complacency or staff bias does not interfere with patients’ rights to experience optimal health and functioning throughout their skilled nursing facility stay. Skilled interventions enhance patients’ quality of life, preserve their sense of independence and functionality, and reduce the burden of care on staff and caregivers.