Housekeeping. Co-Treatment: A Creative Partnership. Harmony Healthcare International, Inc. Objectives. Copyright 2012 All Rights Reserved 1

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1 Co-Treatment: A Creative Partnership HARMONY UNIVERSITY The Provider Unit of (HHI) Presented by: Carrie Mullin, OTR/L Corporate Consultant/Denial Manager Cyndi Ouellette, RPT Regional Director of Operations Housekeeping Sign In Contact Hours Certificate A Little About Me Handouts Contact Information for Questions 2 Objectives Understanding of Skilled Care Criteria Understanding of General Therapy Documentation Requirements for Medicare Ability to Determine When Co- Treatment is Appropriate Understanding of Documentation Requirements to Support Co-Treatment 3 1

2 Skilled Care Review 4 Medicare Eligibility Treatment for a condition which was treated during a qualified hospital stay or which arose while in a SNF for a treatment of condition for which the beneficiary previously was hospitalized. For Example: Fractured hip develops pneumonia secondary to immobility 5 Practical Matter Criteria As a practical matter, considering economy and efficiency, the daily skilled services can only be provided in a skilled nursing facility 6 2

3 Practical Matter Criteria 1. Outpatient services are not available in the area where the individual lives 2. Outpatient services are available in the area where the individual lives, but transportation to the closest facility could cause an excessive physical hardship, be less economical, or less effective that placement in the skilled nursing facility 7 Practical Matter Criteria 3. The availability at home of a capable and willing caregiver should be considered, but the care can be furnished only in the skilled nursing facility if home care would be ineffective because there would be insufficient assistance at home for the patient/resident to reside there safely 4. If the use of alternative services would adversely affect the patient/resident s medical condition, then as a practical matter the daily skilled service(s) can only be provided on an inpatient basis 8 What is Skilled Care? Nature of service requires the skills of RN, LPN, therapist Care rendered by a licensed person: federal regulation define licensed person as physician, nurse and or therapist Provided directly by or under general supervision of a licensed nurse to assure the safety of the patient and to achieve the medically desired result General = initial direction and periodic inspection of the activity 9 3

4 Patient Education Services Example: A patient who has had a recent leg amputation needs skilled rehabilitation services provided by technical or professional personnel to provide gait training and to teach prosthesis care 10 Skilled Rehabilitation Transmittal 262 On a daily basis MD ordered Practical matter An appropriately licensed or certified individual must provide or directly supervise the therapeutic service and coordinate the intervention with nursing services 11 Skilled Rehabilitation Skilled therapy occurs when the skills of a therapist are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation 12 4

5 Skilled Rehabilitation Skilled therapy services are reasonable and necessary services furnished by or under the supervision of qualified professionals 13 Skilled Rehabilitation Skilled services shall be of such a level of complexity and sophistication or the condition of the patient shall be such that the services required can be safely and effectively performed only by a qualified therapist. In the case of physical or occupational therapy services can be furnished under the supervision of a qualified therapist as well. 14 Covered Rehabilitation Services The following is not an exhaustive list of Rehabilitative therapy services and treatment modalities Evaluations; reevaluations Establishment of treatment goals to address each problem identified in the evaluation Design of a plan of care, including establishing procedures to obtain goals, determine frequency and duration of treatment 15 5

6 Covered Rehabilitation Services Continued assessment at regular intervals Instruction leading to establishment of compensatory skills Selection of devices to replace or augment a function Patient and family training to augment rehabilitative treatment or establish a maintenance program. Education of staff and family is ongoing through treatment and instructions may be modified intermittently if the patient s status changes. 16 Basic Criteria for Rehabilitation Services Must be specifically related to the Physician s Treatment Plan Skill of a qualified therapist must be needed Treatment plan must expect the patient to improve within a reasonable amount of time Services must fall within accepted standards of medical practice and be specific to the patient The services must be reasonable and necessary 17 Summary of Treatment Modalities Self care training Therapeutic activities Mobility training Transfer training Neuromuscular reeducation Gait Training Orthotic/prosthetic training Splinting Manual Therapy 18 6

