Occupational Therapy’s Role in Nursing Home Care
Is occupational therapy the key to better nursing home care? Many residents miss out on its benefits. In this week’s episode, nursing home abuse attorney Rob Schenk welcomes guest Dr. Gigi Smith to talk about how occupational therapy improves quality of life and promotes independence in nursing homes.
Schenk: The role of occupational therapy in nursing home care, stick around.
Hey out there. Welcome back to the nursing home abuse podcast. My name is Rob. I’ll be your host for this episode. We’re going to be talking about occupational therapy, what it is, how it works in nursing homes and. And essentially breaking it down to, to brass tacks, but we’re not doing that alone. We have a wonderful guest today, it’s Dr. Gigi Smith, who’s going to be helping us go through occupational therapy.
Again, like I said, we’re talking about occupational therapy this week. We don’t do that alone. We have the fantastic Dr. Gigi Smith with 40 years of experience. Dr. Gigi Smith is an esteemed occupational therapist specializing in older adult care. Across diverse settings as professor and chair of the Occupational Therapy Department at San Jose State University, she advocates for meaningful engagement and activities regardless of age.
Dr. Smith has presented globally on occupational therapy practice, focusing on swallowing disorders and interventions. Her passion for enhancing lives resonates locally as well as internationally. And we are so happy and thankful to have her on the show. Dr. Smith, welcome to the show.
Dr. Smith:
Thank you.
What specific challenges does occupational therapy address?
Schenk:
This is a topic that we haven’t discussed on this show in a long time.
So I’m excited to have you on the show. Occupational therapy. I feel like getting a bad rap is not the right word. It’s like getting no rap. Like I feel like in all of our discussions, it’s physical therapy, then maybe speech language pathology. And no one ever talks about occupational therapy.
I just want to, I want to spend some time on that. So tell me then, what are the specific challenges, what are the specific conditions that you’re treating or you’re trying to address with occupational therapy as opposed to the other therapies?
Dr. Smith:
That’s a great question. And it’s really interesting because we are the little known therapy of the rehab team.
And we actually had our 100 year anniversary as a profession. So we’re not that new. And here at where I teach at San Jose State, we had our 80th anniversary of educating students So we’re not a brand new profession, but we’re just a very quiet profession that does a lot of work and have a lot of positive outcomes with the clients because we work on things that are so personal to them.
But we just, they’re, we’re not as well known and we need to get our name out. That’s something that we’re really working on is how do we get our name out and let people know what we’re doing? We just, instead of quietly doing that. The challenges, I, can you tell me your question again, the challenges of…
Schenk:
Yes. So, what is occupational from a broad standpoint? What are you addressing? What are you trying to achieve with a nursing home resident, for example, with occupational therapy?
Dr. Smith:
Okay. Occupational therapy is a profession that works with individuals to help them regain the ability to engage in daily activities, daily occupations.
So occupations can be anything from this particular population, anything from eating, dressing, being able to participate in activities in the nursing home, being able to comfortably sit up in their wheelchair and do something while they’re sitting up versus just sitting in a chair. Mobility.
Physical therapy tends to work more on mobility, movement, muscle strengthening, and then occupational therapy takes those skills and helps the person be able to put it into what they want to do. What are they interested in doing? And if that is just visiting with their family. That’s fine, but they still need to be able to sit up in the wheelchair or in a chair in their room and with dignity, be able to visit with their family or feed themselves or do their grooming that they want to do or participate, like I said, in the activity program.
So those are all the things we do in nursing homes. Not all the things, but some of the things we work. Occupational therapy, as a profession, works from babies to end of life across the whole spectrum, because everybody has occupations that they engage in. And so if something happens to disrupt that’s where occupational therapy comes in and helps you learn how to modify change, whatever you need to do in order to be able to participate in that activity or that occupation.
