progressive disease in the geriatric...

PROGRESSIVE DISEASE IN THE GERIATRIC POPULATION:

MAINTAINING THE MOVEMENT SYSTEM

WILLIAM DIETER PT, DPT, GCS

DIRECTOR OF PT CLINICAL SERVICES

DIRECTOR FOX GERIATRIC RESIDENCY IN PHYSICAL THERAPY

MEGAN VALENZANO PT, DPT, GCS, CEEAA DIRECTOR OF REGULATORY AFFAIRS

DIRECTOR OF QAPD FOR POST-ACUTE SERVICES

COURSE OBJECTIVES

By the end of this program participants will be able to:

• Identify regulatory resources that apply to assisting the older adult in

maintaining function within their practice setting.

• Understand and base their treatment plans on the difference between

“Restorative/Rehabilitative” and “Maintenance” therapy.

• Apply principles from APTA’s Guide to PT Practice 3.0 and the ICF model

when addressing maintenance plans with their older adult patients.

• Apply appropriate supervisory principles that follow all regulatory guidance

when conducting a maintenance program with their older adult patients.

• Design an appropriate treatment plan that assists an older adult in

maintaining their current level of function.

• Incorporate techniques in their documentation that assist in demonstrating

skilled care during interventions to address maintenance of function in the

older adult.

WHAT IS HEALTHY AGING?

JIMMO V. SEBELIUS RULING

From CMS:

“No Improvement Standard is to be applied in

determining Medicare coverage for maintenance

claims in which skilled care is required.”

• Clarification of Medicare Benefit

• Some instances goal is to restore function: IRF


“The manual revisions clarify that a beneficiary’s lack of restoration

potential cannot, in itself, serve as the basis for denying coverage in

this context, without regard to an individualized assessment of the

beneficiary’s medical condition and the reasonableness and necessity

of the treatment, care, or services in question. Conversely, such

coverage would not be available in a situation where the beneficiary’s

maintenance care needs can be addressed safely and effectively

through the use of nonskilled personnel.”

-CMS Jimmo v. Sebelius Settlement Agreement Program Manual

Clarifications Fact Sheet


• Restorative/Rehabilitative therapy. In evaluating a claim for skilled therapy

that is restorative/rehabilitative (i.e., whose goal and/or purpose is to reverse, in whole or in part, a previous loss of function), it would be entirely appropriate to consider the beneficiary’s potential for improvement from the services. We note that such a consideration must always be made in the IRF setting, where skilled therapy must be reasonably expected to improve the patient’s functional capacity or adaptation to impairments in order to be covered.

• Maintenance therapy. Even if no improvement is expected, under the SNF, HH, and OPT coverage standards, skilled therapy services are covered when an individualized assessment of the patient’s condition demonstrates that skilled care is necessary for the performance of a safe and effective maintenance program to maintain the patient’s current condition or prevent or slow further deterioration. Skilled maintenance therapy may be covered when the particular patient’s special medical complications or the complexity of the therapy procedures require skilled care.

- CMS MLN Matters®Number: MM8458

MAINTENANCE AND MED B

So, what does this mean for me as a treating clinician?

• Clinical decision making is paramount

PTAs cannot provide maintenance services under

Medicare Part B

• Documentation is key

• Knowing the rules can be freeing…


For example, on being Reasonable and Necessary:

“Coverage for skilled therapy services related to a

reasonable and necessary maintenance program is

available in the following circumstances:

• Establishment or design of maintenance programs….

• Delivery of maintenance programs.”

- CMS Benefit Manual, Chapter 15, Section 220.2.D


For example, Progress Reports:

“Justification for treatment must include, for example, objective

evidence or a clinically supportable statement of expectation

that…

• In the case of maintenance therapy, treatment by the therapist

is necessary to maintain, prevent or slow further deterioration of

the patient’s functional status and the services cannot be safely

carried out by the beneficiary him or herself, a family member,

another caregiver or unskilled personnel.”

