Host Ankur Patel, MD, MBA, FAAFP, Chief Medical Officer, Tabula Rasa HealthCare, interviews Jeff Montemurro, Occupational Therapist for Inspira LIFE. Jeff is a dual-licensed occupational therapist and medical massage practitioner specializing in pain management and wellness. At Inspira LIFE, Jeff evaluates treatment for the geriatric population, completes home safety assessments, and provides recommendations to improve safety within the home environment.
Host Ankur Patel, MD, MBA, FAAFP, Chief Medical Officer, Tabula Rasa HealthCare, interviews Jeff Montemurro, Occupational Therapist for Inspira LIFE. Jeff is a dual-licensed occupational therapist and medical massage practitioner specializing in pain management and wellness. At Inspira LIFE, Jeff evaluates treatment for the geriatric population, completes home safety assessments, and provides recommendations to improve safety within the home environment.
Hello and namaste, everyone. I am Dr. Ankur Patel, Chief Medical Officer, Tabula Rasa HealthCare, and the author of the book Age Is Just a Number. Welcome to the episode of Keep up with PACE. I'm pleased to introduce today's guest, Jeff Montemurro. Jeff serves as an occupational therapist at the Inspira LIFE in Vineland, New Jersey. Jeff received his undergraduate degree and his masters of health science degree from Elizabeth Town College. He is a certified Kinesio taping practitioner and licensed bodywork and massage therapist. He has many accomplishments in PACE, but the reason we have him here today is because of his opioid initiative project at Inspira LIFE. Namaste, Jeff, and welcome to Keep up With PACE. Thanks for having me today, Dr. Patel. Let me, Jeff, congratulate you on a great project that you did with Inspira. Nationwide we are suffering an opioid epidemic, and you took this project head on, and showed that how in the PACE program we can decrease the use of opioids. So, congratulations on that. Let's go back to the basics. Why did you decide to become an occupational therapist? So, I knew moving throughout high school that I wanted to enter the world of healthcare. I wasn't sure exactly where that path was going to head, but I knew that I wanted to help people. I enjoyed science courses, and I took an interest in helping people maintain their function and improve with their abilities. And so, I started looking at schools for rehab both occupational and physical therapy. A little bit more investigation - I was led towards occupational therapy just because of the function-based piece of that. And so, I started my process there, applied to Elizabeth Town College. They had a five and a half year master track program, so I was able to enter there as my freshman year initially start taking OT courses to make sure it was something that I felt was going to be a good fit for me, which luckily it was. And, then I finished out my master's degree there in 2011. Awesome. You are the only person I think I know who is certified Kinesio taping practitioner. So, tell us, the listeners, what is Kinesio tape, and why you decided to get a certification in that. So, Kinesio tape is a modality that we can use to treat pain. It was one of the continuing education courses that were offered that I was trying to enhance my toolbox at the time. So, I initially started my career in Pennsylvania where OT's were able to utilize more modalities than they are in New Jersey. The rules are a little bit different here. We're not able to utilize some of the TENS units, and such, unless you have a PAM certification, which I do not hold. So, I was looking for other alternatives to be able to treat pain independently when I'm working with people, and I came across the Kinesio taping method, did a little bit more research and took the courses. Initially, I just took an introductory course to see if it was something that I felt was going to be beneficial, and then I pursued to take the additional courses and actually sat for a national board exam. And then it allows you to become credentialed with using the tape. And, with the tape, you're able to turn muscles on, turn muscles off, increase circulation and blood flow, provide extra space to the area. So, essentially, it's really things that we're already doing as therapists. It just allows you to have a little bit more carryover between your treatment since the tape can be worn for a three to five day wear schedule. So, it will allow some carry over between our treatments with hopes that at the next treatment we can continue to work towards progress with the other tools that we're currently using. Do you need to be certified to use a Kinesio tape, or, let's say an occupational therapy in California or Florida can do it without the certification? Correct. The certification is not required. It's encouraged because obviously, the more knowledge you have about the tape, the more fancier you can get with your applications. Kinesio does encourage you to take an introductory level course just to understand the concepts of how to apply turning on a muscle versus turning off a muscle. But once you get the basic concepts down, you can really get creative with it and apply it with head to toe application. So, if you've identified that the trapezius muscle needs to be inhibited, you now know how to turn that muscle off, or if there's a different muscle that needs to be activated, you know how to turn that muscle on. So, after you were working in Pennsylvania, and then started working in Jersey, how did you come across PACE? So, when I moved to New Jersey, I was looking to make a lateral move in Pennsylvania. I was working at an inpatient rehab hospital, and that was my scope that I was looking for when I moved here to New Jersey. At the time, there were no full time openings, only per diem. Applied for some of those, and was looking for something more full time and stable, and stumbled across Inspira's healthcare network. I grew up in Jersey, so I was familiar with the hospital organization. And at the time that I applied, quite honestly, I thought I was applying for just an outpatient rehab center, didn't really know what PACE was, didn't have a whole lot of education on it in school, and just kind of trial by fire, got in there, learned the insurance regulation piece, and kind of went with it. I honestly did not know what I was getting myself into. Some things happen for good reason, Jeff. So, we have you in PACE, and you have done great work. But, to that point, you are correct, because in my medical school and residency, and even in geriatric fellowship, there's not a lot that we learn about PACE. So, I