Author Archive: Ian Oppel

group and concurrent

Q&A: Group and Concurrent

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Question: 

How can we use RESTORE in the delivery of group and concurrent therapy?

Answer:

Great question. To start we have to understand the difference between group and concurrent therapy:

  • Group Therapy - One therapist/asst. providing treatment of 2-6 patients performing similar functional skill activities that are part of their plans of care regardless of payor source.
  • Concurrent Therapy - One therapist/assist. providing treatment to 2 patients simultaneously, who are performing different functional skill activities (per payor guidelines).

Next, let’s look at some of the potential benefits of these deliveries of care approaches:

  • Socialization - helps mitigate the risks of isolation/loneliness and promotes social interaction skills.
  • Patterning of Behavior - promotes the ability to learn from others. Players of similar or different functional ability levels can benefit from observing/demonstrating how to perform an activity that helps to improve their own performance outcomes.
  • Cooperation - the ability to work together towards a common goal can be rewarding and motivating. By working together, players can achieve outcomes they may never have realized individually.
  • Competition - many players are motivated by competition. They may in fact participate longer, move more, and engage more when there is an opportunity for a winning outcome.
  • FUN - the most important benefit is that skill-building with others is more enjoyable than skill-building alone. 

concurrent therapy

 

RESTORE can be used in support of both group and concurrent therapy

Progress can be accelerated by combining socialization, patterning of behavior, and functional skill-building with immersive, interactive content (preferably person-centered based on the expressed interests of each player). Let’s consider the following:

  • 2-6 patients (players) who share a common interest, such as casino gaming, and have therapy plan of care goals to increase activity tolerance (sitting or standing), upper extremity range of motion, coordination, and sustained attention would enjoy participating in a Jackpot, Plinko, or Bingo competition. Players can be in the same room and remain socially distanced while set up with a device with a webcam (laptop, tablet, iPad) and simultaneously address functional skills while performing a friendly competition or just trying to achieve personal bests. Players are able to encourage one another through social interaction, while additionally patterning behavior from other players to help them better achieve their personal desired skill-building outcomes.
  • 2 players who may or may not share a common interest can each be set up with a device and the therapist can facilitate concurrent activities addressing desired functional skill-building with both players. A therapist may also choose to have both players participating on the same screen at the same time while working on different functional skills. For example, one player may be pulling the handle of a slot machine on the right side with his/her upper extremity while sitting and a second player may be pulling the handle on the opposite side of the slot machine with a squat or lower extremity while standing. Although the enjoyment of the same game is appreciated, each player is working on distinctly different functional skills concurrently.

Set up & selection options for the delivery of group and concurrent therapy

  • Group Play
    • Scoring is recorded on a leaderboard. Players can attempt to beat their personal best score and even make their mark on the All-Time Leaderboard
    • 2 Players - Cooperative
      • Best for grouping two players playing at the same time on the same screen requiring similar functional skill-building
      • Concurrent consideration in this mode is to have 2 players on the same screen at the same time requiring different functional skill-building
    • 2 Players - Taking Turns
      • Best for grouping two players, taking turns to encourage each other, pattern behavior, and facilitate competitive motivation
    • More than 2 Players - Taking Turns
      • Best for grouping more than two players, taking turns to encourage each other, pattern behavior, and facilitate competitive motivation 
  • RESTORE Together
    • Players from different devices compete in the same game, same setting competition to see who can achieve the top score.
    • Private Game
      • Best for facilitating a group of 2 or more players in the same location on different devices who desire to experience interactive game play. Players compete with our default settings in a competition where players are able to see their place (who is in first, second, third, etc.) and scoring outcomes in real time
      • A therapist will create a private game on one device and assist players on different devices to access the private game via a unique code that is entered at app.restoreskills.com/together 
  • Single Game
    • Best for group treatment with the therapist providing each player a device and:
        • Addressing the same functional skill-building with different games or individualized settings for the same games
    • Best for concurrent treatment with the therapist providing each player a device and:
        • Addressing different functional skill-building with different games or the same game but working on a different functional skill
  • Tournament Play
    • This is created by the RESTORE team upon request. Play can be enhanced with the creation of a "same game" tournament or multi-game Olympic event-style competition. Events can occur within one location or across multiple locations simultaneously. An event can be created as a single day or multi-day event.

When players (patients) are having fun and engaged they focus less on targeted skills and more on the game. They have less anxiety or frustration when able to experience success, learn from one another, and feel a sense of accomplishment. Therapists are able to appropriately incorporate functional skill-building groups or concurrent treatment using RESTORE for more effective and efficient outcomes.

 

group_together

neuro rehab

Q&A: Neuro-Rehab

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May is Better Hearing & Speech Month & we're proud to support our dedicated therapist users. On a recent customer success support call, a speech-language pathologist asked if we could provide a marketing summary of the benefits of RESTORE when working with neuro-rehab patients.

How RESTORE can help clinicians accelerate and optimize outcomes with stroke and brain injury patients:

RESTORE-Skills’ therapeutic gamification platform comprehensively supports clinicians by targeting the functional deficits and underlying neurological impairments most commonly presented by stroke and brain injury patients. Using a laptop or mobile device, therapists can quickly access and customize over 200 games and activities targeting the physical, cognitive, and life-readiness skills necessary to accelerate and optimize clinical outcomes.

