2/25/2015. Dementia Therapy Solutions for the SLP. DEMENTIA FACTS Why do we need evidence-based interventions? Its about behavior management

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1 Dementia Therapy Solutions for the SLP What You Need to Know for Effective Therapy & Reimbursement Presenter: Peggy Watson M.S., CCC-SLP Please turn off or silence cell phones DISCLOSURE: A relevant financial relationship exists as follows: This presentation is based on the content of the book Dementia Therapy & Program Development co-authored by Peggy Watson MS, CCC-SLP Nancy Shadowens MS, CCC-SLP Copyright is owned by Consultants in Dementia Therapy PLLC owned by: Watson & Shadowens CDT WEBSITE: JOIN THE CONVERSATION ON FACEBOOK INTRODUCTION Dementia diagnosis requirements: 1. Impairment of memory and at least one other domain (language, personality, executive function) 2. Represents a decline from previous level of functioning DEMENTIA FACTS Why do we need evidence-based interventions? Its about behavior management Repeated falls Decline in executive function Decline in working memory Decline in spatial orientation Odd or inappropriate behaviors Forgetfulness of recent events DEMENTIA FACTS Changes in hygiene Personality changes Increased apathy Changes in language Perseverative behaviors Perseverative random verbalizations Changes in diet preferences 1

2 DEMENTIA FACTS Changes in eating habits Weight loss Dehydration TYPICAL AGING VS. DEMENTIA Dysphagia MEMORY Memory processing includes: Encoding Consolidating Storing Retrieving Forgetting Short Term Memory- Impaired Immediate Memory Working Memory Long Term Memory- Spared Episodic Semantic Procedural EPISODIC MEMORY Episodic memory refers to our ability to recall personal experiences from a particular time and place, when and where an event happened in our past. SEMANTIC MEMORY Semantic memory includes generalized knowledge about the world that does not involve memory of when you learned it. 2

3 Procedural Memory Motor Memory Procedural memory refers to the ability to remember how to perform a motor task. Video Procedural Memory Example pedaling CAUSES & TYPES OF DEMENTIA ALZHEIMER S DEMENTIA Hallmark Presentation: -Gradual onset and continuing decline of memory and cognition -Frontal and temporal lobes (cognition) as well as the hippocampus (memory) are characteristically most affected. BRAIN TOUR 3

4 VASCULAR DEMENTIA Also called multi-infarct dementia Hallmark Presentation: -Step-wise decline pattern sudden cognitive deficits after an event, then a plateau with no changes until the next ischemic event. FRONTOTEMPORAL DEMENTIA Also called Picks Disease Hallmark Presentation: -Personality changes -Behavioral changes -Speech-Language changes word finding/naming LEWY BODY DEMENTIA Hallmark Presentation: - Visual hallucinations - Memory loss - Cognitive dysfunction - Parkinsonism (rigidity, gait disorder, tremors) - Associated with Parkinson s and Alzheimer s disease PARKINSON S DISEASE Hallmark Presentation: -PD is a progressive degenerative disease classically affecting motor control and causing: tremors balance gait problems rigidity 4

5 PSEUDODEMENTIAS ILLNESSES THAT MIMIC DEMENTIA - Chronic Malnutrition - Chronic Dehydration - Hypotension - UTI - Medication-Related Dementia Medication related dementia: Anti-depressants Anti-epileptics Antihistamines (e.g., Benadryl) Cold and flu medications (due to antihistamine component) Antihypertensives Pain medications Sleep aids PSEUDODEMENTIAS CONTINUED - Alcohol Abuse (Wernike-Korsakoff) - Infectious Diseases - Depression - Chemotherapy - Thyroid Disorder - Normal Pressure Hydrocephalus Staging of Dementia Learn the concept of staging and why this is a crucial step for goal setting and for attaining positive treatment outcomes! Staging gives an in-depth look at spared (preserved) vs. impaired capabilities By staging you will know: When it is inappropriate to write a memory goal When communication begins to breakdown When negative behaviors may emerge When the person may be entering their own reality There are seven distinct stages The following descriptions are from the Global Deterioration Scale 5

