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August/September 2002


Rehab Lands a Starring Role

By Cheryl M. Merritt, MS, OTR/L, and Marcie Weinstein, MBA, OTR/L, FAOTA
As Americans live longer and healthier lives, they are increasingly demanding a wider variety of long-term care options that meet their individual needs. Assisted living facilities (ALFs) have become a popular option that provides some assistance with daily tasks while maximizing independence in a safe and homelike environment.1

The definition of assisted living varies from state to state, but national consumer organizations cite common philosophies and characteristics,2 including fostering independence, providing a safe environment, allowing resident choice, and maximizing dignity.3

In the next 20 years, the Assisted Living Federation of America estimates that the number of residents living in ALFs in the United States will increase by nearly 50%.3 As assisted living becomes big business, facilities will increasingly try to differentiate themselves through unique amenities to attract prospective residents. Occupational and physical therapists already provide services in assisted living, and can use this growth opportunity to establish themselves in multiple roles.

DIRECT SERVICES

Traditionally, the rehab role in assisted living consists of direct therapy offered by an outside contractor and under the plan of care of a physician. This intervention may be reimbursed by Medicare, health maintenance organizations, or private health insurance for two to three skilled visits per week.4 Therapy often focuses on restoring activities of daily living (ADL) function, and improving ambulation, balance, and functional mobility. According to Lisa Ann Fagan, OTR/L, an occupational therapist, licensed assisted-living facility administrator, and consultant to assisted-living and retirement communities in New Jersey and Pennsylvania, many residents choose ALFs so they can receive assistance with ADLs and subsequently prefer to focus on their ability to engage in desired leisure activities. She notes that therapists may better serve the interests of residents by focusing on adapting and restoring skills required for leisure.4

Other areas of direct intervention, sometimes overlooked in traditional rehabilitation, are incontinence retraining and treatment of psychosocial issues such as depression. Residents dealing with these issues can isolate themselves due to embarrassment and lack of motivation, thereby reducing their social interactions and physical activity, which can ultimately lead to functional declines.5 By intervening early, residents and care providers can learn to manage these challenges and improve resident quality of life. Aspects of incontinence retraining include: determining patterns of incontinence, developing toileting schedules, training in use of incontinence products, teaching pelvic strengthening exercises, and using biofeedback.4,5 Depression can be managed through promotion of life-affirming activities, such as gardening, pet care, personally valued leisure, and increased interactions with friends and family.4,5

CONSULTATION

The philosophies underpinning both assisted living and rehabilitation speak to maximizing independence by restoring function, adapting the environment for safe and independent occupational performance, preventing further disability, and promoting health and wellness.1,3,6 Therapy consultants can market themselves to ALF administrators by demonstrating how they can help facilities put their philosophies into action. The successful consultant is able to effectively show administrators the functional, financial, and economic benefits of their services. As residents maintain or regain valued functional skills, a positive impact on quality of life is seen.7 Cost savings may be realized by a decreased reliance on personal aides, and the availability of a full array of health-promoting services is a powerful talking point used by ALFs to recruit new residents.8 Therapists may consult in such areas as environmental modification, health promotion, fall prevention, Alzheimer’s programs, and consumer choices.

HEALTH PROMOTION

Many of the declines in function that occur in ALFs can be prevented and healthy aging promoted through early intervention and education of staff and residents. Therapists can develop screening programs with staff and educate them to continually assess functional status of residents, identify potential hazards that may cause accidents, and address common risk areas.

There is a growing emphasis on well care. Studies have indicated the psychosocial and physical health benefits resulting from individuals engaging in a structured program of meaningful occupations.7 One program used in 30 ALFs in the Southeast is designed to enhance resident function and well-being through use of the healthy generation model. This model assesses five domains (intellectual, social, physical, spiritual, and emotional) related to quality of life, and uses residents’ responses to design a monthly calendar of activity programs that meet the needs of the whole person.9 Therapists are the ideal link to administer holistic assessments and help staff identify and suggest programming that is consistent with resident interests and functional levels.

The fastest growing population in the health-club arena today are those over age 50. These Baby Boomers attracted to a fitness lifestyle may wish to continue with exercise programs as they enter assisted living in the next 20 years.8 One study, conducted with 84 residents in two assisted living facilities, was designed to determine the effect of a strength-training program on improvement of strength and functional performance.10 Results showed that attendance at a structured program three times a week for 30 minutes significantly improved functional performance in: balance, walking, decreased fear of falling, improved sleep patterns, and chair stands. Other therapists have instituted programs using the ROM dance, tai-chi, yoga, or walking clubs, with award incentives for distance and consistency with the program.5 Implementation of regular fitness programs in assisted living can, therefore, improve overall function, provide additional social opportunities, and allow residents to continue to engage in occupations they valued prior to admission.

