ALF/ILF Cheat Sheet (Casamba)

Evaluation

Treatment Diagnosis

Muscle Weakness (M62.81), Unsteadiness on Feet (R26.81), Repeated Falls (R29.6)

Reason For Referral

[Mr./Ms.] is a _ y.o who has been referred to PT by [ALF staff, PCP, etc.] with reports of pt having _________ affecting [ambulation, safety, mobility, transfers, etc.] Staff reports pt has had multiple falls since their last discharge from PT.

Example: Mr. L has been referred for PT by ALF staff with reports of having increased knee pain affecting ambulation and safety. Staff reports pt has had multiple falls since his last discharge from PT. Caregivers report that pt has been using facility provided w/c for mobility in addition to walker for ambulation. Caregivers also report that pt has not been participating as much and is in bed more often. Pt has had a recent stint of PT from 12/22/2020 – 4/9/2021.

Therapy Necessity

Pt presents with: [reduced LE strength, functional mobility, reduction in pain, gait pattern, transfers, activity tolerance, balance, righting reactions, etc.]. Without therapy, pt is at risk for [falls, further functional decline, decreased mobility, isolation, contractures, pressure sores, etc.]

Example: Therapy necessary for improved LE mobility, reduced knee pain, improved gait pattern, improved functional mobility, improved transfers, increased activity tolerance, improved balance, and improved righting reactions. Without therapy pt is at risk for falls, further functional decline, decreased mobility, isolation, contractures, and pressure sores.

Pain? During assessment, patient scored _ on the Berg Balance Scale indicating a _ risk for falls. Patient ambulated _ft in 6 minutes on the 6 MWT with _ which is below patient’s age-related normative value and indicative of reduced activity tolerance. Patient able to complete _ sit to stands during the 30 sec Chair Stand Test indicating reduced LE functional strength which is below patient’s age-related normative value and contributing to difficulties with functional transfers and going from sitting to standing from low chairs. Patient demonstrates impaired gait causing reduced stability during ambulation increasing risk for falls. Patient demonstrates poor safety awareness indicating a risk for falls. Patient requires skilled physical therapy to address listed deficits required for patient to return to PLOF.

Discharge Environmental Factors/Social Support

List: environmental barriers, current assistive devices and uses including home modifications, anticipated assistive devices, and support from family and friends.

Example: Pt has accessible ALF apartment with raised toilet seat, grab bars in bathroom, walk-in shower with shower seat, and movable shower head. Pt has daughter in the area that checks in on her, takes her to doctors appointments, and is highly involved in her care. She receives assistance as needed from caregivers in AL for medication management, meal preparation, and housekeeping. She has four other daughters who live out of town but are very involved in her care period she enjoys attending activities with family and with other residents. She also enjoys church outings and is active in her community. She has rollator but is inconsistent with use in apartment and sometimes forgets when walking out of apartment as well.

Patient has modifications in apartment of facility including raised toilet seat, grab bars in bathroom, walk-in shower with shower seat, and moveable shower head. Patient ambulates with rollator / front-wheeled walker and also uses WC when fatigued. Based on evaluation, patient is equipped with appropriate AD at this time. Patient has children in the area who are involved in her medical care and assist as needed. Patient receives assistance as needed from caregivers at facility for various tasks such as: medication management, meal preparation, and housekeeping.

Prior Residence and Living Arrangement

List: where the patient previously lived before facility, who the patient lives with, where the patient lives, and amount of assistance facility provides

Example: Prior to moving into Marchbanks ALF on memory care unit, pt was living at home with his wife in poor living conditions with DSS removing patient from home. Pt’s POA is now his son, John Smith. Pt lives in a private apartment on memory care unit with 24 hr assistance for ADLs medication management, and memory support.

Patient lives alone in apartment of ALF / ILF partaking in facility-sponsored events and activities, requiring assistance as needed from caregivers at facility for various tasks such as: medication management, meal preparation, mobility assistance, and housekeeping.

Previous Therapy

Example: Previous PT from 12/22/2020 to 4/9/2021 with outcome measures at discharge: 6 MWT of 152 ft with SBA, Berg of 26/56 relating to moderate fall risk, seated 1 RM of 10.1 lbs, B knee extension ROM lacking 20 deg.

Precautions

Example: balance precautions include high fall risk. Wounds to B feet causing pain with weight bearing. Safety precautions - needs 24-hour supervision and is at risk of elopement. Functional incontinence d/t inability to get to restroom in time. Impaired cognition.

