Roles of OT, PT, ST in the Long Term Acute Care Setting
1. Roles of OT, PT, ST in the Long
Term Acute Care Setting
By Juhi Gupta
2. Objectives
● Introduction to purpose of Long Term Acute Care (LTAC) facilities
● Introduction to rehabilitation team at LTAC
● Roles of OT, PT, & ST
● Discuss understanding of Skilled vs. Non-skilled services
● Determine importance of recommendations provided by OT/PT/ST to enhance
patients safety with mobility and ADLs.
3. What are Long Term Acute Care Facilities?
● Most patients who need immediate medical
attention are admitted to an “acute-care”
hospital for an relatively short stay.
● However, some patients need longer hospital
stay to receive an extensive medical attention
due to more than one serious condition such as
respiratory failure, heart conditions, kidney
failure etc.
● Long Term Acute Care Hospital such as our
facility are certified as acute-care hospitals,
however, LTACs focus on patients who, on
average, stay more than 25 days.
4. Rehabilitation Department at LTAC
“Rehabilitation services are for the recovery or improvement of function and when
possible to restore function to previous level.”
Rehabilitation services personnel includes:
● Occupational therapist
○ Occupational therapy assistant
● Physical therapist
○ Physical therapy assistant
● Speech pathologist (speech therapist)
● Rehabilitation aide
5. What does a therapist (OT/PT/ST) do?
● Performs initial evaluation when patient is admitted to LTAC
● Device a Plan of Care
○ Establishes a rehabilitation diagnosis
○ Individualized plan for each patient based on how he/she performs during evaluation/reassessments
○ Establishes a treatment program which includes specific interventions such as functional training,
adaptive devices etc.
○ Establishes anticipated goals, expected outcomes, any predicted level of improvement
■ Short term goals
■ Long term goals
■ Frequency, intensity & duration for care
○ Plan of care includes the anticipated discharge plans
6. Occupational Therapy
● “Occupational therapy plays an important role in
facilitating early mobilization, restoring function,
preventing further decline, and coordinating care
including transition and discharge planning.”
● Occupational therapist provides a systematic process of
client-centered evaluation, intervention and task
modification to facilitate progress towards ADLs based
goals such as dressing, eating, bathing, & grooming.
● Occupational therapist analyses patient’s prior level of
function and their likelihood of resuming them after
being discharged from the hospital.
7. Occupational Therapy
● Occupational therapy services in Acute care:
○ Perform bedside evaluation to determine patient’s upper body strength to assess patient’s ability to
perform necessary activities to daily living such as feeding, grooming, dressing, toilet transfer etc.
○ Provide training to patients & caregivers in post-surgical protocols such as weight bearing
precautions, sternal precautions while performing ADLs.
○ Evaluate needs of splints and other positioning device to preserve joint integrity.
○ Evaluate needs of other adaptive devices to enhance independence with ADLs and provide training in
self care activities with use of adaptive medical equipments to patients & their caregivers.
○ Provide training to families and caregivers to assist with range of motion exercises, safe transfers &
mobility.
9. Physical Therapy
● Physical Therapy is a rehabilitation specialty
program that works closely with patients to help
them improve their functional abilities such as
rolling in bed, sit at the edge of the bed with
good balance, walking etc.
● Physical therapy treatments include
strengthening exercises, sit to stand using
assistive device such as rolling walker or cane
etc., gait training, stair training, & safety with
other out of bed transfers.
● The goal of physical therapy is to improve
function so that patients can be safe to discharge
home, skilled nursing facility or acute inpatient
rehabilitation.
11. Speech therapy/ Speech-language pathologist
● Speech-language pathologist are referred to “speech therapists (ST)” provides a
wide-range of services to patients in the Long Term Acute Care.
● Many patients in the LTAC have trach and/or are ventilator-dependent, ST performs
bedside swallowing evaluation to determine swallowing impairments and possible
risk of aspiration.
● STs works with patients on improving swallowing abilities, tolerance for voice
prostheses (PMV value), and optimize patient’s communication.
13. Skilled vs. Non-skilled services
Skilled Non-skilled
● Services where skills of a therapist are necessary
to provide safe and effective interventions whose
goal is to improve in impairments or functional
limitation.
● Skilled PT: therapeutic exercises, training
provided to perform sit to stand/bed to chair
transfer using assistive device, use of wheelchair
to enhance independence, walking with AD.
● Skilled OT: enhance patient’s ability to eat, dress,
groom, bath or use of toilet themselves with or
without assist.
● Skilled ST: Swallowing assessment to determine
aspiration risk, maximizing swallow safety,
Passy-Muir Valve trials
● Services that can be safely and effectively
provided by non-skilled personnel/family
member/caregiver without supervision of
therapists such as maintenance or restorative
services.
● Examples of services that doesn’t require
therapists supervision: use of Hoyer lift/Hover
matt/Sara Stedy for out of bed transfers, assisting
patients with personal hygiene care and complete
ADLs with safe level of assist recommended by
therapist unless patient is completely
independent.
14. Important recommendations from OT/PT
● Fall and fall-related injury prevention:
○ Preventing falls at LTAC is an ongoing challenge to the entire interdisciplinary
care team.
○ Interdisciplinary care team must initiate the process of fall prevention before
the first falls occurs by identifying an individual’s risk factors:
■ History of falls at home
■ Cognitive dysfunction such as delirium, dementia
■ Impaired mobility such as impaired gait, weakness, balance impairment, decreas
coordination
■ Medications such as anticonvulsants, antidepressants, antipsychotics, benzodiazepines, Class
1A antiarrhythmic, digoxin, opiates and sedative hypnotics.
