Physical Therapy Leadership in Home Health –
Solid Footing in Times of Change, Day 1 Speaker(s): Dan Kevorkian, PT, MSPT Diana Kornetti, PT, MA Cynthia Krafft, PT, MS, HCS‐O Tonya Miller, PT, DPT Session Type: Preconference Courses Session Level: Intermediate 1.6 CEUs 1
Page 1 of 140 total pages This information is the property of the author(s) and should not be copied or otherwise used without the express written permission of the author(s). Preconference Course Certificates Preconference CEU certificates are accessible in the APTA Learning Center. In order to earn CEUs for the preconference course, participants must pass a multiple‐choice assessment with a score of 70% or better. The preconference assessment can be accessed at the conclusion of CSM in the APTA Learning Center. To access your assessment and certificate, follow these easy steps: o Go to APTA Learning Center and login. Enter your email, member number or user ID. Use the "forgot your password" link if you need to reset your password. o Click on the "My Learning Activities/My Courses" tab in the top navigation menu, and find your preconference course. o Click "Start" next to the course title. Follow the directions to take the assessment and print your CEU certificate. If you require additional assistance related to your CSM attendance, please contact APTA’s Member Services: 800/999‐2782, ext. 3395, M‐F, 8:30 am to 6:00 pm, ET, or email [email protected]. www.homehealthsection.org Home Health Section of the American Physical Therapy Association Day 1 - 1
2/9/2017
Physical Therapy Leadership in
Home Health
Solid Footing in Times of Change
Disclosure
• Speaker has no relationship that could reasonably be
viewed as creating a conflict of interest, or the
appearance of a conflict of interest, that might bias
the content of this presentation.
• Speaker confirms no relevant financial relationship
exists.
Day 1 - 2
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Course Learning Objectives
• Implement intentional care delivery in the HH setting
responsive to CMS’ Triple Aim initiative.
• Analyze key data related to impact of services on patient and
agency outcomes.
• Evaluate care delivery variations within the context of BPCI,
demonstration projects (i.e., CJR), and Value-Based
Purchasing (VBP) models.
• Develop cost-effective, compliant, and competitive agency
programs and services consistent with regulatory expectations.
Driving Forces
Regulations
Patient
Satisfaction
&
Protection
Alternate
Payment
Methodologie
s
Enhanced
Efficiency
Day 1 - 3
2
2/9/2017
The Struggle is Real
Costs
Aging
Population
• High(er) costs not
achieving desired
outcomes
• Increased users
– Living (longer) with
chronic disease(s)
• Payment models reward
volume of care
National Quality Strategy
• Established by the Affordable Care Act to improve the
delivery of health care services, patient health outcomes,
and population health
• The Strategy was first published in 2011 and serves as a
nationwide effort to improve health and health care across
America
• The Strategy was iteratively designed by public and private
stakeholders and provides an opportunity to align quality
measures and quality improvement activities
Day 1 - 4
3
2/9/2017
National Quality Strategy
• Pursuit of three aims concurrently
– CMS’ “triple aim”
• How it works:
– Improving health & health care
quality can occur only if all sectors,
individuals, family members, payers,
providers, employers, and
communities, make their mission.
Better
Health
Better
Care
Lower
Cost
Motivation - MedPAC
• Annual Reports (2011, 2015)
– The Medicare Home Health Benefit is ill-defined
– Home health payment should not be based on the
number of therapy visits
• Current system incentivizes more therapy visits and fewer
non-therapy visits.
– Home health payment should be determined by
patient characteristics
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Motivation - MedPAC
• Payment Reform Principles
– Improve payment accuracy for home health services
– Promote fair compensation to HHAs
– Increase the quality of care for beneficiaries
• HHGM under consideration
– 30-day period (not 60-day episode)
– Episodes have more visits on avg. during 1st 30 days
compared to last 30 days
What Is this Based On . . .
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Not a Conspiracy Theorist!
‘Big Data’ Speaks
• Nationwide Analysis of Common Characteristics
in OIG Home Health Fraud Cases
– HHS OIG Data Brief, June 2016: OEI-05-16-00031
– www.oig.hhs.gov
– At a glance findings
• > 500 HHA and 4,500 physician outliers on
multiple characteristics commonly found in OIGinvestigated cases of HH fraud
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‘Big Data’ Speaks
• Source: Medicare claims data for CYs 20142015
– HHAs, physicians, and geographic areas
• Disclaimer: “While these characteristics are not
necessarily indicative of fraudulent activity, they
can be useful in identifying providers and
geographic areas that warrant greater scrutiny.”
How You Might Picture HHS . . .
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But Seriously
• The Facts:
– $18.4 billion paid to more than 11,000 HHAs in CY
2015
– Over $10 billion in improper payments estimated in
FY 2015
– > 350 criminal and civil actions & $975 million in
investigative receivables for FYs 2011-2015
The “Characteristics”
• High % of episodes for which the beneficiary had no
recent visits with supervising physician
• High % of episodes that were not preceded by a hospital
or nursing home stay
• High % of episodes with a primary diagnosis of diabetes
or HTN
• High % of beneficiaries with claims from multiple HHAs
• High % of beneficiaries with multiple HH readmission in
a short period of time
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National Medians & Outlier Thresholds for HHAs and Physicians
Qualification: (+) on 2 or more of 5 characteristics
Characteristics
Provider Type
Nat’l Median
Threshold for
Outliers
Number of
Outliers
Outliers as % of
Total
No recent visit
w/supervising
physician
HHAs
22.6%
62.5%
470
3.9%
Physicians
11.8%
54.6%
16,789
4.9%
HHAs
49.5%
--
--
--
Physicians
35.7%
97.1%
1,751
0.5%
HHAs
10.1%
45.1%
483
4.0%
Physicians
5.3%
28.8%
7,937
2.3%
HHAs
6.3%
25.9%
770
6.5%
Physicians
0.0%
13.9%
7,510
2.2%
HHAs
5.6%
19.3%
778
6.5%
Physicians
3.6%
19.1%
3,822
1.1%
No hospital or SNF
stay
No Diabetes or
HTN diagnosis
Beneficiaries
w/claims from mult.
