Dawn De Vries, DHA, MPA, CTRS
Grand Valley State University
devridaw@gvsu.edu
Slippery Rock University – April 1, 2016
Overview
Learning Outcomes
Outline
Participants will be able to:
 Describe how RT can
contribute to restorative goals
when working with older
adults.
 Define restorative services in
a SNF and in the community.
 Identify two regulatory
requirements for working in a
restorative program.
 Introduction
 Definitions
 Restorative Opportunities
 Community Restorative
Opportunities
 Documentation
 Wrap Up
What is Recreational Therapy?
Recreational therapy, also known as
therapeutic recreation, is a systematic
process that utilizes recreation and other
activity-based interventions to address the
assessed needs of individuals with illnesses
and/or disabling conditions, as a means to
psychological and physical health, recovery
and well-being.

Approved 2015 as ATRA Definition Statement – ATRA Board of Directors
What are “Restorative Services”?
 “Rehabilitative or restorative care refers to
nursing interventions that promote the
resident’s ability to adapt and adjust to living
as independently and safely as is possible.
This concept actively focuses on achieving and
maintaining optimal physical, mental and
psychosocial functioning.”
 CMS’ RAI Version 3.0 Manual(October 2013)
 Page O-35
What’s the link?
Regulation: §483.15
F Tag 240
 “A facility must care for its residents in a manner
and in an environment that promotes maintenance
or enhancement of each resident’s quality of life.”
 Guideline: “The intention of quality of life is to specify the
facility’s responsibility toward creating and sustaining an
environment that humanizes and individualizes each resident
…”
Regulation: §483.15
F Tag 241
 Dignity: “The facility must promote care for
residents in a manner and in an environment
that maintains or enhances each resident’s
dignity, and respect in full recognition of his or
her individuality.”
 Emphasis on dignity and respect, self-determination and
participation
Regulation: §483.25
F Tag 309
 “Each resident must receive and the facility must
provide the necessary care and services to attain or
maintain the highest practicable physical, mental
and psychological well-being, in accordance with
the comprehensive assessment and care plan.”
Regulation: §483.25
F Tag 310
 “A resident’s abilities in activities of daily living
do not diminish unless circumstances of the
individual’s clinical condition demonstrate that
diminution was unavoidable. This includes the
resident’s ability to:





bathe, dress and groom;
transfer and ambulate;
toilet;
eat; and
use speech, language or other functional communication
systems.
Section 483.25(a) Federal LTC Regulations
Regulation: §483.25 (a)(2)
F Tag 311
 “A resident is given
the appropriate
treatment and
services to maintain
or improve his or her
abilities specified in
paragraph (a)(1) of
this section ….”
Components of Restorative
RAI Version 3.0 Manual – page O-35
 When are Restorative
Services initiated?
 “…when a resident is
d.c. from formalized
PT, OT or SLP.”
 Admitted with
restorative needs but
not a candidate for
skilled therapy.
 As need arises during
stay.
Areas
RAI Version 3.0 Manual – page O-37 & 38
 ROM: active and
 Walking
passive
 Dressing/Grooming
 Splint/Brace assistance  Eating/Swallowing
 Bed mobility
 Amputation/Prosthesis
Care
 Transfer
 Communication
Restorative Care Criteria
RAI Version 3.0 Manual – page O-36
 Measurable objectives
 Carried out or supervised
& interventions.
 Documented in care
plan & clinical record.
 Periodic evaluation by
licensed nurse in
clinical record.
 Nurse assistants/aides
must be trained in
techniques.
by members of the
nursing staff.
“Sometimes, under
licensed nurse
supervision, other staff
and volunteers will be
assigned to work with
specific residents”.
 1:4 ratio in group settings.
Activity MUST be …
 PLANNED
 SCHEDULED
 DOCUMENTED
Other Requirements
 Nursing staff must establish the purpose and
objective of treatment.
 Others may document restorative care.
 Therapists can provide and count minutes of
maintenance services on MDS; however,
maintenance does not qualify a person for Medicare
coverage.
Why do a RT Restorative
Program?
 Quality of care
 Quality of life
 Functional improvements
 Within scope of practice for RT
 Impact RUGS for individuals on Medicare (low
RUGS categories)
Restorative Program Purpose
 Serves as:
 Fill in where PT, OT and SLP cannot due to the
Therapy cap (past, possibly future reason)
 Screening tool to determine if skilled interventions
are needed.
 Co-treatment setting.
 Discharge site after skilled therapy intervention.
Therapy Cap
 2016 Therapy Cap for Medicare B coverage
 $1,960 for OT services per year.
 $1,960 for PT and SLP services combined per year.
 Can submit for reimbursement if higher but must
meet criteria (documentation, skilled intervention,
reasonable & medically necessary)
Sample Rates of Outpatient Therapy
Services
Source: http://metrohealth.net/about-metro/quality-pricing/physical-occupationaltherapy/physical-occupational-therapy-prices/
OT
PT
 Eval 137.40
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 Functional therapeutic activity

