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I am probably not alone in the summation that the world of physical therapy has drastically changed in the last several years or so. I may be biased, seeing as I work in one, but it seems to me that the setting that has felt the most impact of these changes has been in the skilled nursing facility (SNF) setting. Most noteworthy was the transition from the fee-for-service payment system to the prospective payment system; then most therapists grudgingly went through the transition from paper to more sophisticated computer documentation. Let’s not even get into the multitude of changes in the Medicare system itself, where the requirement for more objective and significant measures of progress is ever-growing. Because the predominant clientele of a SNF is usually medically highly involved — but less cognitively aware — elderly who at times require more sophisticated forms of encouragement, showing objective proofs of actual progress often can be difficult.

Even fellow healthcare providers and family members alike can sometimes question just how much progress the patient is making. As humans, the old adage that “seeing is believing” is a strong weapon to use to show that what we do as therapists is working and can be measured. The family member who lives in a different city and has not seen her mother walk for two years will question any therapist who tells her that Mom is now able to take five steps with a walker. The doctor who has been treating a patient he considers as bedbound and needs total assist for all ADLs will not believe that Mr. Smith is now able to feed himself with supervision. But what if there were a software application that a therapist could use to make this task of providing undeniable visual proof that a patient is making progress? Enter Kinesioplus software.

This simple mobile application actually originated to address the difficulties mentioned earlier: to help therapists show families and their respective doctors the very visual evidence that the patient is, indeed, making progress. As their website (www.Kinesioplus.com) offers, this user-friendly app “gives you the power of video imaging, reinforced with editing options to analyze ROM, input comments, or make circles and lines to correct identified errors during sessions. For objective analysis of movement, Kinesioplus also gives you the option of comparing videos side by side for easy comparison on week-by-week progress.”

In a nutshell, after getting the patient’s (or their responsible party’s) signed consent, you can videotape the patient using the app. The beauty of the software comes with what you do with the images you get. At first, you can use the original image to show the patient’s baseline, which in itself can be an eye-opener for the loved ones who have not seen the patient in weeks. And, yes, you can do a side-by-side comparison of how the patient performed a certain functional task on a weekly basis to show the progress. However, the saved image also can be used hours later to help the licensed therapist type up a more analytical report. By looking at a recorded image, the therapist may see something to address that may not have been as obvious, while the therapist was busy physically assisting the patient or providing verbal/tactile cues.

Taking treatment a step further, you can also videotape the patient as they perform their exercises to make a home exercise program (HEP) upon discharge. As most of us know, most patients need more than the two-dimensional paper that we often hand them when they leave the SNF. When we provide patients and their families with a video of the actual patient doing the exercise and hear his or her therapist providing the instructions, more often than not, they will remember the exercise better. Imagine a patient with Alzheimer’s who goes home and hears a favorite therapist telling her to work out versus a family member or caregiver giving her instructions to lift her leg up and down. In cases where the patient or family does not have the available technology to play the video at home, the images can be printed on paper with written instructions. And to use today’s high-speed technology even more, the images/exercises can be sent via email or text messages to any involved parties.

With the convenience of all these technological resources available to use with the app, the next question might naturally lead to privacy issues. Considering that the two founders/owners of this software application are a software engineer and physical therapist/Rehab Director of an SNF, these concerns were highly anticipated. According to the founders, their app is “compliant with HIPPA regulation. All access to the application and website are all secured with password unique to each user. All information inside the application is separated for each treating doctor. All therapists treating the patient can see all their information. Patients can also access their own progress report with a randomized password given to them for safe access. All information is encrypted to the fullest safeguarding of documents to comply with HIPPA regulations. Therapists will not be able to open the case of a patient if they haven’t signed the consent form provided before opening each case to protect the facility, the therapists and the patient for any misuse of the information.”

