Occupational therapy in nursing homes

In general, the goal of occupational therapy is to help nursing home residents become more independent through meaningful activities and exercises. By improving life skills, substantial improvements can be made to the quality of life and dignity of the resident. On this week’s episode, nursing home abuse attorney Rob Schenk welcomes Susan Touchinsky OTR/L @SusieTouchinsky of Adaptive Mobility Services, LLC to talk about the importance of occupational therapy in a long-term care setting.

Schenk: Hello out there and welcome back to Episode 144 of the Nursing Home Abuse Podcast. I hope that you are having a fantastic time diving into Spring 2020. We are going to be talking about a special topic today and that is the use of occupational therapy on nursing home residents. I know that a lot of times, and we’ll get into this in the episode, but there’s a misconception of literally what occupational therapy is. But I’m not an expert, so in order to talk intelligently about this topic, we have a special guest, and that special guest is Susie Touchinsky.

Susie Touchinsky is an occupational therapist and certified driver rehabilitation specialist. She is the owner of a small private practice, Adaptive Mobility Services, LLC, which services southeastern Pennsylvania. For decades, Susie has been committed to helping drivers understand and to improve their driving ability and confidence after medical illness, a major medical event, health conditions and injury. Susie uses her experiences and training in driving rehabilitation and as a driving instructor to live her mission of providing exceptional care for all drivers and education for occupational therapy practitioners.

Susie offers extensive clinical and professional experience and she has a specialty certification in driving and community mobility from the American Occupational Therapy Association. She’s a certified driving rehabilitation specialty, which she got from the Association of Driver Rehabilitation Specialists. She has 19 years of experience with dementia and mild cognitive impairment patients, and she’s a teacher of occupational therapists on driving and rehabilitation specialist instruction. It’s that 19, almost 20 years of experience with dementia and mild cognitive impairment patients that, in my opinion, makes her super qualified to talk to us today, so Susie, welcome to the show.

Susie: Thank you so much for having me.

Schenk: Fantastic. So Susie, I’m so glad that you have been able to come on this show and talk to us about this topic. A lot of our clients that we get and a lot of residents of nursing homes require some type of therapy and oftentimes we’ll be going through records and the loved ones of these residents will be going through these records and they see these letters, “OT.” They see “occupational therapy” and they don’t quite understand what that means with their loved ones that are in nursing homes. So just from a broad standpoint, would you mind explaining what occupational therapy is in a nursing home setting?

What is occupational therapy in a nursing home setting?

Susie: Absolutely. So occupational therapy in a nursing home setting really looks at the client and focuses on the client or the patient and what that person wants to be able to get done in their day-to-day life. So in a broad spectrum there, occupational therapy looks like what occupies somebody’s time and we figure out a way to help them be able to do that. So if the illness or the injury is impacting someone’s ability to get to the bathroom, to be able to brush their hair, to eat a meal, to be able to have a conversation, we as occupational therapy providers look at what’s making it hard for that to happen and provide interventions so people can do those every day activities that occupy their time.

So in a nursing home, it can really range from helping somebody to be able to get in and out of bed, to be able to sit comfortably in a wheelchair or another seating position or to enjoy a meal, to be able to visit and participate in the social activities, to have the strength in their arms to be able to stand up, to shower, to move, to bathe and dress.

Schenk: So I guess that makes sense that we’re not talking about occupational therapy for non-nursing home residents, which wouldn’t necessarily entail – I’m assuming getting someone back to work, the physical movements that allows somebody to do a job – in this instance, the job is living as a person in a nursing home. So is that a fair statement?

What is the goal of occupational therapy in a nursing home setting?

Susie: Yeah, absolutely. So the toughest thing about being an occupational therapist is people think of occupation, they think jobs, but really just like you said, the resident in the nursing home, their job is living their life. It’s being a grandparent, it’s being a member of the community, it’s being a friend. And so it’s how do we make sure that they’re able to do all the things they want to be able to do in their life and make sure that the arthritis in their shoulder isn’t preventing them from doing that or that the weakness from a stroke isn’t making it too hard, that we can rehab those different things and make them stronger and be able to participate really so they can enjoy life and they can enjoy the little things life has to offer.