HHAs
Readmission shortly
after DC
Source: OIG analysis of Medicare claims data, 2016.
End Result of “Seeing” the Data
• 27 geographic areas in 12
states emerged as hotspots
for characteristics
commonly found in OIG
home health fraud cases
– > 2 characteristics
– Area with 10+ HHAs
– Area with 50+ physicians
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35% all HH episodes; 37% all HH
spending occurred in these areas
Geographic Hotspots for
Characteristics Commonly Found
in OIG Home Health Fraud Cases
2/9/2017
Source: OIG analysis of Medicare claims data, 2016.
Setting Expectations
• I hope I have you excited for who and what you will hear
over the next 2 days.
• You have tools/resources included in your course materials
to take back to your organization and put into use.
• Each day, there is lunch provided – please take the time to
network; reach out and meet new people . . . expand your
circle of contacts.
• Also, each day, we have a Q&A panel of the day’s
speakers available to you.
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Who Will You Be?
• “I am putting tools in my
tool belt that will make
me irreplaceable.”
– Chase Shinn, Sgt., USMC,
Former Active Duty
– Embry-Riddle, Student
Aviation Maintenance
Science with specialty in
Occupational Safety
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Shifting Paradigm: Industry
Drivers/Agency Dashboards
Daniel Kevorkian, PT, MS
Disclosure
• Speaker has no relationship that could reasonably be
viewed as creating a conflict of interest, or the
appearance of a conflict of interest, that might bias
the content of this presentation.
• Speaker confirms no relevant financial relationship
exists.
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CMS Triple Aim
• Improving the patient experience of care
(including quality and satisfaction);
• Improving the health of populations
• Reducing the per capita cost of health care
www.ihi.org/Engage/Initiatives/TripleAim/pages/default.aspx
The Shifting Paradigm?
• The majority of payments made by Medicare are still
under the fee for service model
– More Care = More $$$$
– The model encourages Volume over Value
• Think back to the Magical 10+ therapy rule – what was
the average therapy visits completed?
• When moved to 7/14/20 what shifts did we see as an
industry?
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Shift in Thinking is Needed
• Shifting thinking to drive value over volume
– Initiatives in place
– More coming down the pipe
– Focused on rewarding quality outcomes and penalizing
poor performance
• Clinical and Financial Measures
Shift in Thinking is Needed
• There is new thinking required in meeting these new
challenges:
– Can we get better outcomes in lower levels of care?
– Can we achieve better outcomes by providing less
care?
– What services are we currently providing that do not
provide value to the patient/industry
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CMS Innovation Center
• Established by section 1115A of the Social Security Act (as added
by section 3021 of the Affordable Care Act
• Allows the Medicare and Medicaid programs to test models that:
– Improve care
– Lower costs
– Better align payment systems to support patient-centered practices.
• Evaluates innovative reform efforts widely used in the private
sector, and is unique in:
– Ability to develop provider-proposed approaches
– Quickly adjust models in response to feedback from clinicians and patients.
https://innovation.cms.gov/About
Alternative Payment Models (APM)
• The Patient Protection Affordable Care Act (PPACA)
– Created a number of new payment models that move away
from paying health care providers for quantity of care (feefor-service) towards quality of care
• The APM and payment reform are focused on
delivering:
– Better care
– Better outcomes
– Lower cost.
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Alternative Payment Models (APM)
• Medicare has met its goal to:
– Move 30% of Medicare FFS payments to APM by 2016
– Expand Medicare FFS payments to APM to 50% by 2018
• Additionally, the Department of Health and Human Services
has set a goal to:
– Tie 85% of Medicare fee-for-service to quality or value by 2016
– Tie 90% of Medicare fee-for-service to quality or value by 2018
• Aggressive growth in this area
•
•
•
•
•
•
CMS Innovation Programs- APM
(Areas of Focus)
Accountable Care
Episode-based Payment Initiatives
Primary Care Transformation
Initiatives Focused on the Medicaid and CHIP Population
Initiatives Focused on the Medicare-Medicaid Enrollees
Initiatives to Accelerate the Development and Testing of
New Payment and Service Delivery Models
• Initiatives to Speed the Adoption of Best Practices
https://innovation.cms.gov/initiatives/index.html#views=models
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Accountable Care Organizations
• Accountable Care Organizations and similar care
models are designed to:
– Incentivize health care providers to become
accountable for a patient population
– Invest in infrastructure and redesigned care processes
that provide for:
• Coordinated care
• High quality care
• Efficient service delivery
Accountable Care Examples
(Status)
• ACO Investment Model (Ongoing)
– Testing Pre-Payment approaches meant to support Medicare
Shared Savings
• Comprehensive ESRD Model (Ongoing)
– Designed to improve care for beneficiaries with ESRD while
lowering Medicare Costs
• Medicare Health Care Quality Demonstration (Ongoing)
– Testing major changes to improve quality of care while
increasing efficiency across an entire health care system.
