occupational therapy, OT Settings, Uncategorized

Occupational Therapy in Skilled Nursing Facility

Inpatient Settings: OT in Skilled Nursing facility (Subacute rehab/Short term care;  Long term care) Overview

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Image: Rising Demand for Long-Term Services and Supports for Elderly People

In regard to occupational therapy servicing the rehabilitative patient within the skilled nursing facility (SNF) setting  the occupational therapy practitioner can play a tremendous role in enabling short term patients and long term residents in living life to the fullest.

So you may be wondering why or what in the world subacute rehab, short term care, long term care, patients vs residents, and skilled nursing facility entails or why they are grouped together under one post.

Or perhaps you may ask why the facility isn’t called a “skilled therapy facility” instead of a “skilled nursing facility” #mindblown about so many ways to think of this. Well the mystery increases – as it turns out, the verbiage changes based on location and region of the country / world.

The BEST way I can describe the characterization of the skilled nursing facility (SNF) setting is to first envision a singular large building and second think of the building as two parts of a whole.

  1. Subacute rehab (SAR) – Short term stay patients: Within that large facility encompasses a typically smaller sector of patients that are meant to be there for short term rehab. These are the patients that may have completed therapy in preceding settings in the hospital (such as ICU,  Acute Care, or Acute Inpatient Rehab click each to read OT’s role in aforementioned settings) but lack the resources or are not functionally independent enough to immediately transition back into their homes/communities; therefore, they discharged from the hospital and transitioned into the subacute rehab (short term stay) unit within the skilled nursing facility.
    • Key point: These patients are typically here for a short term length of stay to maximize their potential to return back to their home environment. They usually receive about 1-2 hours of skilled therapy services (divided amongst OT/PT/SLP) 5x/week. In the event that the subacute rehab patient does not make the necessary functional progress to safely return home, they may transition to the longterm care side of the skilled nursing facility.
    • Occupational therapy services in the skilled nursing setting for a short term stay may address… task simplification in effort to streamline activities of daily living, consist of energy conservation implementation when performing simulated instrumental activities of daily living tasks, or how to correctly use adaptive equipment and follow weightbearing precautions safely and consistently. Interventions may be tailored to facilitate ability to reintegrate back into former life occupational roles.
  1. Longterm care (LTC) – long term residents: Within that same large building is the long term care sector that typically hosts the majority of patients. These are the patients -RESIDENTS- who essentially live in the skilled nursing facility. It is their home. Let me reemphasize this. This is THEIR home and we should be mindful of how we interact with them in their “home”. To further add to the mix, within the long term care sector, there may be subsets of smaller wings that may host specific patient populations such as a memory care unit (for patients with dementia) or a psychiatric care unit (for patients with a longstanding history of schizophrenia). Whew that was a mouthful.
    • Key point: These patients LIVE here. They may not ever “leave”. But they deserve our attention and services just as much as anybody else.
    • Occupational therapy services in the skilled nursing setting for the long term residents may focus more on quality of life measures that make a diligent effort to prolong both dignity and choice. Interventions may consist of environmental adaptations such as creating door signs that mimic a road STOP sign to reduce wandering in patients with dementia, providing weighted blankets to calm fidgety residents – think emotional/physical regulation, recommending and ordering seating devices, and coming up with a list of engaging, meaningful activities that match the person’s interests and abilities for activities coordinators to carryout.
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Pictured above are residents from a skilled nursing facility in California collaborating to prepare food for the homeless as part of a project to both provide them with purpose and a way to give back. To read more about this click here to view original article.
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My last Level II Fieldwork was in a skilled nursing facility in which I experienced working with both short term stay patients and long term care residents!! I painted these as a gift for their facility and wrote a blog from my experience there from Aug 2016-Nov 2016 here!!! “FW mOTivation: For the Long Term (care and Inpatient Rehab)

What does Occupational Therapy and Skilled Nursing Facilities look like?

What are some pros & cons of working in a #SNF setting? Productivity, typical day, co-workers, etc | SeniorsFlourish.com #OTtreatmentideas #OT #occupationaltherapy #OTlove
Stop whatever you are doing and go listen to this podcast “Occupational Therapy in Skilled Nursing Facilities” on SeniorsFlourish podcast (by Mandy)
Before we dive in further let's think about Acute Inpatient 
Rehab as part of the many INPATIENT settings occupational 
therapy serves an invaluable role in:

Inpatient therapy services typically occur within the context 
of a hospital or medical facility in which the person 
receives services during their stay at that hospital or 
medical facility. Some specific settings within the 
inpatient category that will be explained in this and 
future blog posts includes the following:

Intensive Care Unit

Acute Care

Acute Inpatient Rehab (Adults)

Acute Inpatient Rehab (Pediatrics)

SubAcute Rehab (short term stay)

Skilled Nursing Facility (long term stay)

DISCLAIMER: The above-mentioned list is not all inclusive. 
This article should not be used as medical advice and paints 
a subjective picture portrayed through different perspectives 
from occupational therapy practitioners. Each setting may 
look entirely different than what will be shared through 
the following interview portions based on region, 
economics, and more.

