Sunday, September 22, 2019

How Can I Prepare for PDPM as an Occupational Therapist

Let’s talk October 2019 and PDPM. I've been sitting on this one for a while...

In fact, I was debating about whether I should talk about it at all.  I asked myself "Will practitioners even read this?  They won't think I understand."  I also kept approaching my finger toward the "record" button on my phone to do this on live broadcast via Facebook ...then after hesitating on that, I thought about writing it in a instagram post...I definitely said to myself "maybe I should just let this play out on its own accord and not have anything to do with the influence and direction of where the future of our profession goes."

As I was debating all of this, I found that I cannot just sit on it anymore.  It's days away from being here and I promised myself I would honor and care for my occupational therapy colleagues when they are faced with a roadblock. 

I risk being shamed for this by some practitioners because they are not ready; ready to take on more work... and frankly too exhausted to fight the good fight. I get that; it’s been a lot... but my desire to get these tips out to you are worth it because I promised to mentor and look out for practitioners like you that need guidance in an uneasy time (especially when facing barriers like the uncertain ones to come at this time in the profession). 

We are talking about shifts in payment for treating clients; within skilled nursing facilities (come October) and soon after in home health settings (January).  

This post is for you if you want to know what you can do about the changes.  
This article is not for you if you expect things to change on their own or do not have the energy to do the work ahead of you.

I want to first start out by identifying one common theme that is happening amongst us: 

fear of the UNKNOWN

There are a lot of questions spiraling around including:

** My boss is not telling us much; we don't really know what to expect.  What do I do?
** Will I have a job after this?
** I was already laid off before it began. Now what? Do I just look outside of the profession to pay the bills? I have a family and myself to feed.There are no jobs in a 40 mile radius.
** They’re expecting me to do more work with less. How is this even possible?
** I've been down this road before, it's all the same.
** Group treatments? There’s only so many allowed in the new payment structure!

** (insert dilemma and disappointment here).
** what about the ethical issues? They'll just look different now.

Feeling scared, tired, sad, mad, upset and lost is reality of change. When there is change brewing in payment sources, our first gut reaction is to wonder what's next for our careers, financial future and mental well-being as practitioners. 

There is no doubt that this transition, like any in life, is EXTREMELY DIFFICULT for those who work in those settings. In fact, it is not just those settings...I personally fear (as I go about my day working in acute care) that not all my clients will have opportunity to be accepted at skilled nursing facilities once the dust settles.  It is this weird fear of mine that creeps up that less clients will be accepted to SNF and home health if we do not understanding how to get them accepted under the new payment structure.  I fear that it will be just as hard to get clients into SNF settings as it is to get them into acute rehab...I thought, "oh no! what if my client doesn't have a discharge plan after their care?"...fears
...fears from the unknown.

There is uncertainty about the future from all angles due to this transition coming.  

But that is exactly what it is, a transition...a different direction...and here's some real talk: 

every TRANSITION in life is difficult

It is difficult because it is uncomfortable. I've mentioned this in a podcast episode I spoke on (with the transparent Brock Cook from the Occupied Podcast), that there is discomfort because we are stretching and growing into something different than we are already familiar with. On a physiological level, we like to know we are safe and that this, like anything else, won't hurt.

I guarantee you, you are not the only one feeling it: aside from physical therapists and speech-language pathologists, your facility staff, including nursing and physicians, as well as your boss and non-therapy administration, will also be going through some growing pains as they process what is coming.  

That is why I want to challenge you to step out of your comfort zone. Step out a wee bit farther than being forced to by external factors right now.  This is to shift that "scary" change into a transformation you can look forward to.

Let me emphasize a point here: 

with change ALSO comes transformation 

So, what is Transformation?:

Transformation is an opportunity to shift into something better, especially from the beginning stages. 

Think about going from a caterpillar to a butterfly. The butterfly must struggle to get out of the cocoon.  They must do so on their own or it risks its life and dies when forced from its shell.