Discharge Plan

List: where the patient will be discharged to (ALF, 1-meal prepared by facility per day), anticipated level of function at discharge.

Ex: Pt will D/C to current ALF with sup level for amb and transfers, moderate fall risk based on Berg Balance Scale and FIST, and improved LE strength and ROM.

Upon discharge, patient will demonstrate improvements in static and dynamic balance, pain reduction, LE and core strength, activity tolerance, requiring less assistance from staff, and safety awareness. Patient will be discharged to ALF / ILF where they will live alone in apartment and will partake in facility-sponsored events/activities, requiring assistance as needed from caregivers at facility for various tasks such as: medication management, meal preparation, mobility assistance, and housekeeping.

Standardized Tests and Measures

LE MMT: hip flex (R= /5, L= /5) hip ext (R= /5, L= /5), hip abd (R= /5, L= /5), hip add (R= /5, L= /5), hip ER (R= /5, L= /5), hip IR (R= /5, L= /5), knee ext (R= /5, L= /5), knee flex (R= /5, L= /5), DF (R= /5, L= /5), PF (R= /5, L= /5)
Berg Balance Scale: /56
6MWT: _ ft with rollator / FWW and CGA
30 sec CST: _x from standard height chair with / without use of B UE
1RM (converted to 55% of pt’s 1RM): hip flex: lbs (55%= lbs), hip IR: lbs ( lbs), hip ER: lbs ( lbs), knee ext: lbs ( lbs), standing hip flex: lbs ( lbs), standing hip abd: lbs ( lbs), standing knee flex: lbs ( lbs), standing hip ext: lbs ( lbs)

 

Evaluation Complexity:

Low complexity evaluation performed. Patient with a history of no personal factors and comorbidities that impact the plan of care. Examination of body systems using standardized tests and measures addressing 1-2 elements (body structures: low back, B hips, B knees, B ankles and functions, activity limitations, and participation restrictions: difficulty ambulating, difficulty with sit to stands, difficulty performing functional transfers, difficulty with bed mobility). Results of standardizes tests (6MWT, Berg Balance Scale, MMT, 30 sec CST) show (reduced activity tolerance, increased risk for falls, reduced LE functional strength). A clinical presentation with stable and uncomplicated characteristics. Clinical decision making of low complexity using standardized patient assessment instrument and measurable assessment of functional outcome.

Moderate complexity evaluation performed. Patient with a history of 1-2 personal factors (_) and/or comorbidities (_) that impact the plan of care. Examination of body systems using standardized tests and measures addressing 3 or more elements (body structures: low back, B hips, B knees, B ankles and functions, activity limitations, and participation restrictions: difficulty ambulating, difficulty with sit to stands, difficulty performing functional transfers, difficulty with bed mobility). Results of standardizes tests (6MWT, Berg Balance Scale, MMT, 30 sec CST) show (reduced activity tolerance, increased risk for falls, reduced LE functional strength). A clinical presentation that is evolving with changing characteristics. Clinical decision making of moderate complexity using standardized patient assessment instrument and measurable assessment of functional outcome.

High complexity evaluation performed. Patient with a history of 3 or more personal factors (_) and/or comorbidities (_) that impact the plan of care. Examination of body systems using standardized tests and measures addressing 4 or more elements (body structures: low back, B hips, B knees, B ankles and functions, activity limitations, and participation restrictions: difficulty ambulating, difficulty with sit to stands, difficulty performing functional transfers, difficulty with bed mobility). Results of standardizes tests (6MWT, Berg Balance Scale, MMT, 30 sec CST) show (reduced activity tolerance, increased risk for falls, reduced LE functional strength). A clinical presentation with unstable and unpredictable characteristics. Clinical decision making of high complexity using standardized patient assessment instrument and measurable assessment of functional outcome.

Re-evaluation performed. Examination including a review of history and use of standardized tests and measures. Revised plan of care using a standardize patient assessment instrument and/or measurable assessment of functional outcomes.

Progress Note

Analysis of Functional Outcomes/Clinical Impression:

(Participating and improving with PT? List functional gains.  Justify any lack of improvement.)