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Accountable Care Examples
(Status)
• Next Generation ACO (Applications under review)
– Provider groups assume higher levels of financial risk and
reward than are available under the current Pioneer ACO
Model and Shared Savings Program through incentives and
support tools
• Rural Community Hospital Demonstrations
(Ongoing)
– Testing the feasibility and advisability of providing
reasonable cost reimbursements for small rural hospitals.
Episode-based Payment Initiatives
• Under these models, health care providers are
held accountable for the cost and quality of care
beneficiaries receive during an episode of care
– Typically, these models begins with a triggering health
care event (such as a hospitalization or chemotherapy
administration) and specified period of time thereafter.
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Episode-Based Payment Initiatives
Example (Status)
• BPCI – Models 2-4 (ongoing)
– In Model 2, retrospective bundled payments are made for acute care
hospital stay plus post-acute care.
– In Model 3, retrospective bundled payments are made for post-acute
care only.
– In Model 4, prospective bundled payments are made for acute care
hospital stays only.
Episode-Based Payment Initiatives
Example (Status)
• Comprehensive Care for Joint Replacement (ongoing)
– Mandatory bundle in 67 MSA designed around Model 2 BPCI.
– Retrospective payments are made for acute care hospital plus 90 days
post-acute
– Performance period: April 1, 2016  December 2021
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Episode-Based Payment Initiatives
Example (Status)
• Surgical Hip and Femur Fracture Treatment (SHFFT)
Model (announced)
– This model focuses on Part A and B items and services provided to
Medicare fee-for-service beneficiaries that are related to SHFFT and
recovery. Surgical repairs not considered to be a joint replacement.
– Same markets as CJR
– Performance period: July 1, 2017 December 31, 2021
Episode-Based Payment Initiatives
Examples (Status)
• Acute Myocardial Infarction (AMI) Model (announced)
– This model focuses on Part A and B items and services provided to
Medicare fee-for-service beneficiaries undergoing hospitalization for AMI
– Performance period: Begins July 1, 2017 and will continue for 5 years
• Coronary Artery Bypass Graft (CABG) Model (announced)
– This model focuses on Part A and B items and services provided to
Medicare fee-for-service beneficiaries that are related to CABG treatment
and recovery.
– Performance period: Begins July 1, 2017 and will continue for 5 years
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Episode-Based Payment Initiatives
Examples (Status)
• Oncology Care Model (participants announced)
– This innovative new payment model for physician practices
administering chemotherapy aims to provide higher quality, more
coordinated oncology care at lower cost to Medicare.
– Encompasses 16 private payers as well as Medicare
– Performance period: July 1, 2016  30th, 2021
Primary Care Transformation
• Primary care providers are a key point of contact for patients’
health care needs.
• Strengthening and increasing access to primary care is critical
to promoting health and reducing overall health care costs.
• Advanced primary care practices – also called “medical
homes” – utilize a team-based approach, while emphasizing:
–
–
–
–
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Prevention
health information technology
care coordination
Shared decision making among patients and their providers.
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Initiatives Focused on the Medicaid
and CHIP Population
• Medicaid and the Children’s Health Insurance
Program (CHIP) are administered by the states but
are jointly funded by the federal government and
states. Initiatives in this category are administered by
the participating states.
Initiatives Focused on the Medicaid
and CHIP Population Ex. (Status)
• Medicaid Incentives for the Prevention of Chronic Diseases model
(ongoing)
– Supporting 10 states
– Providing incentives for Medicaid beneficiaries to participate in prevention
programs and demonstrate changes in health risks and outcomes.
– Applications must include a program to address one of the following goals
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Tobacco cessation
Lowering cholesterol
Controlling/reducing
weight
Lowering blood pressure
Avoiding onset of
diabetes or improving
mgmt of condition
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Initiatives Focused on the Medicaid
and CHIP Population Ex. (Status)
• Strong Start for Mothers and Newborns Initiative
(ongoing)
– Strong Start supports reducing elective deliveries prior to 39 weeks and
offers enhanced prenatal care to decrease preterm births through awards
to 27 organizations.
Initiatives Focused on the
Medicare-Medicaid Enrollees
• The Medicare and Medicaid programs were designed with
distinct purposes.
• Individuals enrolled in both Medicare and Medicaid (the “dual
eligibles”) account for a disproportionate share of the
programs’ expenditures.
• A fully integrated, person-centered system of care that ensures
that all their needs are met could better serve this population in
a high quality, cost effective manner.
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Initiatives Focused on the MedicareMedicaid Enrollees Ex. (status
• Financial Alignment Initiative for Medicare-Medicaid
Enrollees (ongoing)
• Initiative to Reduce Avoidable Hospitalizations among
Nursing Facility Residents
– (stage 1 ongoing / stage 2 announced)
Initiatives to Accelerate the Development and
Testing of New Payment and Service Delivery
Models
• Many innovations necessary to improve the health care
system will come from local communities and health care
leaders from across the entire country.
• By partnering with these local and regional stakeholders,
CMS can help accelerate the testing of models today that
may be the next breakthrough tomorrow.
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Initiatives to Accelerate the Development of New
Payment ad Service Delivery Models Ex. (Status)
• Accountable Health Communities Model (applications under
review)
– Test whether addressing unmet health-related social needs can reduce health care
costs and utilization among community Medicare and Medicaid beneficiaries
• Cardiac Rehabilitation (CR) Incentive Payment Model (under
development)
– Test the impact of providing an incentive payment for cardiac rehabilitation to
hospitals where beneficiaries are hospitalized for a heart attack or bypass surgery.
• Health Care Innovation Awards (ongoing)
– Funding competitive grants to compelling new ideas that deliver health care at lower
costs to people enrolled in Medicare, Medicaid, and CHIP.
