Setting the PACE: An OT Fieldwork with Older Adults

Setting the Pace

Today was my last first day of OT FWI EVER!!! That’s super exciting, because it means I’m one fieldwork closer to living the dream as an OTR!

My last week-long Fieldwork I experience is at a local Program of All-inclusive Care for the Elderly (PACE) facility, and I absolutely LOVE it! The interdisciplinary teamwork, long-term relationships with clients, family involvement, and beautiful facility (with TONS of financial and other resources) are all factors I’m looking for in a potential workplace, so my FWI placement is a great fit. This was my first clinical experience that was focused exclusively on practice with older adults, and although I am on a federal training grant that will require me to work mostly in pediatrics for at least four years, I can definitely see myself working with older adults sometime in the future.

As of October 2015, there were 116 PACE programs in 32 states. Most are concentrated on the East coast, with very few existing in the Midwest and more rural states west of the Mississippi. (Click here to see a map and find the PACE program closest to you!) The goal of PACE programs is to provide comprehensive, interdisciplinary care to older adults to help them continue living safely in the community. The National PACE Association also asserts that “The PACE Model of Care is centered on the belief that it is better for the well-being of seniors with chronic care needs and their families to be served in the community whenever possible” (National PACE Association, 2016).

PACE participants receive primary and nursing care, skilled therapy, medical equipment, transportation, and many other services that are often very costly or unavailable to older adults who are paying for them out-of-pocket or through Medicare or Medicaid fee-for-service plans. According to a federal website, “The PACE model of care is established as a provider in the Medicare program and as enables states to provide PACE services to Medicaid beneficiaries as state option” (Medicaid.gov).

I’m excited to get a chance to work with people in one of my favorite populations, and I’m looking forward to spending a week here. Read on to get the rundown of my first fast-paced day at a local PACE program!


I arrived for fieldwork about 30 minutes before my supervisor got there, and I was glad that this place I’d heard so much about and that I drove 40 minutes to get to was totally worth the drive! The PACE facility was very nice, with a wide variety of therapy equipment, tons of natural light, and friendly faces everywhere. The building included a large activity room, smaller dining/activity room, multipurpose room, therapy/rehab clinic, medical clinic, an outdoor walking area, and tons of offices.

 

Interdisciplinary Practice

After I awkwardly sat alone in the lobby for 20 minutes, a staff member invited me into the PACE morning meeting, where most of the interdisciplinary team (IDT) was meeting to discuss current participants (as the PACE attendees are called) and weekend happenings.

I was surprised to see the huge number of professionals gathered in the room – there were about 24 people in all. As part of my second year in OT school, I got to participate in an interprofessional education (IPE) case study where I collaborated with students from other health and professional programs. Although it was a great experience working with people from eight other disciplines during our IPE event, I never really expected to work in a setting with that many professionals outside a hospital, where rounds with all members of the healthcare team take place.

However, PACE is a place where interprofessional collaboration and teamwork is the only mode of service delivery, and it was such a cool process to watch! During our morning meeting, people from over 15 disciplines were in attendance, including:

  • Occupational Therapy
  • Physical Therapy
  • Social Work
  • Dietician
  • Medicine
  • Registered Nursing
  • Transportation Coordinator
  • Pharmacy
  • Rehabilitation Aide
  • Resource Coordinator
  • Certified Nursing Assistant
  • Administrative Lead
  • Site Director
  • Activities Coordinator
  • Recreation Therapy
  • Home Care Nursing
  • Intake Coordinator
  • Medical Records Technician
  • Dentist
  • Nurse Practitioner

During the morning meeting, the site director took notes as various professionals commented on the status of various participants (recent falls, ER visits, injuries, transportation issues, medication changes, etc.). It was amazing to see the level of knowledge all the attendees had about individual participants, and their level of care and concern. For example, the home health nurse had visited a person over the weekend who had recently been placed in a skilled nursing facility. The woman was apparently quite disoriented and very upset about being removed from her home, and the nurse requested that anybody who saw the woman “give her a little extra TLC” to help ease her mind.

I also appreciated that even when there were disagreements about the best course of action to take with a participant, the atmosphere remained professional and there didn’t appear to be any “turf wars” – i.e. nobody was competing to make sure “their discipline” took charge of a situation simply for the sake of taking charge, they all just wanted to make sure that the participants received the best care possible regardless of who was providing it.

The team “vibe” was truly one of shared achievement, effective communication, and positivity, which was demonstrated by the “Tips for Team Communication” posters displayed throughout the building, the friendly nature with which people interacted, and even the “Good News and Gratitude” part of the morning meeting where people gave kudos to one another for jobs well done! This fieldwork placement is really showing me the value of teamwork – for both clients and professionals – and I hope to be able to work in a place like this in the future.

 

The PACE Participants

Because I have a fieldwork assignment to complete as part of my FWI placement, I am required to learn more about one person’s narrative, diagnosis, health conditions, etc. during my week here. I ended up spending much of my first day (and writing my assignment) with the first woman I met at the center, who I’ll call Ms. Key.