7 Summary of Treatment Modalities Balance training Therapeutic exercise Electrical stimulation Ultrasound Modalities Wound management Wheelchair management Patient/caregiver education and training Compensatory techniques 19 Summary of Treatment Modalities Home management training Community reintegration Safety education Adaptive equipment training Cognitive retraining Visual motor/ perception training 20 Evaluations 21 7

8 Prior Level of Function Medicare supports skilled intervention to assist the patient to attain their highest/prior level of function Gather as much information regarding the patient s functional level prior to recent illnesses PLOF is vital to supporting medical necessity for skilled rehabilitation and support the intensity of services rendered 22 Medical Necessity Avoid: Pt is appropriate for skilled PT/OT services due to decreased functional abilities. The above statement does not convey why these services need to be performed by a qualified professional. Safety Issues Related To: Poor posture Improper gait Weak grip, arthritis Dysphagia Poor communication skills Paralysis/paresis Perceptual deficits Vestibular disorder Cognitive disorder COPD, emphysema 23 Goal Writing Long-Term Goals Level you expect patient to be at discharge (or in 4 wks) Short-Term Goals Incremental steps toward the long term goals Think beyond transfers, ambulation, and ADLs 24 8

9 Goal Writing Avoid duplication of services! Co-treatment may involve the same activity, but each therapists need to have discipline-specific, unique goals Adding different functional components to the end of the same goal still puts services at risk 25 Treatment Encounter Notes 26 Medicare Benefit Policy The purpose of these notes is simply to create a record of all treatments and skilled interventions that are provided and to record the time of the services in order to justify the use of billing codes on the claim Documentation is required for every treatment day, and every therapy service 27 9

10 Medicare Benefit Policy Treatment Notes need to include: Date of treatment Identification of each specific intervention/modality provided Total timed code treatment minutes and total treatment time in minutes. Total treatment time includes the minutes for timed code treatment and untimed code treatment. Signature and professional identification 28 Medicare Benefit Policy To further support services, consider also documenting Patient self-report Adverse reaction to intervention Communication/consultation with other providers (e.g., supervising clinician, attending physician, nurse, another therapist, etc.) 29 Medicare Benefit Policy Significant, unusual or unexpected changes in clinical status Equipment provided Any additional relevant information the qualified professional finds appropriate 30 10

11 Skilled Interventions Skilled: Trained in use of onehanded dressing techniques to facilitate upper body dressing Educated in use of core body exercises to increase trunk strength and stability during ADLs Instructed in scanning techniques to help locate food on their plate Non-Skilled: Encouraged patient to perform ADL s at sink Helped patient ambulate from smooth to inclined surfaces Observed patient attempting to get out of bed without the side rail 31 Progress Notes 32 Medicare Benefit Policy Progress Notes need to include: Assessment of improvement and extent of progress (or lack there of) toward each goal Plans for continuing treatment, reference to additional evaluation results, and/or treatment plan revisions 33 11

12 Medicare Benefit Policy Changes to long or short term goals, discharge or an updated plan of care that is sent to the physician/npp for certification of the next interval of treatment That the patient s condition has the potential to improve or is improving in response to therapy 34 Medicare Benefit Policy That maximum improvement is yet to be attained That there is an expectation that the anticipated improvement is attainable in a reasonable and generally predictable period of time 35 Supportive Skilled Documentation Patient at high risk for Skilled assessment of Alternative treatment initiated for potential increased result Progress within a level of care Repetition required for carryover of learned activity Patient continues to require daily skilled rehab for Patient requires daily skilled evaluation of the plan of care 36 12

13 Non-Supportive Skilled Documentation Plateau in progress Continues to require Patient is unable to follow directions Patient has poor rehab potential Patient refuses to participate in therapy (without documentation of root of refusal) Within normal limits 37 Skilled Interventions Medicare will support continued services when the patient is not making progress if there is documentation that multiple skilled interventions have been trialed It is appropriate to give each trial an adequate amount of time to determine if the patient will progress 38 Co-Treatment 39 13

