DOCUMENTATION GUIDELINES FOR CHRONIC DISEASE Presented by: Julia Osborne, PT, CLT-LANA
Oncology - An Emerging Field in Rehabilitation Oncology Rehabilitation has evolved from simple supportive and palliative care to now include Complex Rehabilitation Interventions Restore the integrity of body systems/organ structure and function Remediate functional loss Allow full participation in ADL s and life roles We will be held accountable to demonstrate treatment efficacy by means of quantifiable Functional Assessment Data and Patient Outcome Measures Gilchrist L S et al. PHYS THER 2009;89:286-306
Models of Assessment, Care and Best Practices Models provide a framework of standardized language and concepts Standards 2012 Version 1.1 NIH, ACA - Chronic Disease Model of Care APTA - International Classification of Functioning, Disability and Health (ICF) US Dept. of Health Survivorship Plan of Care 2015 COC (Commission on Cancer) Cancer Program
CHRONIC DISEASE MODEL OF CARE
Understanding What Chronic Disease Is Definition in 2014 CHRONIC DISEASE IS A LONG- LASTING CONDITION THAT CAN BE CONTROLLED BUT NOT CURED Chronic Disease is the leading cause of death and disability in the United States More than 40% of the U.S. population has one or more chronic condition
Chronic Disease Model of Care Affordable Care Act (ACA) Recognizes Chronic Diseases and their Treatment Requirements The ACA has 10 Areas of Essential Health Benefits One of the Ten is: PREVENTIVE AND WELLNESS SERVICES AND CHRONIC DISEASE MANAGEMENT
Chronic Disease Model of Care What Would Our Implementation Look Like? We Are Taught a Curative Model of Care Return Toward Prior Level of Function Improvement of Physical Function Resolution of Functional Impairments Patients With Chronic Disease Processes require a Disease Control Model of Care They need ongoing help in minimizing and managing their condition So how do we go about this?
Medicare and Medical Necessity with the Chronic and/or Oncology Patient In accordance with the Jimmo v. Sebelius Settlement, the Centers for Medicare & Medicaid Services (CMS) has agreed that coverage of skilled therapy services does not turn on the presence or absence of a beneficiary s potential for improvement, but rather on the beneficiary s need for skilled care. Skilled care may be necessary to improve a patient s current condition To ensure safety and effectiveness in ADL s To retain the patient s current condition To prevent or slow further deterioration of the patient s current condition Centers for Medicare & Medicaid Services (CMS) Transmittal 175 Date: December 6, 2013 - Change Request 8458
We Must be able to Document in Alignment with these Statements APTA EDGE TASK FORCE THE ICF
Current Role of The APTA and the ICF The EDGE Task Force Developed in 2010 Evaluation Database to Guide Effectiveness To Facilitate Identification of Valid and Reliable Tests and Measures that Reflect Clinically Important Outcomes Use the Domains of the ICF International Classification of Functioning, Disability, and Health
ICF Provides an Overall Framework The ICF classification scheme is used to describe overall function of populations who have specific chronic health conditions Gilchrist, L. et al. Phys Ther. 2009 March; 89(3): 286 306
TRANSLATING INTO FUNCTION International Classification of Functioning, Disability and Health (ICF) Health Condition Cancer Type Treatment (Surgery, Radiation, Chemo) Body Functions and Structures Neuromusculoskeletal & Movement-Related Nervous System Eye, Ear & Related Mental Function Cardiovascular, Hematological, Immunologic & Respiratory Digestive, Metabolic & Endocrine Genitourinary & Reproductive Skin & Related Activity General Tasks & Demands Communication Mobility Self-Care Occupational Community, Social & Civic Life Participation Learning & Applying Knowledge Domestic Life Interpersonal Interactions & Relationships Major Life Areas Community, Social & Civic Life Environmental Factors Personal Factors
ICF A Tool for Documentation Documenting how structural or anatomic deficits restrict activities restrict participation Enables therapists to be adept at the intended focus of their therapeutic interventions Enables therapists to use appropriate tools to assess effectiveness of those interventions Gilchrist, L. S., Galantino, M. L., Wampler, M., Marchese, V. G., Morris, G. S., & Ness, K. K. (2009). A Framework for Assessment in Oncology Rehabilitation. Physical Therapy, 89(3), 286 306.