You must struggle to get the wiggle room you desire to fly in your career.  

The freedom to fly stems from YOU; when you decide to move in the direction of opportunity (which takes somewhat of a struggle to get to). It means the struggle we choose to endure (with the goal of achieving the desired direction we want to go) allows you the freedom to fly anywhere you want.

So what does that struggle look like in order for you to fly?:

First, it's not getting up and leaving the profession right away.

Therapy Practitioners: Whatever you do, if you have not been let go, actually even if you have been let go, DON'T FLEE.

Travel therapists: If you cannot find a travel assignment because facilities are halting their contracts, DON'T FLEE.

If you do, you have already decided to reject the future of the profession and reject any opportunity that may exist. Instead of fleeing, try walking into it more deeply.  
  • Step into these meeting rooms where the conversations are being had. 
  • Build a seat at the table to discuss how your facility will be handling the changes. 
  • Be involved in the conversations (without asking for permission).
  • Ask the hard questions.
  • Initiate the narrative around what you have found out so far about PDPM and how you can help.

This is your opportunity to share your ideas about how to help with the transition; from an OT lens and right from the beginning. 

Have a judge-free dialogue about the current state of the facility or it's operators.  Talk freely about what these changes mean for who, while discussing how to utilize each resource in the interdisciplinary staff to get the goals for reimbursement accomplished.  After all, the interdisciplinary approach will be more crucial than ever.

Your first struggle in this though is:

You'll be out of your comfort zone

Might as well step out of your comfort zone on your own time rather than the decision being made for you by being let go (before making your voice heard).  Make the decisions alongside your boss or admin (as they are finding out that they do not know all the answers either).  The unknown is sort of a blessing because it means there is also a blank canvas to create on; take advantage of painting on it. The facility decision makers are also needing to step out of their comfort zones just the same.  Taking a leap, have an impact on that leap and jump together to create a masterpiece.  

 You next struggle is:
Acting like a boss

Instead of waiting for your boss to tell you what comes next with these changes, be the change. This change come October will allow you permission to be a partner alongside them to address the changes.  Respectfully act like an owner, showing you are invested in the health of the company. Instead of submitting to an employee role below the hierarchy, be a partner. 

Your third struggle:
Going back to your roots

You'll be a little rusty and that is okay. However, after you dust yourself off, forgive yourself for doing all that "THER EX" and gather your resources to learn the ropes of what is to come; you will be able to provide your perspective of what OT does for patient driven care. With a bit of trial and error, you will discover along the way what has to happen in order to create and establish an interdisciplinary approach, together. 

I know it’s not easy (I’ve been there with my own hurdles in practice, achieving a voice for OT, and making forward movement); but 
It is truly, truly simple and it is glorious when you get to enjoy the fruits of your labor (because you did the work). 

For many of our peers (and maybe you feel this as you are reading this now) you feel it’s the end of your career because you are tired, you've been through this rodeo already, and this is hard. For some of you, you will tell me "but they.......(insert past burn they placed upon you here)"  This is different because you are all starting from scratch. It is the very beginning of everything you had hoped for in your profession when you started. 

If you wait for your boss to tell you what to do, you are waiting on someone else’s opinion of the subject matter. Truth is, this is new to them too and THEY NEED YOUR help and expertise about what patient's want in order to achieve their outcomes. Show them what they do not know yet.  They need you to show up at the table where decisions are being made and for you to collaborate with them...before they come to the conclusion that what you offer doesn't serve the company (because they cannot see it) you have to show them.

So how do you do this? How do you show your worth to your boss and administrators?:

1. Go back to your roots. 

Utilize your skill set to help your facility through the transition: whether that is using the OTPF or pulling from the Occupational Profile to get back in touch with the framework of what we do, reference what we know and how that speaks to the patient driven outcomes.  In fact, our OT evaluation complexity codes require us to address the occupational profile in order to be reimbursed anyways.  This portion should not be so bad to get used to.

