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Thinking Outside the Traditional Rehabilitation Toolbox
Melissa A. Simonian, M.Ed.Rehabilitation/Wellness Manager
PACE-Rhode Island
Learner Outcomes
Identify opportunities to incorporate a wellness approach to the traditional PACE rehabilitation model Establish a pilot program for a non-
conventional therapeutic approach that meets the needs of the PACE Participant Utilize and evidence based practice model and
associated outcome measures for program development
Rhode Island and Providence Plantations
Not an island
37 miles wide and 48 miles long
The Ocean State
Program for All Inclusive Care for the Elderly- Rhode Island
Only PACE Organization in the state
Est. 2005
300 Participants
3 Day Centers
Our Participants
Avg. age is 73
20% aged 85 or older
42% speak a primary language other than English
Who We Serve
93% are dual eligible
30% meet the state’s “highest” level of care and qualify to live in a NH
46% have six or more chronic health conditions (compared to 14% among RI Medicare beneficiaries
Our Numbers
40% have a formal diagnosis of dementia
33% have three or more ADL limitations
46% have a behavioral health diagnosis
Some Data
31% have had no hospitalizations since enrollment
Avg. enrollment in the program is 3.1 years
36% of current participants have been enrolled five years or more
Rehabilitation Department
One full time Occupational Therapist
Two part time Physical Therapists
One full Time COTA
Two part time PTA’s
Rehabilitation Staffing
Geriatric Massage Therapist (10 hrs. a week)
One full time Registered Dietitian
Rehabilitation Supervisor (SLP)
Restorative C N A (10 hrs. a week)
Rehabilitation Definition
The action of restoring someone to health through training and therapy
after an illness or injury.
Oxford Dictionary
Traditional Therapy
Therapeutic Exercise
Neuromuscular re-education
Therapeutic Activity
Challenges with Participant/Family Engagement
Non adherence to recommendations
Limited follow through with Home Exercise Programs
Decreased participation in Restorative Exercise Program
Barriers to Success
Cultural
Lifestyle
Decreased engagement
Person Centered Approach
Care that is consistent with the values, needs and desires of the individual
Social Determinants of Health
(resources for integrated care.com)
Wellness Definition
Optimize a state of well being
Oxford Dictionary
PACE Model Promoting Wellness SAMHSA.gov
Emotional Support
Coping effectively with life and creating satisfying relationships
Fellow participantsIDTFamily/Caregiver
Spiritual Support
Expanding ones sense of purpose and meaning in life.
Story CorpsBible StudyRecognizing High HolidaysSpanish Rosary
Intellectual Support
Recognizing creative abilities and finding ways to expand knowledge and skills.
Attending local Civic EventsGuest speakersProject LinusCyber Senior Program Art Exhibit
Environmental Support
Good health by occupying pleasant, stimulating environments that support well being.
Day CenterLocal parkOutdoor garden
Financial Support
Satisfaction with current and future financial situations.
Rep PayeePayment plans
Occupational Support
Personal satisfaction and enrichment derived from one’s work.
Volunteer opportunities
Social Support
Developing a sense of connection, belonging, and a well developed support system.
Day CenterIDT
Physical Support
Recognizing the need for physical activity, good nutrition and adequate sleep.
Rehabilitation ServicesNutritional ServicesSpecialty Services
Beyond the Traditional Treatment Program
Balance Groups Aquatics Reiki Therapeutic
MassageMedically Tailored Meals
Standardsof Care
DC Physical Activity
Evidenced Based Group Balance Training Programs
A Matter of Balance (ncoa.org)
Tai Ji Quan: Moving for Better Balance (tjqmbb.org)
A Matter of Balance Program
An 8-week structured group intervention that emphasizes practical strategies to reduce the fear of falling.
1x a week for 2 hours
Program Goal
Reduce fear of falling, reduce the incidence of falls, and increase activity levels among community dwelling older adults.
