Beyond referrals, collaborating with PT means communicating and observing. Some of the ways in which  I try to support PT include:

● Identifying specific PT goals and safety strategies taught, and targeting them during language and cognitive therapy.

● Consulting with the PT or PTA to determine which goals or strategies the patient is or is not carrying over outside of therapy.

● Reporting back to the PT department on any physical limitations that affect the patient's ability to maintain positioning for meals, self-feed, complete ADLs (activities of daily living), or participate in leisure activities.

● Assisting the PT in communicating with severely aphasic patients, and creating language targets that include PT vocabulary.

● Providing suggestions on cueing strategies to increase a patient's ability to attend to PT tasks, recall directions, and sequence steps to complete tasks.

● Assist with any so-called "negative behaviors" associated with dementia and other disorders that might interfere with PT tasks, including repetitive questioning, wandering, emotional lability, etc.

● Assist PTs in educating staff and families about patient safety and ability to independently carry out tasks or ambulate at home or in the facility. Often, once the PT has helped the patient regain strength and balance, that patient is much more mobile, and any safety awareness or other cognitive deficits need to be addressed with the patient and staff in order to reduce the risk of falls.

A team approach will improve patient outcomes better than if each discipline works in isolation. At discharge or when families are deciding on placement for loved ones, each team member from ST, OT, and PT should give objective and honest information regarding the patient's abilities and weaknesses in order to facilitate the best outcomes for that patient.

This week, the Occupational Therapists and I have been raiding each other's supplies, in an effort to try some new activities and to keep from repeating tasks over and over with the same patients.

I have borrowed several tossing games that the OTs use for their goals, and in return, they have tried some of the word puzzles and visual puzzles I keep around. When we share some activities and talk about what our goals are, we all find we are able to plan activities that are more patient focused, enjoyable, and productive.

For instance, a few weeks ago a COTA brought in a ladder toss game, consisting of three wide rungs and three sets of balls to toss. The ball are connected by strings or rope and tossed at the rungs; the objective is to wrap the string around the rung, scoring points based on which rung is targeted. (You can buy them at many stores, order them online, or try making your own).

Initially, I didn't give the game much thought. One day, I was able to observed one of my patients being treated by the COTA, and that proverbial light bulb went off; I thought of several goals that I could target using this game, and it was something that most of patients really seemed to enjoyed. Talking to the OT and COTA, I requested to target speech-language and cognitive goals at several levels by:

• Introducing the game to patients and asking how they thought it was played.
• Teaching the rules and checking for memory and carryover.
• Problem solving and sequencing while setting up the game.
• Naming similar games that the patients enjoyed.
• Describing why the patient did or did not enjoy the game.
• Discussing opinions about being competitive, keeping score, or playing just for fun.

As always, any patient I work with has the opportunity not to participate in a game. I do encourage them to try, especially if I think that it is fear of failure or anxiety about playing well, remember the rules, etc., that is preventing the resident from trying. After I reviewed the goals, the OT or COTA might take over the task in order to work on their own goals. On some days, the set-up, discussion, and teaching took up much of our session; on others, I reviewed the game at the end my therapy time, and planned for the OT or COTA to finish the game.

On some days, I worked with my patient and the COTA or OT worked with another as teams, and we played against each other. I think it has been great activity to target language skills and cognitive skills in a way that the patients really enjoyed, and it gave me a chance to see the patients try to use what we had discussed independently.

This year, I want to focus on how speech-language therapy support the other disciplines in skilled rehabilitation. There is nothing more rewarding than collaborating with occupational therapists and physical therapists, and watching a patient reach his goals. Many times, the OT staff and I use similar activities, so we often exchange materials and ask for suggestions on activities in order to provide variety for the patient. My plan for BHSM this year is to find or create some puzzles, games, and reusable worksheets that all three disciplines can use in different ways to target therapy goals.

This week is also Nursing Appreciation Week, so why not have the residents help to make and decorate a card during therapy? Filling candy bags is also an activity I use over and over in therapy, so it's very likely that I will spend a few dollars on candy, and make candy bags as a way of thanking the nursing staff.

Next week, I will post the specific activities I used or started. Who knows, maybe inspiration will strike and I will come up with something truly original for BHSM or Nursing Appreciation Week! In the meantime, I would love to know what, if anything, you all are doing to promote the profession during BHSM. How do you manage to remain efficient while incorporating something fun into your work routine? Are you focusing your BHSM activities on residents and patients, staff, the community, or your department? Or maybe you are very motivated and are planning something for everyone! Let us know...