Patients move more, stand longer, and refuse treatment less by combining skill-building with fun activities based on their personal interests such as skiing in a world-cup race, pulling a slot machine handle, flying a plane, or practicing their medication management. Every game has settings that can be adjusted to ensure the player can experience success, even if it’s their first time video gaming. A patient’s family members and friends can be invited to remotely join a therapy session via a user-friendly, video-conferencing experience to see their loved one, offer encouragement, and add motivation by playing along all from the safety of their own home.

neuro rehab

 

 

"I feel the games have helped me to improve the movement and coordination in my arm. I'm right-handed so it's important I regain as much as I can to get back to what I used to do. My favorite game is Plinko.  I use my left hand to support my right arm in getting the chips to the top of the board. We had a tournament last week and I actually got the best score on one of the days. It was a lot of fun!"

 

Video games are most successful when they are easy to access, easy to learn, and easy to use.

The game must also be gradable, or adaptable to an individual’s ability. The more relatable and meaningful the games are to the individual, the more the patient is excited to use the program.  When players (patients) are having fun & engaged they focus less on targeted skills and more on the game. RESTORE-Skills makes rehabilitation more fun, stretching patients’ abilities playfully and diverting their attention away from discomfort, anxiety, or frustration.

 

Q&A: Player Dignity

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Question: 

We love the RESTORE technology; however, one concern we have is that many of the games appear “child-like” and we worry about this from a dignity standpoint with our senior population. Have you had anyone else with this concern?  Any insight is appreciated. 

 

Answer: 

Thank you for the feedback and important question. 

Our platform takes into consideration that the majority of skilled nursing residents have a degree of cognitive impairment (in addition to any physical limitations). From my OT and Dementia Capable Care background, we have applied the theory of retrogenesis (back to birth) to our platform. That is not to say treat adults like children, but to appreciate that their developmental ability levels have regressed to the chronological age of 4-16 years old. It is important to keep simplistic themes, actions, and graphics for our population and to be able to grade the games based on the degree of difficulty settings.

 

RESTORE Player Testimonial

The most important key is to ensure an individual is able to experience success. We do not receive concerns related to graphics when the therapists and care partners have ensured the player meets with success and not frustration. Since many have not played these types of games before, the hesitancy is more related to anxiety that they will not perform well and therefore may remark that it is stupid or for kids, but this is typically a defense mechanism.

Video games are the most popular consumed media today and have officially overtaken the sport and movie industries in 2021. We are talking about games like Candy Crush, Mario Kart, Bubble Pop, etc. I'm currently addicted to a Harry Potter Match 3 game (and not even a huge Harry Potter fan lol). If you love games and you love competition, the graphics/animations are secondary to your success and FUN!

 

 

Get Your Game on with Grandma

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How video games can strengthen the relationships seniors value most

While the vast majority of video gaming enthusiasts are millennials, a growing crop of older adults are accessing video gaming technology for entertainment, cognitive stimulation, physical activity, and social fulfillment. They’re even making video games a part of their health and well being.

During the pandemic, the increased adoption of video games among seniors is proving to be more important than ever. This is especially true for skilled nursing and senior living residents in need of a lifeline to counter the effects of social isolation and loneliness.

Some senior care centers are even using video games as a means of skill-building, applying newly developed therapy and wellness technologies into their clinical approach. In my work as CCO and occupational therapist at RESTORE-Skills, I regularly see seniors use gaming technology to reach therapy milestones faster and improve physical and cognitive abilities. At the same time, they’re strengthening relationships with loved ones and friends by connecting virtually via fun, therapeutic video games on our platform. This happens all from the safety of their rooms.

All of this comes as no surprise to those studying the impact of video games on seniors. A study of adults ages 60-80 published recently in Behavioural Brain Research indicated that video games may be used to enhance cognitive health in older adults. The findings suggest that both novel experiences and exposure to rich three-dimensional environments may work together to improve cognition.

Based on these findings and my own experience, skilled nursing facilities and senior living communities need to become early adopters of this new technology or be left behind.

Tournament gaming enhances social connections and fosters a sense of community

Users of RESTORE-Skills also benefit socially and emotionally by playing virtual tournaments against friends and family as part of their therapy and wellness regiment. What’s more, they’re sharing a common language with Millennial and Gen Z grandchildren outside of these sessions. 

This is because there can be limits to conversation among seniors and their loved ones, especially for those in skilled nursing homes dealing with language impairments. It doesn’t help that many younger people are accustomed to rarely making phone calls, preferring text and social media apps instead. 

The wider the generation gap, the harder it is today to make small talk.

Unless you’re talking about video games. 

Skilled nursing and senior living residents learn a new language to share with younger relatives

Consider the following example from among skilled nursing patients we have served in therapy. A male patient, and former salesman with a gift for gab, suffered a stroke and had expressive aphasia, limiting his ability to communicate. He also had limited movement of his right upper and lower extremities. When we introduced him to our therapy video game solution, he was eager to give it a try. Although he had never played video games before, he considered it a way to impress and relate to his son and grandson, both avid video game players. 

This patient is one of many.

 

 

A study published in Sage Journals revealed that sharing in video games fosters relationships and connections while producing positive emotions for both grandparents and grandchildren. “As a consequence, game designers should take into consideration ways to enhance these social aspects of gameplay.”