Schenk: That makes sense and that was actually my question is what’s I guess the generalized goal of occupational therapy for a nursing home resident is improving to the maximum ability the quality of life of whatever the particular movement is, I guess?

Susie: Right.

Schenk: So if the individual is unable or is having trouble being able to lift themselves to the toilet or get themselves to bed, that’s kind of the goal of occupational therapy would be to step in and try to meet the goal of being able to accomplish that task.

How does occupational therapy improve the lives of nursing home residents?

Susie: Right. The other thing from an occupational therapy standpoint is so if you kind compare our partners in rehab tend to be physical therapists, and physical therapy has a very biomechanical approach, how the muscles work, how the muscles are strengthened and corrugated. And occupational therapy certainly looks at strength, but we also look at the cognitive abilities of somebody. Is there a change in memory or communication that’s making it different for that person to understand the directions they’re being given or to follow the directions to be able to participate or even the cognition they might have for safety awareness, knowing that it’s unsafe to stand on their own or that they need assistance for whatever task it is they’re doing.

So I kind of mentioned recovering from a stroke – we all think about a stroke and we can all see somebody has weakness on one side of their body, but there can also be changes in somebody in the way they think and follow directions. And occupational therapy often specializes in the cognitive function in people as well. So it’s the motor, it’s the cognitive, coordination. We approach the whole picture for somebody so that they can get it done.

And a big area, especially in a nursing home, we work with clients with dementia and really understanding where the dementia is and how this is impacting somebody’s participation and their thinking, and then helping to activate those person’s skills so that the nursing staff can work a little bit better with that person, the physician understands a little bit more, the family can interact better with that person as well. So it’s really an amazing and rewarding field because it can help some many aspects, especially in the nursing home setting.

Schenk: That makes a lot of sense. That’s a lot of considerations that you have with a nursing home resident in terms of “Am I providing this unique therapy solution or intervention?” but I’m also having to say things like because of this stroke or because of your limitations, don’t do this. So the therapy is not just helping you achieve a goal but it’s also helping prevent maybe further injury or preventing injury altogether from that so you’re kind of like a counselor in that sense as well.

How does occupational therapy help to prevent injury in nursing homes?

Susie: Yes, absolutely. An interesting way to think about it, there really is a lot of thinking about the person, thinking about what the person’s goals are, thinking about what their strengths and weaknesses are and advocating for them with their family, with the setting, with the staff so that we can provide. You know, nobody wants to have everything done for them. Some of us do, right? Some of us will take it far.

Schenk: Yeah, speak for yourself.

Susie: You know, it’s time to retire. Bring me my ice cream. Let’s go. But for others, we don’t choose to have these medical conditions. We don’t choose to have a stroke. We don’t choose to have a brain injury. We don’t choose to have dementia. So these illnesses change and take things away from people, and I really see occupational therapy as something where we can see what strengths are still there for somebody and maximize that, to be a cheerleader for that client, for that patient, for that resident. It helps to make sure that even if the best of what this person can do is sit up for 30 minutes so they can enjoy a meal and they don’t, because they’re sitting up well, so they don’t get pneumonia and have more complications, that’s an amazing goal and an amazing thing to accomplish.

Schenk: That makes sense.

Susie: Yeah, yeah, or even if it’s someone with dementia who’s able to move around well but their brain is changing how they interpret their environment and they can’t find the restroom any longer, and so maybe that’s leading to different behavioral problems, helping them figure out what works for that person to get to the restroom so they can be clean, so they don’t have hygiene issues, so they don’t have behavioral issues and so they don’t get infections.

Schenk: That makes so much sense.

Susie: Yeah, sometimes it’s just those simple solutions that we’re really working on to improve the overall quality for somebody.

