My Life as A Physical Therapist – Part 12

Written by: Yaffa Liebermann, PT, GCS,CEO

1992-1995 treating patients in nursing home working for Paragon Rehabilitation.

One evening a recruiter called me to ask me if I would like to take a PT supervision job within a nursing home.  During my time at the outpatient facility, I was scheduled to work two evenings per week which meant I missed dinners with my family.   Working daytime only was appealing to me so I looked into this new offer seriously.

The interview took place in a hotel instead of the nursing home.  It was not important to me to see the building or the patients because I knew that they are people and I am going to love them.  I did want to meet those who would be my supervisors in order to determine if there would be a good connection.

The interview went very well and I opened my heart to the nursing home world and deepened my love and appreciation of the elderly. They worked hard all their lives and at the end, when they were under our care, it was our turn to support them while providing skilled care to continue their independency as long as they could.  I would share with you my views on working as a PT in the nursing home.

Introduction to Sub-acute Rehabilitation in the Nursing Home:

A therapist in the nursing home setting has more independence than in any other setting.  The therapist screens the patients and provides skilled therapy to restore strength and achieve the prior level of function.  The therapist can implement a rehabilitation program in a setting where many residents would otherwise remain sedentary.  This kind of program can be challenging but is very rewarding upon completion.  The therapist also in-services the nursing staff on how to decrease the level of assistance provided to the patient, in order to achieve more functional independence.

Admission to a sub-acute facility is the second stage in the recovery process.  It follows an acute hospital stay and occurs when the patient is medically stable.  Within the sub-acute facility, treatment is intensive because the patient is stronger.  Treatment is specific to the individual as the therapist must prepare the patient for their discharge environment.  A variety of equipment is utilized during therapy, and the patient’s family becomes involved in the preparation to ease them back into their previous life.   All facilities subscribe to an integrated approach:  all components within the facility work toward gearing the patient to function in the community.

The therapist treats in the home of the patient: Since the nursing home is the patient’s home, the therapist becomes an integral part of the environment.  When the therapist sees a decline in the patient’s ability to function, they evaluate and provide appropriate therapy.  Just as in any other therapy environment, there are many new programs to be developed and implemented.  Everything depends on the individual therapist.

Short-term patients: We prepare the short-term patients for a safe discharge home by educating them and their caregivers.  We train the patient on functional transfer techniques, pivot while standing, walking through cluttered areas, and climbing up and down from a curb. Our goal is for the patient to be able to wipe himself, make his bed and prepare a small meal. Adaptive equipment is ordered and safe handling provided to the families, as well as an illustrated home program to ensure follow-up.

Long-term patients:  Prime Rehabilitation Services takes a proactive approach to fall management, restraint prevention, and correct positioning with appropriate supportive devices. The patient is encouraged to practice wheelchair propulsion using their hands and legs to achieve independence, thus increasing their confidence and pride.  Upon discharge from rehabilitation, restorative nursing is in-serviced on range of motion, splinting, positioning and appropriate support while walking.

Wheelchair Propulsion.  An important goal toward patient independence; even if he moves just one leg and one arm, he can progress to achieve the desired goal.  If he moves only one leg he moves a few muscles, the blood circulation flows more easily, endurance starts to build up and it is the best preparation for walking.  Every little muscle action contributes to the whole structure to create a complete functioning body web.

Wheelchair propulsion can be performed in three (3) different ways:

1. One hand and one leg: the hand being used as a wheel and the leg as a steering wheel.
2. Both feet acting as pushing, pulling, and steering devices.
3. Both hands propelling the wheelchair. 

No Discrimination Policy:

• Sit in a chair with equal arm support.
• Sit with weight bearing on both buttocks.
• Stand with equal weight bearing on both legs.
• Sleep on both sides.

Demonstrating and teaching correct transfer. In the nursing home, we invest time and effort in-servicing the nurses and the nurses’ aides in bed mobility, transfers, gait and ADL so the patient will repeat the same technique at all times.  The repetition gets to be a fixed image in the brain and helps the patient and the nurses. The patient does not remember the newly introduced movement after one performance.  The therapist should expect some set back.  Whatever the patient achieves in one session, it will be decreased by 75% the next day.  We have to introduce the movement again so the patient will relearn the movement and reestablish the muscle pattern to perform the movement.  It may take weeks for the patient to perform the transfer correct. Usually I find that 3-5 repetitions in a session of any given movement will help the patient to remember it.

Counting exercises out loud: From observation I learned that best way to deliver exercises is by counting out loud. It helps the patient to continue to the end  instead of stopping after three times. If counting by numbers, the patient would know ahead of time how many repetitions.  If counting by minutes, the patient needs to know ahead of time and be reminded when they are halfway and when they are close to the end. In a group performing exercise one of the patient can count. It is inspiring to the patient and the therapist as they are in it together.

Your Relationship with the Nurses: The nurses are the people who are with the patient most of the day.  We, as therapists, should always listen and communicate with them to inform them of any changes in treatment.  If a scheduling conflict arises in terms of your treatment, try to educate them about the importance of therapy; teach them what you do.  It is a good idea to develop a professional relationship with the nurses, a relationship based not only on patients.  Ask them how they feel, listen to their concerns.  The more respect the professionals within the facility have for each other, the more positive emotion is transferred to the patient.  Positive comments to patients about other professionals who are working with them will serve to ease the patient and help them feel more secure.

Documentation: Documentation is an important part of the therapy process.  It helps us during the evaluation process to gear our thoughts toward functional goals and to continuously document our progress.  In the home setting we need to write our notes and submit them to the insurance companies at the same time that we submit our bills.  With documentation “a picture is worth a thousand words,” so, please describe the picture with those thousand words in your notes.  Another guiding phrase: “If you did not document it, then you did not do it.”  Some therapists document WNL: It means -We Never Looked. WFL: It means -We Forgot to Look.  I first heard this from a professor and I adapted it because it helped me to explain to the evaluating therapist that she/he needs to document what they saw and analyze the patients’ difficulties.

Measurable and Realistic goals: During the first month in the nursing home, I had to discharge a resident of the nursing home from therapy to nursing care.  The previous therapist had written a goal of walking  450 ft. The patient was safely walking but it was too much for him to achieve that distance. This happened for a few patients. I went to my supervisor and asked what would be the average distance that a resident needs to walk.  Her reply was 150ft from his room to the dining room to eat and to socialize.  The sub-acute short stay would have a higher level goal adjusted to his home setting.

Learning experience: We should look where the patient is living and made the goals realistic to the patient’s ability and their environment.

The notes should be considered by you as a potential piece of evidence in a lawsuit.  Insurance companies also evaluate your professional treatment based on your notes.  Do not be afraid to show your knowledge which was gained throughout your education.  Describe the treatment that you provide to the patient as a unique procedure that cannot be performed by anyone else.  You went to school to learn when, what, and how much exercise should be provided to the individual patient.  The treatment is what you deliver to the patient, but the notes are a reflection of yourself.

One of the compliments that I cherish was given to me in the outpatient setting, when I documented what the patient performed that day.  A co-worker started to talk with me about my social activity  for the weekend.  My patient who was watching us from her treatment table, said to the therapist who stood by me: “When Yaffa documents her notes, she concentrates and does not talk or make jokes”.  This was and still is the correct statement.

I found my niche in treating patient in the nursing home and have stayed there until today.