OT and Family/Caregiver Education in the Skilled Nursing Facility 

Melanie M. Tidman DHSc, MA, OTR/LAdjunct Professor

AT Still University: Doctorate in Health Science Program

melanietidman@gmail.com

Course Objectives Name common diagnoses and reasons for

admission to a SNF Understand the importance of Family-

Centered care in OT Understand the steps involved in development

of a family education curriculum at the SNF level

Understand the process of creating a Family Support Group in the SNF

Identify attributes of the physical and social environment that are likely to influence patients in a SNF

Define general principles for training Families of patients with Stroke or Dementia

Conduct a Home Safety Assessment Interview with Families of patients prior to discharge

Common Admitting Dx’s Falls with fractures Total joint replacements Metabolic disorders (i.e. CHF, Sepsis, DMII) Infections or Wounds (c-diff, MRSA, MSSA) Drug Reactions (including drug errors or

non-compliance) Nutritional Deficiencies (FTT or malnutrition) Electrolyte Imbalances (hypokalemia,

hyponatremia) Depression or other Mental

Health/Behavioral Issues Stroke, Hemorrhage, Brain Tumors Cancers

The Family/Patient Intake Interview Home and family: PLA and PLOF Info about pt’s learning strengths or

deficits PMHX: comorbidities Hobbies and Interests: what motivates

them? Typical Daily Schedule at home Community Resources in PLA Discharge Plans

Goals of the Intake Interview: Identify family dynamics/arrangements Identify PLOF skills and current deficits Identify Home set up and barriers Identify home equipment already in place Identify home equipment needs Identify community resources in place Identify community resource needs after

discharge5/37

Intake Cont’d Make a list of needed home equipment

and refer to facility Case Manager at evaluation

Identify Goals for patient while in Rehab setting and include family in goal setting

Provide family with community resource list and equipment supply companies to begin to search out equipment

Equipment PrescriptionAssessment of physical needs in

ADLsAssessment of behavioral needs in

ADLsAssessment of caregivers

capacitiesAssessment of community

capacitiesAssessment of financial capacities

Caregiver Assessments Environmental Skill-Building Program (ESP)

– family caregivers Montessori Approach to Care – formal

professionals EASY Method – formal para-professional

caregivers Tailored Activity Prescriptions (TAP) - family

caregivers International Classification of Function (ICF)

The ICF for Caregivers Body Functions and Capacities Body Structures and Physiological

capacities Activities and Participation Outside of

Caregiving Community Support Structures Environmental Factors in Caregiving Family Structures and Capacities Distance Caregiving Ethnic/Cultural Differences in Caregiving

Online Sites for Resources

City of Albuquerque: http://www.cabq.gov/seniors

State of New Mexico http://www.nmaging.state.nm.us/

Sun Vanhttp://www.cabq.gov/transit/paratransit-service

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Medical Equipment in AlbuquerqueHME Specialists http://www.hmespecialists.com/

A& R Medical Supply http://www.armedical.com/

Back in Use (free or low cost equipment) http://www.backinuse.com/

Identify Funding Issues Social Security Disability (SSDI) is

based upon an individual’s work history. To qualify it needs to be determined that the patient may be unable to work up to 12 months or more post injury.

Social Security Income supplement (SSI) a federal program which is based upon income and assets and patient’s inability to work up to 12 months or more post injury.

Funding Cont’d Institutional Medicaid: a state

program which is for individuals who meet income and residency qualifications and patients needing an inpatient setting for 30 days or more.

D & E Waiver services: for disabled and elderly including the COLTS waiver

Educate! The Roles of the Rehab Personnel

Definition of Physical Therapy Definition of Occupational Therapy Definition of Speech Therapy Definition of the role of the CNA, Med

Tech and RN Definition of the role of the Case

Manager Definition and role of the facility MD

Caregiver Training ConceptsCaregiver Information http://c-tips.comA Caregiver Training program created by Mary Cocoran, PhD, OTR/L, FAOTA Facilitating caregivers= focus on their own

emotional health Balancing caregivers=maintain a balance

between their needs and the care of the recipient’s needs

Advocating caregivers= mindful of the care recipient’s well-being (mental, emotional)

Directing caregivers=focused on the recipient’s physical health

Family Training for DementiaEffective Strategies: Use words of encouragement and positive

statements Provide simple, one-step cues Avoid abstract, open-ended questions Redirect or distract person when agitated or

distressed. Modify the environment and make it safe

Adequate lighting Sharp objects and hazardous materials out of sight Avoid overstimulation and excess clutter Pathways and stairways clear Room temperature or odors that may see

unpleasant or distressing.

