Dawn De Vries , DHA, MPA, CTRS devridaw@gvsu

1. Creating a Niche for Therapeutic Recreation working with the ElderlyMaintenance, Restoration, and Rehabilitation Dawn De Vries, DHA, MPA, CTRS devridaw@gvsu.edu Illinois Therapeutic Recreation Association 2013 Conference For HANDOUT, GO TO: http://gvsu.edu/tr/faculty-staff--13.htm

2. Agenda • Check in • Participant goals • Learning Objectives • Therapeutic Recreation – definition • Maintenance Opportunities • Restorative Opportunities • Rehabilitation Opportunities • Documentation for Programs • Wrap up

3. 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.

4. 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

5. Regulation: §483.15F 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 …”

6. Regulation: §483.15F 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

7. Regulation: §483.25F 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.”

8. 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

9. 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 ….”

10. Maintenance Opportunities

11. Maintenance • Definition? • Purpose? • Types of programs?

12. 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.

13. 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

14. 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

15. Major components for Programming 1. Domains2. Relevance (meaningfulness and person-centered)3. Functional Level

17. Programming based on Functional SkillsFunctioning 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

18. RestorativeOpportunities

19. 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

20. 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.

21. Components of RestorativeRAI 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.

22. AreasRAI 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

23. Restorative Care CriteriaRAI 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.

24. Activity MUST be … • PLANNED • SCHEDULED • DOCUMENTED

25. 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.

26. 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)

27. 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.

28. 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)

29. 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.

30. 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.

31. 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

32. Rehabilitative Opportunities Recreational Therapy Rehabilitation and Subacute Programs

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

34. 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

35. 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

36. What is Active Treatment?

38. 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)

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

40. 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.

41. 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.

42. 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.

43. Recreation/Activity ServicesAccording to CMS Covered Service 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. • 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.

44. 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 8-12. • 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.

45. Opportunities • Role on interprofessional team • Individual treatment • Co-treatment • Group co-treatment

46. 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

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

48. PROGRAM DEVELOPMENT

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

50. 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.