ADVOCACY

Therapists can serve as consultants to individual consumers as they grapple with sorting through the wide variety of ALFs to find one that fits their personal needs and preferences. Consultants can work with these prospective residents to identify their individual physical and cognitive limitations as well as personal choices in quality of living environment, which may guide them in facility selection by prioritizing essential amenities.6 Older adults and their families will be better equipped to make informed choices and thereby reduce the need for relocation and adjustment to a new environment.

Therapists can fill a natural role of individual patient advocate as they interact with residents and participate in interdisciplinary care teams. Through close interactions during therapy sessions and structured activities, rehab staff become aware of cultural or religious considerations, personal preferences, desires for collaboration with staff, or other unique lifestyle considerations, that can impact resident quality of life or satisfaction with services.11Therapists can share this information with interdisciplinary teams to facilitate client-centered care. Acting as advocate on behalf of the resident is also essential when working with insurance agencies or administrators to give rationale for necessary therapeutic or preventative interventions.

The broader advocacy role occurs at the systems or policy level where therapists trained in the rehab philosophies can help organizations and administrators realize the objectives of assisted living. Some administrators have a background in hospitality rather than health care, and may benefit from the rehab expertise regarding the relationships between resident choice and empowerment,12 engagement in valued occupations and meaningful functional tasks, and holistic health benefits.

Assisted living is a growing area of long-term care that is widely under-regulated to date. This is an optimal opportunity for rehab professionals to expand their presence in this market through legislation, regulation, education, and focused marketing. There are numerous ways that rehab therapists can benefit an ALF, but their challenge will be in expertly communicating their value and worth to administrators and corporate heads. The face of assisted living residents will continue to gradually change in the next 20 years with a better-educated, healthier, and more consumer-oriented older adult population. Key to the dominance of assisted living in the long-term care marketplace is its ability to create a niche that is resident-centered and committed to successful aging in place. Now and in the future, rehab will play a vital role.

References
  1. Wilson KB. What is assisted living? Journal of Long-Term Care Administration. 1996;24(3):3-4.
  2. Allen JE. Assisted Living Administration: The Knowledge Base. New York: Springer; 1999.
  3. Assisted Living Federation of America. What is assisted living? Available at: www.alfa.org/public/articles. Accessed July 1, 2002.
  4. Fagan LA. OT’s role in assisted living facilities. OT Practice. 2001;6(2):33-38.
  5. Fagan LA. Assisted living 102: Experiences of an occupational therapist. Gerontology Special Interest Section Quarterly. 1999;22(3):1-3
  6. Chialastri PD, Kolodner EL. Assisted living facilities: Function or fiction? Gerontology Special Interest Section Quarterly. 2001;24(3):1-4.
  7. Clark F, Azen S, Zemke R, et al. Occupational therapy for independent-living older adults: a randomized controlled trial. JAMA. 1997;278:1321-1326.
  8. Colarossi G. Fitness makes cents: Keeping residents active and healthy is good business. Assisted Living Success. 2000;5(3):26-28.
  9. McPhee SD, Johnson T. Program planning for an assisted living community. Occupational Therapy in Health Care. 2000;12(2/3):1-17.
  10. Brill PA, Matthews M, Mason J, Davis, D, Mustafa T, Macera C. Improving functional performance through a group-based free weight strength training program in residents of two assisted living communities. Physical & Occupational Therapy in Geriatrics. 1998;15(3):57-69.
  11. Barney KF. From Ellis Island to assisted living: meeting the needs of older adults from diverse cultures. Amer J Occup Ther. 1991;45(7):586-593.
  12. Deeter C, Young K, Weinstein M. Collaboration Between Residents and Care Providers in Assisted Living Facilities [graduate project]. Towson, Md: Towson University; 2001.
Cheryl M. Merritt, MS, OTR/L, is an occupational therapist with Genesis Rehabilitation Services in Newark, Del. Marcie A. Weinstein, MBA, OTR/L, FAOTA, is an assistant professor in the Department of Occupational Therapy and Occupational Science at Towson University in Baltimore.

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