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Therapy plateau doesn't equal Medicare DC?

I saw this article today. Is anyone following this? http://newoldage.blogs.nytimes.com/2013/02/04/therapy-plateau-no-longer-...

Section: 
Rehab
It's nice to see someone look

It's nice to see someone looking at this finally.

This has been a hot topic of

This has been a hot topic of discussion in my facilities, with many wondering if this ruling will change how services are delivered to our residents. Does it mean that residents will be on therapy caseload 100 days regardless of progress? Though the ruling gives the impression that therapy has carte blanche about how Medicare days are used, I really believe the answer to that question is “no.”

As therapy providers, we have to be conscientious about how our resident's Medicare funds are used. Medicare beneficiaries have 100 SNF days; if these are used in one stay, what happens if another event occurs within 60 days of their SNF discharge? That being said, I do believe we have the responsibility of making sure we are doing everything we can to help a patient progress. If a patient is nearing a plateau, rather than setting a last therapy day, we really should ask ourselves if we've utilized the most appropriate treatment plan and treatment modality that would help him or her reach a higher potential.

We should consider making adjustments to the plan of care, therapy schedule, or even change therapists to determine if another strategy, technique, or set of eyes may help the patient to achieve more. I believe families should be involved and informed when a plateau is nearing. They, together with the patient should have a good understanding about the process and be given the opportunity to choose between using and preserving their Medicare days. Given the information, even in the best settings, I believe most patients would choose to return to their homes with their families rather than exhausting their Medicare days.

Need for Skilled Care vs. Plateau

Here is a similar article:

http://www.nytimes.com/2012/10/23/us/politics/settlement-eases-rules-for-some-medicare-patients.html?_r=0

One of our patient's family members actually referenced this case when the rehab team set his father's last day of skilled therapy. It made our rehab team critically analyze why we were discontinuing therapy as well as how to accurately explain it to family members. Our explanation focused on why our skills as licensed therapists were no longer needed vs. the patient's "plateau." I would be interested in hearing if any other facilities are having similar experiences.

 

Plateau of Progress - When is therapy still justified?

Many therapists have raised this question and I'm happy to discuss this on the forum.  A recent court case (Jimmo vs. Sibelius) challenged and struck down the mandate for a patient to make continual progress for therapy to be considered reasonable and necessary.  Although CMS has not yet issued the manual revision, it is important that we understand this ruling and how it applies to the decisions we make and document.  Since this has been widely reported in the media, many families are inquiring if their family member could receive ongoing therapy.

Medicare has always had in its regulations for Maintenance programs that if the situation of the patient was such that they could not be safely treated by anyone without therapy skills and training, it would continue to be paid even without progrss.  Skilled maintenance therapy was always narrowly defined.  As a result of this case there are more options for applying this standard.  

What has not changed however, is that the knowledge, skills and judgment of a therapist is always required for Medicare reimbursement.  So we should not focus on or document the plateau towards goals.  Our decision making and documentation should always focus on whether our skills and only our skills are needed.  Any treatment program which can be carried out by someone without our training will not be covered.

Recently I was consulting with a therapist facing this dillemma.  Her patient was a woman with significant dementia who had suffered a hip fracture and was non-weight bearing.  She was not able to learn this skill and the staff had been trained on how to do a safe sliding board transfer with her.  The therapist was concerned however that she was already showing the signs of developing hip and knee contractures which would likely prevent her from ever standing or walking again once she was allowed to bear weight if she was discharge from therapy.  This was the perfect situation for a skilled maintenance program.  By carefully documenting the risk to the patient, and the fact that e-stim had significant impact on her joint and muscle function as well as keeping her pain level manageable with less medication, this therapist was able to document the need for her skills to continue even though no progress was expected until the weight bearing status was changed.

This was a wonderful example of how this new ruling can be used correctly to benefit patients.  Documentation focused on the skills needed and not on the goal plateau.  So this really should be the center of any discussion to discontnue therapy - can the treatment be done by a non-therapist or is there a need for a skilled maintenance program?  If you have questions about how to document this please contact me and I will be glad to assist.  

IDT

I too have been asked several times about our thoughts as therapists, on this matter more commonly, from either an Administrator or other member on the Interedisciplinary Team. In listening to their questions, I am hearing that they are really looking to us for guidance. As I'm answering their questions, I have referenced some of the comments Elizabeth mentioned above but I also believe that this case stresses the need for Interdisciplinary Team involvement with making decisions regarding discharge planning. Therapists often feel the pressure from the patient, family and other staff members for when a patient is ready to discharge. As therapists, we can help the team understand by educating that we are only one piece of the puzzle and although we play an integral role in the process we do not make decisions for discharge planning. We need the support of an Interdisciplinary Team for a successful discharge.

Questions

I understand in our narratives/daily treatment notes that we are documenting our skilled services, but what is the best way to reflect that in the weekly progress notes, when the goals are not being met/upgraded due to lack of progress?  Do we change the wording of our goals to reflect treatment tolerance or participation vs. functional level changes?  If we haven't stopped treatment, it seems hard to show what will happen (a decline), even if we suspect it.  Also, what about for non-skilled residents who appear to be declining, but don't have medical justification for hospice or chronic pain that responds to modalities allowing increased ADLs, but functional gains don't last if modalities are stopped?  Any documentation suggestions for those?

