RESTORE Self-Feeding Skills

Q&A: Self-Feeding Goals

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
how to deal with therapy refusals

How to deal with therapy refusals

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

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

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.

adopting tech

What it takes to successfully adopt new technology in skilled nursing facilities

And why you'll be left behind if you don’t--especially with COVID-19

By Ian Oppel, OTR, MBA, DCCT

COVID-19 presents an opportunity for skilled nursing facilities to adopt new technology.

After 25 years working on the therapy provider side as an occupational therapist, clinical specialist, and multiple senior operations roles, I moved in 2019 to become co-founder and chief clinical officer at RESTORE Skills. I have seen for myself the power of creativity and innovation to get better results in therapy, and I recognize the tremendous impact gaming software could bring to the 2.4 million seniors living in long term care facilities. 

RESTORE is an interactive software product for adult rehabilitation patients that uses any webcam-equipped, Wi-Fi-enabled device as a therapy tool in the gym, at the bedside, or home post-discharge. The virtual gamification tool ensures skill-building can happen anywhere, and any loved ones can join therapy sessions virtually. It's the kind of technology SNFs can adopt to change the state of therapy now during COVID and beyond.

I joined the RESTORE Skills team because I saw the delight in the eyes of patients and recognized the potential breakthrough this software could make. What I didn't see coming was the unintentional resistance to technology adoption in healthcare that I encountered once I began working on the therapy technology provider side. 

RESTORE's Chief Clinical Officer, Ian Oppel, helping a SNF adopt new tech

Facility owners and therapy leaders experience our software and agree it serves patients better than reaching for cones, manipulating clothespins, or repeating the same motion to increase shoulder strength and ROM. What they struggle with is getting busy therapists to change the way they are used to working.

But, COVID-19 is forcing facilities to change or risk being left behind. Therapists, accustomed to using therapy gym equipment and keeping patients engaged with interactive group therapy, are now having to find ways to bring therapy into every patient room without sharing equipment. COVID-19 has forced all therapists and facilities to adapt and get creative. 

I've come to realize that technology is innovating faster than ever to solve problems created by those who resist technology. It's time to become an active part of this innovation and evolve with technology or risk that components of your job or maybe even all functions of your job being replaced by smart learning. 

Facilities risk being outpaced by competitors that gain a reputation for customer satisfaction, innovation, and better outcomes. 

In every industry, there will be those businesses that confront the challenges of this global pandemic, and instead of just struggling through, use this new normal as a springboard to take action. These will be the businesses that come out on top.

Champions are key to successful technology adoption

On the provider side, I always looked for innovative technologies that could both accelerate and elevate clinical outcomes, improve customer experience, reduce costs, and simplify work for our teams. Some tools were more successful than others, but the common factor in success was having champions who were committed to working through any challenges before succeeding. 

Build time into their schedules

Even before COVID-19, no one likes to take time away from therapists' productivity to allocate time for training and adoption. Hardworking therapists are busy and aren't interested in looking less than competent in front of patients and coworkers. Successfully implementing new technology requires building time for adoption into therapists' daily schedule and then supporting them through trial and error. 

Start with the right champions

Even if new initiatives are intended for everyone, the most successful adoptions start with identifying champions best suited to be early adopters. When selecting a champion, find someone with a genuine interest or understanding of the big picture goal, which will include growing your census, increasing your quality mix, improving your outcomes, and increasing customer satisfaction. 

From there, you'll want to relay to them their essential role, as well as the roles of the center, regional, and company leaders in reaching these goals and your expectations for the process. 

Track and measure results compared to the status quo

Have an easy way to track and measure results so you can determine if the cost and implementation process of the new technology is worthwhile. Analyze what is working, not working, where there are success stories, and what additional recommendations will help to ultimately the establishment of best practices.

Don't expect to be perfect

Once your team begins using a new tool, it's important not to apply a false pressure to have to be perfect. I conducted a virtual training session recently where almost nothing went as planned, was literally sweating, and at the end heard the patient say, "That was so much fun, I haven't skied in years and can't wait to tell my grandson what I did today."

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. Did we mention everyone is having fun while doing it?