Older adults living in skilled nursing facilities (SNFs) and long-term care facilities are particularly susceptible to the coronavirus disease 2019 virus and face unique challenges during their rehabilitation process. This case report highlights the disease and rehabilitation course of an older adult who received all of his medical and rehabilitative treatment while residing in a SNF. The occupational therapy evaluation and intervention processes, as well as the client’s response to intervention, are described. The client’s positive outcomes are linked directly to occupational therapy’s ability to incorporate medical, physical, and psychosocial aspects into part of the interdisciplinary model of care in a SNF.
Long-term care (LTC) facilities and skilled nursing facilities (SNFs) historically care for some of the sickest of the aging population. Since the onset of the coronavirus disease 2019 (COVID-19) pandemic, these centers have experienced significant increases in the medical complexity of both short-term patients and long-term residents because of complications of COVID-19 (CDC [Centers for Disease Control and Prevention] COVID-19 Response Team, 2020). LTC facilities and SNFs are in the unique situation of caring for patients during the acute disease process while also rehabilitating patients after the myriad physical, cognitive, and social–emotional deficits incurred as a result of COVID-19. This case focuses on an LTC resident of a SNF that provides short-term rehabilitation and skilled nursing services. The client contracted COVID-19 while in the center and received all of his medical and therapeutic care from center staff without hospitalization.
James is a 93-yr-old male LTC resident of a SNF in the mid-Atlantic. In addition to therapy services provided to long-term residents, this SNF also provides short-term rehabilitation services through an in-house therapy model. James’s pertinent past medical history includes acute and chronic respiratory failure, heart failure, dementia, hypotension, gastroesophageal reflux disease, glaucoma, and Type 2 diabetes mellitus. James has a history of receiving occupational therapy, physical therapy, and speech-language pathology services at the facility after hospitalizations for heart failure. Before the onset of COVID-19 symptoms, James was able to complete all activities of daily living (ADLs) from wheelchair level with supervision. He also performed transfers with supervision, and he was independent with wheelchair mobility through the center. James was able to independently ambulate short distances in his room. Before the COVID-19 pandemic, James engaged in structured activities through the center’s activities department and enjoyed socializing with patients and residents in the center as well as staff.
While residing in the SNF, James was diagnosed with COVID-19 as part of the center’s weekly monitoring process. During the week before his diagnosis, James had been more confused than usual, and the staff had noticed that he seemed weaker, as evidenced by his needing more assistance with transferring. James experienced a ground-level fall because of lower extremity weakness; because no injury was sustained, James was not hospitalized. The week after James’s COVID-19 diagnosis, the SNF team focused on medical management of his symptoms to prevent the need for acute hospitalization. Approximately 1 wk after diagnosis, James was referred to the center’s therapy team because of a decline in ADL performance, leisure and social participation, functional mobility, cognitive status, and swallowing abilities.
Because James was in a SNF, 24-hr medical care and support were available. The center has ample lighting and space for therapists to complete daily therapeutic tasks as well as an updated air filtration system. Adequate personal protective equipment (PPE) for staff and residents was available as per CDC safety protocols (CDC COVID-19 Response Team, 2020). James had access to occupational therapy, physical therapy, and speech-language pathology services 7 days a week. As a result of the 3-day prior-hospitalization Medicare Part A waiver in the SNF (Centers for Medicare & Medicaid Services [CMS], 2020), James was able to use his Medicare Part A benefit, which allowed skilled services to be provided without a 3-day hospital stay. This waiver provided James access to more extensive medical and therapeutic services while in the center.
Occupational Therapy Evaluation
By the time James was referred to therapy, his ability to engage in leisure and social tasks had declined significantly, he required maximum assist with all ADLs (bathing, dressing, grooming, and toileting), and his oral intake had dropped by approximately 75%. He was cooperative, but the extensive medical, physical, and cognitive effects of COVID-19 limited his engagement in occupations. On the basis of his presenting symptoms and ADL decline, the occupational therapist chose to use both formal and informal assessment tools during the evaluation process; these tools included completion of an occupational profile, structured and unstructured observations, the Barthel Index, the Continuity Assessment/Record Evaluation (CARE) Item Set, and Section GG of the Minimum Data Set (MDS). Results of each of these assessments are described here.