Questions and Answers:

OT in Acute Inpatient Rehab by OT practitioners

#inthefield

The following section of this blog article stems from information collected via online interviewing. Answers reviewed and edited with permission from the interviewees by me (Shannen). To respect the privacy of the contributors, I have provided underneath each interview answer their desired form of identification.

Q: Describe your setting. Are there other similar settings near yours or is the setting you work at one of a kind?

A: I work PRN in several rural skilled nursing facilities. Typically work with other PT’s, PTAs, OTA’s, and speech language pathologists. The team is usually between 2 to 10 therapists. There are a number of small, skilled nursing facilities in the area, including a memory care facility and a VA facility. Some of these are in house facilities owned by local hospitals, and others are big corporations.  -Mandy

A: I work in multiple rural SNFs and a rural hospital. I work with OTR/COTA’s, PT/PTA’s, SLP’s, Nursing staff: MD, RN, LPN, CNA; Tenant Care Assistants from the independent living facilities and assisted living facilities. There are other places nearby like the setting I work in.  -Kelly

A:  I work in a privately-owned skilled nursing facility with 92 beds. 22 beds are subacute rehab (short term stay) and the rest are long term care, including a secure memory care unit with around 30 beds. It’s located just outside the city of Buffalo, in Western New York. Buffalo is an area that is actually very medically saturated with three large major hospitals, about a dozen smaller hospitals, and lots of SNFs and outpatient clinics. There’s also a large VA hospital in the city. We get patients mostly from local hospitals. It’s full of therapists as well…Buffalo has three OT schools, three PT schools, and two colleges with PTA and COTA programs. It’s kind of nice because there’s always lots of continuing ed opportunities put on by local colleges and a lot of people know about the benefits of therapy!  -Katy

A: I work in a Skilled Nursing Facility just outside of Richmond City. There are about 15 SNFs owned by the same company (6 of which are in Richmond, and more throughout VA and NC) and have a decent amount of purchased assessments, although the OT specific treatment modalities are lacking. The facility I work at has 6 OTs, 4 OTAs, 8 PTs, 5 PTA, and 1 SLP.  -Jeanne

A: I worked in a Total Joint Rehabilitation Skilled Nursing Unit– which basically means skilled nursing within a hospital floor. These types of units are few and far between, but important to help people transition home after surgery! Our unit has OTs, COTAs, PTs, PTAs, CNAs, ARNPs, LNPs and 1 attending physician. We have two ‘sister’ facilities that are standalone and true SNF’s – but our unit is the only one of its kind in the area!  -Courtney

Q: Who benefits from OT services in your setting? Is it specific to a certain population? What are the typical patient diagnoses and how can a person get referred to your setting? 

A: Our unit is ortho only, so we receive patients after hip/knee replacement, ORIF placement, spinal surgery, etc. The majority of our patients are geriatric, but every once in a while we get the young ones in their 50’s and 60’s! Generally, the patients we get have either a weight bearing status, spinal precautions, medical needs, or this is their first joint replacement – so they need to learn how to safely return home without risk of falls or reinjury.  We see Medicare, Medicaid, and private insurance patients. Very rarely, if ever, do we have anyone who is private pay.   -Courtney

A: Most of the patients seen in our local skilled nursing facilities are discharged from a local hospital, and not able to go home. The patients are typically older adults and are a combination of both long-term care and short term rehab stays. Typical diagnoses include status post total joint replacements, injury after fall, failure to thrive, dementia and a lot of dual diagnoses with complicated medical histories. Sometimes patients are admitted to LTC/SNF if they have been living with their care partners for a number of years and the partner is no longer able to provide the required assistance at home.    -Mandy

A: When a patient is discharging from an acute care hospital, but does not have the resources or safety to go home, and needs further rehab, options are usually to transition to acute inpatient rehab or SNF. If a patient is older or has more comorbid diseases and/or needs closer nursing supervision, SNF is best because the intensity is less and the patient can likely stay there and slowly recover moreso than at in intensive acute rehab. We have people for us to 100 days in our setting.Common diagnoses are ortho injuries, CVAs, COPD, encephalopathy following UTI or dementia, CAD, amputations, etc.   -Jeanne