Some ideas for supporting all patients when bad news is unavoidable or tragedy strikes include:

● Turn off 24 hour news broadcasts an updates in dining rooms and other locations. Residents who can understand and want to watch might be asked to watch broadcasts in private rooms or less public areas.

● Encourage even highly alert and competent residents to take a break from the constant updates and replays of events.

● Tell residents who they can go to if they feel worried, anxious, or fearful about news events.

● Ask staff and family to refrain from fostering an atmosphere of fear and worry by spreading the news or speculating over events. Staff should not discuss these events among themselves while feeding bathing, or otherwise assisting patients even if they think the patient cannot understand.

● Allow residents to ask questions and express opinions, but model calmness and respect for others. Redirect patients who become too agitated or opinionated about a topic.

● Explain to higher-level residents that some residents cannot understand what has happened and may not react typically or with responses that we would consider appropriate in other residents without imprints.

● Allow residents to grieve, express emotions, and voice fear or anxiety. Let them know that they are safe, and that it is normal to feel sad or frightened.

● Alert nursing staff about any resident whose behaviors change or escalate in the wake of bad news.

At these times, however nervous or scared or angry we may feel, it is important to model appropriate behavior in our interactions with residents and to do everything we can to alleviate and prevent any unnecessary fear or worry. Most residents do have one or more televisions in their room, or perhaps a radio, and will hear the latest news, good or bad. Some residents are able to understand the details of news broadcasts and to understand how, if at all, current events will affect them. Others will not realize what is happening at all; the news simply has no more meaning to them due to dementia or other conditions and they are not affected by the information at all.

Some residents, though, may become increasingly frightened, sad, paranoid, angry, or confused as they try to make sense of what they see and hear. Even worse, if they overhear other residents or staff discussing tragic events out of context, they may believe that a threat is imminent or events are occurring locally. Residents may not understand the specifics of news broadcasts or conversations, but they might pick up on the fear in people's voices, the worry, and the anger, which could also cause these residents undue stress or confusion.

Not all bad news is going to occur on a large scale, either. There are local tragedies that occur everyday, from automobile accidents to illnesses to natural disasters. A patient with minimal or no cognitive deficits and who is emotionally stable should be included in family news and discussions of current events to whatever degree they choose. Such a person might be concerned or sad to hear of a friend's illness, but will also have coping mechanisms in place and friends or staff t talk to.

The confused, depressed or memory impaired patient, however, might panic unduly at the news that a friend is in the hospital for a minor procedure, or that there was a serious natural disaster in another state. The confused patient might have strong feelings of grief, sadness, fear, or eve guilt over difficult news.

(To be continued next week, with suggestions on how to interact with our geriatrics residents during stressful times).

Using standard directions, word search puzzles can be used to address:

• sequencing and visual tracking
• attention to tasks
• recall of directions and information
• identification of letters and written words 
• dentification of errors

If the patient can find words easily on their own, try these modifications to create a more challenging task:

• Cover the list of words to search for, and have the patient remember the category or subject of the word search and find only words that belong.
• Have the patient find any words in the puzzle that are spelled out backwards, diagonal, etc., first.
• Have a patient correct a puzzle that has been attempted by another patient;
• Have the patient search for strings of random letters, numbers, or even symbols instead of complete words.
• Have the patient try to find all of the words in a certain amount of time.

To make puzzles simpler, you can:

• Allow the patient to circle any word, rather than words in a specific category.
• Highlight the first letters of some of the target words.
• Use puzzled that are formatted in a grid that makes tracking easier.
• Use large print puzzles, or enlarge the puzzle on a copier.
• Have the patient search for specific letters, rather than whole words, by asking her to cross out all of the A's first, then B's, and so on.
• Allow the patient to finish the puzzle over several days.
• Find or create puzzles that have only left-to-right or up and down targets.

Books of word-searches are readily available at dollar stores and grocery stores. I usually copy or tear out pages and slip them into a plastic page protector. Then, I have the patient use a dry erase marker to cross out letters or circle words. If a patient has difficulty tracking or scanning, try using a blank sheet of paper or index card to keep the patient  on track by reading one row or column of letters at a time.

There are even websites that will allow you create word searches on particular subject or category.

While some patients in skilled nursing facilities are there for short-term stays in order to receive various therapy and nursing services, others will remain with us for months, years, or possibly for the rest of their lives. We expect to see some patients again due to the progressive nature of some disorders. Others might return unexpectedly to therapy after the onset of a new illness, such as pneumonia, or a neurological event, such as a CVA.

