Functional Geriatrics! Documentation and Treatment Strategies Every - PowerPoint PPT Presentation

Functional Geriatrics! Documentation and Treatment Strategies Every Therapist Must Know to Improve Outcomes 1

COURSE OBJECTIVES 1. Develop individualized, holistic treatment plans for any geriatric setting that sets the tone for treatment with the use of standardized assessment tools. 2. Administer effective treatment interventions that specifically address goals and meet the efficiency demands of managed care models. 3. Compose skilled treatment notes that justify medical necessity of therapy services. 4. Write comprehensive progress reports that provide an accurate analysis of function and justify the need for ongoing services. 5. Establish the necessary steps to prevent and prepare for Medicare audits, specifically targeting therapy. 2

Developing a Comprehensive Tx Plan “Tell a Story” of life before rehab Social Support Who lives in the home, physical/cognitive support, employment, hobbies, responsibilities, lifestyle, access to resources. Environmental Factors Outside: Stairs, Accessible Rails, Accessible/Preferred Entrances, Mailbox Access, Trash receptacles, Ground Type/Condition Inside: Stairs, Rails, Floor Type, Layout, Clutter, Lighting, Doorways, Preferred Seating, Bedroom and kitchen layout Bathroom: Physical Setup – Pedestal or Vanity Sink, Shower stall and/or tub, Commode Type, AE, DME 3

Prior and Current Level of Function Obtain all essential information about the home: Bed Mobility : height of bed/mattress size Transfers : 17 inch and compliant surfaces, favorite chair Gait: Identify at least one gait deviation Stairs: Stair training with one rail only Measure ‐ Doorways, hallways, stair height 4

Prior & Current Level Of Function BADL: includes set up, continence; undergarments; devices Instrumental ADL (IADL): Pet care, trash removal, item retrieval (high, low, floor), plant care/lawn care, gardening, clean up spills, carry beverage Executive Functions: Operate electronics, prepare meal/snack, manage meds, community access, care for others Speech: Voice, volume, intelligibility, auditory & reading comprehension, verbal/graphic expression Swallowing: Status, affected phase, intake ‐ food, liquid, meds Cognition : A&O x 1, 2, 3, or 4; follows 1,2, or 3 step directions 5

Prior and Current Level of Function YIELDS Functional Deficits Underlying Impairments • ROM • Cognition • Alertness • • Executive Function • Strength Sitting Balance • Standing Balance • Articulation • Muscle Tone • Coordination • Voice • Motor • BADL • Pragmatics • Pain • IADL • Aural • Edema • Ambulation • Wounds • Auditory • Memory Comprehension • Sensory • Problem ‐ Solve • Reading Processing • Sequence Comprehension • Perceptual • Follow Commands • Graphic Expression • Vital Signs • Communication • Oral • • Activity Swallowing Motor/Dysphagia Tolerance 6

Hands on Assessment ‐ MMT Modified from 1993 Florence P Kendall. May be reproduced 5 Holds test position against maximal resistance N 4+ G+ Holds test position against moderate to strong resistance 4 Holds test position against moderate resistance G 4 ‐ Holds test position against slight to moderate resistance G ‐ 3+ F+ Holds test position against slight resistance 3 Holds test position against gravity F F ‐ Gradual release from test position 3 ‐ 2+ P+ Against gravity ‐ Moves through partial ROM Gravity eliminated ‐ Moves through complete ROM & holds against pressure 2 P Gravity Eliminated – Moves through full ROM 2 ‐ P ‐ Gravity Eliminated ‐ Moves through partial ROM 1 T No visible movement 0 0 No visible or palpable muscle contraction or movement 7 Note: It is acceptable to test and score within patient’s available range

Standardized Assessments Increase inter ‐ rater reliability Evidence based Little to no equipment needed Administer in 5 minutes or less Many available in multiple languages www.sralab.org/rehabilitation ‐ measures formerly www.rehabmeasures.org 8

Transfers #1) 30 Second Chair Stance Indication: Assesses functional lower extremity strength in older adults Equipment Needed: • Timer • Chair with no arms, 17 inches from floor Instructions: Instruct patient to sit in the middle of the chair, back straight, feet shoulder width apart, slightly posterior to knees, one foot slightly in front of the other. Cross arms and hold against the chest. Demo the task both slowly and quickly. Incomplete stands do not count Interpreting Scores: Average repetitions (moderate activity): 60 ‐ 69 = 14; 70 ‐ 79 = 12.9; 80 ‐ 89 = 11.9 9