An occupational profile (American Occupational Therapy Association [AOTA], 2021) was completed to identify supporting and inhibiting factors contributing to James’s performance. The occupational profile was also used to guide the establishment of short- and long-term goals. Information was gained through interviews with the client, his caregivers at the facility, and family members.
James is a widower with two children and three grandchildren, who all live out of state. He is a retired factory worker who moved into the SNF 3 yr ago after his wife died. James is originally from Boston and does not like southern cooking or cuisine. He often requests alternative meals at the SNF. Before the pandemic, James enjoyed occupations such as being on the resident council, talking to staff, and using his wheelchair to engage in activities offered throughout the facility (e.g., bingo and music nights). The onset of the pandemic, and the resulting restrictions set on health care centers in March 2020, limited where James could go (i.e., exclusive in-room care) and with whom he could interact (i.e., staff wearing full PPE). During this time, James enjoyed reading, watching TV, writing letters to loved ones, and daily virtual telecommunications with family and friends.
As part of the process of developing an occupational profile for James, the occupational therapist identified overarching supports and barriers. Supports included his facility, which offered 24-hr care and therapy services 7 days a week, free tablets with internet access so James could connect with his family, free reading materials delivered to James’ room, and adequate PPE for James and staff members who needed to access his room. Supports also included James’ family, who were willing to be part of his therapy sessions virtually and sent frequent letters. James’ personal factors, such as his high activity level before COVID and his adherence to therapy recommendations, were also seen as strengths. Barriers included the COVID restrictions that limited James’ social interaction with other facility members and outside visitors, his age and comorbidities, and his baseline level of mobility, which required use of a wheelchair to travel within the facility.
Upon evaluation, James was found to have inconsistent alertness and was oriented to person only. He had poor memory and was only able to follow one-step commands. He was compliant and cooperative. The occupational therapist performed manual muscle testing on all extremities; James’ trunk strength was scored as 2/5, right upper extremity and right and left lower extremity strength were scored as 3/5, and left upper extremity strength was scored as 3−/5 (Pendleton & Schultz-Krohn, 2017). Slight increased tone was noted in both upper extremities, a symptom that, although not ubiquitous, has been reported in other cases of COVID-19 in older adults (Garg, 2020). As a result of this decreased strength and increased tone, he had poor coordination and poor sitting balance. James also reported body aches that affected his overall feeling of wellness, as well as new-onset pain in his cervical area during mobility tasks.
James’s blood pressure was very low, requiring intravenous sodium chloride of 75 ml/hour. He was unable to maintain his peripheral oxygen saturation, especially during movement and upright posture, requiring 2–4 liters per minute (LPM) of O2 via nasal cannula. James experienced frequent coughing and had significant congestion.
The Barthel Index assesses a person’s performance in self-care, bowel and bladder management, transfers, and locomotion (Collin et al., 1988). The Barthel Index is a therapist-scored, observation-based index. It is considered to be reliable and valid for functional performance in older adults (Lam et al., 2014). In this case, the same therapist completed evaluation and discharge scoring. Results of the Barthel Index confirmed initial observations that James was unable to bathe, dress, or toilet himself and required maximum assistance for self-feeding and personal hygiene and grooming tasks. Total scores for James are presented in Table 1.
CARE Item Set
The CARE Item Set (American Healthcare Association & National Association in Support of Long-Term Care, 2014) was developed to compare the functional performance of patients receiving care at SNFs, home health, inpatient rehabilitation, and long-term acute care. The CARE Item Set is a therapist observation–based assessment tool. Video training is required to accurately complete the scoring of items in the CARE Item Set. All therapists at the nursing home were trained in proper scoring to improve inter- and intrarater reliability. In this case, initial evaluation and discharge scores were completed by the same therapist. The CARE Item Set allows the evaluator to infer performance on items on the basis of performance on similar items. The SNF described in this case also used the CARE Item Set for internal outcomes reporting. James’s scores for the CARE Item Set are presented in Table 2.
Section GG (CMS, 2019) is a modified version of the CARE Item Set on which functional scores are required to be reported in many postacute care settings. Although no formal training is required to complete Section GG, the same therapist rated performance at evaluation and discharge. Section GG scores are used for reporting on the MDS for all SNFs. As such, scores were recorded for James and reported in this case. James’s scores for Section GG are presented in Table 3.