Some patients, however, return to us unexpectedly. It might be discovered during a quarterly screen that a resident's speech intelligibility has declined, or that a resident has ceased to attend activities he used to love. Subtle changes might go unnoticed until they culminate in weight loss, a choking episode, or a marked decrease in ability to communicate to nursing or family members.

Of course, we want to minimize the potential for decline in communication, cognitive, or swallowing skills that would necessitate therapy services. This can be challenging, as once a patient leaves a therapy program and a Functional Maintenance Program (FMP) or exercise program has been established, we as therapists gradually have less interaction with the resident. There are some actions we can take upon discharge to help lessen the likelihood that a resident will require reevaluation and more services.

• Develop a clear and concise FMP and put it in writing. Review the plan with patient, family, and appropriate staff.
• Begin to work on carryover of exercises and strategies as early as possible in your therapy program. Document if the patient is able to independently use strategies or perform exercises, or if the patient will require the help of staff and family.
• Refer the patient to the restorative nursing program to assist with carryover and performance of exercises and strategies when therapy has ended.
• Create a list of behaviors or symptoms that might be evident even after the patient has finished her course of therapy and met her goals. A patient with expressive aphasia is likely to encounter word-finding problems from time to time, and the patient, family, and caregivers must know what is expected in order to know if a problem warrants reevaluation.
• Create a list of signs and symptoms that would require a referral to therapy, including coughing and choking during meals, reduced PO intake, inability to communicate or avoidance of social situations, confusion during familiar routines, or the sudden onset of anger during daily tasks.

Lists can be saved in a file on your computer, and customized for each patient as needed in order to save time. Alternatively, many treatment manuals include patient, family and staff education sheets that can be individualized and  used in a checklist format. Putting information in writing can seem like more work upfront, but it will save time later and when used consistently, allows staff to refer to you suggestions without having come find you.

I have met people with no family or no home to go to, and I have met people who are very ill and not likely to recover any time soon, if at all. I have seen people gradually enveloped by the confusion and behavioral changes that come with dementia, people who don't remember their own children or spouses, but who ask for their mother and father as if they were children themselves. I have had to inform families that certain communication problems are not going to "go away" as they had hoped, and I have had to reveal the results of swallow studies that recommend NPO status.

In any job, you become fond of some people you encounter. I have been able to meet some truly amazing people, all with stories of their lives and families and experiences that are special. I remember the lady who always talked so fondly of her son who was an artist and later tragically died; she was a poet herself, and wrote about her life in small towns. Another resident would ask me every day whether she had told me about her mule that her uncle gave her. She loved that mule, and would braid flowers in its mane and ride it to the store to get eggs for her mother. After she passed away, her daughter came by my office, just to give me hug and then to peek into the room where her mother had lived in order to say goodbye again. We both cried.

There are so many people who come to our facilities who have so much to tell us and so much to contribute. I have seen firsthand how people of any age want to be challenged, to be heard, to be respected for what they can do and not pitied for what they cannot. Just this morning I read this article about older women with style, and it reminded me of how easy it is to overlook the elderly, to not truly appreciate and respect them as human beings who have a lot to offer.

The SNF is its own little community, with the same kind of friendships, heartaches, drama, and good times that any community experiences. Not all residents are extremely sickly; many choose to live there rather than live alone. Although some are there because they have no one to help them in the community, most have some family or friends who visit each week. It is important, I think, to periodically remind ourselves of the strengths and contributions of the elderly, even those in nursing homes.

We are all on a journey. I left for a week's vacation in Istanbul, and while I was there, I heard the news that a fellow SLP and ADVANCE blogger passed away. Kathie Harrington was a dedicated professional whose work in our field was greatly appreciated. She will be missed, and I hope that the many students and professionals who walk in her footsteps will remember her dedication to our field.

In a foreign country, I was constantly reminded of how important communication is to us in our day to day lives. I am not by any means suggesting that a lack of fluency in or comprehension of a foreign language is the same as a communication deficit caused by a stroke or disease; however, I was able to "walk in their shoes" to a degree as I struggled to ask for a glass of water, or to find the next tram stop or a convenient toilet. I did have friends who possess a better understanding of the Turkish language there with me, and that was more than helpful. I picked up a few words and phrases, but was often embarrassed to try them out.