14 Why Co-Treatment? Increase the benefit of the therapeutic session More comprehensive assessment of patients needs More complex tasks can be safely trialed Improved minute management 40 RAI User s Manual Medicare Part A When two clinicians (therapists or therapy assistants), each from a different discipline, treat one resident at the same time with different treatments, both disciplines may code the treatment session in full 41 RAI User s Manual Medicare Part B: Therapists, or therapy assistants, working together as a "team" to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient 42 14

15 RAI User s Manual The decision to co-treat should be made on a case by case basis and the need for co-treatment should be well documented for each patient Per the RAI User s Manual: Because co-treatment is appropriate for specific clinical circumstances and would not be suitable for all residents, its use should be limited. 43 Reimbursement Multidisciplinary treatment sessions are reimbursable by both disciplines for the total amount of treatment minutes PT and OT treat a patient simultaneously for 60 treatment minutes, each clinician is able to bill the total amount of treatment time 44 Co-Treatment Documentation Each discipline needs separate distinct goals Co-treatment is a modality that can be used to meet existing goals Goals that address co-treatment are unnecessary 45 15

16 Co-Treatment Documentation Treatment notes should support the need for two disciplines to address a task at the same time Ensure the skills of the therapist are evident and documentation supports necessity of both disciplines involved 46 Identification of Patient Functional level of the patient Balance deficits Cognitive deficit Multiple tactile assistance Safety awareness Medical Co-morbidities 47 Post-Operative Patient Postoperative therapy is a time when goals converge Improving trunk control, balance, and upper-extremity function while doing weight bearing activities when the patient may be in upper or lower extremity casts (Or both!) 48 16

17 Total Knee Replacement PT Goal: Patient will improve balance to fair to increase independence with household mobility without the use of an assistive device OT Goal: Patient will stand at the sink x 3 minutes to increase independence with ADL tasks 49 Total Knee Replacement Standing activities are performed in the rehab gym or the patient s room that focus on balance and activity tolerance. PT and OT both assist the patient with standing while patient completes an ADL or ADL simulated activity 50 Total Knee Replacement Treatment Notes: Patient performed grooming activities standing at the sink. OT assisted the patient in identifying signs of fatigue and knowing when to take rest breaks during ADL tasks. Breathing instruction provided during rest breaks. PT assisted patient with complex balance challenges while reaching for grooming items at various heights in the bathroom. PT and OT both assisted patient with transfers between standing activities

18 Medically Complex Patients Patient with poor activity tolerance who may have difficulty tolerating 60 minute sessions of PT and OT each day PT and OT: Trunk strengthening and control, both static and dynamic sitting balance, and functional mobility tasks to maximize mobility Allows patient to maximize gains while minimizing potential impact of fatigue 52 Pneumonia PT Goal: Patient will transfer independently to promote safety and independence at home with a cane OT Goal: Patient will perform lower body dressing independently with adaptive equipment as needed 53 Pneumonia Lower body dressing is practiced in the patient s room. OT instructs on adaptive equipment and energy conservation. PT works on transfer training, balance while standing, and breathing techniques

19 Pneumonia Treatment Notes: Patient performed LB dressing. OT educated on use of reacher to don pants and patient easily becomes SOB. PT and OT assisted patient with sit to stand and with balance while pulling up pants. Increased SOB and decreased balance after 5 minutes of activity. Min assist and verbal cuing from PT to maintain balance while OT assisted with fasteners on pants. 55 Feeding OT Goal: Patient will perform independent feeding during the first 3 minutes of meal after set-up ST Goal: Patient will demo no signs or symptoms of aspiration with min verbal cues for chin tuck technique 56 Feeding OT and ST co-treat during patient s meal time to ensure safety with feeding and carryover of learned techniques by each discipline 57 19

20 Feeding Treatment Notes: OT and ST co-treated during patient s lunch. OT assessed tray set-up and recommends scoop plate. Cues provided throughout meal; patient frequently stops feeding self after 1 minute. Appropriate cuing communicated to nursing staff. ST provided mod cues for chin-tuck, patient able to complete with 60% accuracy. 58 Cognitive Impairment PT Goal: Patient will perform bed mobility with min assist to improve patient performance in activity and prepare for transfers ST Goal: Patient will effectively communicate need for assistance to staff with 80% accuracy 59 Cognitive Impairment Patient is treated in patient s room. PT works on bed mobility while ST works on how the patient can communicate their desire to get out of bed 60 20