Also, consider joining the hub of treatment ideas and support for working with older adults over at Seniors Flourish Learning Lab (as an affiliate, you enjoy 10% off the subscription with use of this link or use of the code " ALEXISOT:111 " at checkout)

2. Seek information from the source, not peers.

Now if you are not into technical things, flipping through the many pages of CMS may not be an ideal way to do some more research.  That's what is so incredible of our own national association's efforts during this transition time.  They have support conversations over at communOT, an entire page dedicated to seminars and CEU opportunities about how to equip yourself during this time, grasping an understanding for PDPM and what it means in terms of your role as a practitioner.

 ...and as a member of the association, you also have many other resources at your fingertips to stay prepared.  My sharing of AOTA's resources is not sponsored and I do not work directly on any committee or board of theirs; I am solely an everyday member, like some of our own colleagues are. I have simply seen the hard work they have pursued to give you the tools to get the work done with during this time.  In fact, a fellow OT I have known for many years (through my own state association, as well as admiring their representative involvement in staying in the know of governmental affairs), is actually one of the presenters in one of the seminar trainings to get practitioners ready for PDPM. 

Allow the associations to help you.  Join them, look at what they are offering you and invest in the tools they have worked hard to develop FOR you.  

Learn EXACTLY what you need to know to navigate these new waters over at their main PDPM page 

3. Invest in a mentor.

This is critical; we need an outside party we trust to support us when we feel lost and when we need some additional tools to navigate.  If you do not have a mentor, stick it out with me into 2020 because I have something coming up for you.  My mentor program will be relaunching to help walk alongside you during the uneven terrain you're about to travel.  

It will be there for you to help guide you during those hard transitions throughout the ups and downs.  

To stay informed of when the mentor program will be re-released, and to receive notice of my current free trainings, updates on what's happening in the world of OT and more, get yourself on my email list to stay informed.  Go to

If I'm not your mentor or you need on the ground, face-to-face support, I'm not offended.  I care less about who you go to and more about whether that person is:
  • external from the context of your work 
  • are real with you when they need to call you out (or to admit when they don't know something)
  • admit their mistakes when they have made them 
  • have your back in tough times 
  • are there to elevate your practice as you grow
Closing thoughts...

This change in healthcare will likely not be the last change; life is fluid... it keeps moving and changing. We need someone by our side during those ebbs and flows.

We need this change inside of us to get to the next level of how we show up and care for our clients. 

Now is the time to make one of two decisions: 

Invest in being informed of how to navigate this; move one foot in front of the other, alongside each other, as one profession


walk out the door onto your new journey 

The choice is always yours. 

with love, Lex

Sunday, December 2, 2018

How to Determine Frequency and Treatment Durations of Occupational Therapy services in ACUTE CARE

Triaging who gets seen first for evaluation typically is driven by both joint commission standards (we address OT consults within 24 hours of receipt) AND how fast it is predicted for clients to leave the hospital setting.  

More likely, clients will not stick around the hospital long; that is why we need to be strategic about HOW we triage evaluations.

In acute care, we know evaluations are king…but what about frequency of treatment and the duration at which we should spend time with clients?

Here are the basics to get you started. 

Let’s first take a look at the five basic components of determining frequency and duration of clients seen in the acute care setting: 

Skilled client needs
Discharge placement security
Length of stay
Readmission risk

All of these work alongside each other and not as one or the other.  Each is a puzzle piece to a triage formula for determining who, how often and how fast.

Skilled Client Needs

Q: Who determines this?  

A: We do as OTPs as in any setting!  As the OT practitioner, we determine duration and frequency based on the client’s skilled needs (not a supervisor, manager, director or caseload number).

Questions to ask ourselves:

Do they have skilled needs?

“Is the client appropriate for OT services at all or are they at baseline?” 

“Do the standardized assessments we have done shown their skilled needs?”  

“Does the patient have goals?”