Ms. Key is a 75 year old white female who was living in a skilled nursing facility as a result of a CVA she suffered right before New Year’s 2016. The CVA resulted in her having left hemiparesis, decreased standing endurance, slowed fine and gross motor skills, and difficulty swallowing food safely. Still, she remained in fairly good physical condition in spite of these issues. Ms. Key had close-cropped, snow white hair, a warmhearted nature, and a sassy sense of humor that she whipped out whenever she got the chance. She planned to return home to live with her adult son “John,” and her stated goal was being “able to do as much for myself as possible when I get home.” I spent much of my day talking to and learning from Ms. Key, and she was such a fun person to spend time with! She participated in most of the facility’s daily programs, and she was very cognitively sharp. Although she did need assistance with most ADLS, including toileting, dressing, bathing, and grooming, she was able to participate in many other activities, including the PACE choir, emotional well-being group, and exercise program.

Other clients in the center were not as high-functioning as Ms. Key. Although I did not learn the formal diagnoses of most other participants, it was clear that many people had conditions common to older adults, including stroke, Parkinson’s disease, advanced dementia, and various orthopedic and vascular problems related to falls, diabetes, etc.

For the most part, participants were friendly and open to having a student observe their sessions with therapists or participation in program activities. It did make me sad seeing the condition that some participants were in, such as having advanced dementia or Alzheimer’s or significant physical impairments that were unlikely to improve. However, the environment was one of hope and positivity, and that made it an easier burden to bear.

My favorite thing about spending time with the PACE participants was seeing the long-term relationships they had with the program staff – it was so fun seeing all the inside jokes and stories shared by participants and program staff, and knowing how meaningful these relationships were to everyone at the center. I’m only going to be here for a week, and I’m already getting sad when I think about leaving on Friday!

 

Working with Families

My first day at PACE was made even better because I was able to take part in one of the IDT meetings with Ms. Key and her family relating to her desire to leave the SNF and discharge to her son’s home in the area. She was planning to have a “trial weekend” at home with her son and two daughters so the family could get a better idea of what it would mean to have her living in the community instead of in a long-term care facility. The meeting took place with Ms. Key, her son “John,” her daughter “Kathy,” and most of the healthcare team listed above, and the focus was on helping her and her family understand what it would be like for her to return home and gauging her family’s capability of supporting her at home safely.

The meeting lasted about an hour, and Ms. Key was an active and vocal participant (although she stated that she could only hear about half of what was said). Each discipline summarized their work and goals with Ms. Key, and then they offered their professional recommendations about how to make her trial weekend (and ultimately, her final transition home) as smooth as possible. For example, the pharmacist discussed ways of packaging Ms. Key’s medication so it would be easier to administer. John was grateful for this suggestion, stating that in the past he always felt like he was “scrambling” to decide which medications his mother needed, as they changed often and he had difficulty keeping track of the most recent prescriptions. At this point, the RN case manager chimed in and offered to call and speak with him directly about any changes in medication and help make sure he was giving his mother the right meds. It was a great example of professionals working together to improve the outcome for the client and her caregiver.

The meeting also involved troubleshooting issues related to Ms. Key’s toileting and self-care needs, which was an area of priority for Ms. Key and the team. Specifically, Ms. Key is mostly incontinent of bowel and bladder and requires a person to be with her in the bathroom to assist with cleaning properly after using the toilet to avoid skin breakdown and avoiding falls. However, she adamantly refused to receive help from her son with personal care, and her son balked at the idea of providing this level of care. The team’s (partial) solution was to find a home health aide who could be with Ms. Key when John wasn’t home, but they were struggling to find an aide. Until somebody could be found, neither the team nor the participant or her family knew exactly what would happen during the trial weekend and in the future.

I’m going to be leaving this fieldwork site at the end of the week, but I hope to follow up with Ms. Key or my supervisor in the future and find out what ultimately ends up happening.

 

OT’s Role

I also spent a lot of time on my first day observing OT assessments and re-evals with various participants. My supervisor “Sarah” used typical rehab equipment, such as a dynamometer, as well as a mix of other cognitive and functional assessments, like the Trail Making Test and having Ms. Key don and doff socks. I also observed Sarah showing the rehab aide how to apply one participant’s splints and completing range of motion exercises with another person. She also provided consults about other clients’ needs related to feeding and other ADLs.

I was slightly disappointed with the limits of OT I observed in this particular PACE setting; as a current student I am only too aware of the huge role that occupational therapy can play in the lives of older adults. While many geriatric OTs focus heavily on ADLs and self-care activities – and with good reason, as remaining independent with tasks like toileting, feeding, and dressing is a priority for many people – there is also a need for us to ensure that older adults are given opportunities to participate in meaningful life roles and social and leisure occupations as well. I knew I might have been in for a little bit of a disappointment when I walked into the rehab clinic and saw the pegboards, plastic cones, and Theraputty lying around. However, I tried to keep an open mind!