6 Global Deterioration Scale Dr. Barry Reisberg, et. al Stage 1: No Cognitive Decline Stage 2: Very Mild Cognitive Decline -forgetting where one has placed a familiar object -forgetting names one formerly knew well Stage 3: Mild Cognitive Decline -word and name finding deficit evident on clinical interview -patient may have gotten lost when traveling to unfamiliar location -co-workers may become aware of patient s relatively poor performance Stage 4: Moderate Cognitive Decline -decreased knowledge of current and recent events -may exhibit some deficit in memory of one s personal history -concentration deficit elicited on serial subtractions Stage 5: Moderately Severe Cognitive Decline -patient can no longer survive without some assistance -patient is unable during interview to recall a major relevant aspect of their current lives -frequently disoriented about time (date, day of week, season, etc) Stage 6: Severe Cognitive Decline -may occasionally forget the name of the spouse upon whom they are entirely dependent -diurnal rhythm frequently disturbed (diurnal=active during the daytime) -frequently continue to be able to distinguish familiar from unfamiliar persons in environment Stage 7: Very Severe Cognitive Decline -verbal abilities lost -incontinent, requires assistance toileting and feeding -loses basic psychomotor skills -the brain appears to no longer tell the body what to do 6

7 The following topics are coming up Should we provide therapy to a stage 7 patient? The new healthcare environment Jimmo vs Sebelius & Medicare Improvement Standard Class Action Lawsuit Introduction to documentation how do I establish medical necessity? Use assessments that are standardized for dementia. Jimmo vs Sebelius Medicare Improvement Standard class action lawsuit Education/Medicare-Learning-Network- MLN/MLNMattersArticles/Downloads/MM 8458.pdf Manual Updates to Clarify SNF, IRF, HH and OPT Coverage Pursuant to Jimmo vs Sebelius. Skilled care may be necessary to improve a patient s current condition, to maintain the patient s current condition, or to prevent or slow further deterioration of the patient s condition. Jimmo vs Sebelius What does it mean for therapists? Out with the old: No progress, no Medicare coverage unless the problem got worse, in which case the treatment could resume. In with the new: Patients will be able to receive therapy services that maintain their current condition or slow further deterioration, regardless of whether their functional status is expected to measurably improve. Documentation of SKILLED THERAPY is Still Required for Maintenance Therapy In the case of maintenance therapy, the skills of a therapist are necessary to maintain, prevent, or slow further deterioration of the patient s functional status, and the services cannot be safely and effectively carried out by the beneficiary personally or with the assistance of nontherapists, including unskilled caregivers. (CMS Transmittal R179BP) 7

8 CMS Definition of Skilled Service Think of it this way A service is not considered skilled merely because it is performed by or under the direct supervision of a licensed therapist. When the service could be safely and effectively performed by the average non medical person without direct supervision, the service would not be considered skilled. The key is whether the skilled services of a therapist is needed to maintain the person s highest level of function or slow further decline. Not whether the Medicare beneficiary will improve. The Centers for Medicare and Medicaid Services (CMS), Definition of Skilled Services for non Medicare and Medicare Patients, CMS HM 11 (The Home Health Agency Manual), Sections and , Accessed 2008, 2009, 2010, 2011, 2012, 2013 For the patient receiving maintenance therapy - document: 1. The functional levels being maintained by the skilled service how the pt will benefit. 2. Why the skill of a qualified therapist is required to provide the treatment. 3. Discharge with a Functional Maintenance Plan. SLP Example Reason for referral: Mr. X Has declined in expressive communication and would benefit from speech therapy to prevent further decline in communication skills of basic and medical needs to ensure ability to express needs in home environment. Recommendation: Pt would benefit from skilled ST to prevent further decline in communication of basic and medical needs. Family to be instructed in knowledge and use of AAC and cues for verbal expression in home environment to ensure pt is able to make basic and medical needs known. DOCUMENTATION OVERVIEW -What is a RAC review? -Recovery Audit Contractors -Program established by Medicare to find and collect overpayments Establishing Medical Necessity Look for Documentation of FUNCTIONAL CHANGE What is functional change? Change in the ability to perform an ADL Functional Change can be documented by Nurses Therapists Physicians 8

