PROGRESSIVE DISEASE IN THE GERIATRIC POPULATION: MAINTAINING THE MOVEMENT SYSTEM

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PROGRESSIVE DISEASE IN THE GERIATRIC POPULATION: MAINTAINING THE MOVEMENT SYSTEM WILLIAM DIETER PT, DPT, GCS DIRECTOR OF PT CLINICAL SERVICES DIRECTOR

1 PROGRESSIVE DISEASE IN THE GERIATRIC POPULATION: MAINTAINING THE MOVEMENT SYSTEM WILLIAM DIETER PT, DPT, GCS DIRECTOR OF PT CLINICAL SERVICES DIRECTOR FOX GERIATRIC RESIDENCY IN PHYSICAL THERAPY MEGAN VALENZANO PT, DPT, GCS, CEEAA DIRECTOR OF REGULATORY AFFAIRS DIRECTOR OF QAPD FOR POST-ACUTE SERVICES

2 COURSE OBJECTIVES By the end of this program participants will be able to: Identify regulatory resources that apply to assisting the older adult in maintaining function within their practice setting. Understand and base their treatment plans on the difference between Restorative/Rehabilitative and Maintenance therapy. Apply principles from APTA s Guide to PT Practice 3.0 and the ICF model when addressing maintenance plans with their older adult patients. Apply appropriate supervisory principles that follow all regulatory guidance when conducting a maintenance program with their older adult patients. Design an appropriate treatment plan that assists an older adult in maintaining their current level of function. Incorporate techniques in their documentation that assist in demonstrating skilled care during interventions to address maintenance of function in the older adult.

3 WHAT IS HEALTHY AGING?

4 JIMMO V. SEBELIUS RULING From CMS: No Improvement Standard is to be applied in determining Medicare coverage for maintenance claims in which skilled care is required. Clarification of Medicare Benefit Some instances goal is to restore function: IRF

5 JIMMO V. SEBELIUS RULING The manual revisions clarify that a beneficiary s lack of restoration potential cannot, in itself, serve as the basis for denying coverage in this context, without regard to an individualized assessment of the beneficiary s medical condition and the reasonableness and necessity of the treatment, care, or services in question. Conversely, such coverage would not be available in a situation where the beneficiary s maintenance care needs can be addressed safely and effectively through the use of nonskilled personnel. -CMS Jimmo v. Sebelius Settlement Agreement Program Manual Clarifications Fact Sheet

6 JIMMO V. SEBELIUS RULING Restorative/Rehabilitative therapy. In evaluating a claim for skilled therapy that is restorative/rehabilitative (i.e., whose goal and/or purpose is to reverse, in whole or in part, a previous loss of function), it would be entirely appropriate to consider the beneficiary s potential for improvement from the services. We note that such a consideration must always be made in the IRF setting, where skilled therapy must be reasonably expected to improve the patient s functional capacity or adaptation to impairments in order to be covered. Maintenance therapy. Even if no improvement is expected, under the SNF, HH, and OPT coverage standards, skilled therapy services are covered when an individualized assessment of the patient s condition demonstrates that skilled care is necessary for the performance of a safe and effective maintenance program to maintain the patient s current condition or prevent or slow further deterioration. Skilled maintenance therapy may be covered when the particular patient s special medical complications or the complexity of the therapy procedures require skilled care. - CMS MLN Matters Number: MM8458

7 MAINTENANCE AND MED B So, what does this mean for me as a treating clinician? Clinical decision making is paramount PTAs cannot provide maintenance services under Medicare Part B Documentation is key Knowing the rules can be freeing

8 MAINTENANCE AND MED B For example, on being Reasonable and Necessary: Coverage for skilled therapy services related to a reasonable and necessary maintenance program is available in the following circumstances: Establishment or design of maintenance programs. Delivery of maintenance programs. - CMS Benefit Manual, Chapter 15, Section D

9 MAINTENANCE AND MED B For example, Progress Reports: Justification for treatment must include, for example, objective evidence or a clinically supportable statement of expectation that In the case of maintenance therapy, treatment by the therapist is necessary to maintain, prevent or slow further deterioration of the patient s functional status and the services cannot be safely carried out by the beneficiary him or herself, a family member, another caregiver or unskilled personnel. - CMS Benefit Manual, Chapter 15, Section D