Schenk: Yeah, what’s interesting to me sometimes when we’re evaluating cases is that I feel like sometimes it is the occupational therapist, it is the physical therapist that are providing the records with the most amount of detail on that subject matter – “Resident is having difficulty orienting to space,” “Resident is having difficulty finding bathroom,” – these types of things that aren’t being documented in the normal nurse’s notes, and it’s because you guys are bringing in, coming in – and I love what you said – is kind of the advocate in all aspects of this individual and their needs. I think that’s a fantastic way of looking at it.

Let’s kind of go backwards. We’ve been talking about trying to achieve this goal, but my question is when you are brought on and you’re first meeting that resident, how do you know? What’s the assessment process of what that individual needs to get done? What’s their baseline? What was their baseline before coming into the nursing home and what their goals are? How do you figure that map out?

How are occupational therapy goals established in nursing home residents?

Susie: The process for that starts with an order from the doctor and the doctor will order an occupational therapy evaluation and I’ll get to meet the client. The first thing I’ll do is what’s called an occupational profile, and that’s really learning this person’s life story – what is their story? What life goals are important to them? What are their goals? So everyone’s got different goals – what’s important to them in the context of their illness, their injury, being a resident in a nursing home? And with some people, they’ll have difficulty expressing that, so that’s when I tap into family, the doctor, even observations from the nursing staff.

And you were just commenting on how sometimes therapy provides a different lens and more detailed documentation of our observations, and I think a lot of that can come from our background and our training. We’ve got lenses for looking at things. But our nursing partners can really have some good observations if we ask the right questions, then we can kind of dig into a case a little bit more.

So once we get a good picture of this person and their occupational profile, we then perform a comprehensive evaluation where I look at the resident’s vision, coordination, motor skills, sensation and cognition. And that can look different depending on the person, their medical condition and what’s going on. For example, if I have somebody who might be in the nursing home because they’ve got a neuromuscular condition, maybe MS or something that’s not affecting their cognition, I’m going to spend more time looking at their muscles, their coordination, their sensation, and I’ll use a quick cognitive screen versus somebody who comes to me with a diagnosis of dementia, I’m going to really dive in and do, probably have them perform some kind of cooking activity or bathing activity or dressing activity for me so I can see what they’re doing, and then I’ll do a more in-depth formal cognitive assessment.

So it’s really individualized and I think that’s kind of the key piece to appreciate is that an OT evaluation shouldn’t always look the same because it should be very individualized to the person. There’s some structure to it and we have our forms we have to fill out, but there should still be a detail that speaks to that person and who that person is individually.

Schenk: Yeah, so with regard to the assessment of the cognitive ability, I guess that’s more going to “Can this person follow directions? Can this person literally think about moving a particular body part,” that kind of thing? Is that what you’re going for with that?

How does cognitive ability factor into occupational therapy in nursing homes?

Susie: It’s even in more detail than that. So we talk about orientation. We talk about direction following. But I want to know things like multi-tasking. I want to know things about judgment. I want to know what we characterize as executive functioning. So that’s the last part in the brain that tends to develop in people in our late teens and early 20s, we get that great executive functioning with judgment and reasoning. So I want to know where those things are with people as well so that we can tailor our approach, we can help the nursing staff tailor their approach on how to communicate and work with this person on their level.

Schenk: That makes sense. That makes sense.

Susie: Yeah.

Schenk: You said something that was interesting in terms of the life experience and what the person’s life was and what was important to them in the past. Can you kind of unpack that a little bit? What’s important about learning the person’s history, the person’s story?

Why is a nursing home resident’s life story important for occupational therapy?

Susie: Right, okay. So for example, their history and their story can give me indicators on potential health considerations but as well as give me insights into things that motivates them. So for example, I’m going to approach – let’s say I get an 85-year-old woman referred to me and maybe she’s come into the nursing home because her balance is off and her life is changing and she’s been falling a lot. And she’s been a stay-at-home mother for her entire life. She lives in a farm house. She loves to cook. Her pride and joy is making Sunday dinner every week for her family. I’m going to tap into those different things and help motivate her and help strengthen. So we can work on cooking activities, one, to understand her thinking and cognition, but then we can work on the cooking activities to get her balance back and her strength back and see where she is.

