I'm a rehab manager at a SNF and also an OT though I rarely practice now due to management responsibilities. My OT team seems to have drifted from the roots of what I feel is OT. I rarely see them in early to do morning basic ADL's with the clients (or reverse ADL's in the evenings). I see them in the gym doing FM/GM coordination activities/ Cog. Skills/ Exercises/ and practicing putting clothes over clothes. I have heard clients complain about playing with pegs, painting, etc. Has anyone else had this experience? As an OT it blows my mind that you wouldn't do ADL retraining when the person actually needs to do their ADL's for best buy in and for most meaningful treatment session and carryover. If you have had this experience either as an OT or as a supervisor - please share with me how you handled the situation. Do you require your staff to be in at a certain time in the morning? I understand that ADL retraining can be completed at all times of the day but with the geriatric population you would be extremely lucky to have them get dressed once let alone getting dressed and undressed in the middle of the day (unless it's shower day - then yippee!). And I do know that what I'm seeing in the gym are in general components needed to do some ADL but I'm seeing the actual dressing skills maybe being addressed once a week if I'm lucky. By the way the CPT codes being billed reflect that ADL's are not being completed at a level that you would expect. Thanks for any input.
ADLs are required where I work in a rehab hosp. I'm not a manager, but I'm an OTR supervising COTAs and it is frustrating when the ADLs are not done.
What are the productivity standards? I have worked in SNFs that wanted high productivity and staff w/ the most units were highly praised. Often those staff members got those high numbers by doing exercise groups or concurrent Rx, not ADLs. Perhaps if you praised or awarded staff members who did more ADLs or had higher improvement in ADLs it would help. Also, the exercises that are done need to be explained to pts. If doing pegs, explain that FMC will improve and fastening buttons or tying shoes will be easier. Pts that aren't concerned about FMC won't want to do pegs.
You have your work cut out for you, but w/ good direction it can be done.
Joanne
Karla - Unfortunately I think that what you are observing is becoming the norm in many SNF practices. I am appalled at the term "simulated dressing" which I often see in evaluations. How are we considering the cognitive and psychosocial aspects of completing dressing tasks when we are "simulating" putting a shirt on? I see many SNF clients who spend their "therapy time" doing putty exercises and moving doo-dads from one side of a ROM arc to another, but never do anything to practice putting their shirt on with limited shoulder ROM. I am in the fortunate position of being a senior OT who was once the only OT in my facility - I long ago established the practice that we did ADLs during normal ADL times. Yes - we sometimes have to work with nursing staff to make them understand that someone can eat their breakfast in pajamas (a luxury I intend to demand in my geriatric years!) so that they can have their OT session later. But I have found that persistence in this does pay off in that everyone sees progress - and OTs pick up on problems - in ways that are not possible in the simulated world.
As a manager, I think you could start to require a certain number or percentage of ADLs to be done daily. When I started my last job, it was easy to see by the culture of the other OTs and the nursing staff that OTs would do at least 2 ADLs a day. Personally, I have found the idea of 'reverse ADLs', as you say, to be appealing in that you could offer a position that was almost second shift time. I suppose your risk in that sort of endeavor is that you're counting on getting all your units at a time when people are getting more tired.
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Cheryl
http://otnotes.blogspot.com
The musings of an OT about the profession, the future, school, work, and the everyday successes that keep me going to work.
I too have had this experience recently. I used to work in adult rehab 10 years ago, when we could see a client for 2 hours per day for 2-3 month rehab stays! We did 2 or 3 ADLs every day.
I took a per diem job at a Life Care Center in RI this summer. The OTs do NO ADLS EVER. There is NO adl schedule, nursing does them all, all the time. I have seen OTs help a client finish toileting or finish a partially completed ADL in order to get them to the gym quickly for their group OT sessions.