One can argue that a regular video camera/smartphone/handheld device can be used for the same purpose of showing the patient’s progress. Why does a therapist need this app to fulfill this goal? The founders argue that their mobile app “gives you the power of video imaging reinforced with editing options to analyze ROM, input comments, make circles and lines to correct identified errors during sessions. For objective analysis of movement, Kinesioplus also gives you the option of comparing videos side by side for easy comparison of week-by-week progress. This app also gives you the ability to share the client’s image with edited version of the video that can support home exercise programs or give a report to other clinicians or even for the client or client’s family to report progress. This app rivals the expensive applications, and it will give you the same analytical perspective at a very affordable price.”

The possibilities with Kinesioplus are exciting! We look forward to this application becoming available for our facilities soon.

By Lisette Maico-Tan, DPT, Brookfield Healthcare Center, Downey, CA

FY2014 Medicare SNF Proposed Revisions are Limited

The Centers for Medicare & Medicaid Services (CMS) released proposed rules for skilled nursing facilities (SNFs) that affect the documentation of Part A therapy treatment time. This policy revision proposal, effective Oct. 1, 2013, would require that distinct calendar days of treatment be recorded in the Minimum Data Set (MDS) in addition to the current requirement of treatment minutes.

For example: If a patient were a Rehab Medium with 150 minutes, but the dates of service were MWF with two disciplines treating three days, this would no longer meet the criteria. Services will have to occur over five separate days in the look-back. The scenario would need to be one discipline M/W/F and the other discipline M/Tu/Th. All other rehab categories currently run one discipline for at least five distinct calendar days in a look-back period.

For the coming fiscal year, CMS estimates that aggregate payments to SNFs will increase by about 1.4 percent, or $500 million, for Part A services. This figure is based on a market-based inflation increase and certain downward adjustments required by law. CMS also reports in the proposed rule that facilities in fiscal year (FY) 2012 reported a decrease in group therapy. ASHA predicted this reduction based on rules initiated Oct. 1, 2011, that penalized each resident’s group therapy minutes if fewer than four patients participated.

Background

SNF Part A is governed by a prospective payment system (PPS) and does not include Part B services for which patients qualify after exhausting their Part A benefit. Since 1998, only treatment minutes per week have been required in the MDS, which made enforcement of the requirements for therapy (three times per week or five times per week) difficult to verify without a tedious review of patient records. The day-of-service identification is expected to be implemented by a revision of the MDS form.

CMS continues to research potential alternatives to the existing methodology used to pay for therapy services rendered under SNF PPS. Payment rates are currently based on therapy provided to a patient during a seven-day look-back period. In the proposed rule, CMS announced contracts with Acumen, LLC, and the Brookings Institution to look at options for improving or replacing the current payment system. Comments on the existing payment methodology are welcomed by CMS at SNFTherapyPayments@cms.hhs.gov. CMS will be regularly updating the public on the progress of this project on the CMS website. The complete proposed rule appears in the May 6, 2013, Federal Register[PDF], with comments due July 1, 2013.

By Tamala Sammons, Therapy Resource

Many of our occupational therapists enjoyed a two-day Fieldwork Educator’s Certificate Seminar on Feb. 2 at Southland Care Center in Norwalk, CA. Our student programs are blossoming all across the organization, and it is so wonderful to be able to provide our therapists with additional training and resources to make our student programs extraordinary. Thank you, Gina Tucker-Roghi, for organizing the seminar and making it a success!

We will be holding more clinical instructor trainings in 2013, so make sure you check with your therapy resource for dates and locations.

Mike Johanson, MSPT for Horizon Home Health in Idaho, wrote and has trained Cornerstone and other therapists with his Stepping Stones program of fall prevention. The one-and-a-half-day course helps therapists to further their understanding of differential diagnosis regarding symptoms of dizziness, disequilibrium motion sensitivity, imbalance, gait instability resulting from BPPV, central dizziness, visual weakness, somatosensory loss, musculoskeletal imbalance and movement disorder.