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113.30
Cognition/perception 113.30
Sensory integration 122.69
Therapeutic exercise 113.30
OT wound care 113.30
Manual OT (15 min) 113.30
Recheck orthotic 63.85
OT supervised exercise 42.88
PT assessment 158.06
Bed mobility 113.30
Coordination trng 113.30
Functional trng 113.30
Gait trng 113.30
Manual Therapy 113.30
Orthotic eval/trng 113.30
Therapeutic exercise 113.30
Transfer trng 113.30
Wheelchair mobility 113.30
Sample Rates of Outpatient Therapy
Source: http://metrohealth.net/about-metro/quality-pricing/physicaloccupational-therapy/physical-occupational-therapy-prices/
SLP
 Cognitive performance



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205.00
Speech/language eval 351.75
Speech/language treatment
255.75
Swallow eval 225.50
Swallow treatment 180.00
Cognitive treatment 298.25
Benefits of Program
 Improved physical




functioning.
Increased and more
consistent utilization of
compensatory
techniques.
Improvements in
cognition.
Return to lesser level of
care.
Improved mood.
 Improved communication

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
and social interaction.
Increased mood.
Reduction in disturbing
behaviors.
Enhanced leisure.
Enhanced quality of life.
Decreased falls.
Decreased utilization of
psychotropic medications.
IDEAS?
Senior Center
Outpatient Services
PACE Program
Assessment
 Facility Need
 Effective restorative
program
 Management Support
 Impact on RUGS
 Benefits
 QI/MDS
 Resources
 Staff
 Finances
 Space
 Residents
 ADL Declines
Planning
 Program Design
 Activity Analysis
 Criteria
 Entrance and exit criteria
 Purpose of groups
 Group ideas
 Length of groups
 Frequency
 Goals
 Education!
 Essential for all
departments
 Understand process,
purpose and referrals.
GROUPS
Communication Group
Example of Program Criteria
Objectives
Activities
 To increase social skills.
 Reminiscing
 To improve communication.
 Current events
 To increase long term
 Memory book
memory.
 To increase short term
memory.
 To improve attention to task.
 To improve word finding
abilities.
 Planning group
 Word games
 Story telling
 Table games
Communication Group
Example of Program Criteria
Entrance Criteria
Exit Criteria
 Appropriate referral.
 Appropriate social behavior for
 Resident has meet goal(s).
 Resident showed no signs of




group setting.
Decline or difficulty in any of the
objective areas.
Decline in communication
skills.
Decreased social interaction.
Potential to have improvement
in cognitive functioning as
determined by Recreation
Therapist or Restorative Nurse.


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
improvement after four weeks.
Resident is not socially
appropriate in group situations.
Resident shows physical decline
related changing medical
condition.
Resident refused group three
times.
Skilled therapy is providing
interventions.
Cognitive Group
Example of Program Criteria
Objectives
Activities
 To improve problem solving
 Table game

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 Arts and crafts

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
ability.
To increase attention to task.
To improve short term memory.
To improve long term memory.
To improve recall of
information.
To increase safety awareness.
To enhance new learning.
To increase social interaction.
To improve sequencing skills.
To improve orientation.
To improve direction following.
 Card games
 Planning group
 Word games
 Memory books
 Reminiscing
 Cooking
 Current Events
Cognitive Group
Example of Program Criteria
Entrance Criteria
Exit Criteria
 1. Appropriate referral.
 2. Appropriate social
 Resident has meet goal(s).
 Resident showed no signs of
behavior for group setting.
 3. Recent decline in cognitive
abilities.
 Potential to have
improvement in cognitive
functioning as determined by
Recreation Therapist or
Restorative Nurse.
 Deficits in cognitive abilities.




improvement after four weeks.
Resident is not socially
appropriate in group situations.
Resident shows cognitive decline
related changing medical
condition.
Resident refused group three
times.
Skilled therapy is providing
interventions.
Physical Group
Example of Program Criteria
Objectives
Activities





To increase endurance.
To improve range of motion.
To increase strength.
To increase gross motor
functioning.
 To increase fine motor
abilities.
 To improve wheelchair
mobility or ambulation.
 To maintain functional
abilities.



