A Day in the Life of a Skilled Nursing Facility (SNF) OT: Guest Interview with Mary Kate Carroll

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In this interview, Mary Kate Carroll shares her insights and experiences about the SNF setting as a new grad occupational therapist and why she loves working with older adults. Be sure to peruse each section below to get all the resources, tools and knowledge you need to thrive! This guest interview is also available on the OT Miri YouTube channel.

Growing up, I had always wanted to be a teacher of some sort. But the older I got, the more I realized pediatrics wasn’t the right fit for me. Thankfully, I had several family members talk about occupational therapy (OT), either as patients receiving care or as therapists themselves, so everything fell into place. I loved how OT combined the medical world, teaching and creativity. During OT school, I had a level 2 fieldwork at a skilled nursing facility and absolutely fell in love with the setting, the pace, the population, so I knew I wanted to work in that setting. I’m happy to share that I got a job at a skilled nursing facility/ long term care facility near Cleveland, Ohio after graduating from Gannon University!!

I was so nervous for the interview it all seems like a blur! Like many new grads, I had found my current job through a job search and listing online. Since the company I work for has several facilities in different locations, I had to fill out a few forms online specifying which location I was interested in, as well as upload my resume, cover letter, references, etc. The interview process incorporated a standard interview with my boss and then a portion that involved talking to and “shadowing” the other therapists. This was something I really appreciated because I got to “pick the brains” of the therapists and observe their treatment sessions, as well as gauge whether or not they seemed happy working there. I also took note of the team dynamics and how the PTs/PTAs/COTAs, and OTs interacted as a team.

Did you have any difficult or unexpected questions during the interview?

I have always struggled with describing myself without sounding conceited or selfish, so the questions describing my interests, education, accomplishments, and why I feel like the best fit for a position made me feel awkward. I did a lot of research before my interview regarding answering interview questions. Fortunately, I have a wonderful older brother in HR who guided me with coming up with responses for “common” interview questions, but there are many resources online that discuss the same topics!

For more OT Job Interview questions and sample answers, check out the article FAQs for OT Job Interview. Also, be sure to also create your ownList of Questions to ask the employer.

What are some ways to best prepare for an interview in this setting?

Research the facility and population beforehand. I creeped through my company’s website to determine what other types of programs/rehab they offer (aquatic therapy, Silver Sneakers, wellness classes, speech therapy). I also found out that my facility specializes in stroke rehab, something I was very interested in as a new grad. If I hadn’t researched the facility and their population, I wouldn’t have found out that info and better formulated responses to my interview questions.

A skilled nursing facility is basically the phase in-between hospital and discharge setting. In other words, it acts as the bridge between acute care and discharge. If the hospital or patient feels they need more rehab after an illness, injury, procedure or a fall, they can opt to stay at a skilled nursing facility for further rehab and care to ensure a safe discharge.

Like most settings, SNF has its hectic days. You’re required to see people for a set amount of time, plus the subsequent paperwork for each encounter. If you have a lot of admits, that’s a whole other load of paperwork. Depending on how many people you’re scheduled to see, plus if you can stay on time, that can affect your productivity and how late you stay to complete your documentation. It can get pretty fast paced if you’re not organized. Luckily, I’m blessed with an amazing rehab team and staff that make even the busiest days enjoyable.

What’s Your Main Role as an OT in the SNF Setting?

The role of OT in the SNF is based on what the patient needs to do in order to return home or to their discharge location. I do evaluations, progress notes, treatments, discharges, and family communication/training. The scope of OT in a SNF incorporates a lot of ADL/IADL training, functional mobility training, compensatory techniques, training in the use of adaptive equipment (AE), as well as strengthening, promotion of functional activity tolerance, and standing balance to ensure a person is safe to discharge. Additionally, I do a lot of home evaluations with the patient and family members and make recommendations before they discharge.

Insurance companies are a big component in skilled nursing care. You must constantly be justifying why your patient continues to require skilled care during their SNF stay. This involves a lot of communication between the therapy team, nursing, and the insurance companies.

Editor’s Note: According to the AOTA Fact Sheet, the Role of Occupational Therapy in SNF also include:

  • Assessing the need for potential home modifications
  • Exploring new leisure pursuits
  • Preparing the patient and family for community reintegration
  • Teaching compensatory techniques for cognitive and perceptual deficits
  • Enhancing safety through assistive technology, AE and environmental modification

PROGRAM DEVELOPMENT

In addition, occupational therapy practitioners are equipped and skilled to develop and implement programs in SNFs for falls prevention, dementia management, restraint reduction, contracture management, therapeutic groups and pre-driving evaluation. Be sure to also review the AOTA Fact Sheet on SNF.

