Creating a Niche for Therapeutic Recreation working with the Elderly Maintenance, Restoration, and Rehabilitation Dawn De Vries, DHA, MPA, CTRS Illinois Therapeutic Recreation Association 2013 Conference For HANDOUT, GO TO:

Agenda 1.Check in 2.Participant goals 3.Learning Objectives 4.Therapeutic Recreation – definition 5.Maintenance Opportunities 6.Restorative Opportunities 7.Rehabilitation Opportunities 8.Documentation for Programs 9.Wrap up

Learning Objectives Participants will be able to: Describe how TR can contribute to maintenance, restoration and rehabilitation services when working with the elderly. Define each of these types of service: maintenance, restoration and rehabilitation. Identify two opportunities for TR to work with the elderly in organization and community settings.

Therapeutic Recreation Therapeutic Recreation is the provision of Treatment Services and the provision of Recreation Services to persons with illnesses or disabling conditions. The primary purposes of Treatment Services which are often referred to as Recreational Therapy, are to restore, remediate or rehabilitate in order to improve functioning and independence as well as reduce or eliminate the effects of illness or disability. The primary purposes of Recreational Services are to provide recreation resources and opportunities in order to improve health and well-being. Therapeutic Recreation is provided by professionals who are trained and certified, registered and/or licensed to provide Therapeutic Recreation. ATRA Definition Statement

Regulation: § 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 …”

Regulation: § 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

Regulation: § 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.”

Regulation: § 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 (a) Federal LTC Regulations

Regulation: § (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 ….”

Maintenance Opportunities

Maintenance Definition? Purpose? Types of programs?

How do you plan and select programs? Conduct assessment at admission and on-going evaluation. Consider individualized interests and preferences. Examine what is age/stage appropriate. Review functional skills and cognition.

Programming Essentials Department philosophy or mission Domains Blend of programs: large, small, 1:1, special events, intergenerational Environment: respect, dignity, acceptance, accessible Value ≠ participation; value = experience Create success and positive feelings Focus on strengths Emphasize independence Repetition, cues, feedback Resources available Activity analysis

OBRA Required Elements Stimulation Solace Physical health Cognitive health Emotional health Self-Respect Male oriented Task-segmentation Seasonal/special events Indoor/outdoor Community based Cultural Religious Special Needs/Adaptations Activities for all ages In-Room

1. DOMAINS 2. RELEVANCE (MEANINGFULNESS AND PERSON-CENTERED) 3. FUNCTIONAL LEVEL Major components for Programming

Programming based on Functional Skills Functioning Level, Programming, Program Setting Track 1: large groups and/or independent activities Track 2: small groups Track 3: one to one or sensory stimulation Dementia Rehab/Subacute Specialty Population

Restorative Opportunities

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

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.

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.

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

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.

Activity MUST be … PLANNED SCHEDULED DOCUMENTED

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.

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)

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.

Therapy Cap 2013 Therapy Cap for Medicare B coverage $1,900 for OT services per year. $1,900 for PT and SLP services combined per year. Can submit for reimbursement if higher but must meet criteria (documentation, skilled intervention, reasonable & medically necessary)

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.

Referrals After discharged from PT, OT and/or SLP. Transition from Medicare unit to long term care. Individual qualifies for Low RUGS category while on Medicare- nursing + restorative services.

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

Rehabilitative Opportunities Recreational Therapy Rehabilitation and Subacute Programs

What is Rehab? Definition? Team Members? Settings? Purpose of RT in rehab? Acute vs. subacute?

Diagnoses Medically complex (chronically ill or multiple medical problems) – need to be monitored medically or receive specialized care Respiratory Care (ventilator care or ventilator weaning) Recuperating from surgery Deconditioning Orthopedic – fracture, joint replacement Stroke Amputations Head injury Cardiovascular – CHF, CAD, COPD Oncology Pain Management Wound Management

Role of RT Assist in adjustment/coping skills Provide motivation Reinforce OT, PT, SLP goals and documentation Structure independent time Leisure Education Adaptation Active Treatment Community Integration

WHAT IS ACTIVE TREATMENT?

