Nuts and Bolts of Maintenance Therapy. Skilled Intervention. Jimmo v. Sebelius 3/21/2018

Transcription

1 Nuts and Bolts of Maintenance Therapy 1 Skilled Intervention Physical Therapy Occupational Therapy Teach & Transition Adapt & find solutions Increase strength & Teach safety in daily balance living Encourage safety & Increase strength & independence balance Speech Therapy Facilitate verbal & nonverbal communication Retrain & maintain Functional swallowing Improve memory & thinking 2 Jimmo v. Sebelius In the case of Jimmo v. Sebelius, the Center for Medicare Advocacy (CMA) alleged that Medicare claims involving skilled care were being inappropriately denied by contractors based on a rule-of-thumb Improvement Standard under which a claim would be summarily denied due to a beneficiary s lack of restoration potential, even though the beneficiary did in fact require a covered level of skilled care in order to prevent or slow further deterioration in his or her clinical condition. 3 1

2 Who is Glenda Jimmo? A 78-year-old Vermont mother of four Legally blind Partially amputated leg due to complications from diabetes 4 toes amputated from opposite limb Wheelchair bound 4 Medical Necessity - Maintenance Medicare reimburses for the development of a medically necessary individualized maintenance program to: Maximize and retain the patient's functional status achieved with therapy services Assure patient safety within their home environment Train the patient and/or caregiver in the maintenance activities Prevent further decline in the patient's condition 5 Medical Necessity - Maintenance Medicare does not reimburse for carrying out maintenance activities when: The activities do not require the skills of a qualified clinician i.e., the level of complexity and sophistication of the activities do not require the performance and/or supervision of a therapist. The condition of the patient is such that the services do not require the performance and/or supervision of a therapist. The activities can reasonably be provided by non-skilled personnel after training is completed by the qualified clinician. It is anticipated that once the maintenance program is established, updates to the program will be necessary on an infrequent basis. 6 2

3 Maintenance G Codes G0159 Physical Therapist in the home health setting, in the establishment or delivery of a safe and effective physical therapy maintenance program, each 15 minutes. G0160 Occupational Therapist in the home health setting in the setting, establishment or delivery of a safe and effective occupational therapy maintenance program, each 15 minutes. G0161 Speech Language Pathologist in the home health setting, in the establishment or delivery of a safe and effective speech language pathology maintenance program, each 15 minutes. 7 Skilled or Unskilled A service that is ordinarily considered unskilled could be considered a skilled therapy service in cases where there is clear documentation that, because of special medical complications, skilled rehabilitation personnel are required to perform the service. Section Coverage for Maintenance PT uses skills, knowledge and judgment to design or establish a maintenance program that: Ensures patient safety and program effectiveness Pursues goals to prevent or slow further deterioration Teaches techniques, exercises, & precautions to treat condition Includes periodic reevaluations of the beneficiary and the maintenance program Generally develops program during the last visit(s) of restorative care, OR clearly explains why if the program is implemented later 3/21/2018 Section Palmetto GBA (d)(2) - Medicare 9 3

4 Coverage for Maintenance PT may perform maintenance therapy if: Special medical complications are identified & documentation clearly explains why PT must perform the program (particularly if it could otherwise be considered unskilled), OR The level of complexity of the needed procedures requires the skills of a qualified therapist to perform them Also, must: Ensure patient safety and program effectiveness Pursue goals to prevent or slow further deterioration Document teaching/modifying of program Section (d)(3) 10 Restorative vs. Maintenance Rehabilitative Intent is to improve the patient s ability to function Therapy assistants CAN provide care Maintenance Intent is to prevent further loss of function Therapy assistants CANNOT provide care 11 Restorative vs. Maintenance Rehabilitative Chronic Disease Influences Higher Frequency Shorter duration Maintenance Chronic Disease Drives Lower frequency Longer duration 12 4

