Skilled Nursing Facility with Amanda

What setting are you sharing about today and can you give a brief description of it? What qualifies a person to receive therapy in this setting?

I will be sharing about my Level 2 experience in a Skilled Nursing Facility (SNF). In this setting, you usually see older adults aged 65+ however I did see the occasional adult in their 40s or 50s. Patients admitted to this setting were previously admitted as an inpatient to a hospital and may further need skilled services to gain more independence for further recovery. I only saw patients for short-term care, but their was also long-term care available as well for patients that needed supervision around the clock, but didn’t necessarily need skilled therapy or specialized care. Patients usually receive therapy usually 45-50 mins/day for 5-6x/week. Medicare covers up to 100 days of SNF services. 

What is OT’s role in this setting?

OT’s role in this setting was highly ADL based. I often trained patients in the use of adaptive equipment, provided compensatory strategies, recommended home modifications and safety equipment for a safe discharge home, and trained in functional mobility to name a few things. 

Did you feel prepared going into this setting based off of your classes? And how did you prepare before starting?

Great question! Truthfully, no. I don’t think anything really compares to the real thing until you are truly put into the position of caring for patients with true deficits or medical complications. Before starting this rotation, I made my own “SNF Binder” with resources on assessments I would be using, diagnoses I would often see (I asked my CI about this information) and I also purchased the OT Toolkit which is amazing!

What resources were the most helpful during your time there?

My site was amazing at providing me with tons of resources on documentation based on how they document. My site also had a bin area of different resources I could utilize for assessments, handouts, etc. I also purchased the OT Toolkit and often listened to the SeniorsFlourish podcast! 

How did you stay organized and manage your time?

My CI actually provided me with a clipboard that had areas for storage in it – I carried this around with me all day long! I would clip my flowsheets for daily notes at the beginning, then whatever I needed throughout the day I would stick inside my clipboard (assessments, handouts, blank pieces of paper, goniometer, sticky notes (these came in handy for treatment sessions as well), and more! I have a highlight on my instagram titled “SNF” where I go into detail about how I organized this binder. It was a total lifesaver! I also wore a cheap watch everyday – every minute counts! This way I could keep track of every minute of my day and to make sure I was spending too little or too much time with pattens during each therapy session or eval. 

What was your schedule like?

My fieldwork was five days a week, M-F. Working 1 weekend a month was also required, and if you had to work a weekend day you had 1 weekday off (usually a Monday or Friday). I would usually arrive between 8-8:30 to grab my schedule, chat with other therapists about patients if needed, do chart reviews if I had an eval, collect items needed for my sessions (I pushed around a rollator all day with all of my therapy items on it so I didn’t have to carry everything around! Tons of therapists did this lol), and then I would also work on a progress note or discharge note if one was due or coming up soon. I started treatments at 9:30am, and then I was usually there until around 6pm (sometimes got off earlier, sometimes later). The days were long, but went by so fast!

What assessments did you use most?

I most often used the Barthel Index, MOCA, 5 Times Sit To Stand Test, ROM, and MMT. 

What conditions/diagnoses did you see most often?

This was an interesting part of my rotation. Around week 4 of my rotation I believe, the SNF I was at turned into a COVID+ only unit. So, we only accepted patients with COVID the majority of the time. So, I saw acute hypoxic respiratory failure A LOT.  However, I also had a few patients with Parkinson’s, THA, spinal procedures like laminectomies, etc. 

What did a typical session look like?

Sessions with patients were typically 45-50 mins long. Sessions looked different depending on the patients goals, however they were highly ADL-based. On the daily, I often educated and provided cues and assistance on how to safely and effectively perform upper body dressing, lower body dressing, bathing, toileting, hygiene and grooming. For higher level patients, I would also incorporate IADL’s such as home maintenance tasks in their rooms as a means of therapeutic activity to work on static/dynamic balance while standing, sitting, as well as to promote activity endurance.

How did you stay client-centered and occupation-based?