- CMS Benefit Manual, Chapter 15, Section 220.3.D

ICF Model

Heather L. Atkinson, and Kim Nixon-Cave PHYS THER

2011;91:416-430

MED B CASE JM is a 69 year old male with a primary medical diagnosis (health condition) of:

• Parkinson’s Disease

• Osteoarthritis

History of Present Illness:

• Fell on steps, no acute injury

• Fear of falling and increased freezing

• Difficulty with transfers and ambulation, SPC>RW>very limited walking

• Sleeps in reclining chair

Prior Level of Function (activity limitations):

• Independent with transfers to/from moderate height chairs using R UE, household

ambulation w/ SPC

• SBA for ambulation w/ SPC outdoors (quarter mile) & stairs w/ unilateral rail

Functional Outcome Measures:

• Timed up and Go: 114.5 sec w/ RW, through doorway secondary to freezes

• Dual task TUG: 196.5 w/ RW, cognitive

• Gait Speed: 0.29 m/s w/ RW

• Four Square Step Test: 80 seconds

MED B CASE The Plan of Care:

• 8 visits from March 31st to April 18th

• Primary Interventions (directed at impairments): Therapeutic exercise,

gait training, neuromuscular reeducation, and therapeutic activities

directed at impairments & education on PD/LSVT

• 16 visits LSVT from April 21st to May 19th

• 15 visits May 20th to July 9th

• Primary Interventions: gait training, therapeutic activities, provision of

Juxta Fit garments

Skilled care techniques used throughout the plan of care:

• Patient specific education on PD and management

• Vital sign monitoring and edema management

• Verbal, tactile, and visual cues for increasing amplitude and speed of

movement

• LSVT treatment technique

• Task specific neuromuscular re-education with skilled manipulation of

environment and task performance

MED B CASE

Timeline of Key Points of Clinical Decision Making:

March 31st : Initial evaluation, began impairment level treatment and

education/preparation for LSVT

April 21st : Began LSVT treatment

May 19th: Ended LSVT treatment, patient purchased exercise DVD to use

during HEP and able to perform w/ his brother

May 20th : Began final portion of POC aimed at task specific training for

difficult activities, edema management, provision of final HEP

May 23rd: Patient diagnosed w/ Multi System Atrophy instead of PD following

PT referral to UPenn due to inconsistent symptoms (environmental factor)

MED B CASE Timeline Continued:

June 16th: Flipped the switch to maintenance therapy

July 9th (Final visit): Final discharge from PT. Condition stabilized enough it

could be performed by a non-therapist. All outcome measures re-assessed

What was the clinical decision for skilled maintenance?

• Patient reached his maximal ability

• Skilled functional training was needed to maintain gains due to

variable physical and psychological presentation

• Skilled need for monitoring vital signs and edema/modifying

schedule

• Further modified and educated on HEP to match his variable

presentation

• Highly motivated and willing caregiver presence (environmental

factor)

MED B DOCUMENTATION EXAMPLES Example #1

Mr. K has completed 16 visits of PT at the end of his current certification period. He has progressed with trunk and LE ROM and mobility to now being able to perform wheelchair positioning and the initiation of transfers with min/mod assist. By using a bar, he can transfer from edge-of-seat to standing and tolerate brief periods of standing with SBA. However, his CP has limited the anticipated progress of ROM and trunk flexibility gains and the return of extension tone after therapy causes him to sit at the end of his seat in lumbar extension and push his feet to the extent of his foot plate straps. Monitoring and subsequent therapy for declining chair mobility and LE flexibility would be beyond the scope of non-skilled caregivers present at his facility. A HEP will address current symptoms and status but due to the declining nature of CP, a skilled PT would be able to address new limitations and symptoms, assess future needs, and provide evidence-based manual techniques to treat increased tone. For these reasons, he will benefit from skilled PT care to address CP progression to keep his current status

MED B DOCUMENTATION EXAMPLES Example #2

Pt has completed 30 visits of PT at the end of her current certification period. She has progressed with trunk and LE strength and disassociation; She is now able to perform bed mobility, transfers, and gait with dec A. She is able to ambulate on level surfaces with a SPC, however still with tremors, ataxia and dec trunk association due to PD symptoms. However, her PD has limited the anticipated progress of ROM and trunk flexibility gains and the return of rigidity and tremors, tone after therapy causes her to have gait ataxia, dec initiation of movement, fenestrating gait and risk for falls. Monitoring and subsequent therapy for declining transfers and gait, and LE/core tone would be beyond the scope of non-skilled caregivers present at this facility. A HEP will address current symptoms and status but due to the declining nature of PD, a skilled PT would be able to address new limitations and symptoms, assess future needs, and provide evidence-based manual techniques to treat increased tone/rigidity and tremor.For these reasons, she will benefit from skilled PT care to address PD progression to keep his current status.