Sarah gave me a copy of the assessment worksheet she uses at the clinic, and while it does provide a lot of important information (and “hard data”) about the level of assistance a client requires and the areas in which they do/do not require help, I feel like it leaves off many important areas of occupation, such as sleep, leisure interests, mental and emotional health, social activities, roles, and routines. For example, Sarah had a ton of information about Ms. Key’s physical capabilities as they related to her ability to get around, move her joints and limbs, and complete various ADLs. However, there was no space on the form to include information about activities she enjoyed, members of her social circle, or how she felt about her current health and living situation. During my talks with her I learned that she enjoys reading, but that she has a hard time reading because she has difficulty using her bifocals properly. I would have loved to work with her on this, and I may mention it to my supervisor, but leisure doesn’t appear to be something that OT in this PACE focuses on.

This may also have had to do with the fact that there was a recreation therapist (RT) at the site as well. Although RTs can play an important role in helping clients develop leisure interests and participate in leisure activities, I think it’s important that OTs focus on this area of occupation too, not only because it is within our scope of practice but because it helps form a holistic view of the client and an intervention plan that may be more relevant or meaningful.

There were several other situations where practice areas overlapped and boundaries were drawn. During a meeting with Ms. Key and her family, the home health nurse planned to visit the home where she was going to be discharged and make recommendations for necessary equipment or adaptations. Although I’m sure the nurse will make plenty of helpful recommendations for the client, I couldn’t help but feel miffed that my supervisor didn’t make more of an effort to visit the home as well. Additionally, there was a “falls risk” assessment worksheet that almost team members completed for the participant’s records. On the document, there was one small “OT” box related to things like depth perception and figure-ground discrimination, and about a page of “PT” boxes related to gait, balance, motor skills, movement, etc. I suppose it doesn’t really matter as long as the client is assessed accurately, but I think it’s quite a loss to ignore OT’s understanding of a whole client (not just their perceptual skills) as it may add information about their risk of falling while engaging in various occupations or for other reasons.

Of course, this was only my first day at the clinic and I am scheduled to do home visits and other “non-clinic” stuff with my supervisor later this week. Sarah did have great rapport with all of her clients, and she was able to motivate them to participate in therapy even when they weren’t necessarily in the mood. The participants loved her, and she has helped many people regain function and independence in a variety of activities. Still, I’m hoping to see a more occupation-centered practice with PACE participants in the days to come.


 

All in all, my first day at the state PACE program was a lot of fun, and I am excited to go back again tomorrow! I’ll try to have a post about the rest of my experiences up next week, but it’s my spring break so no promises…I may also share my fieldwork assignment “case study” of Ms. Key so you can see the final result of my time spent with her, her family, and the interdisciplinary team. Until then, happy spring break for those readers who are still in school, and happy work week to everyone else!

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9 thoughts on “Setting the PACE: An OT Fieldwork with Older Adults

  1. teraanne March 8, 2016 at 11:10 pm Reply

    I love PACE programs too. It’s better if we can keep people living at home. It’s too bad there aren’t more PACE programs.

    • lej1123 March 9, 2016 at 5:04 pm Reply

      Yeah, I think it’s a shame that they aren’t available in all states/areas. There’s also a lack of awareness about who the programs can serve and how…just another area of advocacy for OT! 🙂

  2. Jasmine March 9, 2016 at 11:01 am Reply

    I’m glad you’re enjoying this PACE program! The level of teamwork in that facility is so inspiring and important. I hope to work in such an environment as well. Also, I completely agree with you on getting to know the client as a whole, it makes the care more personal, and they are, first and foremost, people. Enjoy your Spring break!! I look forward to reading more whenever you post. Your posts are getting me really excited to start my COTA program in the fall.

    • lej1123 March 10, 2016 at 7:22 pm Reply

      You are so right! I think k my favorite thing of all about PACE is the people, truly. The staff and the way they care for people who are often going through the worst times of their lives is amazing, and some days this week have been really difficult, but I’m learning a lot about the kind of practitioner I want to be.

      I’m excited for you to start your COTA program, be sure to comment/email me this fall and let me know how you like it and what your favorite practice settings are!

      • Jasmine March 16, 2016 at 11:13 am

        I will definitely email you and let you know how it goes 🙂

  3. taffny March 9, 2016 at 3:49 pm Reply

    My goodness! That’s sounds so fun; I wonder if there are any such programs in SoCal where I’m based? (:

    • lej1123 March 9, 2016 at 5:06 pm Reply

      It really is, I’ve abaolutely loved my week here! And I’m sure there are programs in your area, just click on the link above to see a map and list of PACE programs in the US!

  4. Paige March 15, 2016 at 2:35 pm Reply

    Why are you doing a level 1 FW if you have already done a level 2? Is that just how your program does it?

    • lej1123 March 15, 2016 at 9:14 pm Reply

      Yes, in my program we have multiple Level I fieldwork interspersed throughout the 2 years, in addition to the 2 Level II’s. So I’ve had FW I placements in 4 settings since starting school, which has been great!

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