Transfers #2) Supine to Stand Test Indication: Assesses transitional movement from supine to standing Equipment Needed: Timer and raised mat or bed Interpreting Scores: Mean time (seconds) to complete supine to stand: 18.1 seconds Interpretations based on seniors requiring assistance with at least one ADL (t/f, ambulation, bathing, or toileting) 10

Balance #1) Four Step Square Test(FSST) Indication: Test of dynamic balance that clinically assesses the person’s ability to step over objects in all directions Equipment Needed: 4 canes and a timer Instructions: Instruct patient, “Try to complete the sequence as fast as possible without touching the canes. Both feet must make contact with the floor in each square. If possible, face forward during the entire sequence.” Demonstrate and allow a practice trial. Interpreting Scores: • > 15 second = at risk for falls for individuals age 65 or older 11

Balance #2) Function in Sitting Test (FIST) Indication: 14 item bedside assessment to assess sensory, motor, proactive, reactive and steady state balance. Equipment Needed: Stop watch, standard hospital bed Instructions: 1. Instruct patient to sit edge of bed with ½ upper leg supported, hips, knees at 90°, feet flat, hands in lap unless needed for support. 2. Provide verbal cues and demonstration as needed. 3. Complete 1 trial per item: Nudge (anterior, posterior, & lateral), static sitting for 30 seconds, shake head no, close eyes for 30 seconds, lift foot 1 inch, pick up object from behind at midline, forward reach ‐ dominant arm, lateral reach ‐ dominant arm, pick up object from floor between feet, posterior scoot ‐ 2 inches, anterior scoot ‐ 2 inches, lateral scoot ‐ 2 12 inches to dominant side.

Balance #2) Function in Sitting Test (FIST) Cont. Interpreting Scores: • Score 4, 3, 2, 1 or 0 for each item. • 4= Ind. • 3= Verbal cues • 2= UE support • 1= min. • Mod or Max A needed • Total score out of 56 • <42 = not likely to return home without assistance 13

Balance #3) 360° Turn Test Indication: A measure of dynamic balance Equipment Needed: Tape on floor to mark start position and timer Instructions: Instruct patient to turn completely in either direction. Conduct 2 trials and record the average time as the score Interpreting Scores: > 3.8 seconds = decreased independence Remember • 3 sensory systems provide input to the cerebellum for balance • Check proprioception with by removing vision (I.E. Romberg Test) • Have more time? Consider Tinetti (low inter ‐ rater reliability), Berg (no device), Dynamic Gait Index (incorporates head turning). BEST or Mini BEST (incorporates incline ramp), 2 Minute Walk Test 14 (Dementia)

ADL #1) Barthel & Modified Barthel Indication: Measure of physical disability used widely to assess behavior relating to activities of daily living for patients with disabling conditions. Designed to increase the sensitivity of the Barthel ADL Index Equipment Needed: Modified Barthel Assessment Tool Instructions: Score the patient in each ADL area based on what the patient does over past 24 ‐ 48 hours. Direct testing is not required Interpreting Scores: • 0 ‐ 20 = Total Dependence, 21 ‐ 60 = Severe Dependence, 61 ‐ 90 = Moderate Dependence, 91 ‐ 99 = Slight Dependence, 100 = Independence • <40 = dependence in mobility and care (24/7 help in home or SNF) • 40 ‐ 60 = Some assistance with mobility and care (in home or ALF) • 65 ‐ 80 = community living with support services • 85 ‐ 100 = Independent community living (walking or with w/c) 15

Sample Barthel Assessment Item ADL AREA SCORE DESCRIPTION FEEDING 0 ‐ Unable 5 ‐ Needs help cutting; spreading butter, etc. or requires modified diet 10 ‐ Independent Sample Modified Barthel Assessment Item FEEDING 0 ‐ Dependent in all aspects and needs to be fed orally or otherwise 2 ‐ Can manipulate eating device but needs assistance during meal 5 ‐ Self feeds with supervision. Needs assistance with associated tasks such as adding milk/sugar into tea, salt/pepper, spreading butter, rotating plate or other set ‐ up activities 8 ‐ Independent in feeding with prepared tray except needing meat cut, milk carton opened, etc. Presence of another person is not required during the meal 10 ‐ Independently feeds self from a tray or table when someone places food within reach. May use a device to cut food, add salt and pepper, spread butter, etc. 16