Schenk:
That’s a great distinction. So physical therapy almost is building the muscle, being able to lift things up in order to be mobile for lack of a better word in general, versus occupational therapy, which allows you to achieve the activities of daily living that you want to achieve, whether it’s lifting up your arm to brush your hair standing up out of your wheelchair to go walk and greet somebody.
Things of that nature. That’s one of the distinctions.
Dr. Smith:
Exactly. You put it very well. One time I had a Medicare reviewer ask me why I needed to work on transfers in the bathroom when the physical therapist was working on transfers, and it gave me a great opportunity.
I love when somebody asks me that because then I’ll spend the next 20 minutes telling them why we both need to work with that client. And we do work closely together as a team, physical therapy, OT, speech therapy. If it’s a swallowing problem, we work really well.
How do you get your body forward and they might even do it in the bathroom on and off the toilet. But then OT works with all the other things you have to do in order to go to the bathroom. How do you pull your pants down? How do you then balance on the toilet?
It’s much different than when you’re practicing with all your clothes on. And then how do you do toilet hygiene? How do you pull your pants up afterwards? These are all things that, you Speak to a person’s dignity to be able to do these activities. And so both of us as rehab team members work together to help the person achieve those goals.
Can you explain some common Occupational Therapy interventions?
Schenk:
So walk me through, let’s just take what you said earlier, being able to sit up in a wheelchair with dignity, to receive guests, what would be as an occupational therapist, what would be some interventions or some exercises, if that’s the right word, that you would implement in order for that resident to achieve that goal?
Dr. Smith:
I would look at and first of all, I want to say that in different settings, the roles are delineated a little bit differently. So I’m saying what I would typically do in the settings that I have worked in.
Schenk:
Sure.
Dr. Smith:
So we’d make sure that they’re in the correct wheelchair for comfort. That they have the right cushion underneath them that their clothes are on so that their legs are covered.
If that’s or a foley catheter bag is covered so that they have that dignity and not need to do that and look at how long they can tolerate sitting up. Do we need to work on that? That integrated program so that they can sit up long enough to visit. What happens? Can they move the wheelchair? Do they need a lap tray on the chair to support their arm?
So we look at all of those things, and then we look at the actual visit with the family member, if that we’re lucky enough to do that, which is a fun part of OT. We get to do all these fun things. Fun things and not just exercise. That’s not very nice to say, but not just exercise, but the fun things and the things that just warm your heart is how does that visit go?
Can the person interact with that, their family member, or do we need to do something to make that better? Do we need a quiet environment? Do we need an outdoors environment that might facilitate that to get them in a different setting? So one of the other things that occupational therapy looks at is the context in which the person is living, performing that activity.
And how can that be changed? How can that environment be changed a little bit to make it better for the person to be able to do what they want to do?
Schenk:
So it sounds like there’s an assessment. If the goal is to have this individual be able to sit up, you assess, okay, is there a catheter?
Do we cover the legs? Can you move yes or no? How long is it? 20 minutes that you can sit up essentially evaluating the abilities of the person. Take me through, um, if the individual wanted to be able to sit up longer, are there specific exercises that you do, or is it simply just sitting with that person and trying to build up the tolerance or how would that work?
Dr. Smith:
Unfortunately, I wish that. Medicare would pay for us to do that, but they can’t do that. So what we need to do is set up a routine with the nursing staff, maybe set up a schedule. This person stays up 20 minutes today, tomorrow, 25 minutes. And then assess how they’re doing. And then the next day, maybe 25 minutes. The next day, 30.
And then I might stop back in and say, how are they doing? They’re really uncomfortable. Okay, let’s look at what’s why they’re uncomfortable. Is it the cushion? Is it that they’re uncomfortable in a setting they’re being sat put in and they want it? They need something different than that.
Do they need? What do they need? So we set up a lot of routines with the CNAs and with the nurses and they carry through on them or the families even to say, when you visit and it’s time for dinner, maybe you can ask, we can make sure that the nursing staff has your mom up in the wheelchair and that 20 minutes can be done while they’re eating.
That way it’s a more normal and natural environment than laying in bed and eating.