Expected Outcomes
View falls as controllable Set realistic goals for increased activity Modify participants environment to reduce fall risk factors Increase strength, balance, endurance and flexibility through exercise
Participant Criteria
> 60 y/o Community dwelling At risk for falls Capable of new learning
Staff Training
Eight hours of training to earn certification and 2.5 hours annually to maintain certification
Two Rehab staff and Two C N A’s (Spanish speaking)
Funding provided by a grant from a local community organization
Standard Operating Procedure
Rehab staff identify participants who would meet program criteria (class of 7-12)
Vetted by IDT during morning meeting
SOP
Logistical information is provided to:
Day Center ManagerTransportation CoordinatorHome Care Scheduler
Facility Resources
Designated space where participants can easily move around
Tables/chairs set up in a U shape
AV equipment
Flip Chart
Program Day
Room is arranged by Rehab staff
Drinks and healthy snacks are made available to attendees
Rehab staff gather Ppt’s
Class Protocol
Group discussion around:problem solvingassertiveness training shift from negative to positive thinking
Exercise training
Video
Follow up
Restorative CNA holds an exercise review class 1x a week
80% of the attendees had an increase in participation with an additional physical activity: Aquatics Program Walking Group Restorative Exercise Program
Program Data
100% had a h/o of a previous fall (high fall risk BERG/Tinetti, MAHC)
1% had a fall 3 months after completing the program
25% had a fall within the year of completing the program
Health Outcomes
889092949698
100
Morecomfortabletalking aboutfear of falling
Feelcomfortableincreasing
activity
Plan to continueexercising
Would recprogram
Outcomes
MoB PACE RI
Tai Ji Quan: Moving for Better Balance Program
Transforms martial arts movements into a functional therapeutic regimen
Training regimen for older adults at risk for falling and people with balance disorders
Two 1 hour sessions per week for 48 weeks
Program Goal
To improve strength, balance, mobility and daily functioning and prevent falls in older adults and individuals with balance disorders.
Expected Outcomes
Improved balance and stability
Reduction in the incidence of falls
Participant Criteria
Older adult
Community dwelling
Risk for falls, balance disorders, gait abnormalities
Staff Training
Two day training, refresher course at 2 months, 4 months and 6 months
One Rehab staff member and One (Spanish speaking) C N A
Funding provided by local community organization
Standard Operating Procedure
Rehab Staff identify Ppt’s who would benefit from balance training (class of 8-15)
Vetted by IDT during morning team meeting
SOP
Logistical information is provided to:
Day Center ManagerTransportation CoordinatorHome Care Scheduler
Facility Resources
Mirrored wall
Large enough space for movement
Chair for stability
Program Day
Room is set up by Rehab staff member and C N A
Water is made available
Ppt’s are gathered by C N A
Class Protocol
Warm up movements
Core Practice & mini therapeutic movements
Breathing cool down exercises
Video
Program Data
80% of the participants completed the program
Limited to no cancellations
70% an increase in their TUG scores
Follow up
Opportunity for weekly self practice sessions available in Day Center (smart TV) via tjqmbb.org website
Fall Prevention
Annual Falls Education Daily Team Review Falls Clinic (multiple falls) STEADI Algorithm for Fall Risk Assessment & Interventions (cdc.gov)
Aquatics Therapy
Exercise program done in a heated swimming pool, as part of a rehabilitation program utilizing the physics of water.
