Clinician Tool KIT - The Weston Group – … · Web viewSpecific areas of the therapy clinic or community are identified as “circuit training areas” with activities designed

Transitions

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Clinician Tool KIT

TransitionsTransitions is a Clinical Assessment and Treatment program designed to promptly identify functional risks for residents entering assisted living communities.

Focusing on four critical components that can significantly deter and delay adjustment to their new living

environment, Transitions incorporates standardized protocol based assessments in Breathing, Balance, Mobility and Stair Negotiation.

Key attention is placed on resident/family education and explanation of the Transitions program throughout the initial admission process and on an ongoing basis. Results of the assessments are compared with age range based normative charts and tables.

Upon completion of the skilled therapy evaluations, goals are developed to assist in the resident’s transition to life within the community with the overarching goal of reduction of risk factors which inhibit functional living skills.

Once problem areas are identified and assessed and goals are mutually agreed to, Weston Group therapists follow a formalized protocol of treatment that is both enjoyable for the resident and meets the skilled therapy requirements such to enhance functional performance in everyday life experiences made available in the assisted living community.

Specific components of Transitions can be continued after completion of the program with direction as needed by the Weston Group therapists and/or community staff. The “Transitions Plus” component ensures that routine formalized reassessments are completed timely and re-entrance into the Transitions program can be accomplished as part of the seamless community and Weston collaboration for excellence in resident care.

Components of the Weston Transitions Program

Breathing

Balance

Mobility

Standardized Assessments

Tools/Supplies Needed

Six Minute Walk Test Pulse OximeterBORG-RPE_Dyspnea StethoscopeS/Z Ratio Assessment Blood Pressure Cuff

Stop watchTape MeasureChair

Sample Training Protocols/Focus AreasControlled Inhalation/Exhalation AlternationDeep BreathingPursed BreathingPranayama Breathing Programs (Yoga)Controlled Tonal Program (Music Focused)Sustained Vocalization ExercisesSeated Breathing Graduated Protocol

Standardized Assessments

Tools/Supplies Needed

TUG (Timed Up and GO) Stop watchBERG Tape MeasureSingle Leg Stance ChairTinetti Air Ex Cushion

Cones

Sample Training Protocols/Focus AreasHarvard Senior Balance Training ProgramWeston Falls Prevention ProgramACE Graduated Balance ContinuumMulti Component Balance Program for Older AdultsFocus Skilled treatment protocols – Align at the Wall, Standing Weight Shift, Marching in Place, Toe Touch to Floor, Shuffling from Side to Side, “Tightrope” Simulated Walking, Slalom Course, Toe and Heel Walking, Eye Tracking Training

Standardized Assessments

Tools/SuppliesNeeded

30 Second Chair Rise Stop watchDGI (Dynamic Gait Index) Tape MeasureSelf-Selected Gait Speed ChairTinetti ConesBerg Steps

Pedometer

Stair Negotiation

Sample Training Protocols/Focus AreasWeston Falls Prevention ProgramMarching in PlaceBus Step Negotiation SimulationSustained Leg Lift/ Hip Flexion Exercise ProgramStep Aerobics for Seniors

The Weston Transitions Protocol

Pre Admission to Assisted Living Community1. Transitions Therapists meet with prospective residents and/or POAs to introduce therapy services available.2. Transitions Therapists present Transitions flyer to introduce the program, its goals and program components.

Sample Training Protocols/Focus AreasWeston Walking ProgramPseudo Cardio ExercisePaced WalkingReciprocal Arm/Leg CoordinationUniform Strides ProgramEnergy Conservation in Walking

Standardized Assessments

Tools/SuppliesNeeded

Single Leg Stance Stop watchDGI (Dynamic Gait Index) Tape MeasureTinetti ChairBerg Cones

Steps

3. Orders from the admitting physician are obtained for Transitions. Order reads “Skilled PT/OT evaluation and treatment/Transition Program”.

4. Therapist completes the insurance verification process.

On Admission to the Assisted Living Community1. Resident/POA completes Authorization to Treat form.2. Transitions therapist meets with resident within 24-48 hours of admission (excluding weekends) and initiates

Transitions Assessment Protocol.3. Results of the Transitions Assessment Protocol are discussed with the resident/POA and a skilled

treatment plan is created.4. Results of the Transitions Assessment Protocol and treatment programs (with goals, frequency and

duration identified) are documented and provided to the DON/RSD for information to be included in the resident’s care plan.

Active Transitions Program 1. Resident begins protocol based Transitions treatment program focusing on identified areas of need.2. Specific areas of the therapy clinic or community are identified as “circuit training areas” with activities designed

and tools/supplies provided to complete designated tasks. All areas are located within the community and some can be located outdoors as availability and weather permits.

Circuit Training Areas includea. The “Breathing Station”b. The “Balance Corner”c. The “Walking Club Gate”d. The “Stepping Station”

3. All skilled therapy services are completed, documented and billed by the Transitions therapist.4. All activities completed by the resident are documented in the personalized “My Transitions Score Cards”

which are located in a binder with information related to health, wellness, fitness and safety.5. Results of the Transitions program are shared with the community leadership for purposes of clinical and

regulatory updates.6. Routine communication with POAs is completed on a schedule mutually determined.7. Routine scheduled reassessments and program progress updates are completed by the Transitions therapist.8. Completion of the Transitions program is determined based on objective progress as per standardized

assessments. Information is transferred to the Outcomes Protocol and can be provided to the resident, POA, referring physician, marketing department and other individuals approved by the POA.

9. Resident is presented with a “Certificate of Achievement” at conclusion of the Transitions program.

After the Transitions Program 1. If the resident/POA chooses, the resident can continue on a non-skilled version of the Transitions program,

identified as “Transitions Plus”.2. Resident continues working at each of the circuit training areas with supervision provided, if needed, by the POA

or community.3. Resident completes same protocols as learned and mastered in skilled therapy. This is a carryover protocol and

is similar to a “home exercise” program routinely provided at discharge from skilled treatment.4. Resident uses the “My Transitions Score Cards” to document ongoing progress and participation in the

Transitions Plus program.

5. Transitions therapists remain available to answer questions, provide suggestions for enhanced programs and screen for potential changes with follow-up as needed.