5 Establish a Maintenance Program Program connected to patient specific needs Periodic reassessment of plan and patient to ensure program is safe and effective 13 Providing Maintenance Therapy Hands on, in person provision of the components of the program Qualified therapist, not an assistant Clear support as to why the therapist has to be the one to complete the program with the patient. 14 Initial Assessments There is NO DIFFERENCE between the assessment expectations for patients who receive therapy: Prior level of functioning (reasonable time period) Use of tests and measures Detailed functional assessment Includes a system by system review (cardiopulmonary, neuromuscular, integumentary, etc...) 15 5

6 Establishing a Program Determine current functional status of the patient. Assess rehabilitation potential Create program based on patient specific needs. Determine the teaching needs of patient and caregiver 16 Living Alone Beneficiary not having an at home care provider does not make the therapy skilled. Simply documenting that the patient does not have anyone to perform her exercises with her is not a reason for skilled therapy. 17 ROM Strength Balance Vision Pain Sensation Communication Cognition Environment Equipment Measurements 18 6

7 Functional Impact Ambulation Transfers Bathing Dressing Toileting Incontinence Medication Management Swallowing Home Management 19 Initial Assessment Rehabilitative Expectation the patient will return to prior level of functioning? Maintenance Patient is at the optimal level of functioning 20 Documentation Concepts Rehabilitative Recovery of function Clear prior level of functioning (PLOF) Role of chronic disease in course of recovery Predictable time period for recovery and probable discharge Maintenance Optimize at current level of function PLOF relevance? Chronic disease front and center Potential role of CG s Less predictable time period and discharge 21 7

8 Objective Testing Objective tests facilitate discussions about the following with the care team and patient/family: Current status and relevant history (compare normal values) Goals (associate key tests with goals) Purpose of interventions (prevent/slow deterioration) Rationale for frequency/duration of interventions Rationale for reassessment timing Expected outcomes (discharge planning) 22 Ambulatory Tests Walking Speed Timed Up and Go 30 Second Chair Stand Test * not an all inclusive list 23 Non-Ambulatory Functional ROM Sitting Balance (Forward & Lateral Reach) Timed Functional Tasks 24 8

9 Questionable Care Repetitive documentation without showing skill Not clear why a skilled therapist was needed 25 Medical Necessity Issues Failure to evidence skilled need or identify inherent complexity Poor explanation of medical necessity Lack of objectivity and assessment of response Interventions lacking teaching & modifying Goals not clearly outlined Effectiveness not established 26 Unskilled Simply counting while patients exercise Standing by during patient transfers Merely walking with patients Documenting assessment consisting of Tolerated treatment well Documenting plan after current visit as Continue POC 27 9

10 Skilled Teaching patients which exercises to do, and clearly explaining the reasons why Teaching patients how to safely transfer Teaching patients how to walk safely with fewer deviations Thoughtfully comparing and explaining how objective measures prove effectiveness Documenting specific planned modifications for next visit 28 Maintenance Therapy Decision Tree Do you expect your patient to improve materially in a reasonable and generally predictable period of time with traditional restorative therapy? NO Do you expect your patient to maintain functional progress made or to continue to progress with functional gains without your continued help? YES NO YES Criteria 1 Continue with Restorative Therapy supported by standardized testing if they continue to meet all home health criteria. Is the patient capable himself/herself or is there a caregiver able to help the patient perform and follow through with a maintenance therapy program established and updated by the therapist (not an assistant)? DISCHARGE the patient with a Home Exercise Program YES NO Criteria 2 Proceed with Maintenance Therapy under the skilled criteria to Design or Establish a Maintenance Therapy Program. Monitor, reassess, and update the program at a reasonable frequency/duration. Are complex and sophisticated hands-on therapy techniques required by the therapist (not assistant) to insure the safety of the patient or the effectiveness of the maintenance program? YES NO DISCHARGE the patient Criteria 3 and follow up at an Proceed with Maintenance Therapy under the skilled criteria to Perform appropriate time to see the Maintenance Therapy Services. Services must be complex and how the patient is doing sophisticated OR to ensure the safety of the patient they MUST be done by and to determine in therapist (not assistance or caregiver). Document skill and treat at restorative therapy is reasonable 3/21/2018 frequency/duration. Palmetto GBA - Medicare appropriate again. 29 Progress vs Improvement If the patient has a progressive condition, such as Parkinson s Disease, multiple sclerosis, or amyotrophic lateral sclerosis (ALS), is it expected that the patient show progress when receiving maintenance services? Yes. Progress is not synonymous with improvement. Progress in maintenance therapy would be the responsiveness of the patient to the established course of care. Maintenance therapy is intended to stabilize or slow the natural course of deterioration with a progressive condition, or to prevent potential sequelae that may occur due to the presence of that progressive condition, such as soft tissue contracture due to limb paralysis. Progress, or responsiveness to therapy, would be determined by the patient s capacity to function at an optimal level, consistent with the stage or severity of the underlying progressive condition