remember that you have occupational students coming to your PACE center where they will come and work with you. Do you think that is something that the occupational students are liking it? And, that's how we are also increasing the awareness of PACE, that this is one of the options for occupational therapist? Absolutely. So, I'm contracted with, I believe, four or five surrounding colleges, universities at this point, where we're accepting occupational therapy interns to do their level-two field work with us here, on site, where I serve as their mentor, which is part of the qualification to get your graduate degree and become licensed in this field. And, ahead of time, I always make sure that they look up what PACE is - and, a lot of them, unfortunately, find a lot of trouble researching that online because there's not a whole lot out there. I mean, we've come a long way over the years, but I still think we have a long way to come. Typically for rehab class, you might have a class called "Systems in Healthcare", and they'll talk about what does rehab look like in the hospital system, in the school setting, in psych or mental health, or all these different places you could work. And, I always encourage the students, if their instructors are willing or interested in ever having a presentation on what PACE is and what does rehab look like in PACE, I'd be happy to make that connection and provide a little bit more light to the area. I think this is for listeners too, Jeff, as you know, that this podcast is more to increase PACE awareness. And, this might be a good opportunity for all the occupational therapists who are in PACE, nationwide, can possibly contact the nearby schools where they have occupational therapy schools and kind of give a presentation once a year. What is PACE? What is the role of occupational therapy in PACE? Because, this PACE is a hidden gem that needs to come out. And, we want great occupational therapists. They should not just think about there are
only two options:inpatient and outpatient occupational therapy. There is another option called PACE. Yes, absolutely. Especially from an OT standpoint. Our primary goal is to help maintain safety and independence in the community, which at the end of the day, is really what life stands for, living independently for the elderly. And we're trying to maintain and promote them being safe in their home and avoiding the need for placement, whether that be in the hospital or the nursing home. So, OT is huge - involved within the interdisciplinary team within PACE. Awesome. So, how long have you been with PACE now? So, I joined PACE - I believe it was the end of 2013. About fall of 2013, I came on board at the Inspira LIFE Center in Vineland. That's almost nine years you have been in PACE. Coming up! Do you see yourself outside PACE ever? So, you know, quite honestly, you get used to the chaos, and, there's a little bit of spoilage to it, too. So, one of the benefits of working for a PACE organization is you have a lot of autonomy as a clinician. So, I can remember my career prior to coming to PACE, and you had orders. OT "eval" and treat. You had to evaluate this person, and you were going to see them for treatment, whether or not you think that they were going to benefit, or really required it from a clinician standpoint. And, then you had to see that person for X amount of minutes, 30 minutes, 60 minutes, 90 minutes. It didn't really matter from an insurance standpoint if your patient was nauseous, if your patient was in pain, if your patient was not having a good day and wanted to refuse to rehab, you needed to see them during their scheduled time or on your own time, inconvenience your own personal schedule to make up those units for billable hours, or else the case wasn't going to get covered, or in some circumstances, you weren't going to meet your quota for payment. In PACE we evaluate all of our participants when they join, we monitor them on an annual basis. And, as an autonomy clinician, I am able to make the decision, yes, this person is going to benefit from OT services. I'm going to see them for XYZ. I might see them initially to set up some equipment in their home and do some training, set them up with a home exercise program and then monitor them yearly. Other people are more involved than they might need to be seen twice a week for more traditional treatment. Some people join the PACE program, and quite honestly, they don't really have any rehab needs, but they're benefiting from some of our other supportive services, such as the social work department. Or, they need medical management or transportation. So, not everyone is forced to be on caseload if they're not truly going to benefit. And, those are the things that you'll learn in school how to identify what is truly a skilled need. And, I feel like in the real world, unfortunately, that gets really twisted with insurance kind of being held over our heads. So, being the insurance provider and the clinician has really helped me grow my autonomy and my clinical skills and judgment. And, I really think I would have a hard time going back to someone making those decisions for me on my behalf. No, that's a great point, Jeff, that you mentioned. So, tell us more about Inspira LIFE, how many locations they have, how many participants are in the program. So, we are located in Vineland, New Jersey, on Delsea Drive. We're about only a two to three minute drive from our supportive hospital Inspira Medical Center in Vineland. And, we currently, I believe, are hovering just shy of maybe 300 participants. Right now, our staffing for the rehab department is two full-time OTs and two full-time PTs. And, we have a rehab supervisor, and a rehab aid, or tech, who helps with a lot of our scheduling and equipment ordering, answers our phone calls, and helps just from a management standpoint - making sure that the day flows. And, we are also in the process of opening a new life center in Williamstown. And, that is up and running. We've yet to have an official launch date. I know the building is done and has passed all of its inspections, I believe. But one - we're just waiting on clearance so we can get that area started in. And, that's in Gloucester County. So, we're definitely expanding our territory. And, I'm sure once that site is up and running, we'll have a lot more opportunities there, too, because from a space standpoint, that center was built with PACE in mind versus where we're planted right now. We bought a building and we've kind of grown into it and outgrown it and had to make modifications and be