Determining whether we sign off at OT evaluation, select 5x/wk treatment, or choose 2 follow up sessions before the client discharge is influenced by skilled need.

Whether clients stay 2 days or 2 months; what the client needs is what matters.

That is why we indicate the true frequency needs. Even if the caseload is so slammed and you know you will not get to them for that 5x/wk for treatment, that treatment  frequency represents what the client will require to recover in occupational performance when they leave us. 

Q: What are some cases where treatment may be minimal to no needs?

A: Client is going toward a comfort care approach (with no hospice measures indicated). When the client does not tolerate therapy for the duration we anticipate to see them that day.  Or, we may be trialing our services for 2x/wk before determining a greater frequency because of poor tolerance for treatment or uncertainty in client ability to meet goals.  

There may also be times where we may sign off the client case completely when they do not have goals at all.  Despite our attempts made over the course of their stay with us in acute care, we together (OT and client) cannot come up with any additional goals to progress occupational performance.

Q: How about evaluation complexity codes. Do we factor those into skilled needs determining treatment frequency?: 

A: The evaluation complexity codes are chosen based on the clients number of occupational performance deficits, extent of occupational profile and overall complexity criteria.  When it comes to determining treatment frequency however, code choice actually will play less of a role when the length of stay, discharge placement and readmission risk influence the circumstances.

We may find a client only has a few things to be assessed for with more detail treatment to follow…or lots of things on evaluation to assess are found with less detailed treatment to follow.  

So many factors determining skilled needs.  Truth is, it takes many years of practice to work alongside your client and determine skilled need frequency and duration of treatment (give yourself grace with this).  

Discharge placement security

Questions to ask ourselves to determine how secure discharge setting is (with or without OT services) for our client:

Does the client have a caregiver?  Does that caregiver have the time, availability and amount of assist level necessary for this client’s physical, cognitive, psychosocial needs at discharge setting? 

This will influence what we recommend (and may be necessary information to determine how involved we are in treatment during the client’s stay for training or justification to a higher level of care)

Will the client be returning to skilled service at prior discharge setting?

No acute or infrequent acute needs until their return back.   Example: coming from and going back to a skilled nursing facility.

Does the client have a discharge setting to go to and will they be functional for that setting by the time they discharge?  

The client may be in limbo as to where they will go.  When we do find out, we have to determine if they have enough caregiver assist there and whether they need OT when they go. 

Examples of this:

#1: Client will be going to an assisted living facility (ALF) but, they do not have 24 hour hands on assist (it is supervised level of assist).  We find now after their hospital admission that this client needs physical assist to prevent a fall.  We may be more involved in training the caregivers, or having increased contact with care coordination, to help facilitate their treatment needs going forward when they discharge the hospital.

#2: Client is homeless and there is question as to whether they can discharge back to the streets with those multiple fractures they just sustained.  It is uncertain if they can get home health OT at a shelter but, we would be prioritizing their treatments to maximize their skilled therapies while we have them in the hospital.

Is the client going home with or without OT services?:

We may need to download all we know into the client and caregiver’s brains to best prepare them for their functional well being with a new diagnosis if no OT service is accessible to the them.


Client is medically ready to leave the hospital on post op day #1.  They will not be getting home health OT services. Acute care OT needs to evaluate and provide treatment intervention all in the same day!  Even though the client’s occupational performance is graded at a low complexity - 30 minute anticipated evaluation - we may be with them for a whole hour total to cover all the basics in treatment before the client discharges.

Are we trying to justify for acute rehab services?:

This may require us to see them more often to justify tolerance for therapy and prove it to be beneficial in a critical rehab recovery time. 

Does the client have a good discharge plan for after they receive acute rehab services?:  

If they do not have a set discharge plan in place after rehab, this may play a role as to whether the client is accepted to an acute rehab. 

Sometimes we have to play the role of being their acute rehab services (even though we function like an acute care setting) because the client has a critical functional recovery window (such as in an acute stroke or acute TBI.  It may be time sensitive where the more frequently we can see the client, the better the functional outcomes.   