Documenting when there is no progress

There are several things to consider when we are not able to report progress.  If you think that the goal are appropriate ones,  use the comment box to analyze how you can alter the treatment approach to achieve the goal.  For example if the goal is to transfer, and your assessment is that sitting balance is impairing the patient's ability to shift their UB forward over their base of support you may comment that in the next week, intensive focus will be given to improving sitting balance progressing from over base of support to outside of it in order to progess transfer ability.  As a result you expect the goal to be attained in 1 to 2 weeks.  The same would hold true if other adjustments to treatment needed to be made to address hip pain or LE strength or sequencing.

It may also be that the patient is progressing within the goal but has not yet reached the next level.  For example he may be learning the sequence of the task while he is slowly gaining strength needed to perform it with less assistance.  Analyze the progress in the comment box and give your assessment of potential to reach the goal.

Often, however, the patient does not progress because of the way we have written the goal.  Patients who have many underlying impairments to function will benefit and show progress when goals are written for changing the impairment (balance, pain, cognition), or by writing a short term goal for a subtask rather than for the standard full task (i.e. sit to stand instead of transfers, washing face and hands rather than grooming and hygiene, improving labial closure before the full swallow).  If we have written goals in such a way that does not capture the slow but significant progress a patient is making then we should revise the goal, noting in the comment box that such breakdown will facilitate learning and progress.

If the limited gain is due to something which will resolve, such as a UTI, then putting that information into the box for Additional Analysis / Objective Measurements, along with your assessment of the patient's rehab potential once the medical condition is stabilized then that can justify continued therapy for a time.

If, despite all of these the patient continues to make no progress, there will come a point where you have to assess whether or not the skills of a therapist are still warranted.  If a non-therapist could carry out a maintenance program then it is appropriate to discharge.  It is also possible if those circumstances change in the future and the patient is better able to participate, that you re-evaluate and begin a new Plan of Care.  So ultimately it comes down  to clearly demonstrating that the skills of a therapist to required to analyze, adjust and ultimately to decide when these skills are no longer required.

Therapy Plateau Doesn't Equal Discharge

Glad to see the discussion on this important topic.  I thought it might be helpful to see what CMS agreed to, as far as Manual Revisions, as part of the Settlement Agreement in the Jimmo case. The following is an excerpt from the settlement:

The manual revisions will clarify that, under the SNF, HH, and OPT maintenance coverage standards, skilled therapy services are covered when an individualized assessment of the patient’s clinical condition demonstrates that the specialized judgment, knowledge, and skills of a qualified therapist are necessary for the performance of a safe and effective maintenance program. Such a maintenance program is covered to prevent or slow further deterioration so long as the beneficiary requires skilled care for the safe and effective performance of the program. When, however, the individualized assessment does not demonstrate such a necessity for skilled care, including when the performance of a maintenance program does not require the skills of a therapist because it could safely and effectively be accomplished by the patient or with the assistance of non-therapists, including unskilled caregivers, such maintenance services will not be covered under the SNF, HH, or OPT benefits.

The manual revisions will further clarify that skilled care is necessary for the performance of a safe and effective maintenance program only when (a) the particular patient’s special medical complications require the skills of a qualified therapist to perform a therapy service that would otherwise be considered non-skilled; or (b) the needed therapy procedures are of such complexity that the skills of a qualified therapist are required to perform the procedure.

The manual revisions will further clarify that, to the extent provided by regulation, the establishment or design of a maintenance program by a qualified therapist, the instruction of the beneficiary or appropriate caregiver by a qualified therapist regarding a maintenance program, and the necessary periodic reevaluations by a qualified therapist of the beneficiary and maintenance program are covered to the degree that the specialized knowledge and judgment of a qualified therapist are required.

In our setting we are usually able to hand over maintenance programs to nursing or restorative aides with out a risk of decline. It would be rare that we would be able to justify maintenance level services.  I do beleive there are opportunities to engage in follow up assessments and updates to these programs, but overall, most of them will not require the ongoing skills of a therapist.

Adding Value in What We Do

Thanks for providing so much insight on this topic. I agree with Jonalyn that the decision must include the entire interdisciplinary team...to decipher if the special skill set of a therapist is required versus the monitored instruction of the restorative nurse. One of the most challenging aspects remains is how this decision is relayed to the patient and family members.

As advocates for their loved ones, many of our family members are already asking about the Jimmo vs. Sibelius case. Often, patients and families feel that without skilled therapy...hope if lost.  This is where our Consonus culture can shine.  A strong Restorative Nursing Program will provide patients, families, and team members the confidence they need to ensure that the continum of care is ongoing when patients are transitioned to the Restorative Nursing Program.

One of Consonus' value added service can be providing regular Restorative Nurse Training. This process builds trust that can help the IDT make a responsible decision for transitioning a patient to a maintanence program.  Additionally, a cohesive Therapist/RNA relationship gives patients and families confidence in the discharge plan.  In the rare instance that the skills of a therapist are needed for a pateint's maintanece program, the entire team should work together to document how this plan of care is reasonable and necessary for the patient.

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