US DEPT HEALTH/COC SURVIVORSHIP PLAN OF CARE 2015
Cancer Survivorship Care The US Department of Health and Human Services Requires that Cancer Survivorship Care Plans are in place in Comprehensive Cancer Centers by 2015 The Commission on Cancer (COC) - partnered with American College of Surgeons Standards of Care 2012 Includes referral to Rehabilitation Services as part of its requirements for Comprehensive Cancer Care Pfalzer, L. Rehab Oncology, 2013, Vol 31, No 3: 5
Insurance & Reimbursement Mechanisms Necessary to identify Survivorship as a Stage of Cancer Care Needs to be a professional and cultural shift Insurance and Reimbursement Mechanisms to cover survivorship care are necessary part of cultural shift Evidence is needed to understand the cost implications of providing or not providing survivorship care in an integrated way Silver JK et al. Cancer Rehabilitation may Improve Function in Survivors and Decrease the Economic Burden of Cancer to Individuals and Society. Jan 1, 2013;46(4):455-72.
Standardization of Metrics in Survivorship - Developing Sustainable Rehab Programs Electronic Health Records (EHR's) facilitate metric standardization and consistent data capture Functional Assessment Data Patient Outcome Measures Standardization identifies the Essential Elements of Care instead of a Specific Care Model
Essential Elements of Care - Guideline of Rehab Assessment and Treatment Elements to be Included in Patient Centered Assessment and Care are: 1. Cancer Type 2. Cancer Treatment 3. Treatment Sequelea 4. Timing of Follow-Up Care 5. Content of Follow-Up Care 6. Recommendations for Risk Reduction Practices and how to Retain Health and Wellbeing COC Cancer Program Standards 2012 Version 1.1
DOCUMENTATION GUIDELINES Evidence Based Practice Treatment Plan and Timeframes Care and Quality Outcomes Efficient Use of ICD-10 Codes AND How to Document over an extended episode of care
1. Evidence Based Practice
EBP - Clinical Expertise and Resources Case Studies Photos: Before and After Patient Testimonials Clinical Outcome Measures Functional Assessments: Before/During/End Objective Measurements Patient Outcome Measures Subjective Assessment: Before/During/End
2. Measuring Care and Quality Outcomes Clinical Outcome Measures Functional Assessments: Before/During/End FACT Cancer Specific, FACT Chemotoxicity Specific, PDI, Quick DASH, LEFI, LLIS ( Klose - LLIS Version 1 Jan Weiss 2013) Lymphedema Life Impact Scale, ABC Test, Fall Risk Assessment Objective Measurements PT/OT/ST Specific Time Frames Prehab baselines, IE post tx-intervention, Every 3 months (based on Medicare 90-day rule)
3. Treatment Plan with Time Frames Treatment Plan Parameters Insurance Visit Allowance (~20) Chronic Disease Model of Care (12 months) Rehabilitation Entry Point Surgery, Chemotherapy, Radiation, Reconstructive Phase, Post Active-Treatment Phase Phases of Rehab (based on RMCRI parameters) Acute (Through Active Treatment + 12 Weeks Post) Subacute (3-6 Months Post Active Treatment) Chronic (6-12 Months Post Active Treatment, or Lifelong) (Active Treatment = Cancer Rx: Single Rx Event or Multiple Rx Events) Regular Monitoring (proposed) Year 1 post D/C every 3 months Year 2 post D/C every 6 months
4. Efficient Use of ICD-10 Codes Use REHAB codes familiar to Insurance Companies Use 2-3-4 Diagnosis Codes Leverages Treatment Options Good to Use General Codes to Begin With Lymphedema Postural Dysfunction Difficulty Walking THEN Use Codes Relating to Pain, Stiffness, Scar Tissue Fibrosis, Joint and Muscle Disorders, Weakness and Deconditioning Functional Impairment becomes Key Objective Measurement Statement for Reports & Daily Notes
5. Hints for Documentation with Fluctuating Clinical Status Link CURRENT Physical Function with Symptoms Present on Day of Treatment Document THAT DAY Symptoms/Functional Limitations Document Response to Treatment for THAT Day Always Document CHANGE IN MEDICAL STATUS!!! Always Document Fluctuating Status instability warrants skilled care to stabilize Document ALL Medications and/or Treatment Interventions - especially with long term side effects these are considered by Medicare Chemotherapy Radiation Therapy Adjuvant Therapies (Endocrine Hormonal) Pain Medications
Medicare and Medical Necessity with the Chronic and/or Oncology Patient Justification for treatment would include Objective evidence or a clinically supportable statement of expectation that: The skills of a therapist are necessary to maintain, prevent, or slow further deterioration of the patient s functional status, and the services cannot be safely and effectively carried out by the beneficiary personally or with the assistance of non-therapists, including unskilled caregivers