9 Examples of Functional Change for the SLP: -Increasingly confused, disoriented -Change in memory -Impaired safety and judgment -Swallowing problems -Others: Functional change should be accompanied by an event. Nursing notes reflecting functional change in status. Nursing notes reflecting an event. Potential Events: -Illnesses -Exacerbation of chronic conditions -Other Top Five Denial Reasons Identified By Medicare Claims Reviewers Are you making these mistakes? Prior level of Function Reason for Referral Lack of Skilled Therapy Diagnosis and Coding Errors Negative Behaviors Preferred Terminology Assess Modify Facilitate Red Flag Terminology MEDICARE DOES NOT RECOGNIZE THE FOLLOWING AS SUPPORTING THE NEED FOR SKILLED THERAPY TOO VAGUE Routine Practice General Monitor Patient tolerated treatment well Patient remains stable Continue with POC Establish Skilled Teaching 9

10 Why do we screen? Medicare Reg (a): 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: (i) bathe, dress, and groom; (ii) transfer and ambulate; (iii) toilet; (iv) eat; and (v) use speech, language, or other functional communication systems. Suggested Evaluation/Staging Tools FLCI: Functional Linguistic Communication Inventory FROMAJE: Function, Reason, Orientation, Memory, Arithmetic, Judgment & Emotional Status FAST: Functional Assessment Staging Test GDS: Global Deterioration Scale ABCD: Arizona Battery for Communication Disorders of Dementia Brief Cognitive Rating Scale Video FLCI FUNCTIONAL LINGUISTIC COMMUNICATION INVENTORY Demonstration of a standardized evaluation for dementia that will stage the individual Documentation Essentials on the Evaluation: Five Essential Parts Prior level of function Reason for referral History/Medical Complications Precautions Clinical Impressions ESTABLISHING MEDICAL NECESSITY PRIOR LEVEL OF FUNCTION & REASON FOR REFERRAL SHOULD RELATE TO EACH OTHER 10

11 Prior Level of Function Example Terms NOT to use independently: Living at home independently Reason for Referral Example Terms NOT to use independently: decreased functional status Better ST: Chart reports pt was living at home independently, able to reason, plan ADL safety with walker, communicate basic and medical needs. Better ST: Nursing reported the patient demonstrates increased confusion, difficulty communicating needs, difficulty problem solving related to use of walker. History/Medical Complications HTN CHF COPD A-Fib dementia falls debility anxiety confusion CVA altered mental status Precautions Example terms to use: -Fall Risk -Unsafe with transfers -Poor safety awareness -Aspiration risk -Chronic pain -Cardiac Clinical Impressions Should Include: -Staging information -Areas of functional change -How the pt. would benefit from skilled intervention Developing Goals Always relate goals to functional outcomes for the patient within their environment. All goals should be: a) Functional for the patient s capabilities according to their presenting stage and living environment b) Skilled, Measurable, Attainable, Reasonable and Necessary 11

12 Common SLP Goal Areas: 3 Parts to a Goal Communication Behavior Socialization Dysphagia State: What you want the pt to do Quantify the goal Why you want the pt to accomplish this goal Communication LTG: Pt will utilize a communication system compatible with his/her spared skills to ensure adequate expression of basic & medical needs as measured by mastery of the objectives. STG: Pt. will increase appropriate communication exchanges 10 times in a session to facilitate making needs known. Intervention/Modality Statement /Daily Note: Augmentative alternative communication (AAC) (memory book) and reminisce intervention were used to increase the patients communication exchanges an average of 15/25 times within a session. Behavior LTG: The patient will decrease affective behaviors for improved quality of life and safety within the environment by mastery of the objectives: STG: Pt. will participate in 3 activities within a session and demonstrate decreased verbal outbursts to 1 per session, 5/5 sessions to decrease affective behaviors. Intervention/Modality Statement /Daily Note: Montessori intervention along with calm environment, choices and one step commands decreased verbal outbursts to 3 per session. Socialization LTG Pt. will reduce isolation and demonstrate socialization to max potential as measured by mastery of STGs. STG: Pt. will attend 1 meaningful activity with min assist for 20 minutes to decrease isolation 5 of 5 sessions. Intervention/Modality Statement /Daily Note: Validation and reminisce interventions along with pts semantic memory were utilized to increase socialization to 1 activity for 10 mins. Pt participating well. Goal achievement expected. Dysphagia LTG: Patient will consume mechanical soft and thin liquids without s/s of aspiration as measured by mastery of the STGs. STG: Patient will demonstrate bolus management of mech soft chopped evidenced by min residue in oral cavity over 10 trials within a session 5/5 sessions to reduce risk of aspiration. Intervention/Modality Statement/Daily Note: Neuromuscular re-ed, and mod verbal cues for tongue sweeps were utilized to decrease to min oral residues x 10 trials over 30 min session, 4 of 5 sessions. Approaching goal achievement. 12