creative. And, this new building I'm super excited about because we got to have a lot of input of what do we really need in the gym? What don't we really need in the gym? Do we need private treatment space if we need to work on a modality, or if we need to have a private conversation with a participant? So, exciting things definitely are coming. Now, I'm really excited for you and congratulations on your new center, and for listeners, where the original PACE center in Vineland, New Jersey, that falls under Cumberland County in New Jersey. Cumberland county is the sickest county in New Jersey. So, the population that Inspira LIFE is serving is one of the sickest patient populations in the state of New Jersey. That is true. Absolutely. And before we go towards the meat of the program, about the opioid initiative, I just have a few questions about how your practice, as an occupational therapist, changed during COVID and now. Yeah, sure. So, when COVID hit, it was a huge game changer, as it was for everybody else. So, in the beginning, it was stay home and don't go anywhere. And, as a therapist, that's something we were never told before because we were always involved in the mix. It is very hard to do our job without physically, or so I thought, without physically being present, without physically having our hands on someone, because that's the way we've always practiced. So, initially we had to get very creative with how can we keep tabs on our people? How can we help them to stay safe? How can we continue to help them from falling if we can't physically be present? So, we had to do a lot of brainstorming. We came up with some tele-options. We've instituted this device called the Care Coach, which is an electronic device that is in some of our participants' homes. And, we're able to utilize that. It's a small iPad. We can put home exercise programs on there. And, the Care Coach will provide reminders to our participants to do those programs, or safety reminders - make sure you have footwear. Don't forget your walker, don't forget your wheelchair, don't forget to wear your emergency button unit. So initially, it was a lot of that. Now we have migrated into a hybrid program where the center is starting to reopen. So, we do have some people trickling into the center - our more high risk population. But, for the most part, PT and OT have transitioned to home care-based models. So, we're going into the homes, we're seeing people in their homes. And, from a scheduling standpoint, was initially pretty tricky. Who do you see on this day? We cover a pretty large geographical area. Cumberland County is huge radius, mile-wise. So, on Monday, you're going to see your people in Vineland. On Tuesday, you're going to see your people in Millville, or some of the surrounding cities that we're covering. And, then making sure we're able to hop on meetings for morning meetings to get our updates and our huddles. And, we started using a platform called Microsoft Teams, which has been a game changer for us because you can hop on your meeting from house to house, or you can hop on your meeting during a commute, or if you're in a private space because you're doing your documentation, you can hop on your meeting there. You have earbuds, you're making sure that you're maintaining patient confidentiality, and HIPAA, and all those things. So, it's really allowed us, in some senses, I believe, to be even more efficient because we're not stuck just in a building. We're going into their homes, we're treating them in their natural environments. When they're complaining about a problem that they have in their house, we're seeing it there real time live. So, I would say right now we're kind of a hybrid program. I'm seeing some people in the center, I'm on the road, I'm in their house - a little bit of everything. So COVID has taken PACE outside of a box. Yes! From a four-wall center, to you all have been very creative. Yes. Even more so - we've never really been in the box, but we're way out of it more than what we were initially. Yeah. You mentioned with the Care Coach, you set up an in-house exercise program. How was that received by our participants? Some of them very well, others struggling with it. So, it's on a case-by-case basis. Some of them really benefit from it. They just need the cues and the reminders, and they can carry that out independently. Other people that weren't responding super well to it, that still need that in-person visit, those are our high priority patients, high acuity, that we're still going out to the house. So, from a rehab standpoint, just having to reevaluate, what's my biggest bang for my buck here? Based on what I know about this person, and their cognitive status, and their home living environment, and their accountability to their own health care involvement - who needs to be an in-person visit? Who can be a follow up phone call? Who can benefit from a Care Coach device and just really utilizing all of our resources? And, what will be this one or two lessons that you learn during COVID that you will continue to use moving forward? That's a good question. So, I would say probably just prioritization. So, personality-wise, I tend to be one of those people...when there's an issue, I got to jump on it right away. It's a fire. We got to fix it right now. And, really just taking that moment and step back and say, do I honestly need to drive 20 minutes out to this person's house to make a resolution, or is this something that I could handle sufficiently via a phone call? Or, can I collaborate with one of my other team members because I see the nurse is going to be there tomorrow during a med- path that I could collaborate with the nurse and "Teams-in" if I need to visually see the person - tele? Or, can the nurse bring something out for me if she's already going to be going in that direction, that I could hand off a piece of equipment? So, I would say stepping back and reevaluating, does it have to be a face-to-face visit to meet the need? And, number two being improving collaboration of care between disciplines to work more efficiently as a team, instead of trying to be a one-man job, and just focusing on looking at everything from an OT perspective only. That is awesome. Now, let's talk about the reason we got you on our show. You started an opioid initiative program, and you thought that at your PACE organization, the opioid use is high. So, give us the background to the listener- why you decided to start this initiative. Yeah. So, for those of you that are familiar with PACE, we're not only the clinicians there, but, we're