Seniors who play video games now have a shared language to connect with their kids or grandkids. Instead of brief conversations about what’s happening at school, they can instead play a game together and make it part of the patient’s therapy exercises. 

Prior to the pandemic, one 88-year old senior living resident and great-grandmother was introduced to a virtual skill-building therapy session to improve her range of motion, coordination, and ability to perform activities of daily living. She willingly participated but wasn’t overly enthusiastic. 

Ten minutes into the session, her two great-grandsons surprised her with a visit, raced into the room and asked for a turn. She shared her red ball-shaped controller, and the boys took turns sitting on her lap while they waited to play. 

The staff later learned this was the first time one of the boys, who has autism, had ever entered his grandma’s room willingly and engaged physically. Such is the potential healing and connective power of this essential language and activity. 

This kind of interaction makes a difference in any scenario, but especially in a season where grandkids are holding up signs at windows of skilled nursing facilities in lieu of actual visits.

 

Video games create generational connection while providing crucial therapy

Learning the language of video gaming gives both family members and their senior relatives a productive way to spend time together. And, the pandemic has led more seniors to be open to adopting new technology out of pure necessity.

In 2020, the pandemic propelled the video game industry to make more money than movies and North American sports combined. There’s no indication this will slow in 2021.

As more people adopt video gaming technology, the benefits are clear. Research is showing the power of video gaming, especially on cognition of older adults; making it crucial that video games are widely adopted by healthcare. 

Adding therapy to video games and enabling families to connect through the technology is an incredible opportunity for post-acute rehab providers especially. 

 

Making therapy fun with video games leads to better outcomes

Refusals are always a challenge for healthcare professionals to overcome, especially in skilled nursing and rehab facilities. However, making therapy and wellness sessions fun and engaging can lead to more positive outcomes. 

One male patient who had a history of multiple falls and therefore a reluctance to leave his room was refusing physical therapy support. However, he eagerly agreed to try out the RESTORE-Skills video gaming platform as a fun way to achieve his balance goals and reduce his risk of falling. 

He was able to virtually ski in a world cup race, pull a slot machine handle to win a jackpot, and rock climb to the top of an ancient temple – all interests he had never experienced before. As soon as he finished his session, he shared how excited he was to tell his grandson all about his experience. He actually remained in the therapy clinic to watch and encourage others as they participated. 

Making video gaming accessible for seniors

The key to successfully adopting video gaming technology for those in senior care centers is making the video games accessible and user friendly. Any video gaming technology for seniors must have the following features: 

  • Easy to access
  • Easy to learn
  • Easy to use
  • Gradable (adaptable to an individual’s abilities)
  • Relatable
  • Meaningful
  • Have audio and video call compatibility

Access to virtual communities of friends and peers

Besides making therapy fun, video games inspire users to play and achieve more through gamification. Competition, collaboration, achievements, and a sense of community drive people to meet their goals in an enjoyable way. 

Our RESTORE-Together feature allows patients and players to play interactively with loved ones and friends in a facility or across the country from the safety of their rooms. One patient’s siblings were unable to visit during a recent short-term rehabilitation admission. They worried that their phone calls didn’t provide enough meaningful connection. 

The healthcare team coordinated for the patient’s siblings to join his therapy session to encourage him and participate themselves. They watched their brother stand for ten minutes at a “slot machine,” trying to win the jackpot with a weighted controller. It was a huge improvement over his previous best record of only one minute.

The therapist was then able to send a code to the patient’s siblings so they could play a slot machine tournament together, followed by a “Let it Snow Bingo” game that helped with hand-eye coordination, sustained attention, strengthening, and activity tolerance. 

Being able to share this experience with others is a key to healing success. 

 

In-room player

The fact that seniors can use video games to connect to their loved ones is an added bonus to the physical, cognitive, and psychosocial benefits the technology offers. The gamification and fun aspects make programs like RESTORE-Skills appealing enough for seniors to work on skills more effectively. 

Confidence to strengthen the mind, body, and social connections that matter most  

When seniors have access to video game technology for skill-building, they experience greater confidence, as well as an increased desire to regain social skills and connections. Even the staff enjoys training and learning how to use this technology to benefit their patients. 

Video games are most successful when they are easy to access, easy to learn, and easy to use. The game must also be gradable, or adaptable to an individual’s ability. The more relatable and meaningful the games are to the individual, the more the patient is excited to use the program. 

Skilled nursing facilities and senior living communities must adapt to offer residents the opportunity to learn the language of video games. By creating virtual communities, tournaments, avatars, and immersive experiences in a world without borders, seniors can work on developing skills in a meaningful, collaborative and entertaining way.

Just don’t be surprised when grandma gets the high score! 

We RESTORE-Skills TOGETHER

Q&A: RESTORE-Together

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Question: 

Tell me more about RESTORE-Together and it’s benefits? What is the difference between a live game and a private game?

Answer:

We are very excited to be able to introduce RESTORE-Together, which for the first time allows patients/players to play interactively with their loved ones, other patients/residents in their center, and/or with other players across the country - all from the safety of their rooms or in a socially distanced setting. Our primary motivation was to advocate for older adults, vulnerable to the risks of social isolation, by providing access to a virtual community of skill-builders.

