OT blog resources

Got an email from a Canadian OT student who has started collecting OT blogs and compiling them here for ease of reading and access. Seems a little cleaner than the AOTA blogroll effort, though to be fair, I haven't been visiting that regularly. I keep finding new ones that are OT or related and adding them to my google reader application. I wouldn't be able to read all the things that I do without it, so if you make a cool change to your layout, put it in a blog post so that I know to check it out :-P

I have a whole folder full of links to share... articles picked up on Advance or Therapy Times or the local newspaper. I will get to that soon (I promise!) and also finally watch my awesome sensory integration video and post my reflections from it.

Closing thought: Is Lou Holtz secretly supporting OT? We definitely figure in at least 3 of these-
"Everyone needs four things:
something to do
someone to love
something to hope for
something to believe in"

Happy holiday, unless you work in a SNF

Every setting has its own complex rules and regulations, but it seems that the Skilled Nursing Facilities (SNF) get more than their fair share. Payment for therapy services rendered is dependent upon meeting a set number of minutes in a pt's week (starting on their admission). To be even more complicated, I have heard that the first week's payment actually is a prospective payment for the second week... I cannot go into that as it is far too dizzying. At any rate, a pt. must be seen for at least 15 minutes to count as a 'day' of therapy. In addition to meeting a certain number of minutes of therapy per 7 days, there are also requirements of how many 'days' of therapy a person needs.

blah blah blah paperwork.

So here's where the holidays wreak havoc. If pt. X is admitted on Wednesday the 27th (and is evaluated and treated that day, not a given), they will need 4 more 'days' of treatment for most levels. So between Saturday, Sunday, and Labor Day, this pt. will have to be seen by at least one therapy, and will likely have to make up extra time during the regular work week. So for any pt. that is in their first 14 days, there is a crush to get extra time. Also, this is why most SNFs require therapists to work weekends and many holidays. Kind of a bummer.

Another bummer from the 'days' side of things has been happening a lot at my place recently. A person cannot be discharged from the hospital and admitted to the SNF floor w/o a doctor's order. So even if all the plans have been made through case management and the SNF admission planner, if no one writes an order, the pt. sits and languishes in hospital bed limbo. Also, the therapist's wobble and wait for word on whether the pt. will come that day, night, or the next. You can wait around, have a pt. show up at 4:55 and wind up working over. Or you can wait around for naught since they won't show til 8:30. Regardless of whether they are evaluated or not, treated or not, that still starts their week and leaves only 6 more days to work. And if you just happen to have a person who is too sick to participate 1 or 2 days... it just makes it all harder.

I gave my best today to try to be extra motivating to my lil' ladies down my hallway... especially since I shant be helping the rest of the team again until Tuesday (which also starts new peds sched). I am taking an extended weekend to go home and decrease my loneliness by visiting w/ friends and family. I have been doing fair with my goals... 2 social activities this week and 1 trip to the rec center, a finished jigsaw puzzle, another load of laundry, and a nice long phone call with a friend. But the townhouse gets quiet. So posts might be less frequent than planned this weekend, but at least I'll be having fun. :)

PS- funny note: Laughed a lot the other day as an MD stalled out his manual-transmission sports car while trying to key in the password to the MD lot on a teeny tiny slope. I don't drive a stick very well, but I also didn't drop BIG BUCKS on a fancy schmancy sports car. :-P

Pondering the future

In the same way that working with elderly clients can make you a little morbid, it can also have you question your future. Specifically- what kind of old lady am I going to be? Cranky in the morning, but that's a given. Are my popping knees going to deteriorate badly enough for me to need replacements? Will I be a regarded as a whiny wuss during my rehab by a bunch of young punks? Will I get osteoporosis and become the new record holder for most fractures? Will my rehab from whatever afflicts me go slow, and require me to toil away at a long term SNF for months on end when all I want to do is go home? Will my family offer me physical assistance or leave me to languish alone? Will my body decay before my mind, or vice versa?