11 Goals for Maintenance Therapy What are the patient s stated goals? Are they realistic? Are they still for restorative purposes? What goal(s) would you establish for the program? Do your goals address the patient s greatest fear? Are the goals sufficiently objective to demonstrate program effectiveness? What if the deteriorating condition can t be maintained, but deterioration can be slowed? How would you set goals? 31 Goal Setting Rehabilitative Focus: usually patient but may be caregiver Factors in prior level of functioning Written for improvement: Functional ability From baseline objective measurement Maintenance Focus can be patient or caregiver Prior level of functioning not a factor Written for prevention of deterioration or decline: Functional ability (e.g., bed mobility, transfers) Body structures (e.g., ROM, strength) 32 Appropriate Goals for Maintenance Therapy Maintenance therapy goals include: Preventing unnecessary, avoidable complications from a chronic condition, such as deconditioning, muscle weakness from lack of mobility, and muscle contractures. Maintenance therapy goals also include reducing fatigue, promoting safety, and maintaining strength and flexibility

12 Appropriate Goals for Maintenance Therapy For a patient with a progressive neurologic condition, appropriate maintenance therapy goals include: Maintaining joint flexibility Preventing contractures Reducing the risk for skin breakdown Ensuring appropriate positioning 34 Risk for Deterioration How quickly would the expected deterioration occur without a PT maintenance plan of care? How would the expected deterioration impact activity and participation? Why is planned frequency & duration appropriate to slow/prevent further deterioration? 35 Preventing or Slowing Decline Is Treatment actually preventing or slowing decline without removing the patient from that treatment? In cases where maintenance services are delivered, there must be documentation in the record that demonstrates why not providing the services would accelerate the beneficiary s natural rate of decline, based on the provider s clinical knowledge and experience or other evidence. For instance, when maintenance program is intended to slow further deterioration, efficacy could be demonstrated by showing natural rate of decline that has been interrupted. Maintenance services must still have specific treatment goals. If a person is continuously going downhill or declining, the services may not be meeting their goals 36 12

13 Reassessment Reassessment determination: At mandatory time points When clinically indicated by patient presentation Key components of any HH therapy reassessment visit: Completion of intervention(s) Objective measurement(s) redone Interpretation of findings/changes from baseline Clinical statement to support continued services (if continuing) Modifications to care plan/goals Communication/input from physician 37 Home Exercise Program Status If in place, is it effective for maintaining? If not, why not? Does the patient/caregiver feel confident that it will slow/prevent deterioration? What needs to happen to establish that confidence? Has the teaching by the skilled PT(for both patient and caregivers) been sufficient to establish an effective HEP? Will the HEP need modification in the near future? Would a scheduled periodic reassessment be sufficient to update the HEP, validate effectiveness, and ensure safety? Is the amount & frequency evidence-based 38 Physical Therapy Goal Setting The patient will maintain degrees of lower extremity ROM s/p hip fracture w/o surgical repair to prevent irreversible fixed contracture at hip joint 39 13