I was so thankful when a person spoke to me in English, no matter how halting or simplified. Customs were different, and I was often nervous that I was breaking some rule that I did not even know about. The experience, though, was wonderful and I highly recommend that any speech-language pathologist consider travelling in order to experience new languages in context and gain perspective on how we, as global citizens, communicate and interact. I met so many charming people thanks to my friends Ted and Carla. Carla has a travel blog here.

The most amazing experiences happened when we sat down with friends of Ted and Carla's - merchants, musicians, artists, and just plain folks. So many of them spoke some English, and I was humbled by their willingness to start or carry on a conversation no matter their level of proficiency with the language. We used gestures, facial expressions, and also our best approximations of pronunciations in order to communicate even the most rudimentary of questions, and I was so grateful for the patience of the people we met as we had to ask about tram schedules, food choices and prices. My hat is definitely off to anyone who has learned to speak fluently in another language.

I relate this to my work because I work daily with people who struggle to communicate a basic message, to ask for help, to say "I love you." I am fortunate that I can go on vacation and marvel at our ability to work around languages. Every day, there are people who become forced to use alternative means to communicate because of an illness or injury. I got a glimpse into their world, and I have a new perspective on what they experience.

Whether it makes me chuckle or makes me want to scream, I believe that sometimes we are often seen as a strange mixture of teacher, counselor, dietitian, dietary manager, nursing assistant, personal life coach, professional organizer, and sometimes even magician or miracle worker!

Commonly, I am asked:         

• if I am going to "feed" a patient a meal,
• to do oral care for a patient; 
• to take a patient to activities and stay to assist them;          
• to help a patient with a meal or activity who is not on my caseload;          
• to answer questions for family and friends who are not approved to have such information;
• to give advice about a patient that is not in my caseload, or about a friend or family member of a co-worker or patient's family.
• "Why do you have so many letters behind your name?" This is one of my favorites, actually, because I'm proud of my "C's" and I love talk about our field and what it takes to work as and SLP!
• "Don't you all usually work with kids?"

Frequently, families and even some staff members do not know what exactly it is that I do. If I'm introduced as the Speech Therapist, I am often told, "Oh, she talks just fine." Then, I might have to explain that I am concerned about a swallowing or cognitive issue. This happens quite frequently when I am screening new admissions, who might not actually need my services.

I know that a little humor helps. My own grandmother was screened by a SLP, who introduced herself as a speech therapist, during a hospitalization, and she became a little worried that it was because of her very slight accent, as she moved here from Austria as a newlywed. I got a little chuckle out of it, and she felt better knowing that no one was criticizing her speech.

So, what to do?

Sometimes I introduce myself as a "communication and swallowing therapist" or just say, "I'm Jennifer, and I work with people with communication and swallowing problems." Sometimes this helps some family members feel comfortable by skipping around the titles that they may never have heard of.

Smile, and keep a sense of humor. It can be hard, when we have heard the questions over and over, but the person who asks may genuinely not know what we do.

Have pamphlets and information ready for patients and families about SLPs and the types of therapy we provide.

Remind staff of our scope of practice. If staff are unaware as a whole of your role, you may want to talk to the administrator and DON about holding an in-service during which you can explain your responsibilities, job description, and scope of practice, and the staff can ask you questions.

Promote Better Hearing and Speech Month around your facility in May to raise awareness.

Chronic Obstructive Pulmonary Disease, or COPD, is a prevalent diagnosis in patients admitted to nursing homes. The Global Initiative for COPD, or GOLD, defines COPD as a disease that:

• is characterized by airflow limitation that is not fully reversible;
• is usually progressive; and
• is associated with an abnormal inflammatory response of the lungs to noxious particles or gases, such as cigarette smoke.

COPD includes emphysema and chronic bronchitis.

The Centers for Disease Control and Prevention (CDC) reported in 2004 that 190,000 nursing home residents, or 13% of residents,  had a diagnosis of COPD. In addition, in 2009 a total of 324,000 emergency room visits were attributed to chronic or unspecified bronchitis as a diagnosis.

Common symptoms of COPD include:

• cough, with or without production of mucus or phlegm;
• difficulty breathing or labored breathing;
• tightness in the chest;
• wheezing

Studies show that along with the well-known physical symptoms of COPD, there are also signs of cognitive impairments. In 2009, Science Daily reported on research from the Mt. Sinai School of Medicine, which concluded that severe COPD is associated with lower cognitive function in older adults. The Mt. Sinai study, available here, stated that:

• Periods of hypoxia experience by COPD patients might lead to brain abnormalities that could reduce cognitive capacity.
• Hypoxia may cause or exacerbate diseases that are characterized by cognitive impairment, such as Alzheimer's disease.