I don't worry about this stuff too often (although the knee replacement issue does eat at the back of my mind) but it is interesting to contemplate. I try to adapt my approach to different age groups. I can be a real dictator for the under-60 joint replacements, but do try to show my kinder, gentler side to the 85+ crowd. Not that I'm not nice to everyone, but I'm more likely to let an older pt. say, "I'm too tired" and have it be enough to call off a treatment. I try to impress more on the older clients that they can refuse treatment, that they can take rest breaks, because more often than not they feel obligated to participate as much as physically possible, and really do need the rest. For those of you who haven't worked in a SNF or other environment with the elderly, you've probably never contemplated the physical exercise and strain of sitting up in a chair for the morning. I know with the 85+ crowd that the physically/mentally straining activities need to be in the morning, before sitting up too long tires them out. If I do anything in the afternoon, I usually preface it with "I only need a few minutes" or "we just need to do 1 thing today" or "we will do this and go back to bed." Please don't send me emails about how I'm simplifying this too much or patronizing my clients... this is just a description of the typical response for the age group, not your overly active grandma.

I also ponder my near future a good deal. I have a habit of throwing myself into whatever I'm currently doing, which sometimes makes it hard to plan farther ahead. I've been investing a lot of time into pediatric and sensory stuff, even though that wasn't an area that I thought I'd ever go into before I started this job. I don't want to leave this knowledge behind and start from scratch on my next job, but I don't know what exactly I want to do on my next job. Or the rest of my life. This is part of why I went into OT as a student- because there are lots of options and you can completely change your daily job life without needing more education. But, I don't want to keep starting from scratch bouncing into different settings. I've often thought that my next job should be back into that demanding world of inpatient rehab, but that can really be stressful. I don't have the experience at this point to go to a top-shelf place, and also don't know if I could take the pressure. I feel a responsibility to myself and a lot of different people to do great things, go great places, live up to potential. Probably more of my 'great things' that I actually end up doing will be pretty mundane and in small places, and deep down I know that's ok too and that no one will be disappointed. Still... need some good career goals.

Things that make you go ugh!

Life is never without irony. So, the day after I write up a nice thing on paperwork and goal writing, I discover that I had totally neglected to write goals for a child that I had seen for the eval and an additional session to do the Peabody. I rarely delay documentation and really don't know what I was thinking this time, but it had to be done today since he is on the COTA's schedule next. Must have some kind of treatment plan to begin the collaboration.

In other, crappier, news, we have had more ICU patients than usual. One of them had been doing pretty well and went into a coma. He died yesterday. One had gotten better, moved to the regular unit and even down to the transitional care unit. A few hours after his transfer to the SNF floor, he developed some additional cardiac problems and wound up back in ICU. One has been undergoing very limited treatment, mostly PROM, w/o much progress for 2 weeks or more. One was an outpatient who developed CHF and respiratory failure- her future is bleak.

One of the reasons I went into OT was because I didn't want to be dealing with life and death emergencies. I like my patients to get better, go home, stay out of the hospital. Unfortunately, in the hospital and/or SNF setting, that is not always the case. It's a little morbid, but fairly common, for hospital staff (therapy included) to be regular checkers of the local obituaries. And no matter how uncomfortable it makes us as therapists, there are moments that we do endanger our patients- not knowingly, but still. Several months ago, when I had the patient fall, we didn't know it at the time, but she had developed A-fib and was going into renal failure. She left the SNF floor for ICU no more than a day after we had the fall.

Sometimes the only thing standing between you and disaster is an experienced coworker. There's been a number of times when the rehab aide has taken a look at a patient and advised to lay off, or noticed diaphoresis early... she's probably stopped a lot of falls and other problems just from experience and observation skills. Mad props to her- and attention students- don't rule anybody out as a potential teacher. There are a lot times when your masters/doctorate degree doesn't mean a thing next to someone's experienced observations or practical skills they've developed over time. Make friends with these people, they will save you from being an idiot time an again.

One happy ICU story to mix in with all this sad stuff. Mrs. P was a middle age woman admitted w/ anoxic BI. When we first eval'd her, she was quite flat and making slow progress. Then she got bumped into ICU and was unresponsive for several days. Then... we got orders to resume therapy as she moved out to the regular floor. She was showing good memory, emotion, and moving so much better. It was as if she came out of the coma doing much better than when she went in. She's home now, and hopefully continuing to improve. If not, I guess I'll see it in the paper...