14 Occupational Therapy Goal Setting The patient will maintain degrees AAROM UE to reduce risk of fixed bony contracture. The patient will maintain the ability to perform toilet transfers at moderate assist level to prevent deterioration due to Parkinson s disease with significant intention tremors 40 Speech Therapy Goal Setting The patient will perform oral motor exercises to maintain functional oral motor strength for speech and swallowing capabilities daily with speech therapy cuing and supervision The patient will maintain the use of safe swallow strategies as instructed by Speech therapy at each meal to prevent aspiration 41 Home Health Clinical Notes Home Health clinical notes must document as appropriate: The history and physical exam pertinent to the day's visit, (including the response or changes in behavior to previously administered skilled services) and the skilled services applied on the current visit The patient/caregiver's response to the skilled services provided If a family member/caregiver is involved in the patient's care the documentation must also include this 42 14

15 Home Health Clinical Notes The plan for the next visit based on the rationale of prior results A detailed rationale that explains the need for the skilled service in light of the patient s overall medical condition and experiences The complexity of the service to be performed Any other pertinent characteristics of the beneficiary or home A clinical note must be written for each home health visit 43 Home Health Clinical Notes Vague or subjective descriptions of the patient s care should not be used Terminology such as the following would not adequately describe the need for skilled care: Patient tolerated treatment well Caregiver instructed in medication management Continue with POC 44 Frequency Q: How many visits can we provide per week for a maintenance therapy? A: There is no guidance related to the number of visits. It must be reasonable and necessary for the patient s condition

16 Recertification Q: Do you re-certify patients for maintenance therapy? A: So long as the patient continues to meet eligibility requirements for home health services Medicare does not stipulate a limit on how many episodes are allowed for any home health benefit including maintenance therapy 46 Going Beyond Diagnosis Framework ICF Classification Part 1: Functioning and Disability Part 2: Contextual Factors Parts Body Functions and Structures Activities and Participation Environmental Factors Personal Factors Components Change in Body Functions Change in Body Capacity Performance Structures Facilitator/ Barrier Constructs/ qualifiers 47 Going Beyond Diagnosis ICF Framework Health Condition (disorder/disease) Body function&structure (Impairment) Activities (Limitation) Participation (Restriction) Environmental Factors Personal Factors 48 16

17 Case Scenario #1 Patient is 97 y/o female with dementia (loss of short term memory), LE muscle weakness, and painful kyphoscoliosis. Recently moved into ALF community after another non-injury fall at home. Has supportive family, but they live out of state. She wants to be able to attend Bingo and exercise class, but requires assistance to walk there. Has used a walker for several years. Exhibits great difficulty standing up from her chair and with getting in/out of bed. Needs multiple rest breaks to walk 300 from residence to the dining room. Unsteady turns. Recently completed 6 weeks of PT. Has difficulty with HEP and progress has plateaued. Patient & daughter want PT to continue to prevent her from deteriorating. Current objective test scores: TUG = 28 seconds, WS = 1.65 ft/sec 49 Framework Example AMS, muscle weakness, postural deformity (kyphoscoliosis), fall hx BODY FUNCTIONS 1) NM/Movement fxn s --Muscle power (b730) --Joint mobility (b710) 2) Mental--Memory (b144) BODY STRUCTURES 1) Movement structures -- LE quads/calves (s750) -- T-vert / Trunk (s760) 2) Nervous System --Brain (s110) Impaired ability with: 1.Bed mobility 2.Transfers 3.Balance 4.Gait 1.Unable to attend exercise class 2.Requires assistance to attend Bingo with friends New residence; uses DME(walker); Short term Supportive daughter memory deficit (lives out of state; anxious) Patient anxiety 50 Plan of Care Development Is the patient eligible for home care services? (e.g. homebound, identified skilled need) What are the inherent complexities for skilled care? Are there any teaching opportunities to explore? Are there any environmental concerns to address? Is he/she safe? If not, how would you evidence? Does the patient have an effective maintenance program? What do you expect would happen if we discharged? Is the reasonable and necessary standard met for maintenance therapy? 51 17