Why should SLPs assess and treat cognitive deficits in patients with COPD?

• Cognitive deficits can restrict progress in other treatment areas, such as voice and swallowing disorders.
• The interdisciplinary team can benefit from the development of cognitive strategies to increase patient ability to progress toward OT and PT goals.
• Families, caregivers, and patients themselves may be unaware of cognitive impairments caused by COPD.
• Timely assessment and intervention for cognitive impairments can increase the patient's success in understanding and implementing compensatory strategies for long-term or progressive cognitive impairments.

Also Online!

Exercise for People with COPD

Common Antibiotic Reduces Acute COPD Attacks

Music expresses that which cannot be said and on which it is impossible to be silent.

- Victor Hugo

Let me preface this week's blog post by stating that I am not a music therapist, and that more information about music therapy can be found here. I do not read music, and I have never studied music theory. I enjoy playing percussion instruments, such as hand drums and finger cymbals, with friends, and I accept the fact that no one will ever say that I have a great voice. Music is something I love to listen to and appreciate, and I have happily discovered opportunities at times to bring music into speech therapy.

Sometimes these opportunities arrive spontaneously, when a musician or church band comes into the facility and the residents are singing along. Sometimes I use a CD of familiar music or song lyrics from a book as part of a planned speech therapy session. Familiar songs, including old standards, holiday songs, hymns and gospel music, and even television theme songs, can often be utilized for  an array of therapy targets. Music can certainly help people to feel calm and to focus, and patients will often seem to feel less pressure when singing along to a familiar song than during other naming tasks that put them "on the spot." I sometimes just let a song play and observe how the patient reacts.

A few activities that have worked for me include:

• Playing familiar songs to patients with dementia or communication disorders. Does he start to focus on the lyrics or melody? Sing or hum along? Can he recall the lyrics accurately, or does he repeat a few words? Does singing along increase word retrieval for patients with expressive language deficits?
• Creating a compilation cd of standards and play Name that Tune.
• Writing out lyrics and using them for expressive language tasks.
• Cutting the words out, scrambling them, and having the patient put them into the correct order.
• Leaving a word or two out of a line and having the patient fill in the blanks.
• Giving the patient one line from a song, and having her state the next line.
• With higher level patients, asing them about the meaning of lyrics, or the narrative of songs. Having them discuss music they enjoy, as well as styles they dislike, and why.
• Having the patient list additional songs by a particular artist, or more songs/ artists in the same genre or style.
• For patients with more advanced dementia, having them tap or clap along to songs if they do not sing. Snging one verse at a time to see if they will join in.

That was when I realized that music is the most profound, magical form of communication there is.

-Lesley Garrett

Also Online! Music therapy helps tinnitus patients.

Avoid letting families and visitors say they are "coming right back" if they are really leaving. Some of the most difficult transitions I have seen occur when families tell a person they are "just going to see a doctor," or are just staying "for a little while."

Mark doors to room, closet and bathroom clearly with a written label or a picture. Put these at eye-level to the patient; consider if the patient is in a wheelchair or ambulates! Mark the patient's dresser and side table, as well.

Have a basic list of frequent contacts. Teach the resident to use a simple cell phone, if possible, to stay in touch.

Have photo albums and other items available for memory tasks and to help the patient feel secure. Start a memory book and keep it simple; complicated scrapbooks can be too busy and distracting.

Set up the patient's toiletries and other items in as similar way to at home as possible, and keep them in the same place.

Maintain schedules and visitation plans as much as possible. Write down any cancellations or changes.

Expect behaviors and emotions including fear, sadness, anger and frustration.

Remind the patient where she is and why she there as often as needed. Help her to make call home, when appropriate, or set up a schedule for calls with patients who want to call loved ones when they are work or throughout the day.

Bring the resident to social activities, and assist as much as needed.

Explain clearly and honestly where the person is and why. Write this information down and place it in a notebook that the patient will keep. However, if the person becomes agitated to denies this information, then...

Determine whether reorientation works for the confused patient, or if validation is a better approach. For example, if the patient insists he is living in an apartment in San Diego instead of a nursing home in New Jersey, figure out early on if he becomes agitated and angry when re-oriented, or if he can still understand that his situation has changed. Do not constantly correct the confused patient, but guide them and redirect them toward different topics and appropriate activities.

