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COTA Thoughts

LTC Goals- Therapeutic or not?

Published January 17, 2008 10:38 AM by Tim Banish

Over the holiday week I filled in for a couple of local SNF's. I have to say, several of the patients I was scheduled to see had goals that were not what I consider therapeutic. I'm not sure if this comes from poorly trained OTs, or if these were generic goals that were set to keep the patient on caseload.

One patient with mild dementia (and other physical disabilities) had ADL goals. The patient's goal was to return home. As much as I doubt that this person will ever have the ability to return home, goals for working towards this patient's wishes should have been the focus of therapy. Increasing their independence with dressing skills was something that this person had little interest in, as they had assistance at home with these skills prior to being admitted to the SNF. This was documented in the person's OT evaluation, but for some reason it was included in their goals anyway. Upper body strengthening was another goal for this person. The main thing this person did at home during the day was watch TV. Sure, some activities such as transfers do require some strength for grasping, reach, etc, but the goal was to obtain a 4+/5 strength. I wonder why someone with a power wheelchair, a full time home aide, visiting nurses three times a week, and a very active family member would require that much strength.

Another patient seen had goals for W/C mobility. The goal was to be able to propel the chair 50 feet. As much as this person was physically capable of returning home, their plan included use of a rolling walker for mobility after discharge. In fact, the OT had paperwork in the chart to order the walker! This person told me that at home there was not enough room for a wheelchair. So why teach someone a skill that will never be utilized?

So, are the OTs of today graduating school with little knowledge of setting therapeutic goals? Or have we come to the point where company policies dictate the setting of goals?

To me a goal should be measurable, obtainable, and most importantly something the patient wants to address. A goal established just to have things to work on and keep the patient on caseload is unethical.

I want to believe that OTs have had a course in writing goals during their schooling. I know that coming up with specific and appropriate goals for a person is hard, especially with the time constraints today. On the other hand though, have you ever worked with an OT whose goals seem like they were rubber stamped? I mean every patient has the same goals, maybe with a different level of assist, but written the same way. Yes, these can be therapeutic and appropriate, but it sure gets boring to read.

If however, a company policy, whether written or unwritten, is used to develop goals then I'll be the first in line at the window to report fraud. Goals need to be determined by the evaluating therapist, not a book of rules. I unfortunately have run into this while working for one rehab company (now out of business, thankfully). As an unwritten policy, the company informed all their evaluating therapists that every Part A Medicare patient needed to be in a very high or ultra high category. Therapists were told to develop enough goals that would accomplish this. They were issued a laminated sheet of generic goals in order to assist them in writing up their evaluations. Needless to say many of these goals were not therapeutic, measurable or something the patient needed to address. A couple of the better OTs I worked with quickly placed these sheets in the round file container under their desk, thank goodness.

I guess I've always been a bit of a rebel when it comes to patient goals. I have always questioned the OT as to why a goal was written, more so when the patient refuses to work on it. Occurrences like this can only sour the person's attitude towards OT, and therapy in general. This is something we don't need happening in our profession.

Until next time, hope all your thoughts are good,

Tim

15 comments

J. M. -

Thanks again for your comments.

Yes, PPS came about due to many abuses of the system. Today it seems like everyone has forgotten this, and continues to drain the system for their monetary gain. I also think that many have forgotten the oath they took before becoming a therapist. Ethics needs to be factored in at all times, regardless of what any supervisor says or wants. However, since it's not their license, they don't care. If you lose yours, there's another therapist needing a job out there -Right?

Tim Banish, COTA/L February 26, 2008 2:33 PM
Cincinnati OH

I totally agree that we need more OTs who will do what is right rather than just do as they are told.  I just see too many times a patient gets admitted to the SNF at very low levels and managment wants us to pick them up for therapy.  We as OTs have to do what is right since our own livelihood and conscious is on the line.  I wonder if some folks remember why a lot of folks got laid off 10 year ago after PPS.  If we continue to perpetuate the abuse of the systems we work for, we will all cave in to the failure of it.  I bet when I retired, we will have a new Medicare system, if any, available to us.  