13 Developing Evidence-Based Interventions Sensory Reminiscence Spaced Retrieval Montessori Validation Sensory Intervention (Burns, Byrne, Ballard, Holmes, 2002) - Sensory interventions involve the patient s sense of touch, taste, hearing, smell or sight, or some combination of these. Alive Inside Dramatic Effects of Music! Reminisce Intervention (Chiang, Chu, Chang, et al., 2010) - Refers to a collection of memories from the past. Video Vascular Dementia patient with PT using reminisce -Case Study- PLOF: Patient was able to ambulate 50 feet with RW and propel wheelchair using lower extremities. Reason for Referral: Nursing reported a vascular event. Pt. sliding out of chair, neuro pushbacks out of chair and not propelling self in wheelchair. LTG:Pt. will ambulate using walker with MI by mastery of the STG. STG: Pt. will propel wheelchair using lower extremity from room to dining room with min verbal cues to facilitate independent mobility. 13

14 Reminisce Questions 1. Did you have a favorite pet? 2. What were you doing when you were 21 years old? 3. What was your first car? 4. Which parent had the most influence on you? 5. Who was your favorite comedian? Spaced Retrieval Developed by Cameron Camp, PhD -Gradually increases the interval between correct recall of target items. Montessori for Dementia Montessori Based Programming for Dementia Developed by Cameron Camp, PhD Guided by the principles of Dr. Maria Montessori - She claimed that children who were engaged and interested in what they were doing did not exhibit problematic behaviors such as pushing, screaming or acting out in inappropriate ways. - Connecting past interests and skills with the present spared skills and needs of the patient 14

15 15

16 Video Cat Montessori 16

17 Video Dusting Montessori and Procedural Memory Validation Intervention Naomi Feil Communicating by validating and respecting feelings Video Naomi Feil utilizing Validation Pulling it all together: Case Studies for stages 3, 4, 5, 6 17

18 Case Study Stage 3 PLOF: Chart documents pt with mild forgetfulness, pleasant and cooperative, no assist required to locate bedroom and dining room within facility. Reason for referral: Nursing notes pt increased wandering and anxiety with occasional neg. behaviors, pt c/o not able to locate her room. LTG: Pt will reduce anxiety and confusion related to location of room by mastery of STGs. STG: Pt will restore knowledge and use of room number and location with 80% acc over 5 sessions to decrease agitation.. Example Daily Note Pt participated in speech therapy to facilitate reduced wandering and frustration. Spaced Retrieval intervention was utilized with use of AAC, and pt was able to provide reliable responses over 8 min delay independently. Nursing reports pt able to locate room with strategies of min verbal cues and use of AAC, no report of negative behavior over one week. Case Study Stage 4 PLOF: Patient living in SNF, able to adequately communicate wants and medical needs. Reason for Referral: Nursing notes report a change in communication skills impacting pts ability to make needs known and this increases frustration. LTG: Pt will demonstrate functional communication of basic wants and medical needs by utilizing spared skills measured by mastery of STGs. STG: Pt will participate in structured daily activity to facilitate functional communication of 5 basic needs. Example Daily Note Pt participated in speech therapy to address communication goals and objectives. Pt demonstrated expression of need x 5 over 30 min session, an improvement from yesterday. Pt benefits from use of strategies and interventions including a calm environment, verbal prompts and cues, validation and Montessori activities to increase purposeful communication. Case Study Stage 4 PLOF: Nursing and activity dept. notes pt socializing well, friendly and cooperative and attending activities regularly. Reason for referral: Nursing and activity dept. document increase in pt isolation over past month with decreased attendance at activities and communication with others. LTG: Pt will engage in social opportunities to improve quality of life evidenced by mastery of STGs. STG: Pt will utilize AAC to attend 2 activities per day, 3 of 5 days, min verbal prompts to decrease isolation. Example Daily Note Pt participated in speech therapy to address decreasing isolation with increased socialization. SLP used schedule/aac posted in room to direct pt to activitt. Pt engaged easily at first. When pt began to leave the activity area, SLP utilized reminisce intervention to engage pt verbally using episodic memory, facilitated by memory book supplied by pts family. Others in activity group also engaged in conversation on topic and the patient responded well to the social interaction over 20 min. without need for further redirection to task. Pt benefitted from validation, praise and encouragement and reminisce intervention. 18

