Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
Alixis Van Horn, MSN APRN-C Jennifer Nardi, MSPT Dawn Gordon, MOT, OTR/L Rachael Levy, MA, CCC-SLP
Neurology Day Rehabilitation Program (NDR)
NDR: Evolution
• Model program at sister facility • Focused on neurological injuries • Secondary goal of collecting data
– Support 3rd party payment for rehab as a clustered service
NDR: Development
Needs Assessment: • Gaps in service • Population in geographic catchment • Competition
NDR: Development
• Identify stakeholders • Build a vision and values • Initiate team building
– Creating culture – Skill mix
NDR: Values
• Comprehensive – Acknowledge all domains impacted
• Cohesive – Work as a team
• Holistic – Treatment driven by the patient
• Promote Coordination of Care
NDR: Translation of Values
Comprehensive: • What are the deficits? • What are the goals? • Who else is involved? • What additional supports and resources
are needed?
• Insert photo of space
NDR: Translation of Values
Cohesive: • Strong commitment to the program and
the team • Foster constant, meaningful
communication • Systems and infrastructure supports • Accountability
NDR: Translation of Values
Holistic: • Embracing the patient as a whole person • Acknowledging concerns • Including family and loved ones • Education and support
NDR: Translation of Values
Coordination of Care: • Other HCP’s and their plan • Referrals • Communication of concerns, changes • Advocacy • Ancillary Services
Initial Goals
• 25 enrollees • Stable staff
Emerging Goals
• Ancillary services • Offshoot programs • Specialize staff • Fundraising
Ancillary Services
• Social work • Psychotherapy • Neuropsychology • Massage • Driving evaluations
Ancillary Services
WISH LIST • Music therapy • Animal therapy • Peer counseling • Vocational counseling • Spasticity clinic
Animal Therapy • Harbor Grace
Outreach
• Working with UMASS residents • Clinical rotations for students • Stroke support group • Collaboration with neurology
NDR: Screening
• Neurologic injury • Preferably under 12 months since injury • No underlying dementia • No active substance abuse • Active MH dx under care of psychiatrist • Continent or with caregiver assistance
Physical Therapy
• Land and aquatic – LiteGait – LSVT BIG – Neuromuscular electrical stimulation – AlterG Bionic Leg – Simulated environments
Occupational Therapy
• Land and aquatic • Task and environmental simulation • BTE Simulator II • Neuromuscular electrical stimulation • Cognitive interventions • Driver readiness skills
Speech Therapy
• Cognitive interventions • Memory interventions • Executive function interventions • Dysphagia therapy • LSVT LOUD • Assistive voice technologies • Simulated environments
Nurse Practioner
• Care coordination • Neurologic management
– Seizures, spasticity, depression/anxiety, PBA • Education • Support for families and patients
Additional Offerings
• Groups • Graduation • Social outings
Program Statistics
• ~150 referrals, only 5 inappropriate • About 60% enrollment rate • LOS: 4 weeks – 18 months • Rolling admissions
Barriers to Enrollment
• Transportation – Distance – Variable schedule – Frequency of
appointments – Variable onsite time
– Need for assistance – Cost – Caregiver burden – Stigma
Barriers to Enrollment
• Insurance benefits • Medicare: cap for Speech and PT $1940, cap for OT $1940.
– After cap is reached, will extend to $3700 • Only for medical necessity
– Reduced patient cost in the presence of a secondary payer
Barriers to Enrollment
• Medicaid/MassHealth – Visit limits per year or re-assessment period – Multiple insurance plans with varying
coverage – No copay
Barriers to Enrollment
• Managed Care – Accept most commercial insurance – Policy dependent
• Visit limits per year or re-assessment period • Copay on most primary plans
Who We Serve
Traumatic Brain Injury
Gabrielle Gifford
Stroke
Dick Clark
Metastatic or Primary Tumor
Senator Ted Kennedy
Movement Disorders
• Ataxia • Huntington’s • Parkinson's • Multiple Sclerosis
Spinal Cord Injury
Christopher Reeves
Others
• Anoxic brain injury • Parkinson’s Plus • AVM • Ruptured aneurysm • Seizure disorders
Working Census
• Between 20-25 at any given time • Average 10 patients per day • Waiting list X 6 months, average of 5 pts
Program Challenges
• Scheduling • Group Attendance • Staff Retention
Program Challenges: Scheduling
• Fixed supply • Variable demand • Coverage
Program Challenges: Scheduling
• Accommodating requests • Unrealistic expectations • Popular time slots are limited
Program Challenges: Group Attendance
• “Cherry picking” • No shows • Resistance to suggestion • Mixed population • Varied interests
Groups
• Cooking • Crafts • Tai chi • Meditation • Yoga • Coping skills/support
Program Challenges: Staff Retention
• Internal vs. external culture • Opportunity for growth • Demand for flexibility • Pay scale • Infrastructure
Challenging Cases: KJ
• 49 yr old MWF, athlete, high functioning, independent
• Highly motivated patient • Anxious family in functional denial
Challenging Cases: KJ
• Unreasonable or unrealistic expectations • Transportation • Breakdown in communication
What We Learned
• Pay now or pay later • Setting realistic expectations • Communication is key • People adapt to change over time
Challenging Cases: CH
• CH: older, WWF, retired, living independently
• Poor attendance, short notice changes • Unrealistic expectations
Challenging Cases: CH
• Concerns over HCP’s motives and intent • Suspicions reported to state • Family meeting: progress stressed • Withdrawal from treatment
What We Learned
• Advocacy can be uncomfortable • Try to find common ground • Protect the patient
Challenging Cases: PM
• PM: elderly, WWF, matriarch role • 3 adult sons • Entrenched family relationship dynamics
Challenging Cases: PM
• Lack of buy-in • No follow through at home • Dissonance about goals • Intra-family discord
What We Learned
• Our ability to influence longstanding family dynamics is limited
• Patient goals drive treatment • Meet patients and families where they are