Schenk:
So occupational therapy really, in some ways, relies on the nursing staff in order to achieve the goals.
Dr. Smith:
We need to have a really strong relationship with the nursing staff because they’re the people who are there all the time and we usually are given maybe half an hour to an hour a day for a short period of time, depending on whether they’re in the rehab section or in the long term section of the hospital of this facility.
And so we depend on the nursing staff and frankly on family a lot. And if family’s involved, we really try and do a lot of what we do with the family involved. So the family’s feeling like they’re doing something really worthwhile for their family member and it just is. It’s just a nice relationship to foster.
And if not, we do it with the nurses, the CNAs, the activity directors, whoever else is working with that person.
How can families participate in their loved one’s occupational therapy?
Schenk:
What involvement should the family have? What are you looking for in terms of how does the family’s involvement help you achieve the goal?
Dr. Smith:
Families being involved make a huge difference in a person achieving their goal, but people who I’ve worked with in the nursing homes, they live to see their family.
That’s the big deal for them is that family visiting. And so the more that we can arrange our therapy sessions around when that family is there, the better idea the family gets of how. Much care is involved in what we’re doing and the person gets to interact with their family during activity so that we make sure they’re successful and because that’s our job.
We want to make sure that they’re successful in what they’re doing and it’s just so important and families often don’t know what to do when they visit, do we just sit here and mom’s in the bed? Dad’s in the bed. We just sit here and pay our bills. They really don’t know how to interact sometimes and if we can make that yeah a little bit different and have that the scheduled time make sure the person’s up and ready for them and maybe they go eat dinner together or lunch together and outside on the courtyard.
So that’s a more normal activity. It’s not normal to stay in your room. It’s not even normal to eat in a big dining room with a lot of other people.
So if families visit around lunchtimes, a lot of times that facilitates the person eating more. And also it’s more pleasant because you can go do something with your family member and it’s more normal and natural. That’s what we do. We would go sit somewhere with our family member or our friend at lunchtime and eat.
So we try See what’s important to them. We always should see what’s important to the patient to the client. And then what’s important to the family. And that’s how we determine our goals. Not my goals as an OT is that everybody needs to be able to brush their teeth and put their top on or whatever.
That’s not important. It’s what’s important to that individual. What do they want to be able to do? They may want to just be able to put their makeup on and need help from the nursing staff on everything else. And so that’s what we work on because that’s important to them.
Schenk:
It seems to me that occupational therapy is at least one part doing the physical work to effectuate whatever the objective is, and on the other part, it’s the dignity and the mental health aspect of it that you mentioned that perhaps this resident only wants to be able to put their makeup on and the reason why they want to put their makeup on is because that what makes them that’s what makes them feel good.
And then if they feel good, then that’s going to affect every other aspect of their care. So it’s not just the physical component.
Dr. Smith:
That’s right. And occupational therapists are trained in mental health. And the physical part of it. So mental health is a big part of our profession. We try to always look at our client holistically. What is their mental health like? What do they need to do? What is important to them? What is motivating to them? If it’s not motivating for somebody to put their socks on because a family member wants to do that and that makes them feel good to help them with that. We don’t. Why do we work on it?
Where would we work on that? Because that’s not important to either the family member or the client, even though we know for someone else, it might be very important to put their own clothes on. So we have to look at that and take each individual. We complete an occupational profile on every client that we see.
And we look at their habits and routines. What was meaningful to them and what are their goals and et cetera. A lot of other things we gather and we gather that from family when we can’t get it from the client and then try and adjust ours are what we do with them to meet those goals and then we have to be creative on how we document for reimbursement because you can’t ignore that fact that we have to, we’re paid in there.
And so we learned how to document to support. What we do with the client but we have to be careful and sometimes we’re restricted by what insurances won’t let us do.
What are the challenges of occupational therapy for cognitively impaired?
Schenk:
What are the challenges of providing occupational therapy to someone who has some degree of cognitive impairment? Like how are you approaching those types of patients?