Initiatives to Accelerate the Development of
New Payment ad Service Delivery Models Ex.
(Status)
• Home Health Value-Based Purchasing (ongoing)
– Designed to support greater quality and efficiency among Medicarecertified home health (CHHA) agencies by shifting away from
payments based on volume towards payments based on quality
– HHAs will have their payments adjusted with greater risk each year
• VNAA produced presentation:
http://www.vnaa.org/files/events/AM2016/PPTs/HHVBP%20
preconference.pdf
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Home Health Value Based
Purchasing (HHVBP)
• Incentivizes Medicare CHHAs to provide higher
quality and more efficient care
• Tests whether a payment incentives significantly
improves provider performance
• Test the use of new quality measures
• Updates the public reporting process
HHVBP Geography
• All Medicare-certified HHAs that provide services in the
following states are automatically included:
•
•
•
•
•
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Massachusetts
Maryland
North Carolina
Florida
Washington
•
•
•
•
Arizona
Iowa
Nebraska
Tennessee
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HHVBP Quality Measures
• 6 process measures from existing OASIS data collection
• 8 outcome measures from existing OASIS data and 2
outcome measures from claims data
• 5 HHCAHPS consumer satisfaction measures
• 3 new measures
– Points achieved by reporting data
– Submitted through the HHVBP portal
HHVPB Reward/Penalty
• Home Health Agencies will be limited in the amount of risk or
reward as follows:
–
–
–
–
–
Maximum payment adjustment of 3 percent (upward or downward) in 2018,
Maximum payment adjustment of 5 percent (upward or downward) in 2019,
Maximum payment adjustment of 6 percent (upward or downward) in 2020,
Maximum payment adjustment of 7 percent (upward or downward) in 2021, and
Maximum payment adjustment of 8 percent (upward or downward) in 2022.
• This model is designed so there is no selection bias, participants
are representative of home health agencies nationally, and there is
sufficient participation to generate meaningful results among all
Medicare-certified HHAs nationally
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Do you know???
• Based on recent studies, how long does it take on
average before best practices - backed by research are incorporated into widespread clinical practice?
17 YEARS
• Even then the application of the knowledge is very
uneven.
Initiatives to Speed the Adoption of
Best Practices Ex. (Status)
• Beneficiary Engagement and Incentives: Direct Decision Support
(DDS) Model (Announced)
– This model will test an approach to shared decision making provided outside
of the clinical delivery system by an organization that provides health
management and decision support services.
• Beneficiary Engagement and Incentives: Shared Decision Making
(SDM) Model (Announced)
– This model will test a specific approach to integrate a structured Four Step
shared decision making process into the clinical practice of practitioners who
are participating Accountable Care Organizations (ACOs).
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Initiatives to Speed the Adoption of
Best Practices Ex. (Status)
• Community Based Care Transitions Model (Ongoing)
– Supporting community-based organizations to reduce readmissions by
improving transitions of high-risk Medicare beneficiaries from the inpatient
hospital setting to home or other care settings.
CMS Innovation Center
• These were just an example of initiatives
• More information available on each of these at this
address:
https://innovation.cms.gov/initiatives/index.html#views
=models
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What Does this Mean for Home
Health?
• Direct vs. Indirect financial impact
– Some initiatives have direct impact on your agencies
bottom line
• Ex. Home Health Value Based Purchasing
– Others may have indirect impact
• Preferred Networks in bundled initiatives
• Greater visibility into quality outcomes (STAR ratings, Home
Health Compare, HHCAHPS) by the public and referral
sources
What Does this Mean for Home Health?
• Need for greater internal reporting
– Must have visibility into practice patterns
– Previously HH agencies would look at the standard
reporting items with an emphasis on maximizing revenue:
•
•
•
•
•
Day 1 - 31
Re-hospitalization rates
Home Health Compare
HHRG rates
Utilization patterns (Therapy (revenue) vs. Nursing (cost))
Assistant Utilization
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What Does this Mean for Home Health?
• Important to now look beyond the numbers
– When do hospitalizations occur?
– What services that you provide add value?
– Is there a more efficient way to achieve better outcomes
What Does this Mean for Home Health?
• Need for greater external reporting and visibility
– Previously, referral sources did not have a reason to care
about a HH agencies financials
– As the paradigm is shifting, more and more programs are
requiring referral sources to be aware of practice patterns
after discharge from their practice
– Need to provide visibility into appropriate metrics, based
on referral sources requirements and program specifics.
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HH Current State - SWOT
• Where do we stand as an industry?