What we do currently and what we do in the future will affect us all in some way or another!

J. M., SNF - OTR February 25, 2008 8:44 PM
HI

J.M.-

If there were more OTR's like you this would be a better world.

Thanks for your comments!

Tim Banish, COTA/L February 22, 2008 9:16 AM
Cincinnati OH

As an OTR for 2 sister facilities, I totally agree with Tim on his observations of poor goals.  I am lucky to not have a position of having to pick up each person I evaluate.  I take the time to write good and clear goals for each patient on an individual basis.  I've seen many times where an PRN therapist doing a quickie eval would come in and just write any old goal not even consulting the family on PLOF, which I assess thoroughly on each person.  At my former job, I would get a visit by a manager if I did not pick up a person for OT.  I would have to sit in her office and explain to her why I felt OT was not needed so she could explain it to the administrative and nursing staff.  

If my assessment determined that someone was at their PLOF or had a very poor prognosis, I would not pick them up for therapy.  I don't understand why some OTRs would pick up some residents who had 24 hour CNA care and was at max A for all ADLs and going to be living in a similar setting.  What really is the goal here?  I stand strong to what I believe is appropriate and if the management doesn't like my clinical knowledge, then they can find someone else to do the job.  I worked too hard to jeopardize my license for the financial needs of the facility.  If we do the right thing, good things come our way.

J.M., SNF - OTR February 16, 2008 2:30 AM
HI

Lisa-

I think you see my point here, different attitudes, different goals. It seems like the OT who has the better attitude writes more appropriate goals? And the OT who writes the same goals for a rehab pt. VS a LTC pt. shows a lack actually thinking out the needs for a peticular pt. Some people are more concerned with outcomes, so sticking to the higher level patients VS the LTC pt's will always result in a better outcome. Too sad.

Tim Banish, COTA/L February 8, 2008 8:09 AM
Cincinnati OH

I would just like to say that I am currently working with two different OTRs. One is very boring when it comes to goals and writes the same goals for everyone regardless of whether they are in our rehab wing or our LTC.  I think that this is absolutely ridiculous.  I very highly doubt that these people would have the same goals.  Our other OTR is very good at writing appropriate goals.  Both of these OTR's graduated from the same school at the same time.  I would have to agree that it is not the schooling. It is the individual therapist.  Each of these therapists have very different attitudes toward pt's.  One doesn't like to work with anyone but easy rehab pt's.  She will not keep anyone who is challenging or LTC.  Our facility had LTC, Rehab and SNF all in the same building and it is not fair to the pt's for this one therapist to not have her heart in the right place.  I honestly think that is where the problem comes from.  We do make good money and I feel that some OTRs and COTAs get into this profession for the wrong reason.  I wish that schools would be more selective and that field work supervisors would be more critical and expect more from their students.

Lisa, COTA/L February 7, 2008 4:24 PM
Wheeling WV

Thanks for the comments here. Chris you make a good point about strengthening, however for a elderly person a 4+/5 is almost impossible to achieve. And again, what activities would require this kind of strength? The other patient I spoke of had sufficient strength, and propelling a W/C was a temporary (in the SNF only) activity. I noted many other areas that OT could have been more effective increasing his independence besides pushing a W/C around.

Theresa- Whole body wellness is a good thing to promote, but it seemed like the OT who wrote this goal was looking for Superman or Wonder Woman as an end result. As I stated, where would an elderly person be required to have 4+/5 strength? I doubt most females have that kind of strength.

Tim Banish, COTA/L February 3, 2008 8:43 AM
Cincinnati OH

Just wanted to briefly comment on what Mark said earlier: "A patient can function with 3+/5 strength and does not need 4+/5 strength for ADLs, transfers, and home management."