18 Establish Goals & Interventions What are the patient s and daughter s goals, and are they realistic? What objective goals could you set that would be realistic? Write one short term goal and one long term goal STG: LTG: What interventions are appropriate to achieve these goals? STG intervention: LTG intervention: 52 Establish Goals & Interventions What are the patient s and daughter s goals, and are they realistic? What objective goals could you set that would be realistic? Write one short term goal and one long term goal STG: Pt independent with HEP 3 days/week LTG: Maintain pt walking speed > 1.65 ft/sec What interventions are appropriate to achieve these goals? STG intervention: Teach HEP for LE strengthening and recruit ALF staff to assist with HEP & walking LTG intervention: Gait training with cues to take longer steps, pacing with metronome 53 Plan of Care Development Establish Frequency, Duration & Re-eval What is your recommended frequency & duration? Considering available evidence and best practice, what rationale would you give for this frequency/duration? How soon would you re-evaluation? When you re-evaluate, how will you evidence program effectiveness? 54 18

19 Plan of Care Development Establish Frequency, Duration & Re-eval What is your recommended frequency & duration? 1w4 (4 total visits) Considering available evidence and best practice, what rationale would you give for this frequency/duration? Expectation that will learn HEP in 2 wks. Can modify HEP and prepare for DC in 2 more weeks How soon would you re-evaluate? Weekly When you re-evaluate, how will you evidence program effectiveness? Walking speed maintained, ability to do HEP as instructed 55 Plan of Care Development What is the best case discharge status for this patient? Doing HEP regularly, no anxiety from patient & daughter, assistance lined up to help her get to Bingo What will you do if she declines significantly more than expected? Discuss with team and contact physician What does an unexpected deterioration say about the effectiveness of the maintenance therapy program? Not effective In the event of significant decline, would you consider a return to a restorative plan of plan? Reconsider frequency/duration, interventions, and even possible change back to restorative plan of care 56 Maintenance Patient Example You are seeing a female patient with limitations due to chronic low back pain. You have restored her to her maximum medical improvement and feel the need to discharge her from rehabilitative therapy but because of her diagnosis and her complexities and comorbidities, you feel that if you just discharge her she will return in a couple of months. What do you do? 3/21/2018 mmo-revisited Palmetto GBA - Medicare 57 19

20 Maintenance Patient Example Perform a re-evaluation. re-evaluation would be appropriate in this case as you are about to change the plan of care from a rehabilitative plan to establishing new goals for a maintenance plan. In the assessment of the re-evaluation you will want to document: The patient has made the maximum medical improvement for their condition, however, Without continued skilled intervention there is a strong likelihood the patient's ability to function will deteriorate due to her condition, and it requires the skill of a therapist to: Establish and monitor the patient's skilled maintenance program Instruct the patient and caregiver(s) in the patient's individualized maintenance program. Monitor vital signs (if the patient has conditions that warrant it) Coordinate care with other healthcare providers Perform a home risk assessment and make recommendations for adaptations Periodically review, evaluate, and modify the maintenance program Include an assessment on how the patient's complexities and co-morbidities might affect her maintenance program and require more frequent oversight by the therapist Maintenance Example Upper extremity stretching techniques taught to caregiver to prevent contracture and continue participation in grooming Is this Appropriate? 59 Case Scenario #2 Patient is 76 y/o black male living alone at home. His wife recently passed away. He uses a manual wheelchair for mobility in his home due to LE paraplegia. Some sparing of the quadriceps and hip extensors bilaterally. He weighs 260 lbs and is currently performing difficult transfers from wheelchair to/from bed. He is unable to effectively perform any LE exercises without active assisted ROM techniques due to significant muscle weakness. Has parallel bars installed in his home, but can only safely use them with PT assistance. He realizes he probably won t walk on his own again but this is motivating for him and helps him to maintain strength for safe transfers. He is worried that if he loses that ability he will not be able to live in his own home anymore. Vehicle transfers are too difficult for him to attend weekly church services. Objective measures: Time for wheelchair to bed transfer: 98 sec Bilateral quadriceps & hip extensors grossly 2+/