– Strengths
– Weaknesses
– Opportunities
– Threats
HH Current State - Strengths
• Not limited by physical size
– Medicare enrollees are expanding at an alarming rate
– Baby Boomers starting to retire
– Limited space in hospitals, SNF, IRF will not meet the demand
•
•
•
•
Lowest cost setting
Ability to customize care plans
Ability to impact change in patient’s own home (lifestyle impact)
HH has true visibility into patient needs
– See patients as they truly are
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HH Current State - Strengths
Size
Cost
Lifestyle
Impact
Customization
Resources
HH Current State - Strengths
• Not limited by physical size
– Medicare enrollees are expanding at an alarming rate
– Baby Boomers starting to retire
– Limited space in hospitals, SNF, IRF will not meet the
demand
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HH Current State - Strengths
• Lowest cost setting
– Ability to see patients for extended length of time when
clinically warranted
• 60 day episodes with ability to recertify
• HHRG rates of $2,000 to $6,000 on average
– Able to utilize ancillary services and assistants
HH Current State - Strengths
• Ability to customize care plans
– Take into account patient condition in developing
frequency & intensity of services
– Phone Calls
– Telemonitoring
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HH Current State - Strengths
• HH has true visibility into patient needs
– See patients as they truly are
• Ability to impact change in patient’s own home
– Chronic diseases require significant lifestyle changes that
cannot be accomplished in the length of time someone is in
a facility
HH Current State - Strengths
• Multitude of resources
–
–
–
–
–
–
–
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Social Work
Behavioral Health
Nursing
Home Health Aides
Physical Therapy
Occupational Therapy
Speech Therapy
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Multitude of resources
HH Current State - Strengths
Nursing
Behavioral
Health
HH
Aides
Occupational
Therapy
Physical
Therapy
SpeechLanguage
Path
Social
Work
HH Current State - Weaknesses
• Limited research in support of home health
• History of “following the dollar” – Pre-PPS, 10+
therapy, 6,14,20 thresholds
• Accusations of Fraud and Abuse (Senate finance
committee hearing)
• Multiple small providers with varied levels of quality
• Contract Therapy services
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HH Current State - Opportunity
•
•
•
•
•
Ability to be a high quality partner with low cost
Being flexible to meet the needs of partners with varied goals
Developing programs to address individual program needs
Develop pathways to proactively address potential complications
Meet the challenges with unique new models
– Capitation
– Risk Bearing
– Alternative Payment Sources
Position Your Agency for Success
• What can you do to support provide solutions?
• 11 Step Process
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Position Your Agency for Success
1. Ensure publically reported metrics are satisfactory
or better
• If you were looking for a partner, what is the 1st thing you
would do?
•
Know your historic performance
• If your historic performance has been poor, why would
potential partners believe you could change practice
patterns quickly?
Position Your Agency for Success
2. Understand what initiatives are active in your market
• Many of the current APMs are located in only certain
markets
• Research to find out what risk bearing entities are in your
area and what specific initiatives they are involved with
• Educate yourself on the program and identify the “key
levers”
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Position Your Agency for Success
3. Understand the challenges that each program presents to
the risk-holder
• Each individual program contains its own unique goals
QUALITY?
FINANCES?
REHOSPITALIZATIO
N?
• What can you do to assist in meeting the goals of the program?
Position Your Agency for Success
4. Understand how home health can present potential
solutions
• What is unique to HH that can address the challenges for
the patient?
• Rural markets?
Review SWOT
• Home environment & evaluations
Analysis
• Urgent care delivery?
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Position Your Agency for Success
5. Understand how your specific agency can uniquely
address these challenges
• What will/can your agency do that is different than other
area agencies?
• HH industry operates under the same regulations – what
makes your agency “unique?”
Position Your Agency for Success
5. Understand how your specific agency can uniquely
address these challenges (cont’d)
• Management of complex patients
• How are you preventing emergent care needs?
• Programmatic approach to care redesign
• Upcoming HH Section Learning event: Building Successful
Home Health Programs
• Establish expected protocols, plans, escalation processes and
patient tools
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Position Your Agency for Success
6. Understand what metrics you will measure to ensure
effectiveness of your program
• How will you measure success/failure?
•
•
•
•
Paper or EMR?
Automated reporting v. Customized reporting
Data Analytics
Program Dashboards
• Poor performance does NOT equal failure
Unique opportunity
for “out of the box”
thinking
Program Dashboards
• Chart reviews are important in any agency,
however, how will you manage large numbers of
patients and identify outliers/trends quickly?
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Program Dashboards
• Dashboards are only as effective as:
• The quality of the data entered
• The actual metrics that you are measuring
• The person responsible for reviewing these dashboard
and impacting change
• It’s one thing to identify issues – how are you going to
address them and impact change?
Program Dashboards
• What metrics should you
be looking at?
• What are you trying to
measure?
Day 1 - 43
Financial
Quality
Metrics
Patient
Satisfaction
Protocol
Compliance
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Program Dashboards
• Quality Metrics:
• OASIS
• Home Health Compare
• 6 month lag
• What are you doing to ID issues
more quickly?
• Re-hospitalizations
• Emergency department utilization
Financial
Patient
Satisfaction
Quality
Metrics
Protocol
Compliance
Program Dashboards
• Protocol Compliance
• Timely initiation of care
• Visit frequencies
• Timely feedback to providers
Day 1 - 44
Financial
Patient
Satisfaction
Quality
Metrics
Protocol
Compliance
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Program Dashboards
• Patient Satisfaction
• HHCAHPS
• Patient satisfaction follow-up
surveys
• CMS and risk bearing entities are
VERY interested in the patient
experience
– Patient must not feel as though their
care is compromised or service has
declined
Financial
Patient
Satisfaction
Quality
Metrics
Protocol
Compliance
Program Dashboards
• Financial (External & Internal
interests)
• HHRG Rates
• Therapy Utilization
• Appropriate care provider
Financial
Patient
Satisfaction
Quality
Metrics
Protocol
Compliance
• Utilizing lower cost when
appropriate
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Position Your Agency for Success
7. Thoughtful discharge planning
• Personal experience has shown that many readmissions in 90 day
plans are occurring after patients are DC’d from care providers
• Is your patient truly aware of how to care for themselves; who to
call if issues arise?
• Are your patients aware of what symptoms they should be
looking for to ID a potential complication?
• Advanced beneficiary notices should not be the only DC
planning that occurs
Position Your Agency for Success
8. Identify the key stake-holders at the risk bearing entity
and arrange meetings to present your solutions
• Who is at risk for the program?