Dr. Smith:
Um, we have a lot of resources and we do a lot of education while they’re here at school on cognition and cognitive and executive functioning and how that interferes with your ability to enter, to do what you need to do. And so in a skilled nursing facility and a long term care side, you’re going to be working with a lot of people who have cognitive decline.
And it just presents an additional challenge and that you have to figure out what’s going to work. Sometimes it’s a demonstration. Sometimes, even somebody who’s had a stroke may not understand any of the words you say anymore. So you have to demonstrate. You have to be able to guide them. We do guiding activities a lot.
We find out just It’s I always say you have to find the back door in. You have to find a different way to do what you’re trying to help that person do. And that’s the unique challenge of working with people with dementia, with severe dementia, but there’s always a way to do it. And a therapist who is a strong therapist knows what they’re doing.
We’ll do fine with that. And find different ways because we have a lot of resources, a lot of guidance on working with people with dementia or working with people with cognitive delay or decline.
Schenk:
Is it typical for when a resident is getting assessed for what care he or she needs for occupational therapy to be left out for that reason?
Dr. Smith:
I remember once I had a case where the person had a total hip replacement and they had severe dementia and the doctor did not write an order for occupational therapy because he said they’re not going to remember anything you tell them to do. They won’t remember their hip precautions, they won’t remember that so why would you want to work with them.
And it was a great opportunity for me to say, let me at least do an assessment. And see what I could do because oftentimes, those are natural routines. You get up, you walk to the bathroom, you go to the bathroom. So those are natural routines for that person, we would tap into that and not worry about them using any new cognition.
And for their hip precautions, we would provide that assistant. That person might never be independent, but they’re still going to engage in the activities because they have to. And so we could then train the nursing staff, train the family. Here’s what you do. Here’s how you put their pants on. Here’s how you have them slide their leg forward before they sit down so they keep their hip precautions.
So the person is still able to engage in those activities that are important to them. They’re just common day things that you and I do. Everybody does, and they don’t even have to learn a thing new because we’re not expecting that at that level, and we still can make a huge difference in their quality of life and their ability to be up and moving around.
Schenk:
That’s so interesting that you say that where in that instance, the education is for the nursing staff. It’s not necessarily for either muscle memory or for the resident, him or herself. So occupational therapy, despite the cognitive impairment, despite the fact that the resident may or may not remember any of the exercises.
Dr. Smith:
The education is for the nursing staff, for the nurse, and we always involve the person with it because that’s what we need to do. We’re treating that client. We’re not treating the nursing staff, and we just recently had a huge and the other really positive thing for our profession and with billing is that they recognize family training as something you could do without having to have the client involved if you don’t need to, and before that was never allowed.
They would not pay as he said you’re not your job to treat the family, although the family is going to take that person home and may need a lot of training on what they’re going to do to take care of that person. Finally, it was recognized that an important part of what we do is making sure the nursing staff knows what to do when we’re not there with that particular person and what the family knows.
And sometimes it’s surprising with somebody who has cognitive decline or dementia that they can really do a lot of things if you allow them to do that because of their habits and routines that are not even at that level of thinking of having to use your cognitive skills.
You just do it. Sometimes we do that too. We routinely do that. By the time you’re done, sometimes you have to even think, did I brush my teeth a little bit ago? Because you didn’t have to think about it while you were doing it. You just pull out the toothpaste, you put it on. It’s natural. If we set somebody up at the sink to do their oral hygiene and just put the items out there, even with dementia, they might pick those up and just start doing it cause that’s what they always did.
When we start getting too wordy and talking to them through it and put them in a setting that is not a natural setting to brush your teeth, like in bed or sitting in a wheelchair with a table in front of you, the chances that they’re going to do that activity is much less. They’re much less because that’s not the natural environment or the setup for that person.
Schenk:
It seems that and I’m, I don’t want to make any physical therapist mad, but it seems like there’s a lot more problem solving, a lot more creative thinking, a lot more analytical thinking with occupational therapy. Physical therapy it’s like, all right, move this weight, stand up, sit down this many times.