A: Generally patients that are deemed appropriate for Subacute Rehab (SAR) are those who are medically stable but unable to discharge home from the hospital due to inability to complete ADLs, decreased strength/endurance, or they are cognitively unsafe. We have several area orthopedic surgeons who refer patients to us after joint replacement surgeries (hips, knees, and sometimes shoulders) because our facility has a reputation for good orthopedic outcomes. These patients typically only require 3-7 days of therapy. Most of the caseload ends up being older adults who have had a fall or a medical condition that has caused a functional decline after their hospitalization. Typically these patients come with diagnoses of GI surgeries, UTI with confusion, multiple falls in the home, fractures, or cardiac conditions who typically have longer lengths of stays.

On the skilled nursing end of things, LTC patients are mostly older adults who require some level of assist in ADLs. They range in ability level from setup/supervision to total assist. The patients on the secure memory care unit all have dementia that either has advanced so far that they require extra care, or that they are mobile enough to pose an escape risk. Typically these patients are on the secure unit for their own safety.   -Katy

Q: Why do occupational therapists/certified occupational therapy assistants belong in this setting? What does OT bring to the “table” that is integral to the patients’ wellbeing, particularly to patients with cognitive deficits or impairments?

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A:OT practitioners bring a huge set of skills that not all other therapists have for patients in a skilled nursing facility. Our goal is to help the patient be as independent as they can and hopefully return to their home setting. Completing a functional cognitive evaluations such an important piece of OT for so many of these clients, so we can create goals and treatment plans that are very specific to the patient’s cognitive abilities. This can be helpful for not only knowing what type of cues Is most helpful for the patient, but also gives the OT practitioner a good idea of the types of supports they need to be as independent as they can in the facility or return home.   -Mandy

A: The expectation for therapy for the Long term care setting is that we screen residents based on referrals from nursing or activities staff to see if they have had a change in functional status or may benefit from a Functional Maintenance Program. If they have had a change we pick them up for therapy to see if they will return to their functional baseline or to assess if new recommendations for things like adaptive equipment, ROM, and assist level need to be made for the nursing staff.   -Katy

Q: How do you incorporate salient (meaningful) occupations into your interventions? In what ways do you tailor your treatment to show OT’s distinct value?

A: WE DO IT ALL!!! The beauty of OT is how vast it is. I personally really enjoy writing specific goals of cleaning a litter box, making a grandchild’s favorite lunch, walking a dog, or working a fishing line.”   -Jeanne

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Occupation based intervention of watering a plant – dynamic standing balance, nature as client factor of spirituality, sequencing, motor planning, really can be graded to the patient’s needs to facilitate participation and performance! Image: via google – Infinity Rehab Click to read an article by Infinity Rehab that describes the differences between OT and PT.

A: OT brings value to the many settings I work in by assisting individuals to regain their independence in everyday activities they complete throughout the day. When I work with patients, I try to incorporate activities they like to do or have done in their life to make it meaningful to them. Sometimes its teaching the patient how to play a new game they have not heard of and then the patient saying, “this would be a fun game to play with my grandchild(ren).”  -Kelly

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Image: via google –Wagner Heights Skilled Nursing home

 

Q: What is the duration, frequency, etc of occupational therapy treatment? What is a patient’s typical length of stay and where do they go after discharge -do they transition to another follow up setting….?

A: Treatment and duration of a typical patient in the skilled nursing facilities that I work in, depends on the payer source, if it is a Medicare part a or Medicare part B, private insurance or VA benefits. If they are Medicare part A, in general, and they are needing more intense rehab, as most of the time their goal is to return home, and will have therapy services between five and seven days a week. Many times they will transition home, either independently, with a care partner, or with home health services to follow up.   -Mandy

A: This depends on the facility that I am working in, one SNF sees patients for 55-75 minutes while the other facility is 38-55 minutes depending if they are Med A or B. SNF Med A’s are seen 5x/week whereas Med B’s will be seen 2-3x/week or 10 visits depending on insurance. Length of stay will depend on a patient’s diagnosis, some may be on therapy for 2 weeks or up to 100 days. Some of the patient’s transition to LTC, go home to receive home health or outpatient, or transition to an assisted living facility, depending on patient/family’s decision. Though some patient’s transition to LTC, they may be picked up by therapy again if they have made functional gains after previous discharge.  -Kelly