Let the patient do as much for himself as he possibly can! If he was toileting and self-feeding before the admission, do not let staff start to feed him just because he is slow, uncoordinated, or "seems a little slow."

Read part 1 and part 2 of Jennifer's blog series on helping new residents adjust to long-term care.

Initial contact and discussion with the family and the resident will allow the treating SLP to develop cognitive-linguistic and communication strategies that will help to increase integration and participation in the new environment, and decrease catastrophic reactions to events and negative behaviors.

Imagine that you always put your reading glasses by your bedside lamp before bed, and put your dentures in a cup in the bathroom. Then you put your slippers under the bed, and set your bathrobe on the bedside chair. You have done this habitually, without thinking, for more years than you can remember!

Imagine now that you are in a new environment - you can't quite remember the name or location, but you know you are in a nursing home. There are strangers handling your things. A CNA puts your reading glasses on the dresser across the room and your dentures in a cup on the nightstand. Your slippers and robe are put in a closet, also across the room, and you still cannot quite recall which closet is actually yours - they all look the same, and sometimes you confuse the bathroom door with the closet door.

When you wake up in the morning, you need to use the toilet, but you can't find your glasses, and the floor is cold under your feet. When you get up to find your slippers and robe, your roommate becomes upset because you have opened her closet and are "getting into her things" again! By now, you are quite upset, and then several staff members come in and "fuss" at you for getting into someone else's closet. You forget that you even had to use the toilet, and are directed to sit down in your chair and wait for staff to help you get dressed, when you have never needed assistance dressing before.

In order to help residents with dementia acclimate to the new environment and routine, the team of therapists, nursing staff, CNAs, and family must be involved. Families and staff should be reminded that it may take 3 weeks or more for a resident with dementia to learn a new task or routine.

Considering what a frightening experience a move can be to anybody, it is no wonder that patients with dementia often display negative behaviors and catastrophic reactions as their whole routine is changed, and they are no longer in control.

Next week: Specific tips for transitions with the more confused resident.

Some residents have chosen the move to long-term care on their own, as they realize that are not able to care for themselves at home, and that family members are also unable to provide adequate assistance. While these residents do usually go through a period of adjustment, or even mourning, for their old life and routine, it is often the confused resident who has the most difficult time adjusting. 

Whatever the level of the patient physically or cognitively, providing a few suggestions for the transition can make it go more smoothly, and, ideally, the resident and their family would have these suggestions in order to plan ahead. I often set goals for memory, organization and orientation for new patients, and a little pre-planning or initial setup can help the patient to integrate into the new environment.

This week, let's focus on high-level patients with less severe cognitive deficits. These are also often helpful to patients with no cognitive deficits. Here's how you can help them adjust:

• Bring pictures, photo albums and a few favorite knick-knacks, but avoid trying to fit a household into a single room.
• Discuss your loved one's preferences, or have him write them down, early on with staff, including typical schedule, social habits (Will they enjoy having a talkative roommate? Are they a morning person? Are they a joiner, or a more solitary type?), food dislikes, favorite activities, etc.
• Ask about bringing the patient's own bedspread and pillows.
• Ask about bringing preferred toiletries. Male resident might appreciate their electric razor instead of disposable razors, and women may be very particular about shampoo and soap.
• Ask about bringing preferred foods and snacks, and where they can be kept. Can the residents have a mini-fridge?
• Set up an easy-to-read address book with contact information for all family members and as many friends as possible. Provide stationery, envelopes, and stamps. Find out about phone service, and teach the patient to use a simple pre-programmed cell phone before arrival, if needed.
• Tell her friends from social groups, community organizations and church where the patient will be, what the visiting policies are, and how the patient can be reached by phone.
• Plan ahead for specific days when family and friends will visit, especially during the first few weeks. Avoid having too many visitors arrive at one time, and offer to drive elderly friends to visit once in awhile.
• Notify magazines, charitable organizations, community organizations, and church groups of the move so he can stay in touch and continue to receive mail.
• Find out about policies for visitations by pets. Most facilities are able to allow pet visits!
• Expect some sadness and tearfulness, even if the patient has chosen on his own to live in the facility.
• Organize any important paperwork and decide where it will be kept: in a safe deposit box, with a family member, etc. Write down where it will be. This is especially important for patients in the early stages of dementia who might become more confused later, and might become anxious about finances and documents. Start a notebook for the patient that includes any important information they might want to have on hand.

Next week, I'll offer some suggestions for transitioning patients with more severe cognitive decline into the SNF environment.