1. Dawn De Vries, DHA, MPA, CTRS Grand Valley State University devridaw@gvsu.edu Slippery Rock University – April 1, 2016

2. Overview Learning Outcomes Outline Participants will be able to: Describe how RT can contribute to restorative goals when working with older adults. Define restorative services in a SNF and in the community. Identify two regulatory requirements for working in a restorative program. Introduction Definitions Restorative Opportunities Community Restorative Opportunities Documentation Wrap Up

3. What is Recreational Therapy? Recreational therapy, also known as therapeutic recreation, is a systematic process that utilizes recreation and other activity-based interventions to address the assessed needs of individuals with illnesses and/or disabling conditions, as a means to psychological and physical health, recovery and well-being. Approved 2015 as ATRA Definition Statement – ATRA Board of Directors

4. What are “Restorative Services”? “Rehabilitative or restorative care refers to nursing interventions that promote the resident’s ability to adapt and adjust to living as independently and safely as is possible. This concept actively focuses on achieving and maintaining optimal physical, mental and psychosocial functioning.” CMS’ RAI Version 3.0 Manual(October 2013) Page O-35

5. What’s the link?

6. Regulation: §483.15 F Tag 240 “A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident’s quality of life.” Guideline: “The intention of quality of life is to specify the facility’s responsibility toward creating and sustaining an environment that humanizes and individualizes each resident …”

7. Regulation: §483.15 F Tag 241 Dignity: “The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity, and respect in full recognition of his or her individuality.” Emphasis on dignity and respect, self-determination and participation

8. Regulation: §483.25 F Tag 309 “Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental and psychological well-being, in accordance with the comprehensive assessment and care plan.”

9. Regulation: §483.25 F Tag 310 “A resident’s abilities in activities of daily living do not diminish unless circumstances of the individual’s clinical condition demonstrate that diminution was unavoidable. This includes the resident’s ability to: bathe, dress and groom; transfer and ambulate; toilet; eat; and use speech, language or other functional communication systems. Section 483.25(a) Federal LTC Regulations

10. Regulation: §483.25 (a)(2) F Tag 311 “A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a)(1) of this section ….”

11. Components of Restorative RAI Version 3.0 Manual – page O-35 When are Restorative Services initiated? “…when a resident is d.c. from formalized PT, OT or SLP.” Admitted with restorative needs but not a candidate for skilled therapy. As need arises during stay.

12. Areas RAI Version 3.0 Manual – page O-37 & 38 ROM: active and passive Splint/Brace assistance Bed mobility Transfer Walking Dressing/Grooming Eating/Swallowing Amputation/Prosthesis Care Communication

13. Restorative Care Criteria RAI Version 3.0 Manual – page O-36 Measurable objectives & interventions. Documented in care plan & clinical record. Periodic evaluation by licensed nurse in clinical record. Nurse assistants/aides must be trained in techniques. Carried out or supervised by members of the nursing staff. “Sometimes, under licensed nurse supervision, other staff and volunteers will be assigned to work with specific residents”. 1:4 ratio in group settings.

14. Activity MUST be … PLANNED SCHEDULED DOCUMENTED

15. Other Requirements Nursing staff must establish the purpose and objective of treatment. Others may document restorative care. Therapists can provide and count minutes of maintenance services on MDS; however, maintenance does not qualify a person for Medicare coverage.

16. Why do a RT Restorative Program? Quality of care Quality of life Functional improvements Within scope of practice for RT Impact RUGS for individuals on Medicare (low RUGS categories)

17. Restorative Program Purpose Serves as: Fill in where PT, OT and SLP cannot due to the Therapy cap (past, possibly future reason) Screening tool to determine if skilled interventions are needed. Co-treatment setting. Discharge site after skilled therapy intervention.