atri.org
Program Goal
Increased overall strength and movement
Compliment exercise program on land
Expected Outcomes
Stress reduction Increased ROM and flexibility Reduced joint swelling and tenderness Improved muscle strength and tone Improved heart and lung strength
Aquatics Program
Contract with local YMCA
1 x a week for 1 hour
1 Physical Therapist
1 C N A
Participant Criteria
Continent of B&B
Min A or < for ambulation
Min A or < for ADL’s
Pain, decreased range of motion, arthritis, joint replacement, weakness
Staff Training
Licensed Physical Therapist
Continuing Education Courses
Standard Operating Procedure
Referral to program by IDT Meet program criteria Receive medical clearance Arrange for DC attendance Transport to YMCA by PACE bus Provide water bottles and healthy snacks Personal bathing suit and towel
Program Day
Rehab staff:Confirm DC attendance (Ppt asked to call Rehab Dept. 24 hrs. prior to cancel) Take lunch meal orders and provide information to Dietary AideProvide list of Ppt’s attending to Day Center Receptionist and Lead CNA’s
Program Day
C N A:Gather Ppt’s and escort them to the
bus
Put the Aquatics Kit on the bus (water, snacks, participant face sheets)
Facilities
Facilities
Class Protocol
Body stretches
Body strengthening exercises
Aerobic exercises
Outcome Data
Patient Health Questionnaire (PHQ-9)60% of the participants saw a > 4 point decrease in the severity of their depression after 3 months
No increase in PHQ-9 scores at 6 months
Knee Pain Results
3 months 6 months
60% reported a decrease
70% reported a decrease
20% reported no change
30% reported no change
10% reported an increase
0% reported an increase
Video
Reiki
A Japanese healing technique
It does not have any specific religious affiliation and can be hands on or off
Reiki: The Healing Touch by William Lee Rand
History
Founded in Japan in 1922, by Usui Sensei
He discovered it while atop a mountain where he was doing penance. After 21 days on this mountain, he felt a great REIKI over his head and was spiritually awakened
A simplified version was brought to the West in 1937 by Hawayo Takata
Participant Criteria
Acute or chronic medical or behavioral health concern
Open minded to the experience
Staff Training
Level 1, 2, Advanced and Master Practitioner
The practitioner providing the Reiki is a conduit through which healing energy flows through and into the patient using a series of hand placements and symbols.
How does Reiki Heal?
Reiki states that we have a life energy, or Ki, flowing through/around us
7 pathways called chakras, in fields of energy, called auras
Chakras and Auras
The chakras, each represent a different energy, correspond with the layers of our auras, transforming energy into various frequencies
An aura is an energy field created by our thoughts and feelings
Treat with Reiki
Neurological diseases Cardiac disease Cancer Headaches Pain Comfort Care at end of life
Behavioral Health Issues
Fatigue Insomnia Depression Anxiety PTSD
Healthcare Settings
Reiki is offered as part of regular patient care in over 800 acute care hospitals throughout the US Nursing Homes Hospice Facilities The Reiki Cooperative in Providence, RI, was
accepted by The RI State Nurse’s Association to offer Reiki training for Nursing CEU’s
Program Goal
A decrease in symptom complaints, by strengthening the bodies flow of energy
Increased overall sense of well being
Standard Operating Procedure
Member of the IDT referrers a participant for Reiki
Potential benefits of Reiki are reviewed and a treatment session is scheduled in the Ppt’s home or the Day Center
Session Day
Practitioner reviews the process with the participant Session begins with a 5 minute meditation Session ends with a review of the treatment experience
Response to Reiki
Each Ppt is asked about their level of stress and location/level of pain (1-10 scale) before and after the treatment session
Each Ppt is given a questionnaire after 3 months of treatment
Results
Sleep quality: 90% reported improvement and 10% no change
Muscle pain: 80% reported improvement and 20% not change
Headaches/migraines: 80% reported improvement and 20% no change
Anger/ability to regulate anger: 80% reported improvement and 20% no change
Results
Happiness Factor: 70% reported improvement and 30% stated no change
Overall Wellness: 80% reported improvement and 20% reported no change
Stress Level: 80% reported improvement, and 20% reported no change
Therapeutic Massage
Massage is known for it’s therapeutic, relaxation and palliative benefits in the geriatric population.
nccih.nih.gov
Benefits
Increased blood flow Increases flexibility and ROM Improves proprioception Desensitizes hypersensitive tissue Decreases stress Decreases muscle tension
Participant Criteria
Acute pain
Chronic pain
Behavioral Health conditions
Staff Training
Licensed Massage Therapist
Continuing Education in the special needs of the geriatric population
Sessions
Offered at all 3 Day Centers 3x a week 30 minute sessions 1x a week for 12 weeks 1x a month for 12 months
Outcome Data
Ppts with muscular pain, joint pain, or cramps/spasms:
85% reported decreased pain/discomfort after 12 weeks of massage therapy services15% reported no change 80% reported elevated mood associated with decreased discomfort after 12 weeks of massage therapy services 20% reported no change
Food is Medicine
Medically tailored meals
Home meal delivery
Community Garden
Farmers Market vouchers
Medically Tailored Meals Program
Initially a 3 month pilot program
Collaborate with a non profit food and nutrition program
Weekly home meal delivery
Program Goal
Provide nutritious, appropriately portioned meals to participants with diabetes with the goal of preventing hospitalization and improving diet compliance.