Family Education Concepts

1. Simplify the task

2. Allow extra time

3. Establish a simple routine

4. Set out and arrange needed items

5. Break down the task into smaller parts

6. Label drawers, containers, or cabinets

The Daily Treatment ScheduleEducate Families

The daily routine for Rehab in the facility

and what to expect as far as schedules and

time

Weekend coverage for Rehab

Anticipated timeline or duration of stay

Their participation in treatment sessions:

scheduled times work best for families

Cont’d Incorporate family and patient goals into

treatment Conduct family training during

treatment to ensure safe discharge. (You may write a goal for this in your POC)

Incorporate anticipated equipment into your treatments and train families on this as you go along (document this)

Family Centered! Provide weekly updates on patient’s

achievement of goals with patient and family members

Revise goals with patients and families as patients either progress or don’t progress

Provide realistic goal attainment based on patient progress and prepare families for level of care needed post discharge

Document all of the above! 20/37

Support Group: Family Education on Stroke and/or

Dementia

BRAIN FUNCTION REVIEW Frontal Lobe Temporal Lobe Brain Stem Cerebellum Occipital Lobe Parietal Lobe

What family/friends can do at Cognitive

Cognitive Interventions for Family Members: Levels1-3

Explain to the individual what you are about to do

For example, "I'm going to move your leg."

Talk in a normal tone of voice.

Keep comments and questions short and simple. For example, instead of "Can you turn your head to look at me “ direct them to “Look at me”.

 

Family Interventions: Level IV Tell the person who you are, where he is, why he is there, and what day it is.

Limit the number of visitors to 2-3 people at a

time.

Keep the room calm and quiet.

Bring in favorite belongings and pictures of family members and close friends.

More Level IV Allow the person extra time to respond,

but don't expect responses to be correct. Sometimes the person may not respond at

all. Give him rest periods. He will tire easily. Engage him in familiar activities, such as listening to his favorite music, talking about the family and friends, reading out loud to him, watching TV, combing his hair, putting on lotion, etc.

Level IV cont’d He may understand parts of what you

are saying. Therefore, be careful what you say in front of the individual.

Talk to the patient and not about him/her.

Limit extraneous conversations about other things as he/she may think you are talking about them.

Cognition Level VAvoid playing into inappropriate

behaviorsUse redirection and distractionDo not try to reason with the

personAssume Short Term Memory

deficits, Use frequent repetitionKeep comments short and simple

Cont’dRemind person of the day, date,

name, location and reason they are here

Organize and simplify tasksBring in family pictures and

familiar objectsGive frequent rest breaks

Cog Level VI Person is unaware of their deficits Don’t Argue with the person Encourage Rehabilitation program

participation Frequent Repetition of instructions is

needed Journal with the person on daily events Help to initiate activities through use of

a written or pictorial schedule

Cog Level VIITreat person as their PLOFTry not to tease or use slang. Keep

it simpleReassure and discuss deficitsTry to return to PLOF routines and

activitiesDiscuss emotions and coping

strategiesSeek outside support and

counseling

Symptoms and Behaviors: What can families do?This document defines each RLA level and gives families strategies:

https://www.jhsmh.org/LinkClick.aspx?fileticket=8hAd-OqTIQ0%3D&tabid=298

(note: these strategies also may work with patients with dementia or other cognitive symptoms) 30/37

The Environmental Skill – Building Program (ESP) for Family Caregivers ESP is designed to provide family caregivers with Education about the disease process and

the impact of environments on care recipient behaviors

Problem-solving techniques to identify antecedents and consequences of targeted problem behaviors, and

Technical skills to modify the home. http://

www.rosalynncarter.org/education_support/

Tidman Home Safety Assessment

Date of Home Assessment: Evaluator: Time: Patient: Present:

Home/Neighborhood Setting:   

Cont’d

Kitchen:

Bedroom:

Bathroom:

Transportation:

Garden/Hobby or Outdoor Areas:

Cont’d

Summary of Barriers:

 Equipment Needs and/or Resources:

Assessment Tools NeededTake with you to the Assessment: Tape Measure Manual Wheelchair Front Wheeled Walker DME Catalog List of community resources (DME,

Transportation, Caregiver support)

Questions and/or

Discussion?

References AOTA CEU course: Neuro-Cognitive Disorders, AOTA 2014,

revised. Gitlin, et al., (2005). Maintenance of effects of the home

environmental skill building program for family caregivers and individuals with Alzheimer’s disease and related disorders. Journal of Gerontology: Medical Sciences, 60A(3), 368-374;

Gitlin, et al., (2001). A randomized, controlled randomized, controlled trial of a home environmental intervention: Effect on efficacy and upset in caregivers and on daily function of persons with dementia. The Gerontologist, 41, 4-14.

Retrieved from: http://www.rosalynncarter.org/UserFiles/File/gitlin.pdf

Rancho Los Amigos Recovery Scale Retrieved from: https://www.jhsmh.org/LinkClick.aspx?fileticket=8hAd-OqTIQ0%3D&tabid=298