18. Therapy Cap 2016 Therapy Cap for Medicare B coverage $1,960 for OT services per year. $1,960 for PT and SLP services combined per year. Can submit for reimbursement if higher but must meet criteria (documentation, skilled intervention, reasonable & medically necessary)

19. Sample Rates of Outpatient Therapy Services Source: http://metrohealth.net/about-metro/quality-pricing/physical-occupational- therapy/physical-occupational-therapy-prices/ OT PT Eval 137.40 Functional therapeutic activity 113.30 Cognition/perception 113.30 Sensory integration 122.69 Therapeutic exercise 113.30 OT wound care 113.30 Manual OT (15 min) 113.30 Recheck orthotic 63.85 OT supervised exercise 42.88 PT assessment 158.06 Bed mobility 113.30 Coordination trng 113.30 Functional trng 113.30 Gait trng 113.30 Manual Therapy 113.30 Orthotic eval/trng 113.30 Therapeutic exercise 113.30 Transfer trng 113.30 Wheelchair mobility 113.30

20. Sample Rates of Outpatient Therapy Source: http://metrohealth.net/about-metro/quality-pricing/physical- occupational-therapy/physical-occupational-therapy-prices/ SLP Cognitive performance 205.00 Speech/language eval 351.75 Speech/language treatment 255.75 Swallow eval 225.50 Swallow treatment 180.00 Cognitive treatment 298.25

21. Benefits of Program Improved physical functioning. Increased and more consistent utilization of compensatory techniques. Improvements in cognition. Return to lesser level of care. Improved mood. Improved communication and social interaction. Increased mood. Reduction in disturbing behaviors. Enhanced leisure. Enhanced quality of life. Decreased falls. Decreased utilization of psychotropic medications.

22. IDEAS? Senior Center Outpatient Services PACE Program

23. Assessment Facility Need Effective restorative program Management Support Impact on RUGS Benefits QI/MDS Resources Staff Finances Space Residents ADL Declines

24. Planning Program Design Activity Analysis Criteria Entrance and exit criteria Purpose of groups Group ideas Length of groups Frequency Goals Education! Essential for all departments Understand process, purpose and referrals.

25. GROUPS

26. Communication Group Example of Program Criteria Objectives Activities To increase social skills. To improve communication. To increase long term memory. To increase short term memory. To improve attention to task. To improve word finding abilities. Reminiscing Current events Memory book Planning group Word games Story telling Table games

27. Communication Group Example of Program Criteria Entrance Criteria Exit Criteria Appropriate referral. Appropriate social behavior for group setting. Decline or difficulty in any of the objective areas. Decline in communication skills. Decreased social interaction. Potential to have improvement in cognitive functioning as determined by Recreation Therapist or Restorative Nurse. Resident has meet goal(s). Resident showed no signs of improvement after four weeks. Resident is not socially appropriate in group situations. Resident shows physical decline related changing medical condition. Resident refused group three times. Skilled therapy is providing interventions.

28. Cognitive Group Example of Program Criteria Objectives Activities To improve problem solving ability. To increase attention to task. To improve short term memory. To improve long term memory. To improve recall of information. To increase safety awareness. To enhance new learning. To increase social interaction. To improve sequencing skills. To improve orientation. To improve direction following. Table game Arts and crafts Card games Planning group Word games Memory books Reminiscing Cooking Current Events

29. Cognitive Group Example of Program Criteria Entrance Criteria Exit Criteria 1. Appropriate referral. 2. Appropriate social behavior for group setting. 3. Recent decline in cognitive abilities. Potential to have improvement in cognitive functioning as determined by Recreation Therapist or Restorative Nurse. Deficits in cognitive abilities. Resident has meet goal(s). Resident showed no signs of improvement after four weeks. Resident is not socially appropriate in group situations. Resident shows cognitive decline related changing medical condition. Resident refused group three times. Skilled therapy is providing interventions.