also the insurance provider. So, part of working for PACE comes with trying to be fiscally responsible. And, how can we manage our patients, not just in the here and now, but long term? So, when I first came to PACE at the end of 2013, for a month or two, I was just getting my feet wet. A lot of observation. What is this? How do I navigate in this new field? And then, in 2014, getting more endowed into treatments and stuff, there was a lot of resistance to rehab. No one wanted to do therapy. No one wanted to exercise. And, when I really started digging down and taking a step back and looking "why", it seemed that the common thread was pain. I don't want to move because it's going to hurt. I don't want to move because it hurts. I've done therapy in the past, and it's hurt. Everything hurts. The initial thought was, well, how can we make it not hurt? What do we got to do to kind of unwind that and take a step back? So, looking at the building blocks, you can't crawl, or you can't walk before you crawl, so, you can't do therapy if you're in pain. So, trying to treat the pain, which comes within our scope of practice as practitioners, OT's and PTs, we do a lot of pain management, started to just really try and collaborate with our clinical team and say, hey, what can we do to try and better manage this person's pain? And, a lot of it - at 2015 - that's when you were medical director at the time of the PACE Center, right? In Vineland, Dr. Patel? Yeah, I started January 2016. Okay So, you came with that idea. All right, getting the ball up and running, and trying to make some connections with the clinical team. And, it was tough to make that connection. And, we were doing a lot of pain management, but we were doing it just within the rehab department. And there wasn't that carryover between pain management, between going out for an Ortho specialist, between our in-house life clinic. And, then I know you came on board and we started chatting. How do we work together as a team? Because a patient would be coming to me, and I would be trying to treat them for their pain. And, I look on their calendar, and they're seeing pain management, they're seeing the orthopedic, they're on pain meds. So, they kind of have all these things going on at once, and the process just really wasn't streamlined. So, I remember you coming to me early 2016. I was like, two weeks in, and your first thing I remember you told me, Dr. P, so many of our participants are on opioids and we can reduce it. And, I remember that conversation. And, there's where I think - to all the medical directors who are listening - is whenever an IDT member comes to us with some kind of initiative, we need to encourage them, and remove the barriers for them. Jeff took the initiative here. And, then the next question with us was how we can all work together? So, that's how we got the providers involved. We invited our pain doctor for lunch, and we took him on a tour at the PACE center and showed him what we do. And, he was really surprised with what non-pharmacological treatments Jeff was offering. And, in his defense, he looked into our eyes and honestly told us, when you referred to me, I assumed that you have done everything that you could, and I'm prescribing opioids. A lot of it too, I think, was just education, right? Everybody understanding each other's roles. So, I know that I've done quite a bit of work, and still do, work with the pharmacist who is in with the Inspira LIFE program as well, too. And, understanding - pharmacist is doing the med reviews. They're triggering people that are high fall risk. And, a lot of times the high fall risk meds are meds that they're on for neuropathy, or for pain, or their opioids. And so, working together with them saying, okay, if we're going to try and minimize some of these meds, we got to have a backup plan. What are we going to do to treat their pain? Working with the PCPs, they know traditionally PT works on gate stability and strengthening, and OT works on self care and cognition and safety. But, there's this whole other realm of pain management umbrella that I think a lot of time gets overlooked. And so, just understanding for the nurses and the PCPs and the pharmacist, hey, your rehab department is able to be a huge player in pain management. And, let's see what we can do as far as in-house management for treatment before we consider that outside referral. And, the problem that we ran into is the backtracking piece, right? Once we issue the pill, once we start with the orthopedic referrals, once we start with the pain management referrals - it's: "I want more, more, more." And then, to take that back, it's really hard to unwind. So, it's kind of just trying to set some precedents and policies. And, it's not to say that those things aren't beneficial, or not needed. I just think we need to focus on in- house management as much as possible. And then, obviously we use that as a backup plan if the non-pharm modalities are not successful. Because, they aren't always, but a lot of times they can be sufficient and providing relief. Definitely, to your point, that you mentioned about them. The participant will be dissatisfied. And, I remember those reports coming to my table about why participants' dissatisfaction rate is high, and that's where the balance comes in. One of the biggest advantage that we had after our pain specialist came to our center, see what Jeff and his team is doing, what the providers are doing. So actually, the specialist was also thinking too. He was on the same page like us, that even if the patient was going to him to get opioids, they know that eventually with the help of the Inspira LIFE program, we will be decreasing, and tapering the patient off opioids. Absolutely. And, I mean, historically, it's tough because pain is a sensation, and everybody interprets that differently. So, there's this huge emotional insight component behind it as well, where all of these things kind of factor in. And, the people that we're seeing, being in PACE, they're 55 or older. So, pain is probably not something new for them. For a lot of these people, it's not an acute issue. It's something chronic that they've been dealing with for years upon years. They haven't sought treatment, or the only treatment that they've sought, or received, is pharmacology. So, introducing something new at this later stage in the game is one of the biggest barriers and challenges. And, we have to start to tear down those walls and really work together as a team. I know one of the other barriers we would see quite often is kind of staff splitting - when I would be doing my assessment, and one of the questions I always ask is, are you having any pain? No, I'm fine. Okay. Therapy pain zero out of ten - clinic does the assessment the same day, sometimes within the same hour. And, pain is reported as nine out of ten or ten out of ten. And, often times, then you have to wonder, why is the report so different? One department is going to offer you exercise and modalities, and the other department is going to be offering you medication. So, a lot of times just communicating amongst those departments, hey, I see that in your assessment, they didn't report any pain. In my assessment, they're reporting pain. Then the referral should be coming back to rehab. Okay, well, I want you to meet with my rehab team, and see if there's anything they can do to help you. They have X, Y, and Z going on. And, I definitely remember the staff thing. That was a conversation we had. I remember with the providers, you, our pharmacist, still you are using CareKinesis. And, I remember sitting with Zach, who was our representative for our pharmacy from CareKinesis. He was the one also helping you with the numbers and showing what we are doing with opioids. That's the triangle, I used to say, that providers, the therapist, and the pharmacist working together and communicating because to that point, that patient splitting used to happen. They used to tell you something, and then they'll go and tell provider something else. And, improving that communication was solid. So, how did you implement the program later on? So, initially started out with education, kind of just piggybacking on what you just said. It was setting up an informalized presentation with our PCPs and our nurses saying, from a PT and OT standpoint, these are the following modalities that we're currently offering within our center. These are some of the benefits, these are some of the contraindications, and these are some of the participants that would benefit from it based on diagnostics and their complaints. And then, it was just a little bit of a change of shift for them. Typically, when someone would complain of pain, it was the referral. Okay, well, let me have you follow up with ortho let me have you follow up with pain management, and just that chain of - okay, well, first step is going to be we're going to follow up with PT, OT trial, two to three weeks. If no progress, PT and OT is reporting back to provider. Hey, I've been seeing this person. They're doing well. They're not doing well. They're consistently coming. They're not consistently coming. And then, from there, moving forward with a plan, do we need to bring in a specialist? Because we need some additional eyes on this person. Whether it be orthopedic or pain management. But, I also remember that, that communication was helping us so much because if they were not reporting to therapy, my providers were like, well, if you want your medication, I'm happy to work with you. But, our agreement is also you will go and see a therapist. So, I also felt like between you and the providers, you both were holding the patient accountable also. Yeah. And, that "A" word - accountability - is so, so huge, right? I think, honestly, that is the biggest barrier in PACE programs because we struggle so much with accountability, right? So, someone joins our program, and they have no cost for them. Whereas, out in the Medicare and Medicaid world, you may have a copayment for your rehab, or you may have a copayment for your hospital visit, or for your medication, or for any of those things. Once you enroll into the PACE program, everything is provided at no cost as part of the insurance, which is great for our participants from the receiving end. However, from a clinical provider rehab standpoint, it's very difficult to hold those people accountable other than trying to encourage them their own benefit, and of their own health with progressing with that. The accountability piece is something we continue to struggle with. Patient splitting was one of the barriers. What other barriers you kind of faced when you started this program? One other barrier that we haven't mentioned, I think it's important to point out, is time and space constraints, right? So, in order to provide some of these more intensive, non-pharm modality treatment, clinicians need some one-on -one time with our participants, and, we cover, and we manage a lot of participants. So, sometimes workflow just needs to be looked at as far as how we can manage that. And, about this time is when we kind of expanded our rehab department as well. We were able to get approval to bring on a rehab aid, and that helped greatly with just the workflow of - if we had someone in the gym that needed private space, the rehab aid could hold that spot for them. The rehab aid could assist with setting something up if a heat pack needed to be removed, or provided, or set up. Also with scheduling to make sure that we weren't getting overflooded with having three people coming at once. So, I think that additional restructuring of staff allowed us to use our clinicians for more clinical things rather than just the day-to-day operations. So, that was initially a barrier, but we were able to move past that. So, now let's go towards, now we have the medical director, the providers, the pharmacist, the pain management specialist, yourself, and your team all work together. So, now, let's shift the gear towards the non-pharmacological services that you used to provide to the participants. So, we have a pretty exhaustive list that we provide. I'm obviously a part of that, but not the sole keeper. So, we have a pretty dynamic group of providers. And, amongst our team, some of the services that we currently offer for management of pain is cold laser, cupping therapy, the traditional heat and cold modalities, Kinesio taping, as we mentioned earlier. What is a cold laser like? If you have to just explain in brief. Sure. So, cold laser works at a cellular level to help to reduce inflammation, and it is for a point, tender location pain. So, your patient who's complaining of carpal tunnel, or a golfer's elbow, tennis elbow, something that's really no bigger than a quarter size, half dollar space, that you would be able to use the laser to treat. And then, you mentioned cupping. And, I remember cupping got famous when Michael Phelps has those bruises on his body. How cupping works? The cupping that we use at the LIFE center is more of a dynamic approach. So, rather than leave it on where you see the traditional bruising, we use it more for just fascia work.
