Treatment Plan Goals for Chiropractic Presented by Evan M. Gwilliam, DC MBA BS CPC CCPC NCICS CCCPC CPC-I MCS-P CPMA Vice President 1 Take away Learn how payers use treatment plan goals to determine if care is payable o Prognosis o MTB and supportive care o Complicating factors Understand how to use Create effective and relevant goals in your own care plans 1
Elements of a Treatment Plan 1. Recommended level of care (duration and frequency of visits) 2. Specific treatment goals 3. Objective measures to evaluate treatment effectiveness 3 Elements of a Treatment Plan 1. How long and how often are you going to see the patient? 2. What are you trying to accomplish? 3. How do you know when you have accomplished the goals? 4 2
What is a Treatment Plan? 1. A list of each complaint, with its relevant diagnoses 2. Treatments and modalities selected 3. Duration and frequency of care 4. Treatment goals 5. Objective measures to show progress 6 3
Prognosis Prognosis is used to forecast the probable result of treatment for a patient s condition. Short term symptomatic Long term functional 1. Excellent 2. Good 3. Fair 4. Poor 5. Guarded 6. Unstable Prognosis 1. Excellent full symptomatic and functional recovery expected within 2-4 weeks 2. Good - Symptomatic and functional recovery is expected in approximately 4-8 weeks but the patient may experience intermittent mild pain and some restriction of motion 4
Prognosis 3. Fair - The patient can expect to have a reduction of their symptom although some persistent pain and stiffness from the injury is expected and may require ongoing rehabilitation. 4. Poor - The nature of the patient s injury and preexisting conditions bring into doubt the likelihood of full recovery. It is expected that patient will continue to experience intermittent to occasional paresthesias along with occasional to frequent pain and stiffness, necessitating palliative care. Prognosis 5. Guarded - The patient s condition is not expected to improve in the near future. They may expect to have continued muscle weakness and sensory deficit. Palliative and/or supportive care will be warranted for symptomatic relief and some improvement of function. 6. Unstable - Patient has not responded to the treatment trial and demonstrates evidence of deterioration. The likelihood of recovery with conservative care does not appear promising at this time. Surgical consult would be advisable. 5
Maximum Therapeutic Benefit MTB is determined following a sufficient course of care, where demonstrable improvement would be expected in a patient s health status and one or more of the following are present: the patient has returned to pre-clinical/pre-onset health status meaningful improvement has occurred; however, there is no basis for further meaningful improvement meaningful improvement has occurred and there is no basis for further supervised in-office treatment the patient no longer demonstrates meaningful clinical improvement, as measured by standardized outcome assessment tools meaningful improvement, as measured by standardized outcome assessment tools, has not been achieved there is insufficient information documented in the submitted patient healthcare record to reliably validate the response to treatment 11 Supportive Care Mercy Conference Guidelines: Treatment for patients who have reached maximum therapeutic benefit, but who fail to sustain previous therapeutic gains through periodic withdrawals from care. Private payer: Treatment for patients who demonstrated clinically meaningful improvement, and have reached MTB, and there remain significant residual deficits in the performance of daily activities e.g., usually >20% on a Neck/Back Index, and alternative treatments have been applied or given consideration, and self-care measures alone are likely not to sustain previously achieved therapeutic gains i.e., progressively deteriorate when treatment is withdrawn, and care is rendered PRN i.e., not prescheduled. 12 6
Complicating Factors Mercy Conference Guidelines: Symptoms present for more than 8 days can increase recovery time by a factor of 1.5 Presence of severe pain can increase recovery time by a factor of 2 4 to 7 previous episodes can increase recovery time by a factor of 2 Presence of skeletal anomaly or structural pathology can increase recovery time by a factor of 2 13 Outcome Assessment Tools Outcomes in clinical practice provide the mechanism by which the health care provider, the patient, the public, and the payer are able to assess the end results of care and its effect upon the health of the patient and society. Public Patient Payer Provider 14 7