Weekly Meals
Expected Outcomes
No hospitalizations due to hypo/hyperglycemic event Improved A1C Weight loss Nutritional changes
Participant Criteria
Diabetes diagnosis
Poor eating habits contributing to poor diabetes control
Able or have assistance to store/prepare food appropriately
Staff Training
Site visit
RD training on electronically completing documentation of PMH and nutritional requirements
Standard Operating Procedure
Registered Dietitian met with medical staff to choose 10 participants who would benefit from receiving medically tailored meals
RD completed a nutrition assessment on each participant
Standard Operating Procedure
Initial, 3 month, 6 month and 12 month intervals:
Lab valuesWeightsHealth survey
Resources
Refrigerator (s) to store food until delivery
Food delivery driver/vehicle
Program Day
Food delivered to the Day Center from vendor
Food labeled by C N A with Ppt name and diet
Delivery info provided to Driver and DC Receptionist
Program Outcomes
70% of the Ppt’s in the program continue to receive meals
30% of the Ppt’s voluntarily removed themselves from the program
Data
57% lost > 5 lbs
29% had a > 1% drop in A1C
No new disease specific hospitalizations
Questionnaire Results
80% of the Ppt’s saw a relationship between food and health After 9 months 57% of the Ppt’s felt their
overall health had improved 29% reported that their eating habits had
changed
Disease Specific Standards of Care
COPD
CHF
Falls
Program Development
Best practice:
Evidence basedConsistency of careInterdisciplinary approach
Staff Training
Initial and annual competency
Annual Update of the Standard of Care
COPD
Well Plan
Baseline measures
Individualized exercise program
Respiratory muscle trainer
COPD Ed booklet
COPD
Sick Plan
Adaptive Equipment
Relaxation Techniques
Outcome measures
Energy conservation techniques
CHF
PreventionClass 1,2
Baseline measures
Physical Activity
Skilled services
CHF Ed booklet
CHF
TreatmentClass 3,4
Adaptive Equipment
Outcome measures
Skilled services
Energy conservation techniques
Falls
Identify fall risk
Education Outcome measures Intervention
Home safety assessment
Outcomes
Increased Education
Maximized function
Earlier intervention
Decreased hospitalizations
Maintained independence
Day Center Physical Activity
Walking Group
Competitions
Community outings
In Summary
The current PACE rehabilitation staffing model does not support traditional therapeutic interventions Utilizing a wellness approach to care is patient
centered and benefits outcomes Rehab staff should be encouraged to develop
programming that maximizes functional independence
References
Rehabilitation Measures Database: Rehabilitation Institute of Chicago www.srlab.org Effects of Reiki on anxiety, depression, pain and
physiological factors in community dwelling older adults. Richardson, N., et al. Research in Gerontological Nursing, 2010 Multifactorial intervention with balance training as a core
component among fall prone adults. Beling, J., et al. Journal of Geriatric Physical Therapy, 2009
Additional References
Meal delivery programs reduce the use of costly health care in dually eligible medicare and medicaid beneficiaries. Berkowitz, S., et al. Health Affairs, April, 2018
Effectiveness of a therapeutic Tai Ji Quan intervention vs. a multimodal exercise intervention to prevent falls among older adults. Fuzhong, Li., et al. JAMA Internal Medicine. September, 2018.
When adults don’t exercise: behavioral strategies to increase physical activity in sedentary middle aged and older adults. Lachman, M., et al. The Gerontological Society of America, Innovation in Aging. April, 2018
Additional References
Person centered care for older adults with chronic conditions and functional impairment: A Systemic Literature Review. Kogan, A. et al., The Journal of the American Geriatrics Society. 2015.
The physiological and psychological effects of slow stroke back massage and hand massage on relaxation in older people. Harris, M. Et al., Journal of Clinical Nursing, 2010
Use of alternative therapies by older adults with osteoarthritis. Ramsey, S.D. et al., Arthritis Rheum. 2001