• Who cares about this program?
•
•
•
Lack of awareness in public and health care community
CFO cares about finances?
Care Management looking for other DC solutions
• Is there an outside consultant present?
• Is there some other person responsible for the program?
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Position Your Agency for Success
9. Once a Partner, identify key people with whom to
communicate on a regular basis
•
•
Congratulations, you have been selected . . . Now what???
Identify key people with whom to communicate on a regular
basis
•
•
Ensure regular cadence of communication (Pt. rounds? Outlier
reporting?)
Once you’ve done the work to earn the business, ensure you
protect your interests
Position Your Agency for Success
10. Ensure tracking, monitoring and delivery of any promised
reporting
•
•
•
•
Day 1 - 47
Lots of companies can promise, will you deliver?
Data is frustrating and often times requires constant monitoring
and tweaking to ensure the it is correct
Ensure that there is a plan to gather, review and deliver the
necessary reporting
Be willing to change course and allow data to guide decisions
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Position Your Agency for Success
11. Establish a regular cadence to review performance with
the risk holder
•
Recommend quarterly (or more often) meetings with program
leadership to review performance and make changes
This new age of healthcare requires constant tweaking and
changes to plans to address issues that arise; must have
collaboration across the continuum
Be aware of issues before they are brought to you
•
•
In Conclusion . . .
•
•
•
•
Unique challenges required unique solutions
Nimble agencies have excellent opportunities
Struggling agencies are at risk
Are you willing to take risk and “put your money
where your mouth is?”
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Human Engagement and Team
Building
Tonya Miller PT, DPT
Celtic Healthcare
Senior Vice President
Disclosure
• Speaker has no relationship that could reasonably be
viewed as creating a conflict of interest, or the
appearance of a conflict of interest, that might bias
the content of this presentation.
• Speaker confirms no relevant financial relationship
exists.
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Session Learning Objectives
• Recognize the basics DISC assessment and how they apply to
everyday communication
• Incorporate DISC personality styles into leadership and team
building
• Implement key employee engagement activities which support
the “S” personality style
• Build strong organizational teams
• Incorporate leadership mentoring into everyday organizational
process
DISC ASSESSMENT
OVERVIEW
Day 1 - 50
• What is DISC
– Measure of observable
personality traits and
predictor of behavior
– Instrument for behavioral
tendency
– Tool that allows for common
language for discussing
human behavior
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DISC ASSESSMENT OVERVIEW
•
History of Personality Behavior Assessments
– Empodocles – 400 BC
• Earth
• Air
• Fire
• Water
– Hippocrates 400 BC
• Cholernic
• Sanguine
• Phlegmatic
• Melancholy
– Jung/ Briggs – 1921 (Myers Briggs Type Indicator)
• Thinking
• Feeling
• Sensation
• Intuition
•
•
•
•
DISC ASSESSMENT OVERVIEW
Present day DISC Assessment
– Martson 1926
• Dominant
• Influencing
• Steady
• Compliant
Emotions of Normal People -1928
– Examine observable “normal” behavior in particular environments
– Styles are both natural, internal, innate but also impacted by particular environment at the time
– We can have different styles based on the environment
– All people share in the 4 styles but in varying degree
Walter Clark = 1940
– Expanded Martson’s work to develop DISC personality
Profile report
Interesting Fact- Martson’s other accomplishments
– Father of polygraph
– Wonder Woman Comic
• Desire to promote women’s rights
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The “D” personality Style – 3% of People
• Dominant and Direct
–
–
–
–
–
–
Active – Task oriented
High ego strength
Impatient
Desires Change
Does many things at once
Responds to Direct Confrontation
• Dominant Fear
– Being Taken Advantage of
The “I” personality Style- 11% of People
• Influencing and Impulsive
–
–
–
–
–
–
Active and People oriented
Emotional
People oriented
Disorganized
Optimistic
Encouraging
• Dominant Fear
– Rejection
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The “S” Personality Style – 69% of
People (85% in Healthcare industry)
• Stable and Supportive
–
–
–
–
–
–
Passive and People oriented
Loyal and trustworthy
Team player
Possessive
Great listener/ empathic
Resist change, adapts slowly
• Dominant Fear
– Loss of security
The “C” personality style -17% of the people
• Compliant and Conscientious
–
–
–
–
–
Perfectionist
Sensitive
Accurate and analytical
Ask Questions/needs details
Non-verbal
• Dominant Fear
– Criticism
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UNDERSTANDING PATTERNS OF PERSONALITY STYLES
ACTIVITY
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Day 1 - 63
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Group Discussion Patterns
• Once you understood the pattern it was easier to
locate the numbers
• How does this apply to understanding each other?
• How does this apply to communication?
• How does this apply to leadership?
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Patterns
• Some of these footprints were easy to identify
while others were more difficult to figure out
• Just like some individuals personality styles
– Some be very easy to figure out
– Some may be more difficult to determine
• Still – more comfortable you become with
personality styles – the easier it becomes to
identify styles
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What is your Personality Style
Group Discussion
•
•
•
•
Share you PK
Do you feel it describes you
Example at work how you display your primary personality style
Looking at your own organization
– Can you identify who might be each of the personality styles
– Think about how to interact with them differently to get results
• Verbal Communication
• Email communication
• Amount of information
• Decision making within the organization
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Understanding How the Workforce “S” Personality Style
CULTURE EAT STRATEGY FOR
LUNCH
The Most Dangerous Animal in the
Jungle
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The “S” Personality Style
•
Seeks
– Acceptance
Strengths
– Great Listener
– Team Player
– Will follow-through
Challenges
– Oversensitive
– Slow to begin
– Dislikes Change
Dislikes
– Insensitivity
– Impatience
Decision style
– Conference
– Collaborative
– Slow to decide
•
•
•
•
The “S” Personality Style- Communication
•
When Communicating with “S” personality style DO
–
–
–
–
–
–
•
Build a favorable, friendly, PARTICIPATIVE, environment
Give opportunity for them to verbalize about ideas and people, intuition
Assist them with transferring talk into action
Allow for time for socializing
Give them details in writing but don’t dwell on it
Create incentives for them to follow through on actions
When Communicating with “S” personality style DO NOT
–
–
–
–
Day 1 - 69
Eliminate social time
Be overly aggressive
Ignore their ideas
Make them work alone– THINK ABOUT THIS IN HOME HEALTH!