Support medical necessity by quantifying patient functional loss. They objectify the subjective They measure a change in health status after exposure to a health care delivery system. 15 Roland-Morris Low Back Pain and Disability Questionnaire Subjective and Objective Numerical Outcome Measure Assessment (SONOMA) Bournemouth questionnaires Functional Rating Index (FRI) McGill Pain Questionnaire (MPQ) Headache Disability Inventory (HDI) Disabilities of Arm, Shoulder, and Hand (DASH). 16 8
Neck Disability Index (NDI) Modified Oswestry Low Back Disability Index o Ten questions, six responses scored on an ascending scale (0, 1, 2, 3, 4, 5), total is divided by # of points possible o Higher percentage = worse disability 17 18 9
NDI scoring 0-4 points (0-8%) no disability 5-14 points (10-28%) mild disability 15-24 points (30-48% ) moderate disability 25-34 points (50-64%) severe disability 35-50 points (70-100%) complete disability i.e. 34% on NDI could be documented as moderate functional deficiency 19 Oswestry scoring 20 10
10% improvement = minimum detectable change 30% improvement = meaningful change 50% improvement = substantial change Administer at midpoint of initial trial of care and at a minimum of every 30 days thereafter 21 Scenario 1: Score improves as expected Proof that the treatment plan worked. Care should continue until MTB is reached. Scenario 2: Score worsens or falls short of goal Look for a new treatment and/or refer or discharge. Scenario 3: Score improves more than expected Decrease frequency of care, create new optimistic goals, or release from care. 22 11
Inspired Goals Goals need to be measurable and specific Change ADL by this much by this date Enable patient to lift heavy weights without pain by 5/1/2016. - from NDI, section 3 Improve ability to stand without pain from 30 minutes to one hour by 5/20/2016. - from Oswestry, section 6 23 Weak Care Plans Only address frequency and duration of visits Neglect goals entirely Include goals, but o They are only subjective o They do not address function o They are not measurable 24 12
Short term goals restated: 1. Reduce pain 2. Increase pain-free ROM 3. Restore normal vertebral segmental motion 4. Increase ability to move affected area Short term goals improved: 1. Reduce VNRS from 8/10 to 5/10 within 2 weeks 2. Increase pain-free ROM by 50% within 2 weeks 3. If you restore normal vertebral segmental motion, you can t adjust anymore, right? 4. Same as number 2? Short term focus on symptoms and save function for long term goals 25 Two weeks later Assessment should discuss progress towards goals Were goals achieved? If not, why? Patient went on vacation Patient fell down the stairs How will the care plan change to adapt to goals that were not met? Easier or harder exercises? More or fewer visits? Referral or new diagnostic test? 26 13
Short term goals restated: 1. Reduce pain by 10% 2. Increase strength (Is there documented loss of strength?) 3. Increase endurance (How do you measure this?) 4. Increase ability to move affected area (Measurable?) 5. Increase ability to exert force to affected area AND (these are better) 1. Get 5-6 hours of quality sleep (within what time frame?) 2. Stand for more than 20 minutes (Is this from Oswestry?) 3. Sit for more than 20 minutes pain free 4. Walk for more than 1 block pain free 5. Lift more than 20 pounds from off the floor 27 Long term goals restated: 1. Restore functional independence 2. Promote soft tissue healing 3. Restore maximal strength and stability to joint 4. Transition to HEP Long term goals improved: 1. Improve Oswestry score from 50% disability to 35% disability by four weeks. 2. Promote soft tissue healing by? 3. Improve muscle strength in right toe extensors from 4/5 to 5/5 by week 8. 4. Transition to HEP (can t bill 97110 anymore?) by week 8. 28 14
Two weeks later What happened to the original long term goals? Were they met already? Why were they changed? Long term goals restated: 1. Increase ROM to pre-injury status (two weeks sooner than old LT goal?) 2. Restore health and function to pre-injury status () 3. Promote soft tissue healing (measure?) 4. Restore maximal strength and stability to joint (was strength/stability lost?) 5. Transition to HEP (two weeks sooner than last time this goal was established?) 29 Goals Plan of care should include recommendations for ongoing amelioration of musculoskeletal complaints, such as: o Home program, lifestyle modifications, etc Introduce as soon as possible, reinforce, and document in the medical record. 30 15
Elements of a Treatment Plan 1. Recommended level of care (duration and frequency of visits) 2. Specific treatment goals 3. Objective measures to evaluate treatment effectiveness 31 The ChiroCode DeskBook is available at ChiroCode.com This presentation is covered Chapter 4.5 16
Take away Learn how payers use treatment plan goals to determine if care is payable o Prognosis o MTB and supportive care o Complicating factors Understand how to use Create effective and relevant goals in your own care plans 17