Speaking of critical functional recovery windows…

Q: What diagnosis may indicate more frequent or longer durations of treatment in acute care setting?

A: a client who has sustained an acute neurological incident (TBI or stroke), cardio-pulmonary type surgeries, or clients who are on early mobilization protocol (ventilator weaning), may require prioritization for frequent treatments to maximize neuro, cardio-pulmonary and functional recovery.  

Benefit from greater frequency of OT services in acute care setting can also support discharge placement through our justification. 

Beyond functional recovery windows, seeing these clients more often proves their tolerance for therapy.  To fulfill the skilled need to be accepted into that LTACH or acute rehab, we up the frequency of treatment to better the client’s chances in getting into settings recommend for them.  

Also, those diagnosis that are known for not receiving our services (for example a client on observation for a pelvic fracture), may benefit from our visits more frequently and for longer durations of time during their hospital stay.

Q: What about diagnosis where the condition is terminal?

A: Some terminal diagnoses may have us determining less frequency for clients who are set for hospice or comfort care measures; this may lead to the client being signed off from OT services completely.  We of course have a role in a client’s trajectory of palliative care, however, those needs can be best met at the next level of care/setting.

Additionally, if we know what diagnoses are notoriously known for receiving OT services at the next setting, we may not prioritize them altogether and recommend they receive that upon their discharge.

Length of Stay

Knowing how long a client will stay in hospital will vary.  However, it plays a critical role in determining frequency of treatment.  This will help us prioritize treatment follow up.  

The first questions I ask myself are:

Is this client on an observation status, outpatient in a bed, or ambulatory status of care?

Is this client someone who typically goes home after their medical scans are clear but likely to be predicted to have critical self care and functional retraining needs?

While considering the discharge setting and follow up of OT services available to the client at the setting they leave us for, treatment duration may vary and more reliant on frequency need before they go.


The shorter the stay in the hospital = the more frequent they will be seen for ADL retraining. 

The more frequent you need to see your client may also be a predictor in how long you stay for the duration of treatment on the first few sessions.

Some exceptions for short stay clients:

When you know they will be going back to skilled nursing with skilled OT services (or back home to resume already-in-place home health therapies).

Another component that is critical to consider in treatment is education.  Assume the first time you see your client will be the last. Ask yourself: 

Did I educate the family on the critical points for their loved one to be successful at the next level of care?

Did I go over and have them return demo (if able) all the critical points I can think of that may be impacted by their current diagnosis and acute stages of recovery?

Anything they should know to anticipate during their journey of recovery (to be able to advocate along the way?) 

Readmission Risk

Let’s first ask ourselves: 

Who is at risk for readmission?

1. Clients with acute on chronic conditions.  

Example: client with acute on chronic Congestive Heart Failure (CHF) admitted to the hospital due to fluid overload.  

The physician will take the fluid off of their body with medical treatment and send them home once medically stable.  

These clients may be back sooner than later if their symptoms are a result of client behavior, perception of medical treatment being a disruption to their daily occupations or other circumstances we find out in OT evaluation.  

We as occupational therapy practitioners get to figure that out and decrease their risk of being readmitted.  That is why our interventions with them on day one will be so critical. 

Sometimes our treatment are the resources we provide to them that are available to the client in the community.

2. Complex medical cases. 

With these cases, I sometimes find myself in unknown and uncharted territories as an acute care therapist.  This is because their readmission risk factors are more dynamic than one diagnosis need; think of it like PEOP model on steroids (the environment influences the person and the person influences the environment.  Both influence their performance and the occupation.   Also, the place at which they occupy space is influenced and interchangeable).  

Some examples include:

  • co-morbidity of significant obesity (including beyond BMI and standard scales)
  • homelessness
  • frequent alcohol intoxication with withdrawal
  • social admissions (family can no longer care for their loved one) 
  • psych diagnosis
  • history of falls
  • dementia without placement into a memory care

In our own implicit biases or uncertainties of how to assist these clients, we tend to defer these cases for a variety of reasons.  However, these clients are still at risk for readmission.  