Benefits:

  • Helps mitigate the physical, cognitive, and psychosocial risks of isolation by connecting patients/residents with others they know and love
  • Fosters a sense of community to have patients, therapists, and care partners interacting in a similar skill-building fashion with their peers nationwide
  • Increases fun, engagement, and motivation to accelerate outcomes and provide a better patient experience

Live games:

  • The ability to join a desired game with others is always open and does not require a code
  • A player joins, enters a player name/identifier, indicates readiness, and waits a short time (often less than 1 minute) to see other players that join the competition
  • Players will always know the score in head-to-head games or where they rank in tournament-style games

Private games: 

  • Allow a user to send a code to designated participants who can join the action by visiting the website restoreskills.com/together, entering the code, and following the instructions
  • Adds motivation for the player as he/she will be interacting with family members, friends, or peers that they have expressed an interest in joining a fun and competitive RESTORE skill-building session
  • If an audio exchange is desired during the session, we recommend having a phone or video conference call
    • Note - we are working on a simple, emoji-based way to communicate within the game play if audio is not available or desired
    • Note - some video conferencing apps will need to have the camera turned off so that RESTORE has primary access to the camera
  • Players will always know the score in head-to-head games or where they rank in tournament-style games

Instructions for a player joining upon receiving a private game invite:

  • Open Google Chrome and go to: restoreskills.com/together
  • Secure the four (4) character code from the invitee and enter it in the text box
  • Click “Join” to enter the private game
  • If prompted, select “allow” to enable camera access
  • Have a red, green, or blue rounded object available for play (i.e., ball, apple, container lid, cup, etc.)
  • When prompted, use your mouse to select the color of your rounded object 
  • To calibrate, bring your controller to the center of the square, making sure the camera can clearly see the color of the object

 

  • Enter your name or identifier in the text box and click ‘save’

 

  • Click the ‘Ready’ button. When all players are ready, the game will start after a 20 second countdown 

When players (patients) are having fun and engaged they focus less on targeted skills and more on the game. Fostering a sense of community by connecting with others will help mitigate the physical, cognitive, and psychosocial risks of isolation.

Falls Prevention

Q&A: Falls Prevention

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Question: 

How can we utilize RESTORE with our patients in support of falls prevention?

Answer:

Great question. To start we have to consider the physical and cognitive components required for a comprehensive falls prevention approach:

  • Core and lower body strengthening (squats, lunges, etc.) to improve center of gravity control, stability to support sitting and standing
  • Static and dynamic sitting and standing balance (no reaching, single extremity reach, bilateral hands-free isolated and integrated movement patterns)
  • Weight-shifting, lateral mobility, forward/backward mobility
  • Activity tolerance for posture, movement required for completion of self-care, leisure skills, home and community management
  • Sustained attention, concentration, visual scanning, sequencing, safety awareness, decision making, following commands/direction 

RESTORE can be used in support of each component. Progress can be accelerated by combining functional skill-building with immersive, interactive content (preferably person-centered based on the expressed interests of the player). Let’s consider the following:

 

  • Game controllers calibrate to most red, green, blue objects. 

 

  • If working on functional reaching, select objects appropriate to maintain grasp/hand control or optimized for patients with only gross motor extremity control 
  • The calibrated controller for mobility should optimally have a center of the body placement (between chest and abdomen) so the player can maintain hands-free (especially if in need of assistive device)
  • Use the controller/camera view box (camera or white box in the lower right portion of the screen which tracks controller connection) to assist with patient positioning based on desired movement patterns

    •  

    • Game settings and webcam settings can be graded based on the current physical and cognitive abilities of your player:

     

    • Backgrounds can be adjusted for greater contrast or to simplify visual display
    • Speeds and difficulty can be ranged from easiest to most difficult
    • Music and effects can be varied for appropriate encouragement and engagement
    • Range of motion capture can be reduced for players with limitations or expanded for those with full range capabilities
      • Best for games challenging a combination of up/down, left/right, and diagonal movement patterns
      • Best for games challenging a combination of up/down and left/right movement patterns
      • Best for game challenging left/right movement patterns in sitting, and left/right, forward/backward movement patterns in standing
    • Webcam setting options
    • Full, medium, small screen capture
    • Large, medium, small circular capture (narrows capture from square to circular configuration) 
    • Large, medium, small semi-circular capture (maintains top screen circular capture, but removes bottom screen circular capture requirement

     

    Demonstrate intended movements and explain why they are critical components to limiting or preventing falls

    • Patients are often fearful of falling. Having the ability to pattern their movements after seeing the therapist in action, can instill greater understanding and confidence 

     

    • Determine which skill areas you plan to target and match the game(s) with your plan. A few to consider with default game duration:

     

    • Ski Saga (default is 3 minutes). Players can control a skier in a race by stepping/shifting left/right and squatting, or up/down, left/right upper extremity movements to avoid obstacles, slalom between flags, and obtain coins and gems. Bonus points awarded after 10+ successful obstacle navigations
    • Ancient Temple (no set time limit). Players use both hands, sitting or standing, in an alternating up/down movement pattern to simulate rock climbing, with various integrated movement patterns included to challenge this treasure hunt adventure 
    • Spooky Spiders (default 3 minutes). Players utilize a dynamic, upper extremity or mobility, range to shoo away spiders of all sizes dropping/climbing vertically while watching out for a chance to knock a witch off her broom flying horizontally across the screen 
    • Bounce It (default 2 minutes). Players align with a silhouette, sitting or standing,  and can use their knees, feet in an upward motion to connect and juggle a soccer ball.