Walk/Wheel club
Exercise
Music and Motion
Active Games
Physical Group
Example of Program Criteria
Entrance Criteria
Exit Criteria
 Appropriate referral.
 Appropriate social behavior for
 Resident has meet goal(s).
 Resident showed no signs of






group setting.
Decreased range of motion.
Decline in endurance.
Decreased strength.
Decreased gross or fine motor
ability.
Other change in physical
functioning.
Potential to improve in physical
functioning, as determined by the
Recreation Therapist or
Restorative Nurse.




improvement after four weeks.
Resident is not socially
appropriate in group situations.
Resident shows physical decline
related changing medical
condition.
Resident refused group three
times.
Skilled therapy is providing
interventions.
Implementation

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Roles
Schedule
Environment
Group structure/routine
Participation
Goal Writing: specific, measurable,
individualized, related to functional
abilities
Physician Orders
 Scope
 Duration
 Frequency
 Must include if plan to
utilize group tx.
 Example: RT to treat for
LE strengthening related
to mobility 3x/wk. x 4
wks.
Use of Groups
 1 therapist to 4 residents.
 In restorative programs, restorative aides are able
to provide 1:4 interventions as well.
 In breaking down the time of treatment, you
divide the number of minutes by the number of
residents to determine how much can be
counted for each individual.
 For example, 4 residents in a 60 minute groups = 15
minutes per resident.
Section O Special Treatments, Procedures
and Programs
 Section O 0500
 Use for Restorative or
Maintenance
activities
 Section O 0400 F 1 & 2
 Use only for Active
Treatment



restore, remediate or
rehabilitation
goal of improving
function or resolving a
specific medical
condition (realistic
expectation of
improvement).
Medicare Part A
Restorative & Maintenance
 Restorative
 To qualify for
Restorative Services, a
resident must have the
ability to:


make decisions
be capable of increased
performance
 Maintenance
 Resident does not
have to have decision
making abilities
and/or
 Has severe limitations
caused by illness.
RUGS
 At least two 15 minute restorative activities 6 days a week =
Low Rehab RUGs
 Categories
 Behavioral Symptoms and Cognitive Performance (BB2,
BB1, BA2, BA1)
 Physical Function Reduced (PE2, PE1, PD2, PD1, PC2,
PC1, PB2, PB1, PA2, PA1)

RUG IV Category Descriptors from MDS 3.0
RUGS – Physical Function Reduced
Nursing Rehab Activities > 2,
min. of 6 days/week
ADL
Index
End Splits
RUGS
Category
Urinary/bowel training
15-16
Nursing Rehab > 2
PE2
Passive/Active ROM
15-16
Nursing Rehab > 1
PE1
Amputation/prosthesis care
11-14
Nursing Rehab > 2
PD2
Splint/brace assistance
11-14
Nursing Rehab > 1
PD1
Dressing/grooming
6-10
Nursing Rehab > 2
PC2
Eating/swallowing
6-10
Nursing Rehab > 1
PC1
Transfer
2-5
Nursing Rehab > 2
PB2
Bed mobility/walking
2-5
Nursing Rehab > 1
PB1
Communication
0-1
Nursing Rehab > 2
PA2
0-1
Nursing Rehab > 1
PA1
Day to Day Operations
 Documentation
 Assessment
 Initial Note
 Physician Orders

Scope, duration and
frequency.
 Weekly Notes
 Monthly notes
 Care Plans
 Goals must be specific
and measurable.
 4 week time frame.
 Communication
Evaluation
 Daily
 Weekly
 Monthly
 CQI
Questions? Other ideas to share?
Resources
 Best Martini, E., Weeks, M. & Wirth, P. (2011). Long term
care for activity professionals, social services professionals,
and recreational therapists. (6th ed.). Ravensdale, WA: Idyll
Arbor.
 Centers for Medicare & Medicaid Services. (2013). MDS 3.0
RAI manual. Bethesda, MD: Author.
 De Vries, D. (2004). Enhancing your practice in long term
care: Group treatment. Alexandria, VA: ATRA.
 De Vries, D. & Lake, J. (2002). Innovations: A recreation
therapy approach to restorative programs. State College,
PA: Venture Publishing.