Productivity was expected at 85%, (90% for perdiem OTRs). Evals count as 15 min when it takes over an hour to do them, write them up, and log the information in a computer based program. This mandates that you do all your remaining treatments as concurrent in order to reach 90%. There is no other way, other than falisifying records, which I have seen far too often as well. (Used to work for Sundance while they were being investigated for Fraudulent billing in RI.. fun times.)
I did not last long in managed care.. The staff turn over is high.
I will keep my school aged clients any time (even in this H1N1 scare)
Good luck wiht the battle between required productivity and the Individual ADL treatments.
Lisa
Karla,
I see that a lot in IRF's and SNF's down here in the Rio Grande Valley. Seems to me that young OT grads think of doing ADLs as a "demeaning" job. I even heard of a speech therapist who referred to OTs as "glorified CNA". (sorry for the term, I'm quoting her verbatim.) OTs are relying heavily on unlicensed rehab technicians to do the ADLs or CNAs to report on ADL performance instead of doing it themselves. I work in acute care, and I require my OTs (travellers, PRN and FT) to perform as much functional stuff as possible, given the limited time and activity tolerance that acute inpatients have. I used to work in an IRF and in SNF's back when I was a travelling OT, and I used to do all my ADLs. OTs are trying so much to look good by becoming more and more like PTs in their choice of activities, instead of focusing on "occupation-based" activities. There are other occupation-based repertoire of activities that OTs can use such as gardening, crafts, activity planning for special occasions, shopping, preparing simple meals, making a scrapbook or album for cognition, etc. You can also make any exercise into a game. I recommend using the Wii for that, or to embed the exercise in the form of a game such as horshoe for patients w/ weak upper extremity strength, or playing sitting kickball for patients w/ poor trunk control.
I hope this helps.
Iris
Lisa,
I won this battle against productivity. I proved to administration, that I was not necessarily doing justice to my patients by being overproductive. Infact, it was counterproductive both for the therapist and my clients, me being at risk for burn-out, and my clients being at risk for negligent or poor quality of care. This emphasis on quality versus quantity was very effective, resulting to a more collaborative atmosphere among the members of the multidisciplinary team.
I do want to stress that ADLs are not the only functional activity that OTs can provide. It can be helping a patient identify his own barriers to becoming well again (the occupation of health management), identifying possible community resources for accessing needed care, or assisting the family members facilitate to form adaptive attitudes/outlook towards functional performance and recovery. The challenge is to think about the OT session as more of an "occupation" rather than an "activity".
Greetings, I am an OT myself and I have to agree with you, these are what I call desktop OT's.
and sadly because of that practice we see people have -some times- more respect for PT than OT.
I understand that OT is a very broad practice BUT we do have an identity and many of us choose to deviate from it.
I am happy to report that morning (and... any time of day...) ADLs are alive an well with my SNF population, although I am a new-grad, only working in my SNF for 3 months at this time. AND, I also report that patients respond very well to this activity. My patients value the activity and look forward to demonstrating independence in the activity as part of their rehabilitation.
Our patients value a variety of activities that allow them to demonstrate their independence and safety but the very-personal activity of ADLs seems to be very meaningful for them and somethting that they proudly exhibit to family members.
While ADLs are no the best or only activity that offers growth, it remains viable as an avenue of progress. There are so MANY activities that extend their capabilities, but often ADLs open the door... making them feel capable....
Productivity
Sure wish productivity expectations of our companies could see the impact on the treatment and care we are able to provide. - This would be a great research topic (if not already completed) to study the impact of high productivity expectations as related to LOS and Outcomes and Discharge Placement. I appreciate everyone's responses. I did talk to my OT staff and provided them with a copy of the practice guidelines, alerted them to the unusual minimal useage of 97535 CPT ADL retraining, opened up the discussion...definitely was productivity based reasons for the decline in ADL retraining being completed. So now we are problem solving how we can provide quality, meaningful treatments and still remain close to or meeting the productivity expectations. We do at least one group a week and concurrent treatments and working on point of service documentation with stress on education of the patient regarding their progress that day/week with their treatment. I have seen some improvement but I feel as long as our companies continue to demand high productivity, the patients will continue to not receive the fullest and best OT's can offer them. It is quite unfortunate.