So, it does two things:one, it just loosens up the soft tissue to the surrounding area, and it also brings a lot of circulation to the area. So, a lot of times we know people that have chronic injuries, they have reduced blood flow to the area. And, one of the things we want to do is promote blood flow because that jump starts the healing process. So, cupping treatment to an area would assist with that. Now, we talked about Kinesio taping, but there was specific about Kinesio taping. I remember you putting for lower back pains, and other pains, but I remember for bruises and leg swelling. Am I correct that you used to use that and how do you use that? Yes. So, one of my favorite Kinesio taping applications is actually for rib fractures, because rib fractures, you're very limited with what you can do as far as pain management. You can't really do any binding or bracing because it's going to put your person at risk for pulmonary adverse reactions, especially in our elderly population. With Kinesio taping, we are able to take pressure off of an area. So, there's different applications that you can learn. So, that's the way that we would use it for rib pain and bruising as well too. So, when we're increasing the circulation, it just jumpstarts the healing process. With the swelling piece, there is edema to an area. You anchor your tape towards the closest lymph node, and it actually picks up some of that superficial fluid and brings it back towards the closest, or most localized lymph node, puts it back through your lymphatic system, and helps drain that out - from a swelling standpoint. Is it fair to say - because I remember you used Kinesio tape on a lot of our patients - is it fair to say, like, if you have to tell nationwide occupational therapists in PACE, out of all this non- pharmacological way that works the most, or you saw the most benefit, was possibly with Kinesio tape? I would say that's definitely in the top three for sure, with the primary reason
being for a couple of reasons:one is that it's a take-home application, right? They can wear it for three to five days. So, you have that carryover of the treatment lasting for more than just the 15 or 20 minutes while you're with somebody. And, from an interpretation, and just touch standpoint, whether there is a psychological benefit to it or not, just the fact that you're taking the time to touch someone, to address their complaint, to place something on their body, they visually see the reminder that it's on their body. Absolutely. Scientifically, physiologically, it is benefiting them. But, it also helps from a psychosocial standpoint to know that their concerns are being heard and addressed. Yeah, exactly. I can see that. So, can they shower with the tape on? Yes. So, the tape is waterproof. They can swim with it on, they can shower with it on. Just no submerging for an hour after placement to allow for adherence. But, it is waterproof, and then it dries pretty comfortably as well. The tape is actually made to represent the epidermis, the most outer layer of the skin there. So, it is a comfortable, breathable wear. I know that you also do medical massages. Like, how that is different than a regular massage? So, medical massage is focused solely on function, right? So, you have your traditional massage where you go for relaxation, and they're doing soft tissue work. Medical massage is all function-based. So, a lot of what I do from my medical massage practitioner background is we're looking starting at the core. How are the hips sitting? Is one hip more elevated than the other? Is it rotated forward? And, what muscles do we need to activate or settle down to allow the body to return back to homeostasis, or its normal resting position? Because a lot of times, when your core is involved, you end up with pain in your extremities because things are just out of alignment. And then, they start to take a toll elsewhere. What other services did you give to your participants? So, some of the other services that we
also offer:orthopedic prescriptions, which we try to use as a last resort. But, sometimes it's the bracing that can be helpful. Obviously, we're offering exercise and stretching programs. Our PTs utilize the electrical stimulation and TENS units. As far as topical agents, a lot of times we will provide that in the home for ongoing use. We have something that's called a still point inducer, which is, I know, something that not a lot of people are familiar with, but it is something that you can lay on, or rest your head against, and it hits the two occipital points right behind the base of your skull there. And, from a physiological standpoint, what it does is it activates the parasympathetic nervous system, allows your body to rest, allows the heart rate to slow down there a little bit. And, a lot of times when we have pain, we're always tense. We're always almost hyperactive in all of our sense. So, the people that are suffering from migraines, or your person that you put on the table, and you're trying to stretch them or move them, and, they are tense because they're anticipating pain, or they're nervous, or they're fearful. A lot of times that is a nice little additional tool to have. And, if someone's benefiting from it, it's something that we can order, and they can continue to use in their home environment. So, what was the aquatic program like? Like, pre-pandemic, I remember the bus used to take them, but what did you used to do? The aquatic program that was being offered, we rented space at our local YMCA, and with the assistance of our transportation team, we would bring over a select group of participants. And, it was actually an aquatic Zumba class that was being taught. So, the participants loved it because it was hidden exercise, right? They got to dance and splash around in the pool. Many of them haven't been in a pool, or had access to a pool, in numbers of years. So, just the fact for them to be able to get over there, and from a psychosocial standpoint, was huge for them. But, then we're able to work on their endurance. We're able to work on their