Her life story is going to be completely different from, let’s say, a World War II veteran who comes to me and has served overseas or has been exposed to – or even like a Vietnam veteran who’s been exposed to Agent Orange and might have some neurological symptoms. They’ve got a very different life story. Those gentlemen aren’t necessarily going to want to cook in the kitchen.

Schenk: Right.

Susie: You know, I’ve had people say to me, “I’ve never cooked a thing!” I’m not going to ask them to help fold laundry or do an ironing test. That’s not going to be meaningful for them. What might be meaningful for them may be going to the rotary meeting once a week or being able to march in the Memorial Day parade. Whatever it is, we have to find what’s meaningful for somebody to help motivate them and to help them recover or, as we were kind of saying before, maintain the skills they have so other problems don’t occur.

Schenk: Right. And I kind of cut you off as you were going through how the assessment is performed.

Susie: Well sure.

Schenk: From a logistical standpoint, how long does the assessment take? I’m assuming you are literally laying eyes on the person and asking questions and being hands on with it. Is it something that’s six hours long? Does it take weeks? Can you walk us through that?

What is the assessment for occupational therapy like? What is involved?

Susie: I would love to take six hours. No, so really a thorough evaluation, it can really vary from about 25 to 30 minutes, or some might take longer, up to an hour. It depends on the person and their complexity, and also sometimes it depends on their ability to engage in that process. There are other factors, particularly for a nursing home resident – you have to think about endurance and fatigue. If I’m working with somebody – maybe they’re referred to me because they’re having trouble with their wheelchair and their posture’s really bad and they’re slumping, that evaluation might only be 20 minutes long because that’s all they can tolerate with the sitting and the moving and the different pieces I’m working on. In that situation, my evaluation might happen over a couple days so I can get the information I really need to set the goals and figure out what we’re going to do with this case.

Schenk: That makes sense. So once the assessment is done, you kind of have a road map. You have what the goals are going to be over a certain amount of weeks or months. What are some of the – and let’s just take a hypothetical example to paint a picture, but let’s say you have a stroke victim that now has difficulty walking. What are some of the exercises, what are some of the therapies that you would use to help this individual begin to walk again?

What are some typical occupational therapy exercises in nursing homes?

Susie: Okay. So if we have an individual and they were having difficulty walking, we will most likely engage with our partners in physical therapy as well, and lots of times if there’s an impairment in the leg, there’s an impairment in the arm, and one of the things we have to do from a therapy standpoint is we can’t all work on the same problem, like we can approach it differently, but we kind of need to divide and conquer this task. So it would be common for physical therapy to maybe work on the leg, work on the leg strengthening, where I would work on from an OT standpoint the arm strengthening. You might be doing therapy and exercises with the resident. You might see me using a modality, like electrical stim or even vibration to get motion and nerve regeneration back into the arm. You might see me working on EDL tasks, dressing, grooming, bathing, even toileting, which would involve standing and moving, integrating what they’re working on in physical therapy in a practical standpoint into a dressing or bathing task.

So it can really range from kind of specific what we call therapeutic exercise activity to some neuromuscular work, which is helping to regenerate or get the nerves back going to an EDL, dressing, grooming activity. It can really vary for that person.

And what we’ve found is especially for stroke, it can really vary on how much time somebody needs as well, because stroke, you can recover for quite a while and continue to regain, usually up to a year after the stroke. So sometimes those cases go a little bit longer as compared to a different case. Someone with arthritis, you might only see them a couple weeks to kind of work on the inflammation, the range of motion and exercise, and then kind of get that pain relief back on the way. So on the stroke, we might work on it a little bit longer.

Schenk: So I guess that kind of highlights the difference between what physical therapy and occupational therapy does. So in that example the physical therapist is really their goal is to get the person from a physical standpoint to physically be able to stand up and walk where your goal is to take that injury and turn it back into him being able to – he or she being able to do whatever it is they were doing prior to the stroke from just an activity standpoint. Is that kind of fair, the fair way to look at it?