I work with in acute care. We also have 3 OTR/COTA teams for our IPR unit. Us acute care OT's and outpatient OT's help with AM ADL's on the IPR unit before we continue with our jobs (an hour for the first 3 days- 1/2 hour the rest of the time. We are required to do one "wet bottomed" shower within the first 3 days admit during our evaluation. We start at 7am so that all the patients are able to participate in their own washing, grooming and dressing before breakfast at 8:30 am. . When they are independent in ADL's that task is turned over to them to complete and we focus on more advanced skills including IADL's to prepare for discharge and meet their client centered goals. Educating other professionals on what OT is never ends!!!
What it looks like we are doing to another professional is not always what we are trying to achieve. For instance to a nurse it may look like we are "giving a patient a shower" or "dressing the patient". To a Physical Therapist it may look like we are "walking the patient" or "transferring the patient". We actually could be evaluating and treating dynamic balance, sequencing, range of motion, apraxia, vision, problem solving, safety awareness, DME needs, caregiver training during the actual task. What we are accomplishing (ie: shower, trip to the bathroom) is secondary to what we are educationg the patient on towards their independence.
On another note: If I am ever a patient, do not expect me to be very engaged in what you wish me to accomplish if you have not given me the opportunity to be clean and groomed every morning. Yuck!
I would be so depressed if I had to perform in public without a shower. I really enjoy giving all my patients the opportunity to choose OT goals that are meaningful to them. As long as I am providing skilled OT I can help them achieve their goals AND stay productive.I work in a very busy acute care hospital , helping out the IPR unit AM as needed. I am thankful that my work place supports this.
Hello. I am a rehab director in a 185 bed SNF and also the OTR. I encourage my employees to have a 80% + productivity. The key is...time management. As a director you have to guide your staff and as a therapist look at your POC and then provide direction to your assistants. We provide ADLs of course all day, but we successfully provide full body ADLs starting from 5:30am to approximately 10am. We see approximately 13-16residents for AM ADLS. We use a magnet system to indicate which residents OT will be seeing for Am ADLS. This allows nursing staff a visual cue. Most of the time, those residents are being seen for other aspects of their POC...such as therex,splinting, rom...etc...they then are scheduled to come down to the treatment room. I recommend using a scheduling board to monitor and help guide your use of time. And yes...they don't tell you in school that as a therapist...you work through your lunches. Also...as a director...my staff are salary(40+hours/week)...meaning if they have residents to see still at the end of the day or there is a new admit and it is your time to go home...you stay and see those residents. I hope this helps. IF there is anything else i can help you with or give any other suggestions/ideas that might help...please feel free to contact me.
Hello, In the SNF It's about productivity. That aside. I am a COTA who has found myself having issues with those OT's who are just ADL driven. I have seen therapists "watch" their patients get dressed, perform grooming etc.daily. I think these therapists give OT a bad rep. My ADL's may be what you say "not being completed at a level you would expect" I strongly feel that to perform ADL's, I must be offering a skill. In order to do a shower, dressing, grooming etc I need to be offering a skilled service. I need to show adaptive ways of performing the skill, how to use adaptive equipment, ways to conserve energy, hip protection in adl's etc. I have been complemented for my diversity in tx and creativity. I always have my patients best interest in mind and cover many issues in a tx session. Every session of mine includes ther ex. I run ADL groups that has included education with reacher use dressing pants over their clothes up to their knees. I have seen the benefits of pt to pt encouragement in these skills. I stress to you that expecting "morning" ADL's daily from therapists may look good on paper but not always in the best interest of the pt. I personally relate to someone needing to get the most out of a tx. session. That is why I don't perform daily a.m "ADL's" each persons tx program is unique to their needs. If I'm not looking/sounding any different helping a pt get dressed vs. an aide then I don't need to be there and insurance should be paying me to do so.