     

    When players (patients) are having fun and engaged they focus less on targeted skills and more on the game. They have less anxiety or frustration overcoming gravity and a fear of falling, when not focused on that fear every second. When a player demonstrates appropriate control, sustained action, adequate activity tolerance, and desired cognitive function that is when it is most beneficial to follow up a RESTORE session with a functional activity as they will now have the confidence to complete successfully.

    RESTORE Self-Feeding Skills

    Q&A: Self-Feeding Goals

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    Question: 

    How can RESTORE help therapists to support self-feeding goals with patients?

    Answer:

    Great question. To start we have to consider the physical and cognitive components required for self-feeding:

    • Ability to bring hand to mouth
    • Ability to apply and sustain proper grasp or prehension to a utensil or finger food item
    • Activity tolerance for posture, movement for anticipated feeding duration
    • Sustained attention, concentration, problem-solving, sequencing

    RESTORE can be used in support of each component. Progress can be accelerated by combining functional skill-building with immersive, interactive content (preferably person-centered based on the expressed interests of the player). Let’s consider the following:

    • Game controllers calibrate to most red, green, blue objects. 
      • If working on up/down movements with hands for finger food, select objects to replicate prehension or grasp
      • You may even consider real food items in the color family such as grapes, tomatoes, apples, candy, etc.
      • If working with utensils, select a spoon that is red, blue, green or can have a colored sticker attachment
    • Game settings and webcam settings can be graded based on the current physical and cognitive abilities of your player:
      • Backgrounds can be adjusted for greater contrast or to simplify visual display
      • Speeds and difficulty can be ranged from easiest to most difficult
      • Music and effects can be varied for appropriate encouragement and engagement
      • Range of motion capture can be reduced for players with limitations or expanded for those with full range capabilities
    • Almost every RESTORE game has upper extremity motor compatibility. A few to consider with default game duration:
      • Take Flight (plays based on lives, duration not limited). Players can control a plane in flight with up and down movement to avoid obstacles and obtain coins and gems.
      • Jackpot (default is 5 minutes). Players can have the slot machine handle alternating sides after each pull or remain on one a single side for more concentrated motion
      • Bullseye (default 2 minutes). Players can control a bow and arrow to hit various targets and bonus items, while avoiding penalty items such as dynamite
      • Ladybugs or Car Cross (rounds of play). Players practice up/down movements to assist ladybugs or cars to cross a bridge, while avoiding allowing pests or undesirables to cross

    When players (patients) are having fun and engaged they focus less on targeted skills and more on the game. They have less anxiety or frustration in trying to bring food to mouth, if only working on this during self-feeding. When a player demonstrates appropriate control, sustained action, adequate activity tolerance, and desired cognitive function that is when it is most beneficial to follow up a RESTORE session with an actual self-feeding session.  

    Practice Self Feeding with RESTORE
    nursing home with physical therapy

    How to deal with therapy refusals

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    Know when it’s a clinical indicator or wake up call

    Standard in every skilled nursing therapist’s day is dealing with patients’ refusal of therapy. A typical SNF therapist averages 1-2 refusals of treatment each day. That can be 15-20 percent of a therapist’s day that’s canceled! 

    Of all those therapy refusals, most are legitimate. But among them, there are some SNF patients who could be motivated to get up and exercise. 

    Often, a motivated therapist can cajole a patient to join the scheduled therapy session. But many times, it’s simply easier for a busy therapist to let a tired or distracted patient skip a session. 

    And now with PDPM, where SNFs are no longer reimbursed for therapy minutes, therapists have even less motivation to counter patients’ refusals than they once did under the RUG-IV payment plan with CMS.

    However, therapy is the key reason patients enter a skilled nursing rehab center, and its centrality to patient care is unquestionably essential. Skilled nursing therapy is key to the healing process and to slowing the physical and mental decline of aging patients. 

    PDPM means therapists and SNFs are focused more on quality than quantity, but that still means that a patient who is prescribed any number of weekly therapy sessions absolutely needs to access those sessions in order to achieve the best outcome. 

    The responsibility lies on the therapist to make sure refusals don’t stand in the way of accessing therapy.

    3 underlying reasons skilled nursing patients refuse therapy

    Patients will have a whole host of reasons for refusing therapy, and most of them are absolutely legitimate. It’s up to you as a therapist to consider how the patient is responding and determine the source of the refusal. This way, you can determine if the reason is something you can work around or if it’s a sign of a bigger issue. And sometimes, refusals just might mean that you have work to do to make therapy sessions more worthwhile.

     

    Reason #1: Patient isn’t feeling well 

    Patients may be adjusting to a new medication, still healing from a recent procedure or have any number of clinical challenges that can make therapy more difficult. Speak to interdisciplinary team members to see if they have also received concerns and what subsequent actions have been taken

    Reason #2: Patient has concerns outside of their control 

    Skilled nursing care has to be integrative for therapists to successfully treat patients. This means letting the care team know when a patient doesn’t get enough sleep because of a loud roommate or a patient didn’t eat because the food got too cold. Be an advocate for the patient if action has not been taken to address concerns/complaints. 

