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 currentcondition

– 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)

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

Health Condition• Cancer Type• Treatment (Surgery, Radiation, Chemo)

EnvironmentalFactors

PersonalFactors

Participation• Learning & Applying

Knowledge• Domestic Life• Interpersonal Interactions

& Relationships• Major Life Areas• Community, Social & Civic

Life

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 interventionsGilchrist, 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 CarePfalzer, 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

• 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

4. Efficient Use of ICD-10 Codes

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• Breast Cancer: Invasive Lobular, Stage III, Grade 3

2. Cancer Treatment• 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

SurgeryChemotherapy

RadiationAdjuvant Therapies

Survivorship

THANK YOU