Patient has participated and demonstrated improvement with skilled physical therapy. Patient has an improved balance based on the Berg Balance Scale with a score of ­_ indicating a reduction in risk for falls. Patient ambulated _ft in 6 minutes on the 6 MWT which is closer to patient’s age-related normative value. Patient has demonstrated pain reduction with a pVAS score of _.  Patient able to complete _ sit to stands during the 30 sec Chair Stand Test indicating an increase in LE functional strength and improvements towards patient’s age-related normative value. Patient has improved in safety awareness indicating a reduction in risk for falls.

Skilled Services Provided Since Last Report:

(Static and dynamic balance, LE and core strengthening, activity tolerance, safety awareness, etc. Cues provided?)

Physical therapy has facilitated static and dynamic balance, pain reduction techniques, LE and core strengthening, activity tolerance training and progression, and safety awareness for improvements in patient’s ability to get around apartment and facility safely and with improved endurance, improve transfer ability, and reduce risk for falls.

Patient/Caregiver Training:

(Detailed information on training/education as well as patient response and carryover.)

Patient has been educated on safety awareness with assistive device during gait and maneuvering around patient’s apartment, improved gait mechanics for improved stability with gait, as well as importance of physical therapy and continuing to ambulate regularly. Patient has improved in their carryover with education and demonstrating increased safety awareness and gait mechanics.

Remaining Functional Deficits/Underlying impairments:

(List remining deficits. Why are these necessary to treat? Skilled PT is required for…)

Patient has demonstrated improvements towards short- and long-term goals. Patient continues to require skilled physical therapy to improve static and dynamic balance, LE and core strengthening, activity tolerance training, and safety awareness for improvements in patient’s ability to get around apartment and facility safely and with improved endurance, improve transfer ability, and reduce risk for falls.

Impact of Burden of Care:

(List complicating factors that impact progress. Has the progress affected the ability for the patient to participate in social or medical environments? Pt’s current status and how it impacts functional independence and safety.)

Patient has improved in their balance based on balance assessment, however, remains a fall risk requiring assistance from staff for safety with various functional tasks such as ambulation, transfers, toileting, etc. Patient has demonstrated improvements in activity tolerance based on 6MWT, however occasionally requires assistance when maneuvering around facility.  

Updates to Treatment Approach:

(Any changes to POC or treatment approach based on progress or lack of. Changes or advancements to goals. Documentation that explains communication occurred between PT and PTA.)

Based on patient’s personal goals, patient’s performance on tests and measures, and communication from other therapists, interventions continuing to address static and dynamic balance, pain reduction, techniques, LE and core strengthening, activity tolerance training, and safety awareness are appropriate for this patient. 

 

 

 

Intervention Assessments:

Therapeutic Exercise:

Assessed patient’s ambulation tolerance and aerobic capacity with the 6MWT. Patient ambulated with _ and required CGA/SBA. Assessment of fatigue based on the Borg RPE scale.  

Assessed patient’s functional LE strength with the 30 second CST. Patient able to complete _x sit to stands in 30 seconds with / without BUE for push off from armrest. Facilitated additional sit to stands, _x with / without BUE for push off from armrest, for improvements in LE strength required for functional transfers. Patient tolerated assessment and interventions appropriately.

Therapeutic Activity:

Assessed patient’s bed mobility. Patient required SBA for sitting on edge<>supine. Patient required verbal cues for correct technique. Facilitated additional bed mobility training for improvements in overall strength and technique for carryover. 

Assessed patient’s level of independence with various functional tasks using the Elderly Mobility Scale.

Assessed patient’s stability with gait based on Timed Up and Go utilizing FWW and requiring CGA. 

Neuro re-education:

Assessed patient’s static balance and risk for falls with the Berg Balance Scale. Additional balance exercises performed based on the Berg Balance Scale requiring CGA<>SBA for improvements in balance reaction and ankle and hip strategies for reduction in risk for falls. Patient tolerated assessment and interventions appropriately.

Assessed patient’s dynamic balance and risk for falls with the Dynamic Gait Index. Additional balance exercises performed based on the DGI requiring CGA<>SBA with exercises including incorporation of vestibular input, changes in gait speed, single leg stance with stepping over obstacles, turns, and ambulation around obstacles, for reduction in risk for falls and stability with gait. Patient tolerated assessment and interventions appropriately.

Assessed patient’s seated balance with the Function in Sitting Test. Patient required supervision<>CGA depending on test item. Facilitated additional balance exercises from the FIST for improvements in balance reaction and core strength required for reduction in risk for falls and improvements in transfer ability.