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Image: https://newsroom.nebraskablue.com/medicare-advantage-101/

A: We commonly treat about 5 patients a day. I usually will have an evaluation/tx which I would charge about 60-80 minutes. Then I would have treatments that lasted 55 or 75 minutes (based on the manager attempting to place them into “ultra high” or “high” RUG levels. The patients either transition home, to an assisted living facility (sometimes because that’s where they came from, sometimes because we recommended it along with their families), sometimes to a LTC setting (more common with patients with dementia).   -Jeanne

A: Subacute rehab patients mostly get 65 minutes of OT every day, 5 days a week. The typical length of stay is anywhere from 3 days to 6 weeks, with the average probably being between 2 and 4 weeks. Generally patients who go home independent discharge home and attend outpatient therapy or have home health to assist in further improving their status. At times there are patients who are unable to safely discharge home; we have a discharge planner who sets up plans for discharge to ALF or SNF based on therapy recommendations. Sometimes families choose to provide 24 hour care; in that case one of the therapists trains the family on how to care for their loved one.

Most of the long term care patients are covered for therapy under their Part B insurance; we see them 5 times per week for around 30 minutes and they are usually only on program for 5 days-3 wks. Generally treatment focuses on ADL re-training but my facility also places an emphasis on developing and implementing Functional Maintenance Plans. These can be simple, like a plan for Activities staff to do an exercise group with the patient 2x/wk or more creative and complex, like nursing staff to offer a patient with dementia their weighted therapy doll to aid in transitions after meals. We also work on wheelchair positioning, splinting or range of motion for BUE, and recommending AE for ADLs like feeding or dressing.   -Katy

A: In the ortho only SNF, patients are seen by OT/OTA anywhere between 4-7 times a week (shoulder replacement patients are seen twice a day to ensure follow through of ROM protocols as well as addressing ADL). The frequency is set by the evaluating therapist and varies depending on their CLOF, diagnosis, and prognosis.   -Courtney 

Q: What might an OT evaluation look like in the skilled nursing setting? What types of assessment tools might you use?

A: For a typical evaluation, I start with the occupational profile, and the basic OT evaluation in which I am covering things such as range of motion, ADL, IADL, and cognition. For most of the patients in a skilled nursing facility, I typically do a cognitive screen even if the patient does not have Dementia in the medical history. The screen is easy and fast, such as a MOCA, And gives a lot of insight to see if I need to do further and more intensive Cognitive evaluation. This gives me so much insight and will help me better treatment plan for my patient. Also depending on the patient, some objective evaluations that I like to use Include the CPT (cognitive performance test), Modified Barthel, MMT, Functional Reach Test/Modified Functional Reach Test for balance, and Any specific objective test depending on the patient’s diagnosis.   -Mandy

A: Something unique to our setting is that we administer to ACL to all patients on evaluation. We do this for safe discharge planning to make sure that patients go home safely if living alone (especially if they have surgical precautions!).  We have other assessments such as the 9 Hole Peg Test, grip dynamometer, and the quickDASH as well.  Our average length of stay is 7-10 days, so we have a high turn over rate and patients are usually in and out pretty quickly.   -Courtney

Q: How do you describe occupational therapy to a new patient in your setting who asks “what is OT for me?”

A: With OT, we are going to focus on the tasks you do every day such as dressing, bathing, toileting, grooming/hygiene, etc. We also address things like cooking, laundry and other household tasks. Basically, anything that you normally do at home during your day, we want to make sure that we get you back to doing it safely and independently again.” #MasteredMyOTElevatorSpeech  -Courtney

A: With a patient that didn’t know what OT was, I would say ‘My name is Jeanne and I’m your Occupational Therapist today. Occupational Therapy works with all your daily occupations, all the jobs and tasks you have throughout each day. Some of the tasks we will be working on are dressing, bathing, toileting, eating, cooking and cleaning, fishing and gardening.’ Then I would ask them what motivates them, why do they get out of bed in the morning, and shift my focus to exactly what their needs are. If they still seem confused, or ask how its different than PT, I would say, Image result for help dress old naked adults occupational therapy

It’s definitely necessary for you to walk, but it’s best if you don’t want naked.”   -Jeanne

(I have actually said this same ^^^ thing to my patients before and have had a few disagree, lolol!!! -Shannen)

Q: Why do you like this setting? Describe a moment in which you felt like you facilitated a positive change in your patient’s trajectory of functional recovery? What positive changes have occurred in yourself in this setting?

A: I like the setting because I like to be an advocate for the older adult population. I also like the complexity and variety of the patients I get to work with. 