Understanding the Rationale for a Balance and Falls Program

• Approximately 30 percent of community living adults fall at least once a year
• Ten to 20 percent of these community living adults have two or more falls a year
• Falls are the most common mechanism for injury in older adults
• 10 percent of those who fall will sustain a serious injury
• Approximately 300,000 hip fractures occur annually in the United States
• 25 percent of these hip fracture patients will die within one year
• Somewhere between $25 trillion to $80 trillion are spent on healthcare related to falls

Emotional impact of falls

• Falls tend to lead to fear, leading to inactivity, leading to loss of confidence, leading to decreased quality of life for patients
• It is a spiraling downward path to decreased independence and mobility
• Initial reactions to falls may be to protect, limit mobility and provide restraints — strategies that may decrease the risk of a fall in the short term but ultimately lead to declined mobility and increased risk of falls
• Forty percent of all nursing home admits are related to a fall. Falls are a major reason for moving up/down the continuum of care provided by hospitals, assisted living facilities, SNF, home health and hospice.

Home health has the ability to make one of the greatest impacts on fall reduction. Being in the patient’s home environment gives us the unique opportunity to identify specific problems, deficits and needs and tailor our approach to treatment to address those needs. Nursing has the ability to identify medical conditions, monitor effectiveness of medications, evaluate/assess vital signs, instruct when there are knowledge deficits and act as a liaison between healthcare provider and patient. Physical, occupational and speech therapists are able to address biological factors that increase the risk for falls, i.e., muscle weakness; gait and balance deficits; visual, vestibular and somatosensory deficits; and cognitive deficits. Physical and occupational therapists can also address environmental risks for falls through home assessment — identifying barriers in the home that might contribute to falls; i.e., clutter, unclear pathways, narrow doorways, throw rugs, insufficient lighting, the need for adaptive equipment, etc. They also provide instruction and training for caregivers and patients as needed to minimize the risk of falls or injury to patients.

How Stepping Stones Improves Quality of Treatment and Outcomes

Quality treatment begins with comprehensive assessment: strength, ROM, posture balance, coordination, cognition and motivation. Traditionally, therapists have been effective at assessing strength, ROM, posture and mobility. A better understanding of balance and the systems that affect it will lead to more targeted treatment plans and strategies to address deficits. Balance assessment should include assessment of sensory input from the visual, vestibular and somatosensory systems as well as strength ROM and posture.

• Visual system: the primary system for balance. Therapist will assess for conditions affecting visual acuity, contrast sensitivity, depth perception and visual field deficits.
• Somatosensory system: the ability to feel surfaces below the feet and react appropriately to maintain balance. Therapist will assess for history of peripheral neuropathy and check sensation for light touch and pressure.
• Vestibular system: provides information to central nervous system about movement of head or body, sense of rotation and acceleration. Allows us to stabilize our vision during head and body movement. Therapist will assess for peripheral and central deficits in this system which might cause dizziness, disequilibrium, sensitivity to motion, inability to focus eyes during head movement and benign paroxysmal position vertigo that is the most common cause of vertigo.
• Therapists will also assess patient’s ability to integrate these systems to perform specific balance tasks. An assessment of the central nervous system will be done through oculomotor testing, cerebellar testing and test to determine patient’s ability to multitask.

By identifying the strengths and weaknesses of each of these systems, we can develop a tailored plan of treatment that addresses the specific deficits for each patient. Specific balance, sensory integration and oculomotor tests will be performed at the beginning of treatment to establish baseline, at mid-treatment and at the end of treatment to determine the effectiveness of the treatment plan and determine outcomes.

Our experience has shown that The Stepping Stones program has the potential to improve outcomes, decrease risk of falls in the future, decrease hospitalizations due to falls, save Medicare dollars, maximize patient independence and improve quality of life for our patients in a significant way.

One of the golden opportunities for becoming the rehab facility of choice in your community is to be an extraordinary partner and a preferred provider with managed care organizations. Superior communication is the remarkable simple key to success, yet so many facilities do not implement systems and organizational strategies to keep the external case manager informed and integrated into the overall management of the patient. The external case manager can become our biggest ally, and as trust is built and outcomes are achieved, the result is nothing but extraordinary for our patients.