Documentation of the Evaluation
Because of James’ extensive list of performance deficits, including physical skills, cognitive skills, and psychosocial skills, in conjunction with his complex medical and therapy history, James’ occupational therapy evaluation was recorded as high complexity. He was at risk for falls and further decline in function, which would lead to increased dependency on caregivers. With limited out-of-bed activity, he was also at risk for pulmonary insufficiency, decreased participation in functional tasks and mobility, and decreased ability to return to his prior level of function as a result of compromised general health.
Establishing a Plan of Care
On the basis of the evaluation, it was determined that skilled occupational therapy services were warranted to facilitate James’ independence in ADLs, develop compensatory strategies and adaptation techniques, and increase safety awareness, as well as to minimize safety hazards and barriers in the environment. Occupational therapy services were also indicated to improve his strength and endurance as well as to facilitate dynamic standing balance for fall prevention. Provision of pain management techniques was a priority, as indicated by James’ reports of pain with movement, specifically in the cervical spine. Increasing James’ nutritional intake was also a priority for the entire interdisciplinary team.
James’ priorities and goals for therapeutic interventions included being able to dress and bathe himself in preparation for daily communications with his family via virtual telecommunications. James indicated that this was the highlight of each day, and he wanted to look his best when talking to family and friends. James also wanted to be able to move around the center in his wheelchair to visit other patients and staff once in-room restrictions were removed. The occupational therapy plan of care developed for James incorporated these goals and was established to include therapeutic exercises, neuromuscular reeducation, manual therapy techniques, therapeutic activities, self-care management training, and wheelchair management training, 5×/wk for 10 wk. A list of billing codes used during the occupational therapy sessions is provided in Table 4.
Skilled Therapy Intervention
Physiological and Biomechanical
Occupational therapy, physical therapy, and speech-language pathology worked collaboratively to integrate interval training during James’ sessions to slowly improve his strength and ability to maintain his oxygen saturation during activity. This interval training incorporated low-weight, high-repetition, and isokinetic training to maintain a consistent challenge to muscle groups. The resistance and the time spent on each exercise gradually increased as James’ ability to maintain his oxygen saturation improved.
To increase both upper extremity strength and range of motion (ROM), the occupational therapist instructed James in graded upper extremity active ROM therapeutic exercises with cues for initiation, positioning, and thorough completion of each exercise. These exercises were completed at least 3×/wk during therapy sessions. At first, James required maximum assistance and maximum cueing to complete exercises. By discharge, he was able to complete these exercises with supervision. In addition to ROM and strength activities, the occupational therapist engaged James in upper extremity weight-bearing activities to decrease the tone in both upper extremities.
As a result of these interventions, James was able to more actively engage in meaningful activities. As part of the overall treatment regimen, the occupational therapist collaborated with nursing staff to develop a pain medication schedule to ensure medication administration and therapy schedules were conducive to optimal participation with minimal pain.
Activities of Daily Living
The occupational therapist also provided ADL retraining with modified working surface levels contingent on James’ level of alertness, vital signs, pain level, and activity tolerance. The therapist initiated bathing, dressing, and grooming in supported long sitting in bed and progressed to edge of bed without lateral supports. This progress was slow because James developed orthostatic blood pressure when upright. The therapist’s provision of cueing strategies and use of positioning devices facilitated more joint midline alignment and improved active participation in ADLs. Bathing, dressing, and grooming tasks were often followed by virtual calls to James’ family to promote social engagement when James was looking his best.
To address goals related to self-feeding, the occupational therapist initially used adaptive feeding equipment (built-up handles, divided plate) to facilitate independence with eating. James was able to transition to regular utensils and plate by the end of care as a result of improved strength, dexterity, coordination, and endurance. Motivation to eat was enhanced through preparation or delivery of preferred foods, which was done through collaboration with James’ family. Throughout all interventions, the therapist used cueing strategies to facilitate better organization and planning to task. This organization and planning, as well as initiation of tasks, improved significantly throughout the course of occupational therapy intervention.