I wonder and ask you:

So how do we play a role in their recovery to decrease their incidence of returning to the hospital?  

How frequent do we get involved in interdisciplinary care for these clients?

When do we wean down our treatment frequencies?  

These clients tend to stick around the hospital for a while due to barriers in discharge; it is a question I ask myself regularly but know in my OT heart we have a role.  

I begin with an occupational therapy profile to get started on what treatments and interventions should be addressed.  

The interventions take time to build upon themselves to truly make an impact on clients with these chronic circumstances.  That is because our interventions in acute care are not overnight fixes for this client population.  We are used to treating with one to few sessions in this setting ( such as training the client on how to use of a sock aid for that posterior hip replacement).  With complex medical cases however, there are many years of layers we need time to pull off to get to the client’s ability to perform self care well.  When the client leaves and it is a question as to where they can receive those treatments and interventions elsewhere, what can we do in the short to help them with the long term outcomes?

If you have ideas, I would love to know myself.  Write them below in the comments.

Hope this breakdown of determining frequency and duration of treatment in acute care has served you well to get you started.  There are many more factors to consider beyond this post.  If you have additional questions you would like me to talk about, email me at 

Until then, see you in my IG stories or live video feed

Thursday, October 25, 2018

Occupational Lessons About Head Injury

Once upon a time, in a suburban acute care hospital, there was a client walking and talking within the four walls of their hospital room. Their supportive family sitting all around the client's bed; awaiting the rehab team to come evaluate their loved one.  Their beloved family member sustained what appeared to be a "very mild" brain injury.  

The OT arrived to assess and provide treatment intervention.  The OT thought the client was doing well (based on observation and by what the client self reported).  The OT believed the client could go home; that conclusion was so wrong.  That OT, once upon a time, was me.

At the time of this encounter, I rationalized that the client was "just tired."  

I remember the speech language pathologist (SLP) asking me to watch their treatment session with the client. I wasn't sure why it would be necessary; I had already shared with the SLP that I thought the client could go home because of how well they had been doing. 
I gave it the time and watched the next few minutes go down.  

It was in those few minutes my perspective and OT practice shifted forever.  

It was that moment that took me from what I thought 5 years of OT experience looked like, back to feeling like I had ZERO years of skilled experience and then back to what 5 years of experience is supposed to feel like.

It was embarrassing; to admit to myself I was acting more like a bystander; seeing the client from a superficial lens.  What I thought I was doing was being compassionate and respectful of the client's experience in the hospital.  I was not using my clinical or skilled eye to make a lifelong impact for my client.

So how do you shift from bystander observation to skilled OT practice assessment? 

If you see your client agitated and irritated and "tired" you want to leave them alone out of respect right? The thing is, we aren't doing them any favors by letting them rest.  We are actually creating the barrier to the meaningful occupations they are expected and desired to return back to in the home and community. 

After the SLP elicited the client's true deficits, a lightbulb went on for me. 

Witnessing the client's rationale showed me it was apparent they would not be able to safely take care of their young children...or manage multiple errands in the community...or tolerate conversation in social gatherings...or have a meaningful relationship with their spouse.

Although the client was physically able to do ADLs, including demonstration of getting on their knees (of the hospital floor) to simulate pulling out a broiler drawer of an oven (they used it often to cook for their family); independence with this dynamic activity was not enough for daily activity success.  

To get a perfect score on a MOCA screen does not mean they are safe from the real-life struggle ahead of them (and ahead of their family).

While I felt drenched in humility, the situation convinced me that the client should go to acute rehab (ARF) before returning home.

Then, I came across my next battle:

Convincing the Physical Therapist out of their recommendation "independent; home." 