10 ICF Model Heather L. Atkinson, and Kim Nixon-Cave PHYS THER 2011;91:

11 MED B CASE JM is a 69 year old male with a primary medical diagnosis (health condition) of: Parkinson s Disease Osteoarthritis History of Present Illness: Fell on steps, no acute injury Fear of falling and increased freezing Difficulty with transfers and ambulation, SPC>RW>very limited walking Sleeps in reclining chair Prior Level of Function (activity limitations): Independent with transfers to/from moderate height chairs using R UE, household ambulation w/ SPC SBA for ambulation w/ SPC outdoors (quarter mile) & stairs w/ unilateral rail Functional Outcome Measures: Timed up and Go: sec w/ RW, through doorway secondary to freezes Dual task TUG: w/ RW, cognitive Gait Speed: 0.29 m/s w/ RW Four Square Step Test: 80 seconds

12 MED B CASE The Plan of Care: 8 visits from March 31 st to April 18 th Primary Interventions (directed at impairments): Therapeutic exercise, gait training, neuromuscular reeducation, and therapeutic activities directed at impairments & education on PD/LSVT 16 visits LSVT from April 21 st to May 19 th 15 visits May 20 th to July 9 th Primary Interventions: gait training, therapeutic activities, provision of Juxta Fit garments Skilled care techniques used throughout the plan of care: Patient specific education on PD and management Vital sign monitoring and edema management Verbal, tactile, and visual cues for increasing amplitude and speed of movement LSVT treatment technique Task specific neuromuscular re-education with skilled manipulation of environment and task performance

13 MED B CASE Timeline of Key Points of Clinical Decision Making: March 31 st : Initial evaluation, began impairment level treatment and education/preparation for LSVT April 21 st : Began LSVT treatment May 19th: Ended LSVT treatment, patient purchased exercise DVD to use during HEP and able to perform w/ his brother May 20 th : Began final portion of POC aimed at task specific training for difficult activities, edema management, provision of final HEP May 23 rd : Patient diagnosed w/ Multi System Atrophy instead of PD following PT referral to UPenn due to inconsistent symptoms (environmental factor)

14 MED B CASE Timeline Continued: June 16th: Flipped the switch to maintenance therapy July 9 th (Final visit): Final discharge from PT. Condition stabilized enough it could be performed by a non-therapist. All outcome measures re-assessed What was the clinical decision for skilled maintenance? Patient reached his maximal ability Skilled functional training was needed to maintain gains due to variable physical and psychological presentation Skilled need for monitoring vital signs and edema/modifying schedule Further modified and educated on HEP to match his variable presentation Highly motivated and willing caregiver presence (environmental factor)

15 MED B DOCUMENTATION EXAMPLES Example #1 Mr. K has completed 16 visits of PT at the end of his current certification period. He has progressed with trunk and LE ROM and mobility to now being able to perform wheelchair positioning and the initiation of transfers with min/mod assist. By using a bar, he can transfer from edge-of-seat to standing and tolerate brief periods of standing with SBA. However, his CP has limited the anticipated progress of ROM and trunk flexibility gains and the return of extension tone after therapy causes him to sit at the end of his seat in lumbar extension and push his feet to the extent of his foot plate straps. Monitoring and subsequent therapy for declining chair mobility and LE flexibility would be beyond the scope of non-skilled caregivers present at his facility. A HEP will address current symptoms and status but due to the declining nature of CP, a skilled PT would be able to address new limitations and symptoms, assess future needs, and provide evidence-based manual techniques to treat increased tone. For these reasons, he will benefit from skilled PT care to address CP progression to keep his current status