What is the difference between physical therapy and occupational therapy?

Susie: Right. Yeah, absolutely. And there’s a lot of partnership going on there.

Schenk: Sure.

Susie: And there’s a lot of collaboration. Our physical therapy partners, they’re exceptional in understanding muscles and strengthening and biomechanics and having really great techniques and then, like you said, the occupational therapy side is how do we apply that and how do we help that person do what they want to do? A lot of people, that first goal is being able to get to the bathroom by yourself.

Schenk: Right.

Susie: There’s nothing better than being able to go to the restroom by yourself.

Schenk: Do you see – is it common in your experience to have PT without OT or vice versa? Or is it usually always a tag team effort?

How does physical therapy and occupational therapy work together in nursing homes?

Susie: You know, it really can vary based on the person and their need. Let me give you an example. So if we have a resident in the nursing home and maybe they are walking with the cane but they started falling more. The first referral might be to physical therapy to look at that balance and what’s going on. But my physical therapy partner, as they’re assessing them, like let’s say they’re looking at this person and the strength is pretty good and the balance is really pretty good – that would be a great avenue then to bring in your OT partners. What I would look at for that person is, okay, are there vision changes? Is there something in the environment that this person continually falls over? Are there safety hazards? So in that example, we can start working together where PT would look at the actual ambulation and then I’m looking at the person’s vision, their understanding of the environment, what the environment actually is to bring the whole piece together.

Schenk: So you’re kind of going in there like House. Your job is a little bit more difficult than a physical therapist’s job.

Susie: Yes, well I would never say that my job is more difficult than a physical therapist. We all definitely bring expertise to the table. But I think, in occupation, it’s a different approach. We’re not looking at them all from the ground up. We’re looking at that person and the activity and how it all comes together, so kind of a top-down.

Schenk: More of a holistic approach, yeah. That makes sense.

Susie: Yeah, and OT is very holistic and we really get that not just motor and coordination, but as I was saying, cognition, vision and really that psychosocial – who that person is.

Schenk: Right.

Susie: There’ve been several cases I’ve been called to consult on and even help out with because it’s “a behavioral issue,” there’s a behavior challenge – this person doesn’t want to go in the bathroom or this person refuses to let whatever happen. And so from an occupational therapy standpoint, I come in and I look at what’s going on with this person, what’s their medical condition, what’s their understanding of what’s happening and what’s the environment look like, the environment being the physical environment as well as the nursing staff and everything else? How can we help this person and use what they have to do what they need to do, and not be opposed to it or be characterized as a behavior?

Schenk: What’s the training process for a typical occupational therapist, not necessarily one that is dealing with nursing homes or anything like that, but from a general standpoint, what do you’ve got to do?

What is the training process for an occupational therapist?

Susie: Yeah, so occupational therapists go to college. We either graduate with our master’s degree at this point, or some people get their doctorate in occupational therapy. Along the way, we complete research as well as hands-on field work training, so I guess it would be considered like a mini-residence, like a doctor goes through residency. Occupational therapists do field work, which is much shorter than what a physician would do – we’re not prescribing medication or things like that, but we’re spending six to nine months in hands-on positions learning from other occupational therapists being supervised directly. So it’s that combination of college for master’s or doctorate and then hands-on work.

And the training for occupational therapy really involves – we start off being with medical students. We do our biology, our anatomy and physiology. We have our cadaver labs.

Schenk: Ah.

Susie: Yeah, and then we kind of veer off and we take some courses like psychology, sociology, then a lot of occupational therapy-based courses to really hone skills.

Schenk: That’s a lot. And so you’re doing a lot of good work where you’re at, Susie, and if someone wanted to get in touch with you, what’s the best way they could do that?

Susie: Certainly. So my email address is Susie@AdaptiveMobility.com. I will say I’ve done a lot of nursing home work over the years. I still lend a hand in there. My primary job, I transitioned and I do driving rehab now too, but anyone can reach me at Susie@AdaptiveMobility.com.