The PT said: "_____ should be able to go home to recover; you shouldn't want them to be stuck in an acute rehab!  They walk fine; let them go home to spend time with their family."

After multiple discussions we were able to get the PT on board to recommend acute rehab, begrudgingly.  Encouraging them to use other assessments that were going to challenge the client at a higher level was a strip from their ego.  To ask them to observe the client's reactions, comments and behaviors when participating in the assessment was an easier feat.  After this advocacy, the client did get into acute rehab (whew). 

Skipping forward two years (2018):

One of the things about working in acute care hospital is we do not see (or always hear) about the outcome of the client's rehab recovery at the next setting they go to.

When we do not see the benefit of our work because of lack of closure, we may convince ourselves that what we do must not work or be of that much benefit.

Truth is, we get to be first on the scene of their life changing event.  We get to start our clients on the right track of recovery and cross our fingers what we did or recommended to them worked or made a difference in their lives. 

I got my closure recently on this particular case.  

Two years from the time I saw this client and their family, the client's spouse and I run into each other unexpectedly at a local coffee shop…at an ungodly hour of the morning by the way (I never wake up this early but, I wanted to get a head start on my department’s next competency project before the rush of colleagues came flooding into the office…that’s for another story).  Standing in street clothes, grabbing a straw for my coffee, the client’s spouse remembered my name and what therapy discipline I was. They said to me "Alexis, what you did for ___ and my family made a huge difference in our lives.  We will never forget it. The only trouble they have now is ___.  I have my ____ back again. Thank you."

Two things came to me in that moment:

1. I asked "What did I do?" I shifted attention to thanking the profession of Occupational Therapy for reminding me of the meaningful components that impact our life.

2. I picked myself up off of the floor after knocking myself down. This client's restoration, return to meaningful daily activity and family wholeness could not have reminded me more of why the challenges we face in our day to day practice are worth battling.  

Have you ever had a time where you were able to be facilitate your client's access to meaningful occupation after their traumatic event because of your advocacy efforts?

Have you ever had a situation where you experienced a lesson you will never forget in practice? 

I want to hear from you and your story; you are not alone. 

Monday, October 1, 2018

How Listening to my Client Improved My OT Skillset

I remember that day when I was told by nurses and physical therapists that client X was "in a mood" "upset" and "not participatory."

I was told they were "independent" because they could navigate their oxygen and intravenous lines themselves; demonstrates untangling them around their body to transfer to a chair from the nearby hospital bed.

So I did a chart review to screen to see if I would evaluate one time only, based on the report I received from my colleagues.

When I walked into the client's room, I didn't introduce my name or discipline.  I first greeted them hello and asked "how are you doing?"

They proceeded to tell me "I'm fine; what do you want?"

I followed up by saying "I want to find out more about you.  I see you were admitted to the hospital for exacerbation of symptoms associated with cancer.  I would like to get to know you a bit more to see if  there is anything I can do to support your recovery to compliment what you are already doing now for coping with symptoms. Would that be okay with you?"

They began to tell me their story: long they have had the diagnosis
...what they have been able to do and not able to do in daily activity because of fatigue and pain
...what roles and responsibilities they played in the community and to family

Then they began to share their concerns the more I listened:

...their difficulty delegating tasks they didn't like to do in their day to day
...their difficulty organizing tasks in the day and feeling overwhelmed easily
...their report of finding themselves irritated often
...their report of forgetfulness
....their upset with doctors, nurses and therapists stating "they don't hear me. They listen but they don't hear me.  Instead, they tell me what they want from me."

After hearing all the client's thoughts, perspective and concerns over a 45 minute period, the client turned it back to me to state "thank you for hearing me; what can I do for you?"

I paused for a moment: all I wanted was to help them fill in the gaps they perceived as the obstacles, barriers or stumbling blocks to accessing meaningful activity.