I specifically love it when you have those patients that other medical staff feels that they “are noncompliant, or there is nothing that we can do for them,” And because of the power of occupational therapy, we are able to look at the patient holistically and help them thrive to their greatest ability. I also love when you work with a patient for MONTHS, are able to return home, and come back to the facility to visit you. There’s nothing better!

I also like that you can also get really creative with treatments to make it meaningful and fun by playing games, going on community outings and occupation-based tasks – things that I found a bit harder to do when working in an outpatient setting. There is always a lot of joking around, story-telling, and relationship building, and which are so fun!   -Mandy

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Image via google

A: I love the geriatric population! I think they are the most insightful of all populations, and they deserve more respect that what society gives them. There are so many meaningful moments for me, but there were a few people that truly changed me so deeply.

I went to a funeral once for someone that I just adored who came to our facility often due to frequent COPD exacerbations. When I walked in, there were more photos of me over the years with him than I could ever imagine. His grandchildren came up to me knowing immediately who I was, and told me so many stories that him and his wife have shared about us.

Another touching moment was when my mother stopped in during my lunch break and a women who had lost both legs and 1 hand made it a point to get out of bed (which was a long and painful transfer) because she wanted to thank my mom for raising me, and tell her how amazing I was. All three of us were crying by the end of that chat.   -Jeanne

A: What I like the most is interacting with my patient’s and getting to know them as a person, assisting them in improving their independence to go home if that is their goal. A couple of positive moments was

1) a patient being able to pick up a cup and hold the cup without compensating or pain,

2) patient was able to sleep through the night (***sleep is an integral occupation in our daily lives that somehow sometimes get missed during recovery from an illness / injury***) and able to play an instrument again,

3) assisting a patient in regaining independence and transition from hospice to an independent living setting after working hard in therapy. Some positive changes for myself has been the increase in confidence with my treatment plan, answering questions that may arise with patients or their family and explain the reason for something that was completed during therapy. -Kelly

A:  It’s incredibly satisfying to use creativity as a means to improve the patient’s quality of life and allow them to age gracefully. Especially working with the patients who have dementia… when you can find a way to break through to them and make a connection, it’s an incredible feeling.  -Katy

Wrinkles will only come

where the smiles have been”

-JIMMY BUFFETT

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Check out this article here on NGOT!!

Q: What things do you not like (or wish you could change) about this setting? (What are the barriers to therapy, progress, success?…)

A: We currently don’t have a large gym on the same floor as the patient beds (main gym is 3 floors down, but there is a tiny gym upstairs). So the gym becomes cramped easily. However, this just forces me to get back to functionality and switch up my plan from ther ex to some ther act within the room doing purposeful activity!   -Courtney

A: Working in the SNF world is hard. Productivity is hard, RUG levels are hard. The system is more bureaucratic that you could ever expect. “Meeting the minutes” seems far more important to the administration than providing great therapy. That was probably the most challenging aspect.   -Jeanne

A: There are a lot of barriers in skilled nursing facilities, just like any other setting. The biggest one is productivity, But there are facilities out there where productivity is important, but not the focus. Another barrier is follow through and carryover with recommendations by staff, which can be very frustrating. Another area of frustration is the lack of understanding what occupational therapy can do for the clients in skilled nursing facilities.It is a constant struggle to educate the nursing staff, fellow therapist, and physicians, on our distinct value, and what we bring to the table to help our patients live life to the fullest.   -Mandy

A: One thing that I do not like about the setting is point of service (POS) documentation because I don’t feel like I am giving my patients all my attention since I am trying to read previous notes to see what the patient has completed in the past and to check what their goals are. Also, I do not like productivity since I work PRN, I like to start my day going over the OTR’s Evaluation so I can have a general understanding of the patient along with knowing what their goals are.   -Kelly

A: The worst part…documentation. Some days I feel glued to my iPad when I’d much rather be doing a more hands-on treatments. It’s also hard to deal with death when working with the LTC patients. Many patients that I’ve gotten close to have passed away, and it can be emotionally draining at times. With the SAR patients, the hardest thing is when you realize that a patient is unable to safely discharge home safely no matter what treatment you provide. This setting for sure has the potential for burnout.   -Katy

Q: How did you “get your foot in the door” to work in this setting?

A: I started with them as a PRN OT – I worked PRN for 4 months until a full time position opened and I started full time. The rehab company I work for is very well known for its high-quality therapy and innovative interventions so I always knew I wanted to work for them and learn from some of the best OTs in the area!   -Courtney

A: I completed a fieldwork level II rotation at this setting, and interviewed as I was taking my boards.  -Jeanne

A: I work for three therapy companies.