cardiopulmonary status. We're able to work on their range of motion, and they're able to do it comfortably because they're submerged in the water. So, it takes away the pain that gravity typically provides when you're not submerged under that water there. I remember that somebody from your team was also doing Reiki therapy. Correct, yes. So, one of our therapists, one of our other OTs, actually, Christina, is a Reiki practitioner. So, that essentially is energy transference work. And, this was super nontraditional, but very beneficial for our people that maybe the underlying condition of their pain wasn't orthopedic or musculoskeletal. So, for example, you have your person who has a significant history of depression, right? We know oftentimes that depression can manifest with physical symptoms of pain, and they have complaints of headaches, or back pain, or shoulder pain, or knee pain. And, if we are strictly trying to treat those things from an orthopedic standpoint, chances are they're not going to get better, or they're not going to stay better. But, if we look at the root underlying cause, that possibly this is stemming from some underlying anxiety or depression. And, we can get them on a treatment table and provide the Reiki work, and really help them understand where that fear is coming from, where's it going, what goals do we have to improve? Then, we can move on to the more traditional non-pharm modalities, orthopedically, to then continue to treat any residual symptoms. That is excellent. And, this is where all the examples that you mentioned, that is the benefit of PACE, right? In a managed care setting, my occupational therapist and physical therapists do not have to worry about fee-for-service, and they have to see X amount of patients in an hour, whereas, here you can take your time with the participant, and do what's best for the participant. Yeah, absolutely. I mean, in a fee-for-service world, in the real world, really any world, outside of PACE, a lot of times these services aren't covered where you're trying to provide them, and having to alter your documentation, or bill under a different code. And, in PACE, we're able to treat the underlying condition, we're able to treat outside the box. We're able to spend five minutes with somebody, or two hours with somebody, depending on what their need and availability is. So, it's really nice to be able to meet the need, rather than trying to be stuck in the guidelines outside of a clinical provider or a therapist. And, when the occupational therapist is in a non-PACE world, like, I'm just trying to compare in PACE, what worked was your services, what you were giving, but also the communication that you had with the providers, the pharmacist, yourself. If you were an occupational therapist outside of PACE, did you ever talk to the primary care provider, or a pharmacist, or work together like a team feeling? So, pharmacy? Definitely no. As far as PCPs, maybe on a weekly basis at a weekly meeting for a patient update, but, it was more so just me giving a report out rather than a collaborative of care discussion. And then, the nurses may be on a daily basis to get a medical update. But again, it was a very brief report out, not necessarily collaboration of care. Hey, here's what I'm noticing. Here's what I'm doing. Do you have any additional feedback? Are you seeing any changes for better or worse? So, definitely not in any of the other roles that I've been in, at least outside of PACE. We love to hear success stories. Do you have a patient success story to share? One of the success stories that comes to my mind, initially, was a gentleman who is in the PACE program. He sustained a fall. He is wheelchair bound, but does live home by himself. He's got some pretty serious ataxia, so some difficulty with coordination and movement, but he does manage to do his transfer from bed to wheelchair, or wheelchair to commode. And, when he sustained his fall, he had some significant bruising to his bicep/tricep area, and it was on his right dominant arm. So, initially when we brought him in for evaluation, of course, there was the concern with pain. Of course, there was the concern with how is he going to continue to manage at home? Because this gentleman was pretty much solely relying on his upper body strength to do a stand pivot transfer from bed to wheelchair. So, this was newer on in my Kinesio taping certification. And, I remember seeing one of those pictures in the courses where they show you what a bruise looks like before and after Kinesio taping. And, at the time I thought it was a marketing shenanigan. You know what? We're going to try this tape application. It's surely not going to cause any harm. And, let's see if this stuff really works. So, he was agreeable to try it. We did the Kinesio tape application protocol for somebody who has bruising and swelling, as we talked about a little bit earlier. And, with that, the participant was able to remain home and continue with his transfers independently. And, quite honestly, really helped us avoid a short nursing home placement, because if he wasn't able to transfer, we were not going to be able to send him home because he wasn't going to be able to care for himself. And, he did not have a care support team from family in place. So, I took a before and after picture with his permission. So, clinically, we could actually see what the bruise looked like before and after. And, that was super helpful for our nursing and our providers to see, from an outside standpoint, really what that can do for bruised healing and the changes that you can visibly see on the eye with the skin. But, for me as a therapist, my win was the transfer status. My win was the fall prevention, and the safety, and the pain management. So, that's definitely one that stays in my mind and is near and dear to my heart. Just being able to keep somebody safely home and having to avoid that admission. That is a great, great, great story. And, I have actually a quote that a patient told me that you work with, and gave me a quote, and I still remember it.