There is no empirical evidence for this statement.  Certainly they can function at a 3+/5 strength level, but the questions remaims how well do they function?  If someone has 3+ out of 5 strength and they need to utilize a walker to function, how many minutes do you think they will be able to stand with using their walker before their arms give out?  To me it is a no brainer to strive for the highest strength level possible.  PPS gives us all of these days to make a difference in an individuals life.  Lets not waste it.

Chris Nahrwold February 2, 2008 11:46 PM

I totally agree with Chris' comment.  At our facilities, we really try to stress the whole "wellness" attitude.  As COTA's we work very closely with our OTR's to be sure that the goals are appropriate as well as challenging.  Sure that patient may not be going home, but with the difficulty facilities are having staying fully staffed, our CNA's have a huge job on their hands getting everyone up, cleaned, ready for meals, etc.  Anything we can do to make the residents even a little more independent helps a lot.  It also gives the resident a little more dignity to be able to do more for themselves.  There have been more than a few times that we have seen a resident come in totally bedridden, confused, and max A with everything, and end up needing only minimal assistance or supervision, able to take themselves to the bathroom, go on outings, etc.  This makes a  tremendous difference in their quality of life.  I'm not saying that Tim doesn't make some valid points, as I'm sure there are facilities totally driven by RUG levels.  But please don't think it is that way everywhere.  I'm sure that when contractors come to help us out 1 or 2 days on a weekend with no one else there, they probably think we are totally nuts sometimes.  If you have issues with the goals written for a patient, I believe that it is your responsibility to discuss them with the OTR.  We have a large caseload at our facility, and my OTR and I alternate weeks working with each resident, and we discuss how each is doing when we do their weekly notes so that changes in goals can be make when appropriate.  We also work very closely with PT and SLP to reinforce and encourage their goals for the patient.  It is definitely a team effort to get these people back on their feet.

Theresa, LTC - COTA, SNF February 2, 2008 9:52 AM

Just a few comments on Mr. Banish's well done article on short term goals.  In the first example Mr. Banish explained that the patient had mild dementia.  This tells me that the patient could have an unrealistic perspective on their abiliites (underestimating his or her abilites), in which I would turn to the family to guide my thoughts with goal writing. It sounds like a 24 hour caregiver helps with all ADLs, but wouldn't it be prudent to give it a shot to decrease this burden of care.  Caregiver stress is a prevelent dsyfunction in todays society and I think with a case of mild dementia progress can certainly be made with repetive practice and the right type of home schedule.  I also have some thoughts about UE strength.  It seems Mr. Banish is fixated on linking a muscle grade improvement to every functional outcome made.  In the first example I do not think the 4+/5 goal is that bad of a goal for several reasons.  The first being toilet transfers and dressing.  One certainly has to have adequate tricep isometric, eccentric, and concentrc strength to perform a sit to stand to assist with quadricep control regardless if it from a bedside commode, power wheelchair, or from her bed.  The endurance of the tricep is certainly important because this can prevent the tricep from wearing out which in turn could create a fall during the transition of sit to stand.  The goal of propelling a wheelchair 50 feet could be a measure of both the strength and endurance of the tricep musculature.  To simply only work the tricep musculature during treatment would be dangerous secondary to creating muscle imbalances.  To create an effectve strength/endurance program I believe all major muscle groups should be addresses.  My second concern of Mr. Banish's statements on UE strengthening deals with having to link every improvment with UE muscle grade to functionality.  As occupational therapists and occupational therapy assistances it is certainly in the scope of our practice to assist the patient with developing healthy lifestyles through well living preventitive activities.  An UE program is certainly one of those activities.  Strength training has been linked in the research to improvments in metabolism, cardiovascular health, self esteem, and even balance.  The American College of Sports Medicine recommends that elderly individuals perform a strength training program 2-3 times per week.  Now unless a personal trainer is coming in to work with the residents of you nursing home, I think it is critical that occupational therapists and physical therapists address this area.  I realize that working in a nursing home is a challenge and that many patients are not motivated at all to attempt any therapetic actvities.  I think we need to take all measures to motivate the individual.  The nursing home therapy program is often their final shot with having a somewhat functional life.  I see so many therapists giving up on a patient just because the patient is not motivated to perform the activities.  Depression is often a reality in nursing homes!  I think we all need to raise the bar with what we expect with our nursing home residents.  I believe that this could change the poor image that many skilled nuring home therapy programs have.  The issue is not the goal writing, but the attitude.  Thanks.