1) I got my foot in the door by completing my FW rotation at the facility

2) one of my FW educators told me to apply at the facility she works at currently

3) at the hospital, I walked to the reception desk and asked if there were any openings, which resulted in them taking my number and a followup email to the corporate office.   -Kelly

A: The Buffalo area is super saturated and full-time jobs are very hard to come by…I just kept applying and this was the first facility that offered me a position! It helped that one of my Level II’s was is a very similar setting so I knew what I was getting into and felt comfortable with the population.   -Katy

Q: Where do you see yourself in 5 years? 10 years? How does working in this setting help you reach your personal professional goals?

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A: This is tough – I have learned that life changes so frequently its hard to plan too far ahead but ideally I would like to explore other specialties (outside of ortho) and see what is available. Our company has a PT ortho residency program, so I am hoping that some day they make an OT ortho residency program!   -Courtney

A: Some people really stigmatize SNFs, but I loved the experience. I think if you can work with the geriatric population with so many comorbidities, so many loving (and sometimes scary) family members, and in a setting that your ultimate goal is doing the best for the patient, even though sometimes the bureaucracy makes that difficult, you can do anything. I have transferred to a more specific route, into Brain Injury, but my heart will forever be with my loving old people.   -Jeanne

A: Because of my experience in occupational therapy, including my work in skilled nursing facilities, I’m now using my skills to help other OT practitioners and students working with older adults be the best they can be, by disrupting the norm, being occupation based, and providing skilled care. My goal in the next five years is to expand the learning lab and be a solid, reliable, and evidence-based resource for OT practitioners and students, and be published in an occupational therapy textbook.   -Mandy

A: In the next 5-10 years, I would like to see myself working more consistent hours either full or part time along with becoming certified in lymphedema and possibly wound care too. I’m looking at taking some shoulder courses to become more rounded when treating patients with shoulder issues. Lymphedema is seen a lot in the geriatric population and working in the settings I do can help increase my knowledge and along with asking questions of coworkers who are certified come help increase that knowledge until I am able to take the course.   -Kelly

A: While this is a great first job, I have high hopes of working on a specialized inpatient rehab floor in a larger hospital. Working with veterans in a VA hospital or working with neuro patients is my dream! I may also look in the near future to do some early intervention in the city, just because I  love working with babies and families as well.   -Katy

Q: What specific “special skills” (like things you aren’t prepared from entry level OTA/OT skills) do you need to be successful in your setting?

A: You have to learn how to be flexible. Patients refuse, med holds happen, new admits don’t show (leaving terrifying gaps in your schedule). In a perfect world, once your schedule is set, it would stay that way. I am here to tell you… if that happens…. Go buy yourself a lottery ticket because you are lucky haha!   -Courtney

A: You have to have the confidence to push the boundaries. You are advocating for the patients, sometimes against the facility. Those people were my goal, and I was going to fight anyone I had to make sure they received the same treatment I would want my grandmother to receive.   -Jeanne

A: In order to be successful in skilled nursing facilities, I feel that OT practitioners need to be open to learning constantly and use the evidence to guide your practice. Sometimes the culture of skilled nursing facilities focuses on providing rote and preparatory exercise (which can be absolutely appropriate at times!), but being client centered, and occupation based should be a key component in this setting.Be a good listener, think outside the box, and be the therapy practitioner you want to be by providing the services and treatments that you feel is most important for your patients to succeed (regardless of the facility’s culture)!   -Mandy

A: Skills that you need to be successful is time management skills, communication and flexibility because you need to be able to manage your time when working so you don’t keep patients for hours and know when they have appointments or activities they would like to attend. Communication is a ‘big’ skill because you must be able to communicate with other staff in the facility and explain the role OT has where you work. Flexibility is important because you must be willing to work around your coworkers’ schedule, activities schedule, MD/DO appointments, meal times and even haircuts. When you are willing to work with your patient, they may be willing to work with you in return most of the time.   -Kelly

A: Basically the “special skills” that help the most are learning to work with people, empathize, and push people to do their best. That’s something that can’t really be taught, but with experience will get stronger! An understanding of dementia is extremely helpful for LTC and SAR. My facility sent me to a Dementia Capable Care course to get certified and it’s helped immensely in treating both the residents and some of the rehab patients.   -Katy

Q: How do you deal with grief, illness, sadness, loss, caregiver burden…etc in your setting? How do your prevent burnout and maximize your own self care and occupational balance??)