    Reason #3: Patient is apathetic

    Sometimes patients will refuse therapy without a specific reason. Statements like “Maybe tomorrow?” or “I don’t want to do it today” can mean that the patient isn’t seeing the value of the therapy sessions.

     

    Reassess your approach to skilled nursing therapy for apathetic patients

    If you are unable to identify the source of why your patient is refusing care, it’s time to ask yourself some hard questions.

    We as therapists are taught the therapeutic use of self approach. This means we use all our faculties to meet our patients where they are, with empathy, and bring them to where we want them to be for the session. We use our creativity, attitude, and effort to make patients feel positive, motivated, encouraged, and successful. This is how we gain their trust and ensure they feel empowered.

    7 questions therapists should ask when facing refusals 

    • Are you offering a care approach that has meaning to the patient?
    • Are you offering a care approach in which the patient believes they have the opportunity to experience success?
    • Can you grade your approach to gain trust and agreement?
    • Are you conveying enthusiasm and excitement in your approach or are you going through the motions and thinking about the end of the day?
    • What is your strategy to motivate? 
    • Can you modify the environment to one that will promote a more successful experience?
    • Can you modify the intended activity based on the fluctuating physical and cognitive ability output of your patient? 
    Health visitor and senior

    Therapists’ methods to deal with refusals

    Once you’ve taken some time to ask yourself the hard questions above, you are poised to better address therapy refusals. The following are some steps you can use.

    Step 1: Show empathy to patients’ needs

    Your first reaction to therapy refusals should always be empathy. Most patients have legitimate hesitations to therapy, such as overall weakness, pain or emotional struggles. Of course, therapy can improve the physical and mental state of patients, but it’s a long process, and the journey can be hard. 

    Listen well to your patients’ concerns and repeat what you hear them saying to you to validate their concerns. If the patient is refusing to exercise because he is in pain or needs an improvement to his care, you may need to advocate for him to the interdisciplinary team.

     

    Step 2: Use a person-centered approach for therapy

    One obvious solution to refusals, of course, is to have a more person-centered approach. Provide therapy on the patients’ schedule, when he is at his best. This is obviously harder to coordinate, but if it reduces refusals to offer a late sleeper a later therapy time slot, then you will have more luck cajoling him to exercise. 

    It also helps to offer the patient something engaging she wants to do. Get to know her interests and goals and relate the therapy back to those goals. Your patient wants to walk her granddaughter down the aisle? Remind her that it starts with working on standing for two minutes.

    Don’t be afraid to get family members involved in what a patient enjoys. Therapy is a great time to jump on a Zoom call with a patient’s loved ones. This makes the family feel connected, increases transparency, motivates the patient and helps you get to know more about the patient. This is why we included a video-conferencing tool right within our RESTORE Skills therapy gaming platform.

     

    Step 3: Make therapy fun and engaging

    Armed with the latest technology that makes therapy interactive, engaging and even fun, therapists can significantly reduce refusals. As the Chief Clinical Officer of RESTORE Skills, where we’ve created just this kind of therapy gaming platform, I see examples every day of patients actually requesting to play our therapy games. They are motivated by the fun they are having skiing, golfing or playing the slot machines, as well as the results they see as they improve their game scores.

    To add to the joy, we are known for an “I hit the jackpot with RESTORE” t-shirt for those patients who hit “Wild, Wild, Wild” on our slot machine game. We are constantly hearing about patients relentlessly playing this therapy game until they win. Meanwhile, they are actually winning at therapy, as they push themselves to reach and stretch farther.

    The right attitude, approach, and activity can make therapy easier and reduce refusals, but sometimes you need added help

     

    Refusals can feel personal. Most therapists have developed conscious and subconscious defense mechanisms related to these remarks. However, simply shielding yourself from the impact is not necessarily best for your patient or your professional growth and development.

    Even the most passionate and creative therapists will still face regular refusals on the job. This is where innovative technology can fill the gap. Having access to a variety of interactive treatment content and the ability to connect loved ones for added encouragement and participation is the perfect compliment to an empathetic, positive and motivating therapist’s approach. Hope these strategies help you realize better outcomes with less refusals.  

    snf-therapy-during-covid

    Let’s use the state of SNF therapy today as a springboard for more positive outcomes

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    There’s no question that therapy today in skilled nursing facilities looks vastly different than it did several months ago (and for many years before that). What is yet to be determined is whether or not these changes can result in positive outcomes for all parties involved--patients, of course, therapists and skilled nursing facilities.

    Just recently, the federal government released a much-needed $5 billion aid package to SNFs--one that came on the heels of the industry's first-ever decline in margins reported since 1999. That funding, combined with the collective will to improve therapy challenges that existed in the industry even prior to COVID-19, is a rare opportunity. Of course, COVID-19 exacerbated challenges SNFs were already facing, it is also an opportunity for a total redesign of how SNFs provide therapy. I would like to propose that the vastly different climate in SNFs this summer 2020 should be a springboard for a more positive future for therapy in skilled nursing facilities. 