19 Case Study Stage 5 PLOF: Living at home with daughter, pt. able to communicate wants and needs. Example Daily Note Reason for Referral: Physician reported a change in pt. function, unable to communicate wants and needs, verbal perseverations were noted in speech along with crying and behavioral outbursts. LTG: Pt. will participate when LTM is cued to increase communication and decrease anxiety by mastery of the STG. STG: Pt will increase communication of purposeful exchanges 5 times within a 30 min. session to facilitate expression of need. Pt participated in speech therapy to address improving communication of basic needs. Pt. was able to communicate 10 exchanges during therapy session and crying was less than 10%. The following interventions and strategies were successful: Reminisce, Montessori, Validation, calm environment, and yes/no questions. Case Study Stage 6 PLOF: Chart documents pt living in home with caregiver, min difficulty communicating wants and needs. Reason for referral: Chart documents change in function, unable to communicate wants and needs, increase in verbal perseveration and anxiety. LTG: Pt will communicate wants and needs using spared skills to max potential by mastery of STGs. Example Daily Note Pt participated in speech therapy to facilitate communication. Pt engaged well in Montessori activity and reminisce memory book and elicited 2 self initiated requests of needs including one request of being hungry, and min occurrences of verbal perseverations. Pt verbally communicated 8 long term memories independently during reminisce. Pt benefitted from Montessori, reminisce, validation, verbal prompts and cues, praise and encouragement. STG: Pt will produce communication of 3 basic wants and needs per session over 5 sessions. Smile Speak Slowly Praise and Encourage Structure Daily Routine Use Concrete Language Demonstrate the task Voice Pleasant Enter Their Reality Treatment Strategies Ready to write your Functional Maintenance Plan The goal of a Functional Maintenance Plan is to: provide meaning and purpose provide a predictable daily routine reduce stress compensate for the patients impairment 19

20 Developing a Functional Maintenance Plan (FMP) The FMP is utilized per Medicare to address behaviors, swallowing issues, falls, communication issues, confusion, and so on, with specific strategies identified as productive toward achieving and/or maintaining the patient s highest quality of life and safety in their living environment after therapy is completed. Example FMP by OT, PT, SLP Name: Physical Assistance Requirements: Requires walker during all ambulation with gait belt. Requires assistance with: - walker to and from activities SBA - verbal cues to take longer steps to avoid shuffle -verbal cues to stand tall when walking - verbal cues w/ bed mobility: roll to side first, then come to sitting position Requires supervision for bathing and grooming. Place grooming tool, utensils, etc. in his hand and he is independent using them. Example FMP, continued Suggested Daily Schedule: Mr. would benefit from -walk to dine and activities -B & B program/walk to bathroom -involve in activities during the day Use simple language, smile. Use divided plate, finger foods when avail. Mr. enjoys Montessori activities including music, exercise, bingo, sanding wood, snacks, sorting nuts and bolts, pvc pipe construction, jig saw puzzles. Also, enjoys his Memory Book, reminisce and going outside. Director of Nursing Date Recertification: Documentation supporting recertification requires notes reflecting good management in the patient s ability to reach your short-term goals, and that skilled therapy is required to advance functional safety, mobility, and ADLs or maintenance to avoid decline, and the new goals are measurable, attainable, reasonable and necessary. When to Discharge: When it becomes clear that the patient is not going to benefit from further therapeutic intervention, even if you are only halfway through your certification period, you must consider establishing your FMP and discharging the patient from your caseload. 20

21 The End Thank You! Peggy Watson M.S., CCC-SLP Nancy Shadowens M.S., CCC-SLP Consultants In Dementia Therapy PLLC Join the Conversation on FACEBOOK! facebook.com/consultantsindementiatherapy 21

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