A: As the only full time OT in our unit (Ortho only SNF), I take on many responsibilities. I have things that have to be done and reviewed and I don’t always get time in my day to complete these additional tasks. Some days I feel beyond burnt out (which is not a fun feeling when you have been working for less than a year). One way I help with this is to completely unplug from work related tasks on the weekend. I sleep in, clean my apartment, and do the things that fulfill me! Another way I do this is by exercising when I get home from work! The first thing I do is mix my pre-workout, drink it, get changed and then crush a workout! My workouts are my way of releasing stress!   -Courtney

A: The setting can be just heartbreaking. But as far as I see, if I give it my all and do everything in my power to practice therapeutic use of self, empathy, and motivational strategies to connect with them, I can feel good about my work. Dealing with loss in this setting is very, very common.

But if it wasn’t me working with them on their last days, it could have been someone that wasn’t treating them as well and supporting them. I rarely referred my patients, but if I saw they were in need psychologically or emotional, I sat with them and I listened. I tried to make them smile, the best medicine!”   -Jeanne

A: Being PRN, if I am feeling overworked, I can tell my facilities that I don’t have availability, so I can focus on myself. I love being able to create my own schedule and have time off, so I can complete tasks that I want to get done.   -Kelly

A: It is very very easy to get burned out! Best ways I’ve found to beat it are take advantage of PTO, spend lots of time outside work doing meaningful activities, and building a relationship with coworkers where you feel like you can talk about your day and discuss your feelings about work. I work with a great bunch of (all women!) PTs, OTs, and SLPs and everyone is so wonderful…we definitely all talk to each other and offer tips or just some humor/wisdom.   -Katy

Q: Advice you would give to someone thinking about / wanting to work in your setting? What do you wish you knew about this setting x years ago (before you started)?

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A: I never knew this type of setting (an ortho only SNF) existed until I applied to work there! I think it was a great setting for me as a new grad because I was given adequate shadowing and training. I know that some facilities kinda throw you to the wolves. Make sure that you ASK for help and ask questions! The first few months you will feel like you have nooooo idea what you are doing! Just being honest. It took me about >>>>>>5 months<<<<<<< before I felt truly confident about my daily routine and tasks at work! Just like it takes time for our patients to get better, it takes time to transition into being a clinician! -Courtney

A: Advocate for the patient, ALWAYS.

Sometimes the administration, the CNAs and nurses, even other therapists will make sure feel like you cannot. But you can! Continue practicing functional tasks, don’t stick to pegs and cones, the beauty of this field is our creativity!   -Jeanne

A: When choosing your fieldwork rotations, try to get rotations in settings that you could see yourself working in the future when you become a practicing OT/COTA. Try to talk to OT staff from the setting you are looking to work at and see if it would be a fit for you. I wish I knew on what each setting entailed and job shadowed more than just one therapist for the school requirement so I could see how OT was incorporated in each setting.   -Kelly

A: To anyone who wants to work in a similar setting, I would try to (if you’re in school) do a fieldwork placement in either an inpatient rehab or LTC environment. It’s incredibly helpful and you’ll feel a lot more prepared! If you don’t have experience, make sure you look for a facility that has a good rehab team. I lucked out and have wonderful coworkers who were experienced, had been at the facility for a while, and who have all shared lots of knowledge with me. On the other hand, of my classmates went into a SNF right after graduation and they basically started her out doing four evals per day and had her seeing a crazy amount of patients with very little training. Also be mindful and do your research on each facility.

The SNF setting has the potential to be extremely unethical, and there are many places with unrealistic productivity requirements and patients who are inappropriate to therapy. Keep your eyes open and don’t settle for unethical practice!   -Katy

Q: Anything else your heart desires to tell the OT world about …?

A: We have found the most beautiful career. Be proud, teach the world what we can do, if you feel like you are burning out, move along and try something new. The patients we work with deserve us at our best because we teach them how to be their best.   -Jeanne

A: Overall… SNFs seem to get a bad rep but if you find one that is ethical and reasonable it’s honestly a great learning experience for a new grad! You get the best of both worlds with long term care and subacute rehab and you’ll get to put some great OT into practice.   -Katy

A: I feel many people in this setting our “forgotten” and I feel, as an OT practitioner, if we can really complete a full evaluation and look at the patient’s needs, environment, context, and create a plan as a team, we can them achieve their goals. There are also a lot of challenges in skilled nursing facility, besides the productivity and insurance demands, we have to truly look at the patient holistically, work together with all the other disciplines, the families and, most importantly, the client. I love the challenge of working with older adults that have comorbidities, because I feel like I can use a lot of my skills to really make treatment sessions occupation based, meaningful, and work towards the goals that are important to our clients.   -Mandy

In summary: Occupational therapy services in acute inpatient rehab play a dynamic role in facilitating functional independence and quality of life into the lives that we serve on their journey back to reinstalled purpose, wellness, health, and occupational engagement.