16 MED B DOCUMENTATION EXAMPLES Example #2 Pt has completed 30 visits of PT at the end of her current certification period. She has progressed with trunk and LE strength and disassociation; She is now able to perform bed mobility, transfers, and gait with dec A. She is able to ambulate on level surfaces with a SPC, however still with tremors, ataxia and dec trunk association due to PD symptoms. However, her PD has limited the anticipated progress of ROM and trunk flexibility gains and the return of rigidity and tremors, tone after therapy causes her to have gait ataxia, dec initiation of movement, fenestrating gait and risk for falls. Monitoring and subsequent therapy for declining transfers and gait, and LE/core tone would be beyond the scope of non-skilled caregivers present at this facility. A HEP will address current symptoms and status but due to the declining nature of PD, a skilled PT would be able to address new limitations and symptoms, assess future needs, and provide evidencebased manual techniques to treat increased tone/rigidity and tremor.for these reasons, she will benefit from skilled PT care to address PD progression to keep his current status.

17 MAINTENANCE & MED A (SNF) Therapy services in connection with a maintenance program are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist If all other requirements for coverage under the SNF benefit are met, skilled therapy services are covered when an individualized assessment of the patient s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of a safe and effective maintenance program. Such a maintenance program to maintain the patient s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program. -CMS Benefit Manual, Chapter 8, Section E

18 MAINTENANCE & MED A (SNF) Case Example: A patient with Multiple Sclerosis who has been recently hospitalized may require the services of a physical therapist to determine the type of exercises that are required to maintain their present level of function. The initial evaluation of the patient s needs, the designing of a maintenance program, and the instruction of the patient or caregivers in the carrying out of the program, would constitute skilled physical therapy and must be documented in the medical record.

19 MAINTENANCE & MED A (SNF) Case Example: Documentation Patient seen for maintenance plan training today to review stretching techniques to maintain muscle length and prevent excessive fatigue during self-stretching. Session focused on hip stretching of hip flexors, hamstrings, and gastroc/soleus complex due to noted spasticity. Educated on use of RPE to self-assess and use of adaptive equipment (strap/belt) to assist with LE stretching during periods of increased spasticity. Patient able to independently demonstrate techniques 5/10 stretches, continued to require verbal instruction for technique and use of RPE to prevent excessive fatigue during remainder of exercises.

20 MAINTENANCE AND MED A (HH) On being Reasonable and Necessary from CMS: The patient s clinical condition requires the specialized skills, knowledge, and judgment of a qualified therapist to establish or design a maintenance program, related to the patient s illness or injury, in order to ensure the safety of the patient and the effectiveness of the program, to the extent provided by regulation The skills of a qualified therapist (not an assistant) are needed to perform maintenance therapy. - CMS Benefit Manual, Chapter 7, Section

21 MAINTENANCE AND MED A (HH) Special Considerations for Home Health: When designing or establishing a maintenance program, the qualified therapist must teach the patient or the patient's family or caregiver s necessary techniques, exercises or precautions as necessary to treat the illness or injury. The instruction of the beneficiary or appropriate caregiver by a qualified therapist regarding a maintenance program is covered if the specialized skills, knowledge, and judgment of a qualified therapist are required. However, visits made by skilled therapists to a patient's home solely to train other HHA staff (e.g., home health aides) are not billable as visits since the HHA is responsible for ensuring that its staff is properly trained to perform any service it furnishes. The cost of a skilled therapist's visit for the purpose of training HHA staff is an administrative cost to the agency. - CMS Benefit Manual, Chapter 7, Section

22 MAINTENANCE AND MED A (HH) Special Considerations for Home Health: When the development of a maintenance program could not be accomplished during the last visits(s) of rehabilitative/restorative treatment, the therapist must document why the maintenance program could not be developed during those last rehabilitative/restorative treatment visit(s). - CMS Benefit Manual, Chapter 7, Section

23 MAINTENANCE AND MED A (HH) Case example: Patient is an 89 y/o with Rheumatoid Arthritis after a hospitalization for pneumonia. Having achieved all of his rehabilitative goals, you know he can be discharged to a home exercise program. However, you are concerned that due to unpredictable c/o pain and noted atrophy in his shoulders that impacts the kinematics of the joint you decide a skilled maintenance program would be more appropriate.