■ Environmental such as lack of bed rails, floor matts, lack of handrails in the bathroom.
15. Helping Hands for fall prevention
● Helping Hands is a fall prevention program initiated
at the LTAC by the Rehab team members.
● Therapists evaluate patients (using all the points
mentioned on the previous slide) and place a purple
hand at the patient’s door and main patient board
across from the nurses station.
● When the alarm light is on, it is crucial to remember
that if the patient is assigned a purple helping hand
then he/she is at high risk for falling, and need
immediate attention from the staff to prevent fall.
16. Important recommendations from OT/PT
● Understanding importance of precautions s/p surgery or fractures such as sternal,
hip, spinal and specific weight bearing precautions.
● If unsure of what these precautions mean, it is essential to get trained by an
occupational or physical therapist.
Sternal precaution No pushing, pulling, lifting more than 5lbs or
lifting arm above head.
Hip precautions No bending of trunk or hip more than 90
degrees, crossing over the leg or rolling leg
inwards
Spinal No bending of trunk > 90 degrees, twisting of
the trunk and perform log roll when getting out
of bed.
17. Important recommendations from OT/PT
● Understanding of mobility plan for individual patient: therapists perform
evaluations when patient is initially admitted and reassessments every week to track
patient’s mobility progress.
● It is crucial to understand the recommended mobility plan and know that these
recommendations do change as patient progresses with rehabilitation.
● With turning over in bed, supine to sit, sit to stand, bed to chair, walk in the room
below is the language that is used to communicate between interdisciplinary team.
Patient needs:
1= Unable (total assist) 2 = A lot of help (mod/max assist)
3 = A little help (Min assist) 4 = No help (independent)
18. Important recommendations from ST
● Understanding of patient’s nutritional and hydration
needs as well as compensatory swallowing strategies is
critical: speech therapist rely on the nursing/nursing
tech’s observations in terms of dietary consistency
tolerance, nutritional pattern changes in patients, and
changes in aspiration risk behaviors.
● Communication between nursing staff and speech
therapist is critical to track patient’s oral intake needs
as their recommendations has an impact on nutrition
and hydration which is beyond assessing aspiration
risk.
19. ● Rehabilitation team can
influence, however,
cannot drive mobility
culture alone
● Interdisciplinary team
including nursing team,
physicians, PUC team,
infectious disease team,
rehabilitation team etc.
need to work together
to optimize patient's
mobility safely.
20. References
1) What are Long Term Care Hospitals? Centers for Medicare and Medicaid Services. https://www.medicare.gov/Pubs/pdf/11347.pdf. Revised on September,
2015.
2) Physical, Occupational, Speech Therapy Services. Centers for Medicare and Medicaid Services.
https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/Downloads/TherapyCapSlidesv10_09052012.pdf.
Published on September, 2012.
3) Available at: http://www.aota.org/about-occupational-therapy/professionals/rdp/acutecare.aspx#sthash.Ozhef1Tm.dpuf. Accessed July 11, 2016.
4) Sponholz, M. The difference between Physical, Speech and Occupational Therapy. Aging Care.
https://www.agingcare.com/Articles/geriatric-rehabilitation-services-what-is-physical-therapy-143151.htm. Accessed on July, 2016.
5) Available at: http://www.lakewoodcare.org/Services/Physical-Therapy.aspx. Accessed July 11, 2016.
6) Available at: http://www.apta.org/PTCareers/RoleofaPT/. Accessed July 11, 2016.
7) Available at: http://www.asha.org/uploadedFiles/SLP-Medical-Review-Guidelines. Accessed July 11, 2016.
8) Available at: http://www.asha.org/slp/healthcare/LTAC/. Accessed July 11, 2016.
21. References
9) Available at: http://www.asha.org/Practice/reimbursement/medicare/Examples-of-Documentation-of-Skilled-and-Unskilled-Care-for-Medicare-Beneficiaries/. Accessed July 11, 2016.
10) Available at: http://www.ascseniorcare.com/physical-therapy-for-seniors/. Accessed July 11, 2016.
11) Available at: https://www.icsi.org/_asset/dcn15z/Falls-Interactive0412.pdf. Accessed July 11, 2016.
12) Hausdorff JM. Gait variability and fall risk in community-living older adults: A 1-year prospective study. Arch Phys Med Rehabil. 2001;82(8):1050–6.
13) Cahalin LP, Lapier TK, Shaw DK. Sternal Precautions: Is It Time for Change? Precautions versus Restrictions - A Review of Literature and Recommendations for Revision. Cardiopulm Phys Ther
J. 2011;22(1):5-15.
14) Available at: http://www.dukehealth.org/repository/dukehealth/2010/10/28/09/36/28/6495/Posterior Hip Precautions. Accessed July 11, 2016.
15) Available at: https://ahc.aurorahealthcare.org/fywb/x15161.pdf. Accessed July 11, 2016.
16) Friedman M, Stilphen M. ESTABLISHING A CULTURE OF MOBILITY IN THE HOSPITAL SETTING. John Hopkins Medicine and Cleveland Clinic.
17) Available at:
http://www.amyspeechlanguagetherapy.com/blognews/swallow-assessment-in-the-long-term-acute-care-hospital-more-than-just-an-evaluation-for-aspiration-guest-blog-by-eric-blicker. Accessed July
11, 2016.