CMS’ Definition of Recreational Therapy Services that are provided or directly supervised by a qualified recreational therapist who holds a national certification in recreational therapy, also referred to as a Certified Therapeutic Recreation Specialist.” Recreational therapy includes, but is not limited to, providing treatment services and recreation activities to individuals using a variety of techniques, including arts and crafts, animals, sports, games, dance and movement, drama, music, and community outings. Recreation therapists treat and help maintain the physical, mental, and emotional well-being of their clients by seeking to reduce depression, stress, and anxiety; recover basic motor functioning and reasoning abilities; build confidence; and socialize effectively. Recreational therapists should not be confused with recreation workers, who organize recreational activities primarily for enjoyment. CMS’ RAI Version 3.0 Manual, Appendix A – Glossary and Common Acronyms, page A-18 (December 2011)

Active Treatment 1.Is physician ordered treatment that includes scope, duration and frequency of treatment 2.Requires supervision and evaluation by a physician 3.Has the reasonable expectation of improvement

Individualized Treatment Plan Services must be prescribed by a physician and provided under an individualized written plan of treatment established by a physician after any needed consultation with appropriate staff members. The plan must state the type, amount, frequency, and duration of the services to be furnished and indicate the diagnoses and anticipated goals.

Physician Supervision and Evaluation Services must be supervised and periodically evaluated by a physician to determine the extent to which treatment goals are being realized. The evaluation must be based on periodic consultation and conference with therapists and staff, review of medical records, and patient interviews. Physician entries in medical records must support this involvement. The physician must also provide supervision and direction to any therapist involved in the patient's treatment and see the patient periodically to evaluate the course of treatment and to determine the extent to which treatment goals are being realized and whether changes in direction or emphasis are needed.

Reasonable Expectation of Improvement Services must reasonably be expected to improve the patient's condition. The treatment must be aimed at improving or maintaining the patient's level of functioning.

Recreation/Activity Services According to CMS Covered Service Activity therapies but only those that are individualized and essential for the treatment of the patient's condition. The treatment plan must clearly justify the need for each particular therapy utilized and explain how it fits into the patient's treatment. Non-Covered Service Activity therapies, group activities or other services and programs which are primarily recreational or diversional in nature. Outpatient psychiatric day treatment programs that consist entirely of activity therapies are not covered.

Differences ACTIVITIES Purpose: designed to meet individual needs of residents Focus: diversional and maintenance activities- “therapeutic activities”- quality of life emphasis. Format: usually large group, also small groups Not physician ordered. AD requirements. RECREATIONAL THERAPY Purpose: individually focused to improve or restore functional abilities. Focus: therapy aimed at restoration or improvement- active treatment that is medically necessary. Format: 1:1 treatment or 1:4 ratio. Physician ordered. CTRS or CTRA under the direction of a CTRS.

Opportunities Role on interprofessional team Individual treatment Co-treatment Group co-treatment

Treatment Areas Physical Balance, ROM, FM, Mobility, Falls reduction, Endurance, Strength, Coordination, Gross motor Cognitive LTM, STM, Direction following, Communication, Problem Solving, Sequencing, Word Finding, Number/Letter identification/matching, Attention to task, Decision making, Organizational Skills, Safety Awareness, Money Management Psychosocial Social Skills, Communication, Relationship building, Coping, Self-Esteem, Anger Management, Time Management, Behavior, Community Integration, Reduction of depression and/or anxiety, Adjustment, Motivation, Assertiveness, Initiation Leisure Adaptation, Skills, Energy Conservation, Life Roles, Leisure Education, Involvement, Awareness, Community Resources, Quality of Life, Fitness

Interventions Functional Area? Activity idea(s)? Roles of each discipline? What will OT, PT, and SLP work on in a group treatment?

PROGRAM DEVELOPMENT

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

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.

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

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

Care Plan Problem Ex. Resident displays LE weakness AEB inability to stand for 5 seconds with max. assist of 2. Goals Specific Measurable Related to functional abilities Ex. Resident will demonstrate increased LE strength AEB standing for 30 seconds with CGA. Interventions What will be done to address the goal? Ex. Innovations Program 5x/wk. x 4 wks.; use weights on LE for exercises Time Frame How long to achieve this goal? Ex. 4 weeks

Group Treatment Definition: therapeutic environment in which therapists treat patients to achieve individual and team goals in an efficient and effective manner.

Using Group Treatments Benefits Multiple perspectives Information sharing Natural learning environment Motivation Social interaction Adjustment/ acceptance Teamwork Fun/interest Constraints Distracting/ overstimulating Space needs Mix of patients Burden Teamwork among therapists

Guidelines for the 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.

Section O Special Treatments, Procedures and Programs Section O 0500 Use for Restorative or Maintenance activities Restorative Maintenance 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

Day to Day Operations Documentation Assessment Initial Note Physician Orders Scope, duration and frequency. Treatment Notes Monthly Notes (restorative) Discharge Summary Care Plans Goals must be specific and measurable. Time frame? Communication

QUESTIONS?