Whereas you’re having to assess desires, wants. How to get there. You know, there’s a puzzle you’re putting together, a puzzle almost as opposed to a physical therapist.
Dr. Smith:
And I love working with physical therapy. In fact, I thought I would be a physical therapist early in my career.
And then I changed for a variety of reasons, but they are such an important part of the team because The physical skills are so important to have, but you’re right, when we look at a patient, it’s a very complex assessment. It may look very easy to you. I might give somebody a comb and say comb your hair.
That looks super simple, but I’m looking at their perceptual skills, their cognitive skills, their sequencing skills, their ability to motorically do the task and then their ability to figure out what comes next. So I’m looking at a lot of different things in a very simple task. We don’t have to do standardized tests, although we do those as well.
We just have the person do what they do and then analyze. And interpret why that’s happening. And if it’s not working well, what can we do to make it work better? What part of that piece, that puzzle, what’s missing? Is it? Is it strength? Is it coordination? Is it cognition? Is it perception? What is it that’s causing that person to not be able to do that activity?
Role and Involvement of Occupational Therapists in Patient Care
Schenk:
In general, how does the occupational therapist know to get involved, and then how is that care planned? I guess what I hear you say is, the physician or the physician’s assistant says, okay, this individual is a candidate for occupational therapy. The occupational therapist then goes in, assesses what is needed, and care plans that out.
Does the physician get involved after that? Or, tell me about typically how that works.
Dr. Smith:
Okay in many nursing homes, in many skilled nursing homes, they recognize the value of the team, OT, PT, speech, to come in and work with a client. And so there’s often a protocol. If a person comes in with some, with a CBA or stroke, they will get all three disciplines and the doctors will just order it.
And then we do our assessment. We write up our intervention plan. We put it on the care plan. We have a team meeting with the nurse and the doctor. And usually those are in some places. but in most nursing, skilled nursing homes, it’s longer duration, maybe monthly, but we are documenting right in the chart.
And most of us are pretty bold at talking to the doctor. If something comes up that we need them to know involved with the social work. So it can be in a well run facility. It can be a really collaborative team process to make sure that person’s getting all the care, that nothing’s slipping through the crack.
In others, we have to solicit for our orders. We have to have orders to see someone. So in the long term care side, many times the doctor won’t order if they’re not familiar with occupational therapy, they might not order anything for that client. But we might see that person sitting up sideways in their wheelchair and not participating at all in the activity just rolled there and left there.
And so we might then solicit an or a request for an order to assess that person. And we’re pretty bold at that as requiring, doing our thing to go out and just periodically take a walk around the facility. Nurses will often say, OT, they’re not feeding themselves as well as they did before.
Would you mind coming in? And then they will ask for an order. So I think the more, the better. Outgoing the occupational therapist is in the setting, the more referrals they’re going to get to help people or families may say they may hear something and say, I heard this, and I think maybe somebody can help mom eat better or dad sit better, or whatever.
And that kind of prompts them to put in either an order for screen, where we go on screen and say yes we think we can help. We need an order or no, here’s what you can do. But we don’t need to come in at this point.
Schenk:
Dr. Smith, this has been incredibly enlightening for me and for our audience.
And we really appreciate you taking time to talk to us. And I just want to say again, on the record, that you have a lovely office. So anybody, if you’re not just listening, go on YouTube or on our website and watch this episode, because you’re going to see that her office is absolutely beautiful. I’m looking at some, some orchids, Yeah.
And some paintings. It’s fantastic. Anyway, thank you so much, Dr. Smith.
Dr. Smith:
You’re welcome. Thank you.
Schenk:
All right. I hope that you found this episode educational. I most certainly did. If you want to reach out to Dr. Smith, you can email her, which is gigi.smith@sjsu.edu. gigi.smith@sjsu.edu. That was very painful. And I apologize.
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