Chris Nahrwold February 2, 2008 6:13 AM

Thanks for your comment Mark-

Again, most OT's doa great job writing goals, but then there are some who make me wonder where they were during the eval. As much as they tend to ask the right questions, they still develop goals that are not appropriate, or maybe dictated by the contract company.

Tim Banish, COTA/L January 22, 2008 4:51 PM
Cincinnati OH

In the facility I work for I have the freedom to discharge these patients without fear of reprisals.  It is true that goal writing for these patients can be very difficult, but it should be up to a therapist to take on the challenge.  It looks to me that that therapist did not talk with the resident, much less ask what their goals are to return home.  

I believe that goal writing is not properly taught in schools.  The goals taught in school are measurable and achievable, but lengthy and not applicable in all settings.  I can honestly say that I learned more from my fieldwork supervisors than anything in the classroom.  

On a personal note, I only write goals to increase strength to 2+/5 (for example) for a neuro patient and not a general exercise goal.  A patient can function with 3+/5 strength and does not need 4+/5 strength for ADLs, transfers, and home management.

Mark, OT - Occupational Therapist, SNF January 21, 2008 5:51 PM
Emporia KS

Thanks for these comments. Melissa, you are lucky to have a good OT who discusses the pt. goals with you, as well as the rest of the team. Ang, these are the same issues I run into. Because the pt. is in assessment, they MUST stay on therapy so the SNF doesn't lose a bunch of money. PPS has driven the industry to thinking cash VS pt. care.

Tim Banish, COTA/L January 21, 2008 4:59 PM

I just want to take a moment to say that I have worked with both a generic goal writer, and a need-based goal writer. I don't believe that it has so much to do with the education as it does the heart of the goal writer.

The generic goal writer I am referring to (strength/ADLs for everyone) is an experienced OTR who does PRN work as well as full time. The need-based goal writer is my current clinical supervisor. She is a recent grad from Gannon University in PA. Whenever doing a screen or eval, she looks at where they are going after D/C, if they will have help, and how important it is to them to be able to what we are asking as well as the probability of meeting the goal. She also meets with myself and the other COTA/L to discuss the goals on a regular basis, just to make sure that they are still reasonable.

I belive that she stands out because she knows that it is important to collaborate with the people that are working so closely with the individual as well as PT/SLP to maximize the benefit of therapy for each individual.

Melissa, rehab - COTA/L, Presque Isle RNC January 20, 2008 10:24 AM
Erie PA

Hi Tim, Here are some of my recent experiences with the above issues.

1. Pt. ready to d/c from OT (goals met or max potential reached) but pt. is in assessment so needs to stay on, maybe for close to a week in a high rug level!!!

2. Being asked to do a community outing with a 80+ year old pt. who's family does all the shopping ect.  In general, I don't get the Comm Outing goal anyway.  I don't see what the gains are.  You can determine if they have adequate cog skills, end, ect whithout going out.  Also, most, if not all my SNF/ short term rehab pts patients have zero interest in being in a store with a therapist!

3. Pts in asess, not in asess, in asess, not.  Im thinking of d/cing but if I keep them on they must go back to 50 mins in assess for a week, when maybe I only need a couple of days to tie things up.

4. Discharges/tx  in general being minute driven vs clinical.............and don't get me started on GROUPS.

I guess it's just the way it is with PPS???

for now, Ang

Ang, SNF - Cota/L January 17, 2008 6:50 PM

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