Keep Dementia Training Front of Mind: Harmony often discusses clinical review of individual patient interventions with the rehabilitation and nursing team regarding identification, assessment, and management of patients with advanced dementia. While treatment of low functioning, demented, or long term patients is challenging, Harmony believes that with increased training regarding targeted strategies, this particular group of residents will benefit greatly from skilled interventions. There are three levels of Rehabilitation that meets skilled criteria in the SNF setting.
First, the Restorative patient, who will likely return to the community, tends to be the type of patient who is easily identified for Rehabilitation services. Secondly, there is the Compensatory patient, who will likely be a long term resident, and for whom the goals is to restore as much function as is possible, followed by development and education of strategies to compensate for deficits that may not be able to be remediated. This type of patient as well is usually easily identified and managed via the Rehabilitation caseload. The third type of patient is the patient at the Adaptive level of care. This type of patient may not interact with the clinician, and may be end-stage in the disease process. At times, the adaptive patient may be less identifiable as a potential candidate for Rehabilitation services given their greatly reduced functional capability, decreased communication ability, and seemingly decreased ability to make functional gains. However, wound care, swallowing, positioning, and contracture prevention may all be considered skilled within well defined parameters, and may benefit patients at this level of care.
The following factors contribute to the development and implementation of an appropriate treatment plan for this segment of the long term population:
- Clinical Objectivity: This tool is essential to assessment and fosters confidence to evaluate patients regardless of their cognitive functioning level, whether by direct or indirect methods.
- Clinical Approach: The ability to communicate and establish rapport requires modification of established assessment practices in some cases, i.e., modification of the therapist’s tone of voice, communication method, (verbal versus non-verbal), presentation of sub components of a standardized evaluation, the allowance of increased time for residents to process information, as well as the addition of tactile cues to facilitate response initiation.
- Clinical Decision Making: The goal of intervention in the cognitively impaired patient may be to restore function, but it may also be to provide staff education regarding the treatment approach utilized to promote successful interaction with the patient in order to facilitate the patient’s best response. The patient’s plan of care may also indicate long term goals such as to reduce pain improving quality of life, to increase blood flow to the area to enhance the development of new epithelial tissue in order to promote wound healing.
- Staff Communication: Often the most important component of intervention for many patients is the caregiver training aspect, which educates caregivers regarding successful strategies to perhaps mobilize the patient to reduce risk of patient or caregiver injury, or to promote safe swallow techniques to reduce the risk of complications related to signs and symptoms of aspiration. This component should be accompanied by written materials and sign in sheets, identifying who was trained and verifying what information was presented.
The following brief video can assist providers in educating staff on the progression and implications of this disease.
(Developed in partnership with Alliance for Aging Research)
The successful SNF embraces care at all levels along the continuum of care, even if for brief intervals, in order to equivocally care for patients along the entire spectrum of their needs.