So we worked together to identify all the things that we could work on.  Two things came out of it:

Identifying what we have control over
Asking what can we take action on now

I felt slightly out of my element that session because I walked in thinking I would interview and discontinue from OT services...maybe see if the client needed energy conservation and work simplification strategies for an exacerbation of respiratory related symptoms and fatigue.  Instead, I was taught the lesson that when you truly hear your client, you pick up on what they really need.

In this client's case it was two things:

1. a way to let go of some of the responsibility they took on (having too many occupations that weren't serving them well).

2. how to get organized and keep on the tasks they identify as important or of value.

It turns out the client had an pre-existing brain injury as well that was not identified in their medical history; the client told me that 40 years prior they sustained a TBI and never received any OT services for this.

So we worked on cognitive strategies to address the client's needs (not my plan or the other staff's plan, my client's plan).

The client expressed significant gratitude to have an intervention that fulfilled her request.  Not only could she plan a better system to be less hindered by fatigue emotionally and physically, she was heard.

Wednesday, August 15, 2018

From RUGs to Patient Driven: 4 Ways to Prepare for What's to Come

Writing today because you just never know what is coming around the a week, a month, a year.  Time travels faster than we know what to do with it.  That's why I want to give you options when change is on the horizon.  Change can be annoying and scary. We can sit back and take a "wait and see" approach to change or shift how we do things; including how we practice OT.  Either way, it is important to:


Stay in the know of changes and knowledge. Knowing all details of the good, bad and ugly gives you power to make decisions.  ...and in this case with shift from RUG driven payment models in skilled nursing settings to a patient driven one (in just over a year from now), it helps us best prepare for how we desire to practice OT.

You can do so much in one year; preference of how you want to practice is in your hands: 
--> to practice OT while abiding by (and advocating OT's inclusion for) what is coming in Oct 2019 
--> you have the choice to prepare to transition out if this isn’t what you truly want to do.

Ultimately, the decision (and actions) are up to you.
Here are some different routes you can chose from:


Daily; this is an investment to be certain you will be utilized
(if you decide to stay, each of the over 365 days, each day counts to make this effort... to sustain your utilization, the time and energy to speak to be heard is non-negotiable)


ask of each (the DOR, the administration, the owner, the supervisor and managers) of their perspectives (separate from one another) regarding the upcoming changes...
this will help you make an informed decision about whether it’s the facility (and setting) you want to continue to work at.
If they don’t know how they feel about it yet, give time to continue to gather their developing perspectives.


Start studying for that different population or service setting. Learn about the ins and outs of something unfamiliar. Pick up per diem work. Get a trusted mentor in those settings.
Remember: just because you have little to no experience in another setting, does not mean you do not know how to practice OT. It’s just a different shade of what you do (it’s not easy but not impossible. It takes practice, exposure and willingness to try).


research what it is like to start your own; this is actually the wave of our future.
(and to be honest, it’s where we would thrive being our creative selves).
Where there is more control over our circumstances...where our hands are tied by rules and restrictions of insurance...and what feels like it dictates how we practice, the more you will see OT practitioners stepping into their own businesses.
There are so many opportunities to develop your own thing. 

Service, invention, product.

Don’t be mistaken; those who do it started afraid (or will be when they do).
They will do it unprepared but will learn and grow overtime.
They may start off inexperienced but they will grow in skill with practice and time.
One important thing, they will be happy.

We get so bogged down by the limitations in front of us that we miss the opportunities there as well.   It’s just a matter of believing you deserve it more than believing you can’t do it.

To sum up, there are always options in uncertainty:
* Do OT, show OT, be OT - AlexisJoelle
* Stay informed.
* Research, investigate, explore.
* Do something that aligns with your OT spirit and do it scared anyways
* Be limitless

Appreciate you for stopping by.  
To stay informed of upcoming resources, courses and support to decrease barriers in your day to day activity of practicing OT like those mentioned above, be sure to sign up with to stay informed

To review the article referencing the Oct 2019 change from RUGs to Patient Driven Payment Model:…/CMS-SNF-PPS-Patient-Driven-Payment-M…

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