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The “S” Personality Style – Communication
•
•
•
•
The “S” with the “D”
– “S” may see the “D” as argumentative, dictatorial, arrogant, domineering
• “S” may resist “D” personality styles and slow down action
The “S” with the “I”
– “S” will view the “I” as superficial and overly optimistic to self assured and inattentive
• “S” may attempt to slow down the pace of the “I”
The “S” with the “S”
– “S” view other “S” as dependable, self-controlled, kind, accommodating and attentive
• “S” will enjoy time with other “S” but may have difficulty getting things accomplished – if you
disagree “S” will not confront each other about it
The “S” with the “C”
– “S” will view the “C” as too focused on details, too cautious, too compliant
• “S” will move slowly with the “C” and neither will want to make a decision, however the “S”
will see the “C” coolness as rejection
Pull Don’t Push The “S” – Group Discussion
• Discuss ways to Pull not Push in these incidents
• You need to change scheduling practices and everyone will now
need to do more weekends
• A new regulation requires increased Discharge paperwork to be
completed and reviewed with the patient
• Frontline supervisors are late with getting annual reviews completed
and you need them completed for an audit by the end of the month
• Doing state survey preparation and you need staff to actively
participate in educational sessions
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The Three Things Employees Want
• Sincere Appreciation
• A Way to Express Ideas
• Clear Expectations
This means something different to each
personality style
Sincere Appreciation – The “S” personality
•
•
•
•
•
Immediate recognition
– Celtic GROW program
– Social Media
– Storytelling
– Handwritten thank you cards
Competition with Rewards and Recognition
Time to interact with each other and include their life outside of work
– Sunshine committees
– Will need structure to ensure things move forward
Compensation models that include reward to what is valuable to “S” personality styles
– Quality patient care
– Positive feedback for positive patient and referral interactions
– Perceived as FAIR
Dream Manager
– Link work to personal life
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Sincere Appreciation – Discussion
• Do you feel you provide sincere appreciation to your
staff ?
• Does your organization provide sincere appreciation
in a formal process ?
• What ideas can you share with the group around
sincere appreciation?
A Way to Express Ideas- The “S” personality
• Participative Leadership
– Being part of the decision but not owning it
– Taskforce
– Provide a suggestion or a change – give team time to ask questions and give
feedback but remember in the end you need to make the decision
• Surveys
– Do you have a formal employee satisfaction survey
– Do you show results and actionable items to address the areas
• Retention Interviews
– Need to re-recruit your employees
– Operations and HR collaboration
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A Way to Express Ideas- The “S” personality
• Peer to Peer feedback
– Remember “S” to “S” communication advantages
– Mentorship programs – exceeds beyond precepting
• Provides a way for a new “S” in the department to have their voice heard
• Forums with key organizational individuals that promote a sense of
comfort with communication
– “Cookies and Compliance”
• Complete the feedback loop
– Provide results based on their ideas and feedback
– Make sure the connection to the idea is clearly communicated
Expressing Ideas – Discussion
• Do you feel you allow for your staff to express ideas
• Does your organization provide formal and informal
means for expression
• What ideas can you share with the group around
expressing ideas
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Clear Expectations – The “S” personality
•
•
•
•
Job Descriptions
– How often are they updated
– Do the clearly reflect the role
– Do you review with the team regularly
– Do you have a staff responsibility checklist
Performance reviews
– Are they linked to what is important for the organization
– Does the staff member know exactly how they get an increase
Clear Communication Process
– Staff 1:1 meetings
• Are the standardized, recorded, and audited???
– Interdisciplinary Team Meetings
• Are the standardized, recorded, and audited??