30. Physical Group Example of Program Criteria Objectives Activities To increase endurance. To improve range of motion. To increase strength. To increase gross motor functioning. To increase fine motor abilities. To improve wheelchair mobility or ambulation. To maintain functional abilities. Walk/Wheel club Exercise Music and Motion Active Games

31. Physical Group Example of Program Criteria Entrance Criteria Exit Criteria Appropriate referral. Appropriate social behavior for group setting. Decreased range of motion. Decline in endurance. Decreased strength. Decreased gross or fine motor ability. Other change in physical functioning. Potential to improve in physical functioning, as determined by the Recreation Therapist or Restorative Nurse. Resident has meet goal(s). Resident showed no signs of improvement after four weeks. Resident is not socially appropriate in group situations. Resident shows physical decline related changing medical condition. Resident refused group three times. Skilled therapy is providing interventions.

32. Implementation Roles Schedule Environment Group structure/routine Participation Goal Writing: specific, measurable, individualized, related to functional abilities

33. Physician Orders Scope Duration Frequency Must include if plan to utilize group tx. Example: RT to treat for LE strengthening related to mobility 3x/wk. x 4 wks.

34. Use of Groups 1 therapist to 4 residents. In restorative programs, restorative aides are able to provide 1:4 interventions as well. In breaking down the time of treatment, you divide the number of minutes by the number of residents to determine how much can be counted for each individual. For example, 4 residents in a 60 minute groups = 15 minutes per resident.

35. Section O Special Treatments, Procedures and Programs Section O 0500 Use for Restorative or Maintenance activities Section O 0400 F 1 & 2 Use only for Active Treatment restore, remediate or rehabilitation goal of improving function or resolving a specific medical condition (realistic expectation of improvement). Medicare Part A

36. Restorative & Maintenance Restorative To qualify for Restorative Services, a resident must have the ability to: make decisions be capable of increased performance Maintenance Resident does not have to have decision making abilities and/or Has severe limitations caused by illness.

37. RUGS At least two 15 minute restorative activities 6 days a week = Low Rehab RUGs Categories Behavioral Symptoms and Cognitive Performance (BB2, BB1, BA2, BA1) Physical Function Reduced (PE2, PE1, PD2, PD1, PC2, PC1, PB2, PB1, PA2, PA1) RUG IV Category Descriptors from MDS 3.0

38. RUGS – Physical Function Reduced Nursing Rehab Activities > 2, min. of 6 days/week ADL Index End SplitsRUGS Category Urinary/bowel training15-16Nursing Rehab > 2PE2 Passive/Active ROM15-16Nursing Rehab > 1PE1 Amputation/prosthesis care11-14Nursing Rehab > 2PD2 Splint/brace assistance11-14Nursing Rehab > 1PD1 Dressing/grooming6-10Nursing Rehab > 2PC2 Eating/swallowing6-10Nursing Rehab > 1PC1 Transfer2-5Nursing Rehab > 2PB2 Bed mobility/walking2-5Nursing Rehab > 1PB1 Communication0-1Nursing Rehab > 2PA2 0-1Nursing Rehab > 1PA1

39. Day to Day Operations Documentation Assessment Initial Note Physician Orders Scope, duration and frequency. Weekly Notes Monthly notes Care Plans Goals must be specific and measurable. 4 week time frame. Communication

40. Evaluation Daily Weekly Monthly CQI

41. Questions? Other ideas to share?

42. Resources Best Martini, E., Weeks, M. & Wirth, P. (2011). Long term care for activity professionals, social services professionals, and recreational therapists. (6 th ed.). Ravensdale, WA: Idyll Arbor. Centers for Medicare & Medicaid Services. (2013). MDS 3.0 RAI manual. Bethesda, MD: Author. De Vries, D. (2004). Enhancing your practice in long term care: Group treatment. Alexandria, VA: ATRA. De Vries, D. & Lake, J. (2002). Innovations: A recreation therapy approach to restorative programs. State College, PA: Venture Publishing.