Writing Goals

This blog was started with interests in helping students and also in describing my current OT life, so this entry should be an interesting mix. My husband left for an extended trip to Europe today, and I was trying to make a list of things to do while he's away and realized it would be a good time to offer some instruction on goal writing. Some of this information is taken from my notes on the required documentation book from my first year (long since sold, so I can't check on anything else in it).

There are a few basic types of goals, but most of what I write are restorative, modification, or new skill goals. If you are writing a goal with the intent to maintain something in a client's life, or prevent something from happening, you're on shaky ground (ie- may not be reimbursed by insurance or covered in scope of practice). If you've got a grant for a special program focusing on preventive care or health promotion, more power to you, but most people want evidence that the goal has been achieved within a reasonable time frame and primarily due to your OT intervention before they pay you.

When starting at a new setting or when out on fieldwork, focusing on writing good goals can be a little overwhelming. A note to the fieldwork students- every supervisor has different expectations for documentation (also, they have every right to be demanding, as their name goes on it too). A good supervisor will tell you though that as you start being 'a real OT/A' that you will develop your own style of documentation that still retains the basic needs (hopefully!). This can be easier to do if you have a framework to go off of. I used the SMART model in school, here are a few more:

• SMART: Significant, Measurable, Achievable, Relates to person, Time based
• ABCD: Audience, Behavior, Condition, Degree
• FEAST: Function, Expectation, Action, Specific conditions, Timeline
• RHUMBA: Relevant, How long, Understandable, Measurable, Behavioral, Achievable

Ideally, you would include each of these elements (from 1 acronym) in each goal. One of my coworkers uses a method that explains the reasoning of each goal prior to the specific action. It is key to notice that time is an element in all of these... you cannot have a goal for an interminable period. A goal should never be permanent- you should be reviewing it to see if it has been met, explaining the limiting factors if not met, and adapting it if necessary to provide the "just right" challenge for the client. Incidentally, your setting and overarching frame of reference will dictate the wording you use to describe the person achieving the goal. In a hospital, "patient" is the common term (undoubtably noticed in this blog), while "client" is often used in outpatient settings. Some settings prefer using the person's name. Other titles may be "student" "participant" "family" or "resident." Even though I occassionally do this, you really should not write goals with the therapist as the action-taker (ie "therapist will further evaluate cognition). This belongs in a formal plan of care rather than the goals.

Another problem that fieldwork students often have is knowing what issues to write a goal about. As a rule, if you want to work as an OT practitioner, you need some occupation-based goals. It simply cannot be all about ROM, strengthening, or mobility in your wording, and should not be in your approach. With my hospital patients, I try to have 2 ADL goals, 1 mobility goal, 1 exercise goal, 1 home safety goal. (That's the baseline, I add and subtract based on pt ability) In the few hand evals that I did, I would have a ROM goal, strength goal, HEP goal, and 1-2 specific occupation goals. (the CHT at my site often uses "pt. will identify x# new daily tasks she is capable of performing w/ RUE") With the kids, it is all very different due to their needs, but there is often a sensory goal, 1-2 school readiness goals, parent program goal.

Examples- these are all based off of my life, and written while watching softball, so they aren't exactly what you would want in your setting, but it should give a reasonable idea.

• To demonstrate increased leisure participation, Cheryl will attend activities with friends 1x/week for 3 weeks.
• In 3 weeks, Cheryl will complete 10 crossword puzzles at modified independent level with use of google.
• Cheryl will complete 80%+ of her exercise program at the wellness center 3 days/week.
• Cheryl will play fewer than 50 computer games per week to decrease c/o wrist pain.
  

I could go into more detail on determining length of time for goals (totally different in different settings), good goals vs bad and why, other documentation notes, but I have rambled on this for awhile already and will hold off on that unless there is reader interest in those. School is starting again, so it will be interesting to see what kinds of emails I start getting.

One thing about goals that I need some HELP in!! Does anyone know the legality of whether you can write a goal for a child that directly relates to their MRDD Waiver Program family goal? Since the family is financially reimbursed for meeting the goal, it seems like shaky ground. Anyone have information on this?

