Functional Maintenance Programs in Long-term Care

Perhaps one of the biggest challenges for therapy professionals is helping patients as well as facility staff maintain the gains made during therapy, which is why Functional Maintenance Programs are so important. FMPs are designed to help maintain the functional capabilities of a nursing home resident beyond the time spent in an active therapy program.

An FMP is developed by a skilled therapist but carried out by the caregivers in a long-term care setting. These may include family members, nursing assistants, activities staff, or social services personnel. FMPs are designed to optimize residents’ functional performance in areas such as ambulation, transfers, wheelchair mobility, ADLs, communication methods, and safety.

Identifying Residents Appropriate for FMP

Identifying individuals who are appropriate for an FMP requires some thought and effort, but general guidelines include residents that are:

• At significant risk of decreased function;
   
• Able to use present abilities in a functional manner;
   
• At risk of further medical complications; and/or
   
• On active therapy and continue to require specially trained procedures to prevent further decline and maintain function.

It is important to note that often a patient may be on active treatment after coming from the hospital and will eventually return to the long-term care portion of the facility. The functional maintenance program can be incorporated into the final days of the rehab plan as part of the discharge process. This is often the best way to ensure all the gains made in therapy are preserved following discharge.

The 5 Essential Components

Each facility must develop an effective process to identify residents that have a need for an FMP. The five essential components of establishing/designing an FMP are: Screening, Evaluation, Training, Documentation, and Follow-up.

• Screening. While the screening process may vary among facilities, the APTA defines a screen as follows: Determining the need for further examination or consultation by a physical therapist or for referral to another health professional. A rehab screen may also be generated by a referral by any staff member and/or family member at any time a documented change in the patient’s functional or medical condition occurs.

Screening should be an interdisciplinary collaboration and may potentially include input from the entire staff as well as family members. Remember the “three Vs” to ensure you have a complete picture of the resident’s needs: Visit the resident, Visit the Staff, Visit the chart. Finally, screening referrals often happen by word of mouth. A member of the housekeeping staff, for example, may mention a certain resident in need. Because documentation is extremely important, it is strongly advised that the medical chart be updated when a referral is made for a rehabilitation screen. This notation should also include the change in condition that warranted the referral.

• Evaluation. In order to justify an FMP, certain essential features are required with regard to documentation. This is particularly important during the evaluation process and should take into account the following:
  • Current functional abilities must be included to establish a baseline functional status.
     
  • The primary problem or decline in function must be identified and described.
     
  • An explanation of how the program will prevent, resolve, or reduce the risk of the current problem—including the expectation of an enhancement of function.
     
  • Objective measures and descriptions such as photographs, ROM measurements, Functional Independence Measure (FIM) scores, or other scales/tests as needed.

• Training. The purpose of training is to help the care team carry out the FMP and demonstrate independent implementation of the FMP safely and effectively. This process involves teaching and demonstrating the techniques and modifications of the FMP as well as observing and providing feedback to the caregiver until a desired result is achieved. Therapists are well suited for this type of work; we do it all the time with our patients. Caregiver training is just a logical extension of this skill.

Remember that the resident is the most important person involved in training and should be trained to the level of their understanding about their FMP. Then, they can fully participate in the design and structure of an FMP. Because of changes in personnel and shifts, the resident will be the most consistent part of the plan and can pass on information to others. In effect, when appropriate, the resident will train his or her caregivers.

• Documenting. Documentation is a large, essential part of the therapist's job, and this applies to the FMP as well. Because FMPs are interventions of such short duration (usually no more than a few visits), it is best to complete a daily note to describe the actions taken and the responses observed. Documentation of the FMP includes the notes that describe the plan for the FMP in all of its necessary detail—including specific information for the caregiver, instructions, diagrams, pictures, and schedules for frequency and duration of interventions.

• Follow-up.  Prior to discharge there should be an analysis and discussion period with the patient and caregivers with regard to the results of the FMP. If a change in status has been noted, the patient should be considered for evaluation. Occasionally a brief reinforcement of the past techniques is all that is required as intervention. As it is inherent in the nature of long-term care for the residents’ level of function to change over time, there can be a cyclical nature to the need for intervention, in which periodic intervention is required to maintain one basic level of function.

Changing Our Mindset

We often settle into the mindset that therapy is solely a short-term dynamic between the therapist and the patient. However, we need to remember that maintaining the positive results of therapy is a long-term process that involves the entire care team. The functional maintenance program is a valuable, necessary, and often underutilized tool, but one that may provide significant benefits for you and your patients.

To learn more about Functional Maintenance Programs, including government policy and regulatory components surrounding FMPs as well as therapy-specific programs, take our online course: Functional Maintenance Programs.

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