PUTTING IT ALL TOGETHER
Patient Case Example - Essential Elements of Care 1. Cancer Type Breast Cancer: Invasive Lobular, Stage III, Grade 3, ER+ 2. Cancer Treatment Surgery with ALND, Adjuvant Chemotherapy, Radiation Therapy 3. Treatment Sequelae Soft Tissue Healing Phase Transition with Surgery and Radiation Therapy, Chemo-toxicities, Lymphedema 4. Content of Treatment/Follow-Up Care FOM s, Objective Measurements, PT/OT/ST Treatment Protocols, Patient Self-Care Management, Patient Home Exercise Management 5. Timing of Follow-Up Care 1x/week or 1x/every 2-3 weeks throughout Treatment Episode 1-3x every 3 months for 12 months following Treatment Episode 6. Risk Reduction Practices and Retaining Health and Wellbeing Lymphedema Risk Reduction Exercise Prescription and Progression
Patient Case Example 1. Cancer Type Breast Cancer: Invasive Lobular, ER+, Stage III, Grade 3 This tells us that the patient is going to have extensive surgery, chemotherapy, radiation therapy, and at least 5 years of an AI All these are leverage points in documentation
Moving on to Active Ca Treatment & Rehab Response 1. Cancer Type 2. Cancer Treatment Breast Cancer: Invasive Lobular, Stage III, Grade 3 Surgery with ALND, Adjuvant Chemotherapy, Radiation Therapy AI Therapy 3. Treatment Sequelae Soft Tissue Healing Phase Transition with Surgery and Radiation Therapy, Chemo-toxicities, Lymphedema
Surgery and ALND Stage 0 1 Lymphedema secondary to decreased lymphatic transport capacity, resulting in a prolonged inflammation phase of healing and an accumulation of both inflammation exudate and lymph fluid in the interstitium Decreased Sh ROM resulting in decreased overhead reaching and HBB in all ADL s (home, occupational, recreational, community)
Radiation Therapy Severe scar tissue formation in the axillary region results in loss of overall functional mobility and postural balance in the upper quadrant, thereby affecting all ADL s ((home, occupational, recreational, community) Patient progress is slowed secondary to daily targeted chemotherapy AI (eg. Anatrazole) that results in increased althralgic pain to the region concurrent to existing radiation fibrosis that restricting muscular skeletal components
Stages of Lymphedema Stage 0 Reversible: Lymph Fluid in Interstitium Stage 1 Reversible: Lymph Fluid & Inflammation in Interstitium Stage 2 Irreversible: Lymph Fluid AND Secondary Skin Changes Fibrosis Life Long Stage 3 Irreversible: Lymph & Skin DISEASE Fibrosis, Adipose Tissue Life Long
ICF - Body Structure and Function Measurement of Lymphedema Lymph Volume as a This is NOT the only method used to describe the severity of lymphatic impairments The National Cancer Institute's Common Terminology Criteria for Adverse Events Version 3 has expanded the number of scales to: 1. Grade the severity of lymphatic & integumentary toxicity 2. Grade the severity of skin color changes 3. Grade tissue fibrosis 4. Grade phlebolymphatic cording
Adjuvant Chemotherapy 1) Cardiotoxicity 2) Myelosuppression 3) Cancer Related Fatigue 4) Chemo-induced Peripheral Neuropathy 5) Chemo-induced Cognitive Changes
Cardiotoxicity Functional Assessment Tools/Outcome Measures Heart Rate, BP (At Rest, and at End of Selected Test) 6 Minute Walk Test (Or Similar Aerobic Test) WITH Dyspnea Scale (Breathing Difficulty) Borg Rate of Perceived Exertion (Exertional Difficulty)
Myelosuppression Hemodynamic Impairments - MYELOSUPPRESSION Chemotherapy Agents cause destruction of bone marrow stem cells Anemia FACT-An Neutropenia FACT-Ne Thrombocytopenia FACT-Th
Cancer Related Fatigue Functional Assessment of Chronic Illness Treatment Fatigue (FACIT-F) Best used to measure Fatigue as a specific QOL subset problem Roskevensky, G. et al. Rehab Oncology, 2013, Vol 31, No 3: 14-18
Chemo-Induced Peripheral Neuropathy Functional Assessment Tools/Outcome Measures modified Total Neuropathy Scale FACT-Taxane, FACT-NTx Dynamic Gait Index Berg Balance Scale, Tinetti Balance Test Functional Independence Measure (FIM)
Chemo-Induced Cognitive Impairment Functional Assessment Tools/Outcome Measures The Mini-Mental State Examination FACT-COG
Continuum of Care Treatment Within the Spectrum of Phases of Soft Tissue Healing Inflammation Proliferation Remodeling
Continuum of Care Treatment Within the Spectrum of Lymphatic System Function Stage 0 Reversible Stage 1 Reversible Stage 2 Irreversible Stage 3 Irreversible
Continuum of Care - Treatment Within the Spectrum of the Cancer Rx Process Radiation Adjuvant Therapies Chemotherapy Surgery Survivorship
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