Occupational therapy goals for functional mobility prioritized James’ independence with toileting transfers and transferring to his wheelchair for participation in preferred tasks. The occupational therapist and physical therapist worked together to develop a system of cueing for James to prompt him for proper foot and hand placement during functional transfers. These strategies were shared with other caregivers and were shown to improve performance through consistency. Initially, James used a 3:1 commode beside the bed for toileting tasks. By the end of the plan of care, he was able to use his wheelchair to navigate to the bathroom. Because of the limited space in James’ bathroom and the need to manage his portable oxygen tank, a return to the prior level of independence was not achieved for toileting, although James was able to complete the tasks with minimum assistance.
Education and Training
Throughout the duration of occupational therapy services, nursing staff received training on cueing strategies to facilitate the carryover of skills to maximize James’ independence. At the beginning of the plan of care, this training also included use of positioners to facilitate James’ midline alignment while in the bed and in the wheelchair for safe feeding and eating, as well as during the use of adaptive equipment during ADLs. These positioners and adaptations were gradually eliminated, and the nursing staff was educated regarding James’ functional improvements. The occupational therapist also instructed nursing caregivers on cueing strategies to increase James’ level of alertness during meals. This instruction helped increase his oral intake and hydration status. The therapist used verbal and demonstration instruction techniques, including return demonstration with nursing staff, to ensure accuracy of all skills learned. James’ family regularly participated in care planning meetings using virtual telecommunication. He reported that this method reduced his isolation by involving his family in his recovery.
Therapy Outcomes and Discharge
James was discharged from occupational therapy services after 10 wk of care. Functional status was reevaluated using the Barthel Index, the CARE Item Set, and Section GG; outcomes are presented in Tables 1–3. At discharge from therapy, James was approaching his prior level of function but was still unable to walk short distances by himself. This was primarily the result of ongoing pulmonary difficulties and the need for 2 LPM/O2 via nasal cannula. James was unable to move his nasal cannula to the portable oxygen tank by himself or set the dial on his portable oxygen tank independently. He was, however, able to manage the oxygen tubing during ADLs and basic transfers.
COVID-19 has infiltrated nearly every occupational therapy practice setting worldwide; thus, this case highlights how, using a client-centered approach, occupational therapy can be used in a SNF in the United States. While operating in a U.S.-based medical model, occupational therapists working in LTC facilities and SNFs are still able to focus on occupational performance goals that are meaningful to each person. In this case, the Person–Environment–Occupation Model (Baptiste, 2017; Law et al., 1996; Strong et al., 1999) was used as a theoretical framework to integrate and interface aspects of James’ person factors, the environment, and occupational performance goals. Accordingly, James’ interests and values were considered despite his acute illness and cognitive deficits, and he was actively involved in setting priorities for treatment. The occupational therapist working with James considered the many complex factors influencing his ability to perform desired tasks and worked within the occupational therapy scope of practice (AOTA, 2014) to remediate, adapt, and educate for optimal task performance. Throughout the course of James’ recovery, therapy strategies and adaptations were modified to match his skills and abilities, as well as the environmental constraints imposed by state and federal safety guidelines. In James’ case, the virtual environment became an integral part of therapy that was a much better occupational fit for James and a strong motivator for participating in self-care routines.
Implications for Occupational Therapy Practice
This case report has the following implications for occupational therapy practice:
Occupational therapy practitioners can provide patients with COVID-19 with skilled services in SNF and LTC settings, even without a prior hospital admission, through the Medicare Part A waiver.
Patient motivation to participate in occupational therapy sessions (e.g., self-care activities) can be enhanced through incorporation of virtual communications with family and friends.
Education and training of nursing care staff by occupational therapy practitioners on aspects of positioning, cueing strategies, adaptive equipment use, and client goals can promote greater carryover and faster recovery for patients with COVID-19 in SNF and LTC facilities.
James’ successful outcomes after contracting COVID-19 highlight occupational therapy’s integral role on an interdisciplinary team for medical and therapeutic management in a SNF. Changes in federal regulations as a result of the pandemic allowed SNFs to more independently manage the medical and complex needs of some patients. With this autonomy, the need for a strong interdisciplinary team is heightened. Occupational therapy’s ability to incorporate medical, physical, and psychosocial needs highlights its distinct role on an interdisciplinary team in a SNF.