More than half of skilled nursing facility rehab residents classified under Ultra-High, CMS finds
More and more, therapists and other rehabilitation professionals in long-term care are being asked to do more with less: see more patients in less time, document more objectives, accept less reimbursement. Yet one challenge remains consistent — the ongoing need to keep patients engaged and motivated.
Why are some therapists so good at motivating residents while others have a history of flat-out refusals or a lack of participation?
According to American Physical Therapy Association Spokeswoman Alice Bell, the most important component of establishing success in rehab therapy is getting to know your clients and understanding what makes them tick.
“I don't believe there is an unmotivated person — it's just a matter of figuring out what they're motivated toward or away from,” says Bell, vice president of clinical services and director of physical therapy for Genesis Rehabilitation Services. “The reality is that if we don't take the time up front to talk to and listen to our patients and build a good foundation, then nothing else we do has value.”
Most therapists can usually pick up on patients who might need more help engaging in therapy through the initial evaluation process. In doing so, they take into account a patient's social and medical history, says Neely Sullivan, education director at Select Rehabilitation.
“If a patient hasn't engaged in physical activity their whole life, they're probably not going to be eager to participate in physical activity later in life, either,” Sullivan says. Michael Biel, CScD, agrees, noting that being ill often affects motivation as well.
“If I'm seeing a person who has multiple medical problems, their speech behavior may not be at the top of the list of things weighing heavily on their mind right now,” says Biel, a professor of Communication Disorders and Sciences at California State University-Northridge. “Sometimes, people simply aren't ready to engage in our treatment until they've made headway on some other medical issue.”
In addition, some patients can't help but display a demotivated state during therapy sessions, as a result of changes in their central nervous systems due to dementia or neurodegenerative diseases such as Parkinson's, Biel says. Rather than convincing these patients to become motivated to participate, therapists have to understand that they don't have as many goal-directed thoughts as other people do, and therefore don't experience the same kind of reward sensations.
Whether or not a patient takes an active role in rehabilitation therapy can also often depend on their diagnosis, says Kristy Brown, CEO and founder of Centrex Rehab in Minnesota.
“Someone who has just received a terminal diagnosis is not as likely to be motivated to participate in therapy unless it means that they just have to do enough to get home to a more comfortable setting,” Brown says. “On the other hand, therapists typically cannot work fast enough to get people with elective joint replacements home, as they are extremely motivated to get back to their day-to-day functioning.”
One way to engage clients is to dig deep in understanding the patient as an individual, says Mark Besch, vice president of Clinical Operations for Aegis Therapies.
“Ask them about their family and their grandchildren, what kinds of activities they enjoy, and pick one or two nuggets to use as an aspirational goal,” Besch says.
Therapists might also consider using functional-based assessment tools to help develop goal-directed therapy, Sullivan says.
“This way you're not just focusing on what the patient can't do anymore, but instead on what they want to get back to doing,” she says. For example, if a patient used to be a great cook in her home, perhaps there are opportunities for her to get involved in a cooking club, or to cook small meals for other residents.
“Just figuring out what's meaningful to that patient, and planning out the small steps they can take to incorporate that into therapy can really help a patient get back to doing the things they love,” she says.
It's also important to focus on goals that are achievable in a relatively short period of time and have some value and meaning to the patient, particularly at the onset of treatment, say Bell and Biel.
“A lot of this is about self-efficacy — this sense of our ability to achieve goals,” Bell says. “Part of being a therapeutic agent is making sure that we instill in our patients a confidence in their ability to achieve things, which means we have to have realistic goals.”
It's also important for therapists to communicate compassion and empathy in every patient interaction, says Holli Benthusen, regional director of business development and client relations at Select Medical Rehabilitation Services Inc. When patients feel that the therapist really understands how they're feeling, it can help address common problems therapists may encounter with patients during a therapy session, including anxiety, anger, confusion or pain.
“As a therapist, I find these to be some of the biggest barriers to reaching patient goals, and when I can work through them, I feel more empowered and more successful, which reduces my own anxiety and helps me to enjoy my job more,” Benthusen says.
Making therapy fun
Forget orange cones and resistance bands. Today's physical and occupational therapy sessions are more likely to use Google Earth to have patients take a virtual walk on the beach or make use of giant touch-screens to task patients with putting together a life-size jigsaw puzzle — all while practicing standing balance, endurance, coordination, range of motion, dual tracking — the list goes on.
“Once you bring technology into the picture, it opens up a new world of ways to find different connections with different residents,” says Christopher Krause, director of the therapy business unit for It's Never 2 Late. “If you're at all creative as a therapist and committed to getting to know your patient, you can use a smartphone, a tablet, a laptop — any computer system — and basically start riffing on what's of interest to that individual.”
Incorporating gaming systems such as the Nintendo Wii Fit or Wii Sports into therapy sessions can keep people engaged while also adding in a competitive component.
In speech and occupational therapy, patients often tire easily of doing traditional paper and pen activities, which undermines the therapy's effectiveness, says Dan Michel, CEO of Dakim BrainFitness. To address this issue, many therapists are now using computer-based “brain fitness” software, which incorporates graphics, music and videos to keep patients stimulated and engaged in their cognitive exercises.
Steve Sarns, vice president of sales and marketing for NuStep, notes how much the environment — and whether or not it makes people feel alive — can play a role in motivation.
“We need to move away from the more clinical environments and make the therapy rooms a more motivating place to be,” he says.
Facilities that are committed to providing updated, bright, spacious, comfortable gym areas, along with adequate equipment and updated technology, also often inspire therapists to infuse their approach with more positive energy when initiating a treatment with a patient, says Tammy Begler, director of Clinical Services at Synertx.
“Walking into a facility that values and supports therapy motivates the therapist and therefore motivates the patient,” she says.
When to take a break
Krause says it can be easy to look at patients who, for all intents and purposes, appear fairly old and frail and to want to give them a break. But when it comes to building strength, endurance and coordination, the only way to really do that is to push them beyond their comfort zone.
But it's also important to know your patient's limits and when to push and when to hold them back, he says. This is a skill that just comes with on-the-job experience, Begler says. By monitoring vitals during activities and exercise, assessing the quality of a patient's movement and effort, over time therapists get to know when to take a break and when to push the patient to the next level of capabilities.
“This can be as simple as noting breathing rate and effectiveness of deep breathing versus shallow breathing during a gait activity,” Begler says.
Paying attention to these vitals is important, because one downside of pushing too hard and too soon is that it may actually delay recovery, explains Laszlo Bayer, vice president of sales and marketing at Therapeutic Industries Inc.
“The key is developing a relationship of trust with the patient, and there are many products and technologies available that greatly reduce the risk of injury for both patient and clinician, and provide greater productivity,” Bayer says.
For medical or therapeutic equipment to be effective, it must be operating properly, and inspected, tested and calibrated on a timely basis by a company that has experience with physical therapy equipment, says Morton Beckman, director of operations at GDC Medical Electronics. Some PT equipment, for example, imparts some type of energy, such as transcutaneous electrical nerve stimulation (TENS) therapy or low-volt therapy. The right tests can prevent burns or shocks.
“Testing and inspection of that equipment should be important to the therapist for safety reasons and for proper treatment of the patient," Beckman says.