Brief recap

Last week:
-Mondays are not Fundays... especially when only 2 people are left to manage inpatient and outpatient... 1 COTA, 1 OT... 2 outpatient schedules... plenty of hospital evaluations.
-Tuesday was also shorthanded and always unfun. We usually split patients not by the amount of time required to treat, but just by the number of patients, which can lead to some major discrepancies on these days.
-Wednesdays are also not fun due to routinely scheduled staffing shortages. Made it through and then got a visit from my parents! First time they have been out to my new place. The rest of the week (parts not devoted to work) was devoted to tourist-type fun and awesome restaurants.

This week:
Another shorthanded Monday with 5 evals and treatments of adults and 5 kids as well. Worked through lunch to make a social skills worksheet identifying "potential friends" for a kid w/ Aspergers. Will post that later...
Today I had some extra clerical work but was unwilling to stay and do it after an 11 hour Monday.

I've been a very involved Olympics fan for a long time... I'd 1994 is the first games that I remember, though I do remember the 92 Dream Team somewhat. Really hate that I have to go to bed before fun stuff happens (Men's gymnastics bronze!!) and need to get better w/ the DVR. I've highlighted all the fun events I want to see (approx 2200) and will not have a lot of computer time devoted to non-Olympic pursuits for awhile. :) Husband is leaving for overseas multi-week job placement soon, so I'll have a considerable amount of time to dedicate to different projects. Part of that will be uploading various files to share with the online community. Other OT-related projects include preparing for my annual review, calling and scheduling parents for the school year, and looking at the feasibility of doing a research study at my facility.

Girl Scout Camp Postmortem

It is with considerable relief that I can finally sit down to type again of this week. Thanks to the beauty of scheduled posts, I could assure that my devoted readers (ha!) never missed me during my long and hard-fought days of work and scout camp. I was working with older girls, entering 5th-8th grades, on the theory that they would be more self-directed and require less help throughout everything. HA! There was a lot that I had forgotten about teenage girls, and between the age range and the sheer number of girls (15) we had some considerable struggles. But we persevered, earned our badges, and made it through the week. During the times when I wasn't leading a rowdy band of scouts, I also saw a bunch of kids and inpatients, as is par for the work course. Had to plan out the new school year schedule... it has 3 afternoon/evenings of kids, 2 eval spots, and 17 30-minute slots. Party. Also, I will be starting work a little later to avoid the dreaded 10-12 hour days that I was working. Hopefully I can work this so that I will also be able to be a scout leader (for most of my camp kids) on Tuesday nights, but it is too far to tell if that will work out.

Arm pain is back... I am now fairly certain that it is referred pain from my neck that is controlled by how I am sleeping at night. I am now trying a memory foam traveler's neck pillow to see if it will force me to sleep on my back w/o flexing my neck.

Had some interesting kids this week. Little Mr. Q is 4 y.o. but not in preschool, b/c mom can't afford it. I Peabody'd him, showing 10-month delays in object manipulation (ball use) and Visual Motor Integration. He jumps at a ball when you throw it to him, and thus, usually does not catch it. He also cuts with extreme forearm supination, which is the skill that tipped off the MD. I will be interested to see what the PT comes up with on Monday, and also need to tell Mom that Ollie's Bargain Outlet (one of my haunts) is carrying Pre-K instruction packs for $20.

Another child, Lil Mr. P, is an interesting story indeed. He was referred w/ a CP diagnosis, w/o his caregivers knowing it, and really does not match CP at all. I actually called the MD to make sure that he had written the dx correctly. What he does certainly have is dyspraxia, though the caregiver regarded me with extreme suspicion when I mentioned this and recommended Sensational Kids for further reading. (I like to refer to this book as I find it very informational and know that it is both at the local library and relatively inexpensive online.) Caregiver stated that he had an appt w/ a developmental pediatrician and that she would not make any more OT/PT appts until she had talked to him, b/c she doesn't think he needs therapy. Hopefully he will reiterate that Mr. P is not developing along the typical timeline and that he will need continued therapy, b/c he really can benefit.

That's about it for now... my parents are visiting later this week. I picked up the 2 headed crayons, but the RoseArt version, as they were only $2. I will also be making a list of projects to work on during the 3 weeks that my husband heads overseas for work. This really should include writing up some SPD stuff so that I can synthesize more of it in my brain, but also needs to have some tangible work for me to do. I'm thinking working out more, puzzles, artsy things. If I don't force myself to have a list, then I will just sit on the couch and do nothing.