21 Case Scenario #2 B LE paraplegia with quad & hip flexor sparing(2+/5), obesity BODY FUNCTIONS Impaired ability with: Unable to attend 1) Movement functions --Muscle power (b730) 1. Transfers church regularly --Muscle tone (b735) (difficult) Very limited 2) Digestive (sit to stand, community --Weight (b530) BODY STRUCTURES w/c to bed, vehicle) access 1) Nervous system 2. HEP (required -- Spinal cord/pn (s120) 2) Movement structures AAROM) -- Bilat LE s (s Ambulation (only w/ skilled assistance) Lives alone, manual w/c, Possible depression (widower), parallel bars desire to remain at home motivates to exercise 61 Plan of Care Development Determine If Appropriate Is the patient eligible for home care services? (e.g. homebound, identified skilled need) What are the inherent complexities for skilled care? Are there any teaching opportunities to explore? Are there any environmental concerns to address? Is he/she safe? If not, how would you evidence? Does the patient have an effective maintenance program? What do you expect would happen if we discharged? Is the reasonable and necessary standard met for maintenance therapy? 62 Establish Goals & Interventions What are the patient s goals and are they realistic? What objective goals could you set that would be realistic? Write one short term goal and one long term goal STG: LTG: What interventions are appropriate to achieve these goals? STG intervention: LTG intervention: 63 21

22 Establish Goals & Interventions What are the patient s goals and are they realistic? What objective goals could you set that would be realistic? Write one short term goal and one long term goal STG: Maintain quad/hip flexor strength > 2+/5 LTG: Maintain w/c to bed transfer time < 100 sec What interventions are appropriate to achieve these goals? STG intervention: AAROM exercises for UE s/le s LTG intervention: Assisted ambulation for strengthening; explore home equipment options to facilitate safe transfers and/or independent strengthening 64 Establish Frequency, Duration & Re-eval What is your recommended frequency & duration? Considering available evidence and best practice, what rationale would you give for this frequency/duration? How soon would you re-evaluate? When you re-evaluate, how will you evidence program effectiveness? 65 Establish Frequency, Duration & Re-eval What is your recommended frequency & duration? 2w9 Considering available evidence and best practice, what rationale would you give for this frequency/duration? Only able to do isometric HEP in between sessions; largely sedentary individual; high risk for loss of strength & mobility How soon would you re-evaluate? Weekly When you re-evaluate, how will you evidence program effectiveness? Time w/c to bed transfers and LE manual muscle testing 3/21/2018 (objective since < 3/5) Palmetto GBA - Medicare 66 22

23 Discharge Plan What is the best case discharge status for this patient? What will you do if he declines significantly more than expected In the event of significant decline, could you justify a return to a restorative plan of plan? 67 Discharge Plan What is the best case discharge status for this patient? Enhanced home mobility equipment and ability to do HEP independently What will you do if he declines significantly more than expected Increase frequency and/or consult with physician regarding restorative therapy plan of care In the event of significant decline, could you justify a return to a restorative plan of plan? Yes 68 Case Scenario #3, Health History: Pt is 86 year old male resident of assisted living facility with underlying dx of Parkinsonism. Two months ago, patient ambulated independently in apt. with RW and with distant supervision to and from breakfast and lunch daily with RW. However pt. experienced significant functional decline after he sustained 3 falls in one week with inability to ambulate as a result and 3/21/2018 confined to wheelchair. Palmetto GBA - Medicare 69 23