Schenk: And can you quickly – what is driving rehab? What is that?

Susie: Yeah, so driving rehab is a specialty area of practice for occupational therapists. So after OT, I worked in a bunch of settings, and then I went and got advanced training to learn how do medical conditions affect someone’s performance in the car and how can I help somebody return to driving after an illness or injury. So let’s say this stroke patient that we’ve been talking about, let’s say they’ve recovered and they’ve returned home and they’re wanting to go back to work, but they have still a change to their right foot. They may come see me as a driving specialist and I’ll evaluate should they be using their right foot for driving or do we need a different piece of equipment and what can we do to help make sure they have the fitness to drive?

And I also do kind of the other side of that where I have family members who are telling me, “Oh, I’m scared about Mom or Dad. I’m seeing this change in them and I’m seeing this change in their driving and I’m not letting them drive their grandchildren anymore and I’m wondering if it’s time for them to stop.” I help with those cases as well – if something’s going on, is it indeed time to retire from driving or is there something going on that we can improve to make them safer?

Schenk: That seems very niche and very unique. Is that common? Are there a lot of people doing what you’re doing?

Susie: No. So there’s only about 500 of us in the country. We are a growing number, but I’ll tell you one of the reasons why it’s not a very popular niche to go into is, one, I think you have to be really passionate about driving and being in the car and helping people in that manner. Also driving takes vision, cognition, motor skills, so you really have to be OT comprehensive and comfortable with all those potential deficits. But the third thing is it’s not covered by insurance, so when somebody sees me, it is an out of pocket expense, but it’s a nominal expense when you look at if it’s safe to get back on the road, knowing from a liability standpoint if you’ve recovered and you’ve kind of checked everything or helping to answer that question and giving it the gravity of the driving retirement consideration.

Schenk: Exactly.

Susie: Yeah, I love it.

Schenk: Well that sounds pretty amazing. You sound very passionate about it and Susie, we really appreciate you coming on the show and sharing your expertise in this and shedding some light on what families can expect with regard to occupational therapy and their loved ones in nursing homes. Again, thank you so much.

Susie: Yeah. It’s been my pleasure. I have to tell you I absolutely love being an occupational therapist and the nursing home setting is one of my favorite settings because of the stories and the connections you can make with people. And if I were to give any advice to your listeners, to your family members who are listening, whoever it is, is that make sure you get to know who the people are working with your loved ones and hopefully you find people who are also excited and have passion as well because I think that’s so important when we’re caring for residents and caring for people that have really lived a long and honorable life and deserve to have that care.

Schenk: That’s a great recommendation. Thank you so much, Susie, very much.

Susie: Oh, you’re welcome. Thank you. I hope you have a really good day.

Schenk: What I feel like is special about this podcast is that I fee like I learn something every other week, something new every other week. Up until about 30 minutes ago, I had no idea that there was a specialty within occupational therapy for driving rehabilitation services. That’s just something that I never even considered, never even thought of, never have encountered in all my life. And I am a better person now knowing that that exists and knowing that there are special people out there like Susie who do a great job and it’s their passion to get people over that particular hurdle. So that’s super interesting. I love the fact that this podcast, particularly this episode, I’ve learned something new that would be completely off the wall for me, but I’m sure is very normal for her. But anyways, I think that’s great.

Well I hope that you have, as much as I have, enjoyed this episode. New episodes are available for consumption every other week, bi-monthly as they say, on Monday mornings. You can watch every episode either on YouTube or on our website, which is NursingHomeAbusePodcast.com or you can check us out on any application where you get your podcast. We are on the Stitcher, the Spotify, whatever – I always forget this – iTunes was finished last year, but whatever iTunes became, we’re on that as well. And if you like what you hear, be sure to like and subscribe and leave a review for us because that helps somehow. I don’t know. Or don’t. Whatever you like. But at any rate, we appreciate you sticking around this long, and with that, we’ll see you next time.