How do you describe OT to your patients and team members?

During my evaluation process, I always explain OT to my patients as “the things you need to do in order to get home, whether it’s simple things like self-care tasks, or higher level things like homemaking skills. Before you leave, I want to get you to do things like dressing, bathing, toileting, getting around your home, and completely basic home making tasks as safely and as independently as possible without pain, fatigue, or shortness of breath.”

What do you love about the SNF setting?

Can I say everything? I love working with people—hearing their stories and seeing them progress from day 1 to discharge. It is incredibly rewarding and motivating to know “Hey, I helped them do that!” The smallest things in this setting have the biggest impact—something as simple as helping someone put on their socks with a sock aide can just make someone’s entire day. I love getting them back to what they want and need to be able to do. I also love the pace and the variety in diagnoses. Every day is something different.

What are some challenges you see in this setting?

One of the biggest challenges I’ve faced, and I believe it’s applicable in other treatment settings as well, is leaving work at work. I am very empathetic and really feel deeply about my patients. Ironically, this is both a blessing and a curse in the healthcare field. I would find myself going home after a long day and being unable to really stop focusing on my patients. I would constantly be researching treatment ideas and feeling guilty, thinking “If I had done this, or if I was more competent with this, maybe they would have gotten better/ been able to go home.” This is an incredibly toxic mindset. Sometimes, you can’t “save” everyone. The important thing is that you treat everyone with kindness and respect and help them to the best of your ability. It took a lot of changing these thought patterns and my own self-talk to get out of that harmful habit. It is still something I have trouble with, especially with the patients I really want to see succeed.

I usually come in around 7AM to complete any documentation, check messages, and catch up on events from the day before. Then, I start seeing patients around 7:30. Usually, if I have any evaluations, I see them first thing for an ADL to get a gist of what they’re able to do. On a typical day, I will usually see 7-8 patients a day with 1 to 3 evals. New evals typically take around 90 minutes and treatment sessions can last anywhere from 30 to 60 minutes.

EVALUATION

The “hands on” portion of the evaluation combined with the documentation takes around an hour and a half. My evaluations consist of scanning through the chart for their History and Physical (H&P), precautions and labs. I also gather any information on MMT and ROM. Finally, I assess whether the patient is alert and oriented to the 1) person, 2) place, 3) time, and 4) situation (A&Ox4). The evaluation also consists of interviewing the patient about their home, discharge plan and gathering their occupational profile. If a patient has cognitive deficits, I call the family to get an understanding of their prior level of function.

TREATMENT

Once my evaluations are done for the day, I start my treatments with my caseload and any progress notes I need to complete. I see patients for 30-60 minutes per session and my treatments can range from anything from therapeutic exercises/activities and IADLs to neuro-re-education,  e-stim and aquatic therapy. Around 12, I get a half hour for lunch.

STAFF AND REHAB MEETINGS

Once a week, there is a caseload meeting in which OT, PT, and ST meet to discuss each patient, their progress, and discharge planning. There is also a weekly rehab meeting that includes the COTAs/PTAs in which we discuss company policies, concerns and clean the therapy gym. If a day is really fancy, it might include a home evaluation or a care conference with the patient’s family, nursing, dietary, social services, and myself.

How did your expectations differ from the reality of your actual experience?

The facility where I did my level 2 SNF fieldwork had a whole different documentation system than the facility where I landed my first job. I went into my first job knowing I would have to be completing paperwork, I just wasn’t aware of how much I would have to complete on a daily basis. As I stated before, SNF is all about justifying why your patient requires skilled therapy services. That means you have to be documenting everything to ensure your patient is able to receive therapy services. As an OTR, I have to complete my evaluations, progress notes, treatment notes, and discharges, as well as reviewing my COTAs documentation to make sure they are adhering to the plan of treatment and providing skilled services. 

Do you have any tips for documentation?

Starting out at my facility, I took absolutely no shame in asking my co-workers for help, or even asking my boss to schedule in some extra time at the end of the day for paperwork. I wanted to ensure I was getting in the habit of doing thorough, skilled documentation. Once I got the knack of the system, I began utilizing Point of Service Documentation when appropriate. It’s always a challenge balancing between documenting too little or too much during a treatment session. I’ve gotten very good at typing fast!