    Moving from RUG-IV reimbursement to PDPM for therapy

    Last October 2019 when the federal government entered a new fiscal year, the new Patient-Driven Payment Model (PDPM) replaced the long-held Prospective Payment System, RUG-IV approach to billing for therapy based on time spent per patient. The immediate effect of that change was that 43 percent of operators reported laying off therapists to a Skilled Nursing News SNF poll, as well as a reduction in hours. Facilities started providing more group therapy and concurrent therapy sessions, offering patients a chance to be motivated by one another as they each worked toward personal goals.

    That was until COVID-19 hit in March 2020.  

    We in the industry would still be sorting out the ripple effect of the move to PDPM this year, except that a bigger tsunami hit the skilled nursing facility industry in the form of a global pandemic. 

    COVID-19 results in bigger changes for therapy

    Five months into the COVID-19 pandemic, and most long term care patients are still spending the majority of time in their rooms, with little to no outside visitors. Therapy gyms are closed or only available to a limited number of patients at a time--at a social distance. And skilled nursing facilities are no longer getting reimbursed by therapy minute thresholds.

    Therapists are now providing therapy within patient rooms, but this can be limited to the creativity, experience level and motivation of each individual therapist.

    You could look at this as a disaster for the state of therapy in skilled nursing facilities, but I see it as an opportunity. As an experienced occupational therapist, I long ago recognized the need for a new approach to SNF therapy. The tired therapy exercises of batting at balloons and using cones or a pegboard are not enough to motivate patients to reach new goals. I despised going through the motions of cookie-cutter therapy. I knew I wasn’t providing the best opportunity for healing to my patients.

    The SNF therapy industry needed a shakeup, and now we have it. 

    The change to PDPM means the number one focus is on patient outcomes. This should always be our goal as therapists and SNFs, and COVID-19 doesn’t change this goal either.

    COVID-19

    Here are 4 ways we can take 2020’s changes to SNF therapy and use it as a springboard for better therapy and more positive outcomes in the future

    Focus on our ability to accelerate outcomes

    Patients, therapists and SNFs are all now aligned around one goal every time: achieving the best outcome in the shortest, most responsible period of time. This has always been what the patient wants and what is best for the facility, but now the PDPM reimbursement aligns with that goal. 

    How do we achieve this? By focusing on the patient experience. We make therapy fun, engaging and rewarding. Patients who are motivated in therapy will achieve a more positive outcome in a shorter span of time. Of course, every therapist appreciates the rare patient who is motivated and agreeable, but this isn’t always the case when patients can have a whole host of complicated reasons that leave them less motivated in therapy. Therapists need tools they can use that make therapy effective and engaging. The technology exists to do this. I work for a cutting edge company that is leading the way in this area with therapy gaming technology, and the early adopters of this kind of therapy will be among those who are best poised to achieve accelerated outcomes for their patients. 

    Focus on connectivity and transparency

    Prior to COVID-19, SNF facilities could rely on family visits to keep families connected to their loved ones. Families could easily pop in and ask a question to a nurse or social worker during these visits and, of course, schedule a care consultation.

    Now with limited visitation for the foreseeable future due to COVID-19, facilities must proactively keep families in touch with their loved ones and informed about their care. Connectivity and transparency needed to always be a priority, but now all SNFs are forced to make this happen.

    Most facilities have succeeded in scheduling Zoom and Facetime calls with families. Some facilities are mandated to do so by their state. But imagine if instead of talking from a chair or bed, families joined parts of a therapy session? Technology offers an incredible level of transparency, as families can motivate patients and celebrate their achievements as they watch. Families will recognize the value of long term care rehab and rest assured their loved one is getting excellent treatment. Gone are the concerns about what is happening behind the walls of a SNF when the relatives aren’t there. 

    We at RESTORE have incorporated video conferencing into our platform, and no doubt, this will be an initiative with staying power.

    Improve continuity of care

    SNFs have always had high turnover and a constant need to aggressively hire new staff. And in therapy, the use of PRNs can mean that new therapists frequently join the care team. COVID-19 escalated this issue as SNF employees were suddenly called upon to soldier through a battle they hadn’t realized they signed up for, and facilities faced more shortages than ever.

    The need to standardize care for every person providing treatment has always been a priority, but now it’s an absolute necessity. This is where technology comes in. With therapy technology, every therapist on the team can facilitate a similar session experience, regardless of how well they know the patient. Obviously, rapport in therapy is key to overall success, but when that’s not a possibility, it’s still essential that the patient continues to reach individual goals. Technology that tracks this progress and helps therapists facilitate the actual exercises is key.

    Skilled nursing facilities that do this well will have an evidence-based practice to identify patients’ needs and show progress.

    This is what we developed with RESTORE Skills, and this is where the future of SNF therapy lies.

    Differentiate the care approach and share success stories

    Competition is fierce for the same type of patient now with PDPM. It’s not enough to just have an aesthetically beautiful facility. SNFs have to offer a higher quality of care than their competition and then share those stories through marketing. 

    Those skilled nursing facilities that differentiate themselves from their competitors by offering better therapy outcomes will be positioned to succeed in the future.

    Ultimately, to achieve all of these improvements, SNF employees need to work as a team. When it comes to creating positive outcomes for patients, none of the goals of SNF employees can be individual or exist in a silo. For example, I can’t manage to succeed with a patient in OT if he didn’t get the nutrition he needs or a good night sleep because his roommate kept him up. SNFs need more collective leadership to actually achieve the integrative care approach. This is more than just a morning meeting. It’s one where every team member realizes that they are one piece of a puzzle, working together for a greater goal that can only be achieved with all of them together. 