Some of the key factors that have proved to aid in achieving that goal include providing documentation and updates to the managed care organization’s case manager, either directly or indirectly through a case manager at the facility.

The top five ways the therapy team can help may be summarized through the following tips and ideas:

1) Provide accurate, concise, thorough and comprehensive information. It is critical that the information shared with the managed care organization’s case manager be a reflection of the patient’s current status. It is also a good idea to discuss the overall treatment plan and discharge goals at this time. This review must be supported by documentation and should reflect detailed information relevant to the current status and progression toward the discharge goals for the patient. It should also reflect our commitment to the patient achieving the outcome necessary to produce a successful and safe discharge. Assist by stressing to the team how important the process of identifying a discharge goal is and how it can eventually become warranted justification for extensions in Length of Stay (LOS). If progress has not been made, be prepared to assess if the current stated goals are still appropriate or if a change in treatment plan is required. The managed care case manager will not continue to authorize days or extend a LOS if given the same information week after week and if progress is not evident.

2) Review all documentation/updates before sharing the information with the managed care organization. It is important to review this information before it is presented so you can justify what may be your eventual request for additional days or a higher level of care. For example, if the overall status of the patient has declined since last week, be prepared with an explanation as to why and what occurred prior to anyone calling the managed care organization’s case manager. These are just some of the questions to be considered and answered prior to submitting documentation/updates:

• Has there been a change in the patient’s overall health status that has impacted the treatment plan for therapy? If yes, make sure it is documented appropriately.
• Is the patient refusing therapy? If yes, why and how many times has therapy been refused and how has the patient’s progress been affected?
• If the patient does not seem to be progressing at all, does the documentation/update reflect why? Are we targeting realistic, achievable goals for the patient?
• Is the current discharge plan achievable? Do we need to revise the plan? Make sure the revisions are communicated with detail as to why. In most situations, sending therapy notes is not sufficient in itself and will probably be sent back with a request for more information. A clear understanding of the content of the entire documentation/update (nursing and therapy) can prove to be a timesaver. Read it before you send it!

3) Ensure timely reporting. Make sure documentation/updates are submitted on the date they are requested. Most managed care organizations will stipulate a deadline for review, but if possible, it is good practice to tell the managed care case manager when the facility team meetings/conferences are held and suggest that updates are scheduled on those days, thereby providing the most current and accurate information. It is good practice to make sure a definitive date for the next review is agreed upon.

4) Anticipate the managed care case manager’s questions/concerns. It is always good practice to try to anticipate what the managed care organization’s case manager will need in order to authorize additional days or bump a patient to a higher level of care. The obvious question is, “Did the patient make appropriate progress?” If the patient has not made appropriate progress, we must be prepared to answer why and give them clinical justification as to why the patient’s inpatient stay should be extended (e.g., strengthening, safety issues, cognition). In any event, the managed care case manager will almost always want to discuss the current treatment and discharge plan’s viability — for example, when the discharge plan is for the patient to return home, but treatment progression has clearly defined the patient unable to gain enough function to manage at home. At this point, the managed care case manager will expect that we identify a new discharge plan. The Ensign Team should recommend to the managed care organization’s case manager the new most appropriate discharge plan. Also, if we are asking for additional services to be covered, we will need to be prepared to explain why that service is needed and how it will impact the agreed-upon discharge goal. For example, if you are requesting more units, be prepared to defend the rationale as to what value the extra units of therapy bring to the outcomes of the patient’s stay.