COMMON DIAGNOSES

With skilled nursing, I see a lot of ortho (hips, knees, broken bones), neuro (CVA/TBI), falls and cardiovascular diseases. I also have a lot of co-morbidities— nobody ever comes in with “just a knee” problem. COPD, depression/anxiety, diabetes, spinal stenosis, and dementia are super common co-morbidities.

ASSESSMENTS

With every patient, I administer the Barthel Index. Some other frequently used assessments include the Mini-Mental State Examination, the Arm Curl test, the Patient Specific Functional Survey, as well as specific upper extremity ROM/MMT. Depending on the injury, I also use the Box and Block, 9 Hole Peg Test, and an upper extremity pain survey I really enjoy is the QuickDASH.

Editor’s Note: OT Miri uses MedBridge and offers a discounted rate for our readers at $200/year using the Promo Code “OTmiri.” This is a $175 discount, which is the best discount available to individual subscribers. If you are a student, you can take advantage of this wonderful resource for $100/year by using the Promo Code “OTmiriStudent” and your .EDU school email. Find out more at MedBridge for Students.

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Gait Beltis absolutely essential to perform safe transfers. I also recommend a good old fashioned goniometer—bonus points if you have a wrist and finger one as well. A Pulse Oximeter and Blood Pressure Cuff are necessary for taking vitals. I would also stock up on measuring tapes to measure edema, complete hand ROM measurements like thumb opposition, and measure doorways in homes.

PATIENT HANDOUT FORMS

Upon discharge, I basically give everyone an upper extremity home exercise program and a therapy band corresponding with their strength level. Depending on their diagnosis, I’ll also give them energy conservation tips, home safety checklist and stress ball exercises. I get all of my handouts from The Occupational Therapy Toolkit by Cheryl A. Hall, OT/L. It has every possible handout imaginable. It’s an excellent resource that I definitely recommend to every new grad. I would also use handouts from reputable websites, like AOTA or even reference your old textbooks like Pedretti’s Practice Skills for Physical Dysfunction (I keep this textbook and my ROM measurement book on my desk for quick reference—no shame!)

AOTA MEMBERSHIP

If you’re not already signed up to be an AOTA member, that would be my first recommendation! As a member, you get full access to their website, as well as the weekly magazine “OT Practice,” and cutting-edge AJOT articles. As nerdy as it sounds, I really like researching evidence based articles from different databases—it’s fun for me.

For those who are exploring this setting for the first time, what would you recommend they review?

Knowing things like cardiac precautions, hip precautions, cervical precautions is essential. Also, I would recommend researching how to work with and communicate with individuals with dementia, since that is a really common co-morbidity I encounter and those individuals require a bit more care. I also think it would be really helpful to research “insurance terms.” Things like knowing the difference between Medicare A and B, why it’s important to get your minutes in a day—those are the more technical side of SNF OT that are inevitable to daily life.

Is there anything you wish you had known before starting your job?

I wish I knew more manual therapy beyond just passive stretching! I wish I had more “hands on” labs in school teaching me about myofascial release, lymphedema massage and joint compression.

What are some attributes or skills you need to be successful in the SNF setting?

GO WITH THE FLOW

As long as it’s something that isn’t unsafe or will cause harm to the patient or therapist (improper transfer techniques), I’ve always been open to “going with the flow.” There are many ways to be a good therapist. I would learn as many techniques as you can, then pick the ones you like best and find your “style.”  Also, it helps to be organized and have good time management skills because you need to stay on schedule and on top of your documentation.

 

BE GENUINE AND PASSIONATE

Being genuine and passionate about your field is something that people really pick up on–you need to be empathetic and kind, but firm. You also need to be able to motivate people. Not everyone wants to get up and do exercises—it’s up to you to make sure they’re receiving therapy!

Currently I’m working on getting Saebo certified, which is a cool company that makes a lot of devices for the neuro population (biofeedback, mobile arm supports, orthotics, splints). I’m planning to get some kind of dementia certification since that is a very common co-morbidity I see working with older adults. I’d be interested in taking a few more psych-based CEUs—individuals with mental illnesses are another very common co-morbidity in this setting. I’m also toying with the idea of getting my doctorate so I can eventually transition to teaching down the line…not sure if I’m ready for all that extra research yet!

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