I always tried to incorporate tasks that were appropriate for the patients. Obviously I was not going to incorporate folding laundry into a session if a male patient has had his wife do that task all his life and she enjoys doing it. I would always scan the patients room to try to incorporate something they have already, such as cleaning out their flower vase, unpacking their items in their closet, hanging up posters/cards they have received, etc. And then also some days, I would ask them, “what would YOU like to achieve during our session today?” Most of the time, they would often need to use the restroom, change their clothes, brush their teeth, shave, etc. which would often align with their goals anyway!

Did you have to do a project or in-service? Could you share what topic you chose? (if you can)

I completed an in-service! I did mine on utilizing technology during treatment sessions! This idea came about during an actual session I had. My patient had a goal to increase her standing tolerance and I also scanned her room and saw that she had an iPad. I decided to incorporate her iPad into the session. I placed her iPad on an adjustable side table she had in her home, so when we stood she could check/delete her emails she had wanted to do. This alone allowed us to work on standing tolerance, weight bering through her feet, maintaining static balance, and also working on controlling her breathing – all while doing something she enjoyed! It went great! So for my in-service I created a list of apps that could be utilized in sessions (or outside of sessions as well if patients are bored because during COVID it can be pretty lonely). I also demonstrated the use of the iBreathe app as we often incorporated pursed lip breathing into sessions with patients. 

What was your favorite part of this fieldwork experience?

Truthfully, my CI. She was absolutely amazing and even did research for her OTD on the student and CI relationship! The way she worked with patients was truly amazing. She always went the extra mile to teach me, quiz me randomly, properly show me techniques, and provided me with tons of resources. Our personalities mirrored each other well and we clicked. I was also always open to feedback and suggestions, which is HUGE during fieldwork! I also just loved working with the patients, even if I was anxious or timid sometimes if its was performing something I’ve never done. I was always willing to jump in and learn and I think that is how you truly shape yourself during fieldwork. It was also just so reassuring to hear patients and even other practitioners say “You’re so sweet.” “Thank you so much” “You are a great therapist” “You will be an amazing therapist.” Hearing those things kept me going. (Writing this makes me miss this fieldwork rotation lol). I also really enjoyed being able to build a relationship with patients in this setting! 

What was your least favorite part of this fieldwork experience?

Some days I came home and I was dead TIRED. When I woke up some mornings, I was so sore! lol There were definitely days where it was just mentally and physically exhausting, especially if you have a lot of progress notes or discharge notes due the same week/day. Some days, none of your patients will be on board with doing therapy and nothing will go as planned – you’ll be okay. Just continue to chug along and don’t let that get you down. 

What is something you learned that you will take with you for the rest of your career?

So. Many. Things. I truly learned how important communication is with all disciplines and truly makes the world of difference in patient care. Be sure to document when you spoke with a nurse, write down patients response to treatments and if they had pain (and what you did about it), communicate with PT to see if patients are reaching goals with them, communicated with Speech if they are receiving it, and update the families on how their loved one is doing and to also build on your evaluation. Communicate, communicate, communicate.

What advice do you have for a student about to start in this setting?

Be ethical at all times and document everything. I would highly suggest carrying around a clipboard to stay organized and to wear a watch to keep track of time. Also, patients know when you care and when you don’t. Go the extra mile for them. You may be the only one that truly takes the time to listen to what they are saying or get them the cup of water they have been asking about for 2 hours. Also, you can learn something from every single person. I learned how to roll/fold sheets under a patient during a brief changing by a CNA while providing a patient cues for bed mobility. Be open to all opportunities that arise. There is so much to learn!

Resources:

OT Toolkit: Occupational Therapy Toolkit

SeniorsFlourish

Mandy from SeniorsFlourish has a great Podcast I would listen to on the way to fieldwork, and she has great tips on treatment ideas in a SNF setting! She also has tons of resources for students/practitioners on goal writing and more! I actually won a goal bank resource of hers and it was phenomenal! 

View my Amazon storefront for the clipboard I used during my fieldwork

Feel free to connect with me on Instagram – I would be more than happy to answer any questions about my experience that I did not address on here!