And, the quote goes like:"not only did they give me my life back, they have given me a reason to live." And Jeff, that means a lot when it comes from our participants. And, thank you, and congratulations for the great job that you and your team have done. So, we are moving towards the end of our session. And then, before I go and talk about the results of the great work you have done, I would like to ask this question to all my guests. If you could step into my shoes, what would you ask yourself that I didn't ask you? I think the only thing that I would add is just, and we slightly touched on earlier, is the hidden gem of PACE. And, it being that not all health care providers are aware of what we do, what it entails. It is heavily an interdisciplinary practice. And, from a therapist standpoint, if you are looking for a role where you have autonomy in your clinical practice and you really want to make a difference in somebody's life and not be regulated by the traditional insurance company and be able to practice for what you went to school for, then I really think that this is a field worth considering and exploring further. How can the listener connect to you? As mentioned earlier, I'm at the Inspira LIFE Center in Vineland, New Jersey. So, you could always Google that website, and there would be a phone number there that you could ask to speak to the phone, the therapy department, leave a message, and I'd be happy to connect with you there. Or, if it's more convenient, I would be happy to reach out via email, and my email address would be: Montemurro: M-O-N - as in Nancy -T-E-M - as in Mary - U-R-R-O-J -@ IHN.org. Before we go to end of the show, which is my favorite part, rapid-fire round, nationwide, we all are struggling with opioids right now. In the PACE program, Jeff and his team has proven that how they can decrease the use of opioids. When Jeff started, and he came up with me to the proposal, and CareKinesis helped us out to pick up the data. In 2014/15, we had 206 participants, 79 were on opioids. That was 38.3%. And after Jeff and his team's great and excellent work, in 2017, we had 307 participants, and only 29 were on opioids. And, that is 9.4%. That decreased from 38.3%, in 2014/15, to 9.4% of the participants in 2017 and 18. And, that is 75% reduction in use of opioid. Congratulations on great work, Jeff. Wow. I'm excited to hear that. Thank you. And, that's what we want to tell everywhere. That, PACE is something that we learn from PACE, how you can apply this kind of a model at a bigger scale, like Medicare Advantage plan, or any other managed care, where you have the privilege to work in a team fashion. And, this was just one example from us that this is how one program at Inspira LIFE decreased the opioid use. And, many of you can do the same thing at your PACE Center. Or, if this is something, a model that works, you can expand it to a different level there. Okay, Jeff, we will go to our rapid-fire round. I'll ask you five questions, and you can answer in one to two sentences. Okay. What message do you have for other OTs, or IDT team members, across the nation? Don't get stuck in a rut, or in a box. Think outside of the box. Describe PACE in one sentence. Unique, comprehensive care. Who inspired you, and why? I can't think of one specific person, but I would probably just say my family as a whole. I was the first college graduate from my family, so that was a big personal accomplishment for our family, and just them constantly pushing me, and wanting me to do my best as far as advancing my career and my clinical skills. Great - family. One tip to survive IDT meetings. I would say movement. They sometimes last longer than they need to. So, stay moving and stay active. Keep your blood flow. And, the last question, if you have to tell a medical director, or executive director, at the PACE program one thing, what that will be? Listen to input from your front line staff, and take the time to realize how it could impact the program as a whole. Also, making sure that the interdisciplinary team feels supported in career advancement. So, whether that's providing continuing education hours, or allowing supervision and shadowing at other sites for program development. Great point. And, I will also encourage, and I'll second that, to all the medical directors and executive directors, that if your IDT member is excited for growth, and for some certification exams, that they can help our participants, please, please look into that and budget that also in the upcoming budget, so they can use that fund, and get better education and take care of our participants. Jeff, you have been great. Thank you for your time. Congratulations on this great project, and thank you for being our guest. It was a pleasure speaking with you. Awesome. Thanks so much for having me. Thank you for joining us for this episode of Keep up with PACE. We hope that you found the information shared valuable, and I invite you to join us for the next episode. Keep up with PACE is sponsored by CareVention HealthCare, a division of Tabula Rasa HealthCare. CareVention HealthCare provides comprehensive services and solutions for PACE organizations at every stage. For information about CareVention HealthCare, visit our website at CareVentionHC.com. See you in the next episode with a new guest. Until then, namaste and goodbye.