    I left my position after 25 years as a therapy provider, clinical specialist and multiple senior care operator because I saw in my position as CCO at RESTORE Skills an opportunity to impact the whole industry. I recognize how new ways of thinking about therapy in SNFs can have a greater impact on patients and on the facilities and their employees as well. As we continue to deal with the ripple effect of these past few months, I have no doubt that more innovation and new ways of thinking about SNF therapy will develop. Those skilled nursing facilities that embrace this technology and look for ways to achieve more accelerated positive outcomes will come out on top.

    Click here to learn more about how RESTORE Skills is helping skilled nursing facilities meet therapy needs, improve patient outcomes, and keep patients engaged and connected, especially during COVID-19. 

    About the author:

    Ian Oppel is a healthcare executive with over 25 years of post-acute healthcare leadership experience providing expertise in rehabilitation, fiscal and clinical operations, memory care, senior living, reimbursement, and regulatory compliance. Ian is currently the co-founder and chief clinical officer for RestoreSkills, a leading edge therapeutic gamification and telehealth company.

    Dementia care

    Dementia Capable Care enhanced with RESTORE

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    By Ian Oppel, CCO of RESTORE, occupational therapist, and 20-year Dementia Capable Certified Therapist

    While residents in skilled nursing facilities continue to struggle in the fourth month of this new normal, those with Alzheimer's disease and dementia have the added challenge of communication barriers, decreased engagement, and the struggle to maintain cognitive function now even more. These are people who depend on a familiar routine, secure connections with loved ones, and group activities to slow the progression of a cruel disease. 

    In honor of this June's Alzheimer's and Brain Awareness Month, I want to raise awareness of how RESTORE's interactive gaming therapy software is key to supporting long term care's most vulnerable residents.

    Those at the highest risk for deterioration of the disease process with COVID-19 are dementia patients.

    Individuals with dementia function best with routine. They need the familiarity of a caregiver and a consistent environment. But because of COVID-19, regular routines are completely disrupted. Like everyone in skilled nursing facilities, those with dementia are spending most of the day in their rooms, often alone and isolated. They aren't able to socialize in group activities and with loved ones, which usually keeps them engaged and able to pattern behavior after others. 

    The goal when working with individuals living with Alzheimer's and dementia is to promote their best ability to function to slow or delay the deterioration of a progressive disease. It starts with gaining agreement, followed by making changes to the environment, activity, and/or care partner approach. After working with this population, I know firsthand this takes time and patience because helping residents with Alzheimer's can be so much faster than supporting them to be independent. It's a good intention to want to jump in and help, but supporting these residents too much can leave them more helpless. This is a challenge always, but no doubt, it's even harder now that facilities are staffing challenged.

    This is why I consider RESTORE the perfect medium to slow the progression of memory care patients. I've seen patients find engaging games connected to their life history, interests, and abilities. The games support cognitive and behavioral skills, and of course, physical skills. 

    Take the WWII pilot I met at our client's facility before COVID-19 hit. He didn't want to work on the motion of lifting his arm to reach for a cone; his therapist was extending in front of him. When I learned that he was a pilot in World War II, I offered to show him our Take Flight game. He ended up getting really engaged and even told me the highlight of his life was meeting General Patton. By the end of our session, he had held his arm and sustained action several times for over two-minute intervals, something that's hard even for me but necessary for completing activities of daily living. And this is just one example of so many.

    I'm seeing therapists and even activities staff customize RESTORE to support patients' cognitive and physical abilities, as well as their interests, preferences, habits, tendencies, professions, and family history. Players can golf, pull a slot machine lever, ski in a race, or fly a plane. RESTORE's 30+ games keep players engaged, as well as help with issues such as attention span, concentration, problem-solving, decision-making, and sequencing. Every game exercises cognitive functioning, helping patients with dementia to maintain attention, concentrate, and tap into procedural, working, and long term memory centers. 

    Add to this personalization feature the fact that RESTORE is portable and works on any device with a webcam. It's easy to set up and allows every staff member to support skill-building therapy. It's one thing to bring a dementia patient an iPad to play a sensory game or call a family member, but how much more impactful is software that lets patients actively play without handling a device, get immersed in the activity, and invite loved ones to participate virtually?

    Connect to family and friends

    Just as COVID-19 hit, we added a feature to invite loved ones to join therapy sessions virtually. Having family interaction takes engagement to a whole different level. This is something that we just really haven't ever had the ability to do as therapists. It's incredible to share active treatment sessions with family members who can offer support, encouragement, and help build trust.

    While family members are not able to come to the facilities these days, RESTORE can connect family members from where they are and bring them into the room virtually. Once you gain a patient's trust, now they can play RESTORE and have their family members come up on the screen and be able to interact. 

    If the family video is too distracting, we can always hide their video, and players can continue with just their loved one's voices. 

    I hear clients' stories every day of how RESTORE is keeping residents happy, active, and engaged during this new normal. It's keeping them connected to their families and able to do meaningful therapy work together with their loved ones' support.  And for Alzheimer's and dementia patients, who are the most at risk right now, RESTORE is helping to slow down deterioration even amid the COVID-19 pandemic.