5) Be able to discuss progress toward desired outcomes/discharge plan and estimated LOS. When giving an update, focus the discussion on the desired result of care and the resultant discharge plan. Concurrent reviews of the patient’s status during the stay should evaluate the appropriateness of the current treatment plan and its success at achieving the final discharge result. For example, let’s say you have an 85-year old man who just suffered a massive stroke. His deficits are significant. Upon admission, he requires maximum assistance with all ADLs and transfers and is only able to take a few steps on the parallel bars. He suffers from significant swallowing problems and currently has a feeding tube. He is also incontinent of both bowel and bladder. His wife is 81 and very small in stature. The team agrees that an appropriate discharge plan must include, but not be limited to, her husband being able to toilet independently, transfer on his own and manage three steps to enter the home in order for the wife to be able to care for him alone. Every time this patient’s progress is reviewed, the focus should be on progression toward the discharge goals. If at some point it is clear that the patient is making minimal progress, the team must re-evaluate and design a more appropriate discharge goal and plan. For instance, it becomes clear that the patient will not reach his goals and be able to go home; you should be able to document that a different option has been identified. Finally, always be prepared to give the managed care organization’s case manager an estimate of how much longer the patient needs to achieve the agreed-upon goals/desired outcomes.

By Dawn Webster, Managed Care Resource

Curtis Merring, OTR/L, MOT developed a seating and positioning course for our therapy programs, and piloted the training at Panorama Gardens on March 21, 2013. Staff from Panorama, Glenwood, and Mission Care learned about the most recent research and seating and positioning solutions specifically for our population. Curtis will hold the course for more to attend at the Service Center on March 27, 2013. This is an excellent opportunity to develop positioning strategies for both our short-term rehab patients and our long-term residents. We will be offering this course across the organization, so check with your therapy resource for when the training will be in your area.

Kinesio Tape Course (KT3)

Location: University of North Texas Medical Education & Training
 1000 Montgomery St; Fort Worth, TX

Ensign Services, Inc. hosts seminars in facilities that are ADA accessible. Please let Jon Anderson, jonanderson@ensigngroup.net know if you need any special accommodation.

Instructor: Virginia “Dee” Ellis, PTA, CKTI

Dee is a Physical Therapist Assistant who has practiced in many different settings and states. Dee specializes in aquatic therapy, Pilates based spinal stabilization and orthopedic outpatient rehab. She has been a PTA for 15 years, graduating with her A.A.S. from Community Colleges of Southern Nevada in Las Vegas with a Gerontology Wellness Specialty. She also did undergraduate study at San Diego State University in California. Dee has a special interest in wellness and prevention.

Dee has been a Certified Kinesio® Taping Practitioner for 8 years and has been a Certified Kinesio® Taping Instructor since 2005. Dee has her American Physical Therapy Association (APTA) Advanced Proficiency in the musculoskeletal realm and was the recipient of the Texas Physical Therapy Association’s (TPTA) Joy Davenport award in 2008. She is an active volunteer in the APTA, the TPTA and the Aquatic Section of the APTA. Dee has presented continuing education on Electrical Modalities, Aquatic Physical Therapy and Kinesio® Taping: Fundamentals and Whole Body Techniques.

Dee currently works for as a PRN for local south Texas hospital systems and home health agencies.

KT3 Costs:

For non Ensign therapists the cost will be $279.00

KT3 Course Description:

Purpose: Assimilate and progress clinical problem solving skills using the Kinesio Taping Method

Required Text: Kinesio Taping Work Books (WB) 1-6—pg references for taping (bring from KT1/2)

Suggested Text: Clinical Therapeutic Applications of the Kinesio Taping Method (page #’s in parenthesis)

KT3 Course Objectives:

1. Demonstrate ability to problem solve clinical case studies and utilization of Kinesio Tape to effectivelyenhance patient status/progress.

2. Fulfill requirements to apply for Kinesio Taping Practitioner Certification through Kinesio Taping Association, USA

REGISTRATION & Check in begins at 7:30 a.m. Course from 8:00 a.m. – 5:00 p.m.

For information regarding pre-registration and to hold your spot for the course, please contact Kelly Wallerstedt at kwallerstedt@ensigngroup.net