It is up to us to continue to advocate for and highlight what we bring to the table in regards to providing necessary, useful skilled services to all populations.

About the contributors:

Mandy Chamberlain MOTR/L (IG: @seniorsflourish) 

Mandy is an expert (***note-I-Shannen-added “expert” to her bio cause let’s be real-Mandy is actual geriatric OT goalsssss****)  in working with the geriatric population and has been practicing in the field of occupational therapy for over 16 years. She runs SeniorsFlourish.com and the Learning Lab membership, which helps OT practitioners and students be the BEST they can be when working with older adults through treatment ideas, resources, tips and videos. When not working on resources for fellow OT practitioners, she is enjoying the life in the mountains of Colorado with 3 energetic kids and an inspiring husband, all while sipping coffee and planning their next family travel adventure. Below are a few examples of valuable resources she shares on her site.

Occupational Therapy in Skilled Nursing Facilities (SNF) podcast

Changing the Culture of Nursing Homes Through “Flipping SNFs” podcast

SNF OT Practitioner: 6 Lessons Learned Within My First 6 Months blog post

Jeanne Laign, OTR/L (IG: @jeannelaign)

Jeanne is an occupational therapist currently specializing in post-acute, community-based, neurorehab for both transitional and long-term skilled services for persons with acquired brain injuries. She recently transitioned to this focus in October 2018. She is a 2014 graduate of the MSOT program at Virginia Commonwealth University. She worked at a skilled nursing facility in Richmond, VA for four years and says that the geriatric population will always have her heart. Her drive for OT lies in neuro based treatments including CVA, Parkinson’s Disease, Dementia, and TBI. She resides in Richmond, Virginia with her cooking extraoridinaire husband Kevin and a grumple ole beagle named Bob.

Courtney Lindblom, MS, OTR/L (IG: @courtneylindblomfitness)

Courtney graduated with her Masters degree in Occupational Therapy from the University of St. Augustine for Health Sciences in December 2017. In April 2018, she began working PRN and later transitioned to full time in the skilled nursing setting tailored to ortho injuries and diagnoses. She is also known as a “Wheelchair Champion” also known as the go to OT in her facility for patients who need special wheelchair measurements and assessments. Courtney also enjoys empowering occupational wellness through her fitness journey as a health and wellness coach. She thrives on using social media as a means to motivate and inspire others.

Katy S., MS, OTR/L (IG: @sunshineandot)

Katy graduated from Keuka College, in the Finger Lakes region of New York State, after completing a five year combined Master’s degree program. She graduated in May of 2017 and began practicing full-time at a skilled nursing facility in Buffalo, NY in August of 2017. Katy enjoys getting to work with subacute rehab patients that make up most of her caseload as well as the sweet long term care residents. Her passions include helping patients achieve independence for their valued occupations and helping the geriatric population maintain their best ability to function.

Kelly T, COTA/L  (IG: @k.titel)

Kelly is a COTA/L with experience in SNF setting including ALF/ILF, Outpatient, and Inpatient. She works between Iowa and Wisconsin. In order to increase her skill set, she would like to specialize in lymphedema, stroke rehabilitation, along with taking CEU’s to expand her knowledge related to the populations she works with.

Thanks for reading!! Love to hear from our readers, comment below where you work!! Next up COMMUNITY SETTINGS: OCCUPATIONAL THERAPY IN HOME HEALTH!


Resources

American Occupational Therapy Association. (2014). Occupational therapy practice framework: Domain & process (3rd ed.). American Journal of Occupational Therapy, 68, S1–S48. http://dx.doi.org/10.5014/ajot.2014.682006

Images

https://www.cbo.gov/publication/44363

https://www.infinityrehab.com/a-primer-on-occupational-therapy_2015-04-01

Nursing Home Residents Find Purpose Through Service and Community Commitment

http://www.covenantcare.com/Locations/Wagner-Heights-Nursing-Rehabilitation-Center/Facility-Home

https://www.nationaldebtrelief.com/going-retirement-stress-heres-fix/

https://newsroom.nebraskablue.com/medicare-advantage-101/

View at Medium.com

 

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