AAPACN is dedicated to supporting post-acute care nurses provide quality care.

Involve the Therapy Team to Address Changes in Condition and Improve Resident Outcomes in Nursing Homes

By Liz Barlow, RN, CRRN, RAC-CT, DNS-CT, AVP Clinical Innovation, Synchrony Rehab

At the end of August, the Centers for Medicare & Medicaid Services (CMS) held a National Provider Stakeholder call to review some of the recent COVID updates. CMS commented that data collected, along with nursing home surveys, are showing concerns in the following areas for resident outcomes:

  1. Increase in Weight Loss
  2. Loss of Mobility
  3. Need for Help with ADLs

This probably comes as no surprise to most professionals working in long-term care right now. Recent events have been a perfect storm: residents in social isolation for months, along with a staffing shortage, and needed attention for infection control and prevention are just the tip of the iceberg of risk factors for these types of resident outcomes.

Despite the struggles facing nursing homes, it’s important to remember that a team approach always works best for resident care. To help improve resident outcomes, it’s important to include the therapy department in any conversation around a change in a resident’s function or cognition. 

Here are a few helpful tips to consider for involving the therapy team in addressing changes in condition:

  1. Develop a routine screening process for therapists to review any possible change, if the facility doesn’t already have one. A screen is a cursory review with one decision to be made: Is a therapy evaluation warranted?
  2. Encourage a culture of open communication. Implement a process, such as an email inbox or online form, that allows the team members and others in the facility to speak up when they notice a change in a resident. Establishing a communication process is one of the best ways to notify therapy to perform a screen. It’s also important to include CNAs, office staff, dietary, and housekeeping in this communication as they may be the first ones to notice a change in a resident. Encourage them to speak up at any time if they notice something different.
  3. Involve therapy in the care area assessment (CAA) review. Physical, occupational, and/or speech therapy can have an impact in all 20 CAA areas. It’s also important to involve them before developing a care plan because if a CAA indicates a change, a therapy evaluation may provide more insight.
  4. Include a therapy representative during At-Risk Resident meetings to be a part of the team discussion. Therapists can have great insight during these meetings, and they can review potential residents for screening and evaluation if indicated.
  5. Don’t forget speech therapy. Speech language pathologists can impact swallowing but are also experts in cognition. Let them help define a resident’s abilities so that he or she can be successful and so that the team can better identify when a change occurs in this area.

Nursing homes certainly have many challenges that have the potential to impact quality of care right now. Continuing to have a team approach and keeping a watchful eye on all residents is an important step in maintaining their highest practicable physical, mental, and psycho-social well-being.  


About Synchrony Rehab

Synchrony Rehab provides comprehensive rehabilitation services across a vast continuum of healthcare environments, including skilled nursing and assisted living facilities, as well as outpatient and home health. Synchrony’s skilled physical therapists, occupational therapists, and speech language pathologists empower their patients to achieve what they never thought possible: their maximum independence. Synchrony Rehab is an AAPACN Diamond Partner.

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