21 Cognitive Impairment Treatment Notes: ST provided patient with basic communication board. Bed mobility reinforced, as patient was assisted by therapists out of bed when correct field on communication board chosen. PT instructed patient to roll to side and use of side rail to decrease physical strain during bed mobility. Mod assist of two stand pivot transfer bed to chair. 61 Neurological Deficits Extra set of hands to assist in the mobility efforts Unique perspective of understanding how their goals converge and interrelate to achieve their highest functional outcome 62 CVA PT Goal: Patient will initiate rolling in bed with moderate tactile cues to prepare for edge of bed sitting OT Goal: Patient will tolerate edge of bed sitting for 3 minutes with moderate assist to initiate ADL tasks bedside 63 21

22 CVA Patient is treated on the mat in the therapy gym. PT works on manual techniques to initiate muscle contraction in the trunk. OT works on weight bearing and postural support to maintain upright posture. 64 CVA Treatment notes: PT provided vibration stimulation to initiate contraction in the trunk to assist patient in initiating reaching across midline in supine. Patient supported by OT reaching across to weight bear through hemi-arm when reaching for edge of mat. Patient completed supine to sit with maximum tactile cues by OT and PT to get to edge of bed with maximum assist of Power W/C Training OT Goal: Patient will demonstrate adequate fine motor control for independence with joystick and forward/reverse switch on power wheelchair PT Goal: Patient will safely, independently navigate from room to dining room in power wheelchair ST Goal: Patient will be able to travel throughout facility by independently asking directions from staff (as needed) and following those directions with 100% accuracy 66 22

23 Power W/C Training OT and PT can co-treat while working on safe navigation in hallways and independence with w/c controls ST and PT can co-treat while working on safe navigation and following directions OT and ST can co-treat while working on fine motor skills and following directions (may not even be in power w/c during session) 67 Group Co-Treatment PT and OT both perform cooking group with four patients OT addressing cooking safety, energy conservation, sequencing, and adaptive kitchen equipment PT addressing standing balance, safety with kitchen mobility, gathering objects, and the transportation of objects in the kitchen 68 Progress Notes At times, clinicians may have difficulty identifying progress in medically complex patients in which co-treatment techniques are the only safe way to complete treatment. When this is the case, do not be fearful of including this in the progress notes as well

Progress Notes PT progress note: Patient has made progress with functional mobility this week evidenced by the patient s ability to initiate reaching across midline with the use of vibration

24 Progress Notes PT progress note: Patient has made progress with functional mobility this week evidenced by the patient s ability to initiate reaching across midline with the use of vibration techniques to initiate trunk rotation assisted by Occupational Therapy with the involvement of active assisted PNF movements of the upper body. 70 Conclusion Resilience and flexibility of successful rehab teams to adapt frequently to meet the needs of the SNF population in the most efficient and clinically appropriate manner possible is key Co-treatment remains a viable method to conserve resources of both clinicians and patients in multiple ways to help achieve long term goals efficiently and effectively 71 Questions/Answers Harmony Healthcare International 1 (800) CMullin@Harmony-Healthcare.com COullette@Harmony-Healthcare.com 72 24

25 Harmony Healthcare International Have you Considered a Customized Complimentary HARMONY(HHI) MEDICARE PROGRAM EVALUATION or CASE MIX ANALYSIS for your Facility? Perhaps your facility has potential for additional revenue Benchmark your facility against key indicators and national norms us at for more information RUGS@harmony-healthcare.com Analysis is cost & obligation free 73 25

Patient Name (Last Name, First Name) & MRN: Mileage: Gender: Agency Name/Branch: DOB: / / BP: (Prior) Position Side Heart Rate: Respirations:

Patient Name (Last Name, First Name) & MRN: Mileage: Gender: Agency Name/Branch: DOB: / / BP: (Prior) Position Side Heart Rate: Respirations: Clinician: Mileage: Gender: Agency Name/Branch: M F Time In: Time Out: DOB: HCPCS Select the home health service type that reflects the primary reason for this visit: (G0152) Services Performed by a qualified