24 Case Scenario # 3 Activity Limitations: Current status is noted as able ambulate with rolling walker 140 feet with varying amounts of assistance from stand by to minimal assist. Transfers require minimal assist. Patient has been unable to return to independent level of ambulation in facility due to balance, retropulsive tendencies during sit to stand, and decreased memory processing. Endurance has improved but is currently stable with a 2MWT of 32 feet. Walking speed is about 1 ft/sec indicating continued risk for falls with ambulation. Facility staff training has been initiated to assist with daily walking program. SLP working with patient and caregivers for recall techniques and signs of aspiration during meals. Participation Restrictions: Patient unable to safely ambulate to dining room without assistance. 70 Case Scenario # 3 Plan: A daily walking program is required to maintain patient s current level of function without which patient would be at risk for skin breakdown and rapid deterioration overall if confined to a wheelchair. Will plan to educate each staff member re proper gait facilitation technique and transfer facilitation at staff change for the early morning and late afternoon shift change with a focus on safety and mitigating patient s retropulsive tendencies. Then will follow up with patient weekly with facility staff present to evaluate for maintenance of current level of function providing direction as needed. 3w2, 1w4. 71 Goals CG continues to demonstrate the ability to safely and independently assist with ambulation 250 feet to and from the dining room for all meals using a FWW CG able to provide appropriate cues to mitigate retropulsive tendencies during sit to stand and transfers 100% of the time Patient will maintain walking speed of 1ft/sec Patient will maintain current level of endurance with a 2MWT of 32 feet

25 Case Scenario #4 Health History: Patient has history of multiple exacerbations of COPD with hospitalizations and frequently on/off service for therapy for functional impairments and poor endurance with activities. Patient has severe osteoporosis due to steroid dependency and multiple recent compression fractures. Patient has reached a stable level of function after recent episode with a home exercise program established by this visit 73 Case Scenario #4 Activity Limitations: Patient employs effective energy conservation techniques for light housekeeping, and meal making for 3 meals per day maintaining RPE between MWT is 38 seconds with RPE at level 2. Risk for fracture during basic ADL s is high. Participation Restrictions: Patient unable to grocery shop/run errands without the assist from family or friends due to poor endurance and risk for fractures. 74 Plan and Goals Plan: Ensure patient is compliant, consistent and safe with established HEP with respect to fracture risk. 1w2, 1w every other week for 3 weeks. Goal: Maintain function and keep patient out of hospital. Patient to maintain RPE between 1-4 during light housekeeping Patient consistent and compliant with HEP and any modifications needed 75 25

26 Case Scenario #5 This patient lives in an ALF and presents with Parkinsonism and Chronic Dysphagia (difficulty swallowing). He has had a prior hospitalization due to Pneumonia likely from aspiration. Patient has failed restorative therapy to improve signs and symptoms of aspiration during meals but continues to be at risk and on a modified diet. Patient continues on a modified diet and thickened liquids to honey consistency. The facility does not provide the thickener but the family consistently ensures the patient has a supply kept with the assisted living staff. The therapist determines the patient determines that the patient is not likely to make objective, functional improvement with swallowing but with interventions that include exercises, caregiver training and electrical stimulation for dysphagia, the patient will be able to maintain a safe swallow with precautions and avoid another hospitalization. The therapist is going to recertify the patient under Criteria 3 maintenance therapy and criteria 2 maintenance therapy. Criteria 2 to continue to provide input to assisted living staff regarding signs and symptoms of aspiration with meals and appropriately thickening fluids. Criteria 3 for application of estim during 2 meals per week to maintain the 3/21/2018 current swallowing strength Palmetto GBA - Medicare 76 Goal Maintain safe swallow, prevent rehospitalization Caregivers to effectively verbalize and identify signs and symptoms of aspiration during meals Caregivers consistently thicken liquids for patient 77 Questions? 78 26