24 MAINTENANCE AND MED A (HH) Case example Documentation: Patient has been seen for the last 30 days for rehabilitative services to address c/o shoulder pain, weakness, impaired balance, and difficulty with transfers and ambulation. During that time he has made significant gains in all areas. He has minimal c/o shoulder pain after ambulation only, demonstrated improvement in 30 second sit-stand test, and is able to transfer and ambulate with minimal assistance. Family and his caregiver have also been trained on appropriate strategies to assist with pain control, massage techniques, assisting in a home exercise program, and appropriately facilitate transfer and ambulation practice to maintain gains made in therapy. However, patient continues to present with difficulty weight shifting due to pain in knees as a result of Rheumatoid Arthritis. He also has very small muscle bulk t/o his body, which requires exercises to be modified and adapted to appropriate challenge and protect his remaining musculature and joints. These two factors require the skill of a therapist on occasion to modify/update his home exercise program and continually train family to ensure maintenance of gains made and delay progression.

25 SMALL GROUP STUDY Med B Case: SNF Case: Home Health Case:

26 Questions?

27 REFERENCES Centers for Medicare and Medicaid Services. (January 14, 2014). Manual Updates to Clarify Skilled Nursing Facility (SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to Jimmo vs. Sebelius (MLN Matters Number MM8458 Revised). Retrieved from Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8458.pdf Centers for Medicare and Medicaid Services (January 14, 2014). Medicare Benefit Policy Manual, Transmittal 179. (CMS Pub No ). Retrieved from Guidance/Guidance/Transmittals/Downloads/R179BP.pdf Centers for Medicare and Medicaid Services. (February 2, 2014). Jimmo v. Sebelius Settlement Agreement Program Manual Clarifications Fact Sheet. Retrieved from Centers for Medicare and Medicaid Services. (February 13, 2015). Medicare Benefit Policy Manual, Chapter 15 Covered Medical and Other Health Services. (CMS Pub No ). Retrieved from Centers for Medicare and Medicaid Services. (March 13, 2015). Medicare Benefit Policy Manual, Chapter 8 - Coverage of Extended Care (SNF) Services Under Hospital Insurance. (CMS Pub No ). Retrieved from Centers for Medicare and Medicaid Services. (May 11, 2015). Medicare Benefit Policy Manual, Chapter 7 Home Health Services. (CMS Pub No ). Retrieved from Guidance/Guidance/Manuals/downloads/bp102c07.pdf

28 REFERENCES Crowner, B. (February 2015). Central and Peripheral Benefits of Exercise. Powerpoint presentation at the Combined Sections Meeting of the American Physical Therapy Association, Indianapolis, IN. Drummond-Dye, R. (February 2015). Improvement Standard Lawsuit and Its Impact on PT Practice. Powerpoint presentation at the Combined Sections Meeting of the American Physical Therapy Association, Indianapolis, IN. Fox, C., Ebersbach, G., Ramig, L., Sapir, S (2012). LSVT LOUD and LSVT BIG : Behavioral Treatment Programs for Speech and Body Movement in Parkinson s Disease. Parkinsons Disease, Pahor, M., Guralnik, J.M., Ambrosius, W.T., Blair, S., Bonds, D.E., Church, T.S., Williamson, J.D. (2014). Effect of structured physical activity on prevention of major mobility disability in older adults: The LIFE study randomized clinical trial. JAMA, 311(2), Santos, D. A. (2012). Sedentary behavior and physical activity are independently related to functional fitness in older adults. Experimental gerontology, (37), Toto, P.E., Raina, K.D., Holm, M.B., Schlenk, E.A., Rubinstein, E.N., Rogers, J.C. (2012). Outcomes of a multicomponent physical activity program for sedentary, community-dwelling older adults. Journal of Aging and Physical Activity, 20,

29 THANK YOU!

CMS CLARIFICATION JIMMO VS. SEBELIUS

CMS CLARIFICATION JIMMO VS. SEBELIUS Liz Almeida-Sanborn, MS, PT, President Maria Maggi, PT, Vice President of Compliance Jodi Wenzel, MPT, Vice President of Operations OBJECTIVES Participants will: Understand