MAINTENANCE & MED A (SNF)

“Therapy services in connection with a maintenance program are considered skilled when they are so inherently complex that they can be safely and effectively performed only by, or under the supervision of, a qualified therapist…If all other requirements for coverage under the SNF benefit are met, 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 to maintain the patient’s current condition or to prevent or slow further deterioration is covered so long as the beneficiary requires skilled care for the safe and effective performance of the program.”

-CMS Benefit Manual, Chapter 8, Section 30.4.1.2.E


Case Example:

A patient with Multiple Sclerosis who has been recently hospitalized may require the services of a physical therapist to determine the type of exercises that are required to maintain their present level of function. The initial evaluation of the patient’s needs, the designing of a maintenance program, and the instruction of the patient or caregivers in the carrying out of the program, would constitute skilled physical therapy and must be documented in the medical record.


Case Example: Documentation

Patient seen for maintenance plan training today to review

stretching techniques to maintain muscle length and prevent

excessive fatigue during self-stretching. Session focused on hip

stretching of hip flexors, hamstrings, and gastroc/soleus

complex due to noted spasticity. Educated on use of RPE to

self-assess and use of adaptive equipment (strap/belt) to assist

with LE stretching during periods of increased spasticity. Patient

able to independently demonstrate techniques 5/10 stretches,

continued to require verbal instruction for technique and use of

RPE to prevent excessive fatigue during remainder of exercises.

MAINTENANCE AND MED A (HH)

On being Reasonable and Necessary from CMS:

“The patient’s clinical condition requires the specialized skills, knowledge, and judgment of a qualified therapist to establish or design a maintenance program, related to the patient’s illness or injury, in order to ensure the safety of the patient and the effectiveness of the program, to the extent provided by regulation”

“The skills of a qualified therapist (not an assistant) are needed to perform maintenance therapy.”

- CMS Benefit Manual, Chapter 7, Section 40.2.1


Special Considerations for Home Health:

“When designing or establishing a maintenance program, the qualified therapist must teach the patient or the patient's family or caregiver’s necessary techniques, exercises or precautions as necessary to treat the illness or injury. The instruction of the beneficiary or appropriate caregiver by a qualified therapist regarding a maintenance program is covered if the specialized skills, knowledge, and judgment of a qualified therapist are required. However, visits made by skilled therapists to a patient's home solely to train other HHA staff (e.g., home health aides) are not billable as visits since the HHA is responsible for ensuring that its staff is properly trained to perform any service it furnishes. The cost of a skilled therapist's visit for the purpose of training HHA staff is an administrative cost to the agency.”



Special Considerations for Home Health:

“When the development of a maintenance program could not be accomplished during the last visits(s) of rehabilitative/restorative treatment, the therapist must document why the maintenance program could not be developed during those last rehabilitative/restorative treatment visit(s).”



Case example:

Patient is an 89 y/o with Rheumatoid Arthritis after a

hospitalization for pneumonia. Having achieved all of

his rehabilitative goals, you know he can be

discharged to a home exercise program. However,

you are concerned that due to unpredictable c/o pain

and noted atrophy in his shoulders that impacts the

kinematics of the joint you decide a skilled

maintenance program would be more appropriate.

MAINTENANCE AND MED A (HH) Case example Documentation:

• Patient has been seen for the last 30 days for rehabilitative services to

address c/o shoulder pain, weakness, impaired balance, and difficulty

with transfers and ambulation. During that time he has made significant

gains in all areas. He has minimal c/o shoulder pain after ambulation only,

demonstrated improvement in 30 second sit-stand test, and is able to

transfer and ambulate with minimal assistance. Family and his caregiver

have also been trained on appropriate strategies to assist with pain

control, massage techniques, assisting in a home exercise program, and

appropriately facilitate transfer and ambulation practice to maintain gains

made in therapy. However, patient continues to present with difficulty

weight shifting due to pain in knees as a result of Rheumatoid Arthritis. He

also has very small muscle bulk t/o his body, which requires exercises to

be modified and adapted to appropriate challenge and protect his

remaining musculature and joints. These two factors require the skill of a

therapist on occasion to modify/update his home exercise program and

continually train family to ensure maintenance of gains made and delay

progression.

SMALL GROUP STUDY

• Med B Case:

• SNF Case:

• Home Health Case:

Questions?

REFERENCES Centers for Medicare and Medicaid Services. (January 14, 2014). Manual Updates to Clarify Skilled Nursing Facility

(SNF), Inpatient Rehabilitation Facility (IRF), Home Health (HH), and Outpatient (OPT) Coverage Pursuant to

Jimmo vs. Sebelius (MLN Matters Number MM8458 Revised). Retrieved from https://www.cms.gov/Outreach-and-

Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8458.pdf

Centers for Medicare and Medicaid Services (January 14, 2014). Medicare Benefit Policy Manual, Transmittal 179.

(CMS Pub No. 100-02). Retrieved from https://www.cms.gov/Regulations-and-

Guidance/Guidance/Transmittals/Downloads/R179BP.pdf

Centers for Medicare and Medicaid Services. (February 2, 2014). Jimmo v. Sebelius Settlement Agreement Program

Manual Clarifications Fact Sheet. Retrieved from https://www.cms.gov/medicare/medicare-fee-for-service-

payment/snfpps/downloads/jimmo_fact_sheet2_022014_final.pdf

Centers for Medicare and Medicaid Services. (February 13, 2015). Medicare Benefit Policy Manual, Chapter 15 –

Covered Medical and Other Health Services. (CMS Pub No. 100-02). Retrieved from

https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c15.pdf

Centers for Medicare and Medicaid Services. (March 13, 2015). Medicare Benefit Policy Manual, Chapter 8 -

Coverage of Extended Care (SNF) Services Under Hospital Insurance. (CMS Pub No. 100-02). Retrieved from


Centers for Medicare and Medicaid Services. (May 11, 2015). Medicare Benefit Policy Manual, Chapter 7 – Home

Health Services. (CMS Pub No. 100-02). Retrieved from https://www.cms.gov/Regulations-and-

Guidance/Guidance/Manuals/downloads/bp102c07.pdf

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM8458.pdf











https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R179BP.pdf






https://www.cms.gov/medicare/medicare-fee-for-service-payment/snfpps/downloads/jimmo_fact_sheet2_022014_final.pdf

























REFERENCES Crowner, B. (February 2015). Central and Peripheral Benefits of Exercise. Powerpoint presentation at the

Combined Sections Meeting of the American Physical Therapy Association, Indianapolis, IN.

Drummond-Dye, R. (February 2015). Improvement Standard Lawsuit and Its Impact on PT Practice.

Powerpoint presentation at the Combined Sections Meeting of the American Physical Therapy Association,

Indianapolis, IN.

Fox, C., Ebersbach, G., Ramig, L., Sapir, S (2012). LSVT LOUD and LSVT BIG : Behavioral Treatment

Programs for Speech and Body Movement in Parkinson’s Disease. Parkinsons Disease, 1-12.

Pahor, M., Guralnik, J.M., Ambrosius, W.T., Blair, S., Bonds, D.E., Church, T.S.,…Williamson, J.D. (2014).

Effect of structured physical activity on prevention of major mobility disability in older adults: The LIFE

study randomized clinical trial. JAMA, 311(2), 2387-2396.

Santos, D. A. (2012). Sedentary behavior and physical activity are independently related to functional

fitness in older adults. Experimental gerontology, (37), 12. 908-912.

Toto, P.E., Raina, K.D., Holm, M.B., Schlenk, E.A., Rubinstein, E.N., Rogers, J.C. (2012). Outcomes of a

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and Physical Activity, 20, 363-378.

THANK YOU!

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