Chart Audits
– Is there an immediate feedback loop for staff education from chart audit results
– Cross walk Chart Audits to Policies and have supervisors review in 1:1 meetings
Clear Expectations
•
•
•
Chart Audits
– Is there an immediate feedback loop for staff education from chart audit results
– Cross walk Chart Audits to Policies and have supervisors review in 1:1 meetings
Email communication
– Does your agency have standardized method of email communication the creates an
atmosphere of clear expectations
Mission and Vision or Core Values
– Are these clearly identified and discussed
– Do you link actions to your core values
– Are the core values part of your review process
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Create an environment of self
accountability
• https://www.youtube.com/watch?v=QpE90gY1MY
Supporting the “S” style workforce
•
Handout Review
– Supervisor – Staff 1:1: Structure
– Audit for Supervisor- Staff 1:1
– Military Email Process
•
Group Exercise
– Discuss how your organization currently meets the three areas
• Sincere Appreciation
• Express Ideas
• Clear Expectations
– Discuss 2-3 ways you can work to improve your interactions with staff to meet the three
areas
– Share tools and ideas with your group and present to team
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Team Building – Everyone has a part
•
•
•
•
•
T- Theorist
E- Executor
A-Analyzer
M-Manager
S-Strategist
Why Brainstorming doesn’t work
• Exercise
– Half of the room meet together and come up with
reasons using DISC why Brainstorming may not be
effective
– Other half of the room- work on this problem alone for 5
minutes then get in your groups and share your ideas
• Handouts
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•
•
•
•
•
•
Building Leadership Development into
Book Clubs
Everyday
TED talks- short clips to start meetings with time to reflect
Audio books sections to start meetings
Homework prior to meetings or activities and share with the group
Art of the Leader
– Leadership basics
– Train the Trainer
– Certificate program
Vary leadership materials
– Personal experience books- learn from others
– Books based on researched material and leadership theories- important to understand the why
– Short articles and how to list – get to have a tips book
– Create a resource library for your organization
Summary
•
•
•
•
•
•
•
•
•
Thinking about personality “styles” has been around since 400 BC
The Key to using DISC is to remember that people are different but they are predictably
different
Recognizing patterns of behaviors will help you understand expressed personality styles
You can use DISC to understand individuals dominant fears and what motivates them
The “S” personality style makes up the majority of individuals in the workplace
By using key strategies that motivate the “S” personality style leaders can successfully
motivate the majority of the team
Teams need all types of styles to have successful outcomes
Brainstorming may not produce your best ideas
By employing a few basic activities you can incorporate leadership into everyday
workplace activities
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Reading List- My personal favorites
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Art of the leader
Dream Manager by Mathew Kelly
Creating Magic by Lee Cockwell
Switch by Dan Heath and Chip Heath
Good to Great by Jim Collins
Lean In by Sheryl Sandberg
The Snowball by Alice Schroeder
Sway by Rom Brafman and Ori Brafman
Crucial conversations by Kerry Patterson
It worked for me by Colin Powell
Nudge by Cass R Sunstein and Richard Thaler
Onward by Joanne Gordon
How remarkable women lead by Joanna Barsh and Susie Cranston
Rockefeller Habits- Verne Harnish
Scaling up - Verne Harnish
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Care Redesign in
Home Health
Cindy Krafft PT, MS, HCS-O
Disclosure
• Speaker has no relationship that could reasonably be
viewed as creating a conflict of interest, or the
appearance of a conflict of interest, that might bias
the content of this presentation.
• Speaker confirms no relevant financial relationship
exists.
Day 1 - 79
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Lay of the Land
• Affordable Care Act
• IMPACT Act
• Med PAC Recommendations
– HH therapy utilization scrutinized
• Focus on Value and Quality
– Bundled Payment Care Initiatives
– Comprehensive Care for Joint Replacements
• Home Health Payment Reform
Data Driven Decision Making
Objective Data
Analysis
Subjective
Opinions
Day 1 - 80
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BPCI Model 2 Successes
• Lewin Group:
– BPCI episodes from Q4 2010-Q4 2013 show
approximately a 10-15% savings in Model 2
Lower Extremity Joint Replacement (LEJR)
• Utilization trends in LEJR include :
– Decreased IRF / SNF
– Increased Home Health
Source: Lewin Analysis of Q4 2010 – Q4 2013 standardized Medicare payment outcomes and enrollment data for BPCI participants and
comparison group available at - https://innovation.cms.gov/Files/reports/BPCI-EvalRpt1.pdf
BPCI Changes Noted – Lewin Group
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SO -WHAT DOES THAT
HAVE TO DO WITH
ME AND MY
ORGANIZATION??
Care Redesign
• CJR sharing arrangements (as an example)
must be solely related to the contributions of
collaborators to care redesign that achieve
quality and efficiency improvements.
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Why Partner with Home Health?
• Lower cost for care
– 31% less expensive compared to SNF
Mahomed NN, Davis AM, Hawker G, et al. Inpatient compared with homebased rehabilitation following primary unilateral total hip or knee
replacement: a randomized controlled trial. J Bone Joint Surg Am. 2008
Aug;90(8):1673-80.
Why Partner with Home Health?
• Similar outcomes for therapy
Comparison of Home Health Care Physical Therapy Outcomes
Following Total Knee Replacement With and Without Subacute
Rehabilitation. Chimenti C, Ingersoll G. Journal of Geriatric
Physical Therapy. Vol.30;2:07, pp 102-8.
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Case Scenario: Mrs. K’s New Knees
A tale of 2 joints . . .
•
•
•
•
•
•
•
•
Initial replacement – 1998
Anesthesia/post-op period
CPM
No therapy after 5PM
Used wheelchair
4-day hospital stay
Possible SNF, then HH postacute course of care
HH SOC on 2nd day home
•
•
•
•
•
•
•
•
Last replacement – 2012
Spinal + twilight meds
Internal anlagesic-eluding joint
bath (36hrs)
NO CPM
PT within 1 hour of return to
room (6PM) + joint class
No wheelchair
< 36 hour hospital stay
Directly home with SOC next
day
What Makes Us Different
Inpatient Care
• 24/7 in person access to
skilled care
Home Care
• Intermittent visits by skilled
care
• Direct control of the
physical environment
• Limited to no control of the
physical environment
• Focus is health care
• Focus is on daily life
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Home Health and Care Redesign
•
•
•
•
•
•
•
•
•
Therapy Frequency and Duration
Intentional Interventions for Mobility and Self Care
Pain Management
Wound Care
\Medication Management
PT/INR Monitoring
DVT Monitoring
Staple Removal
Constipation Issues
Care Planning
• What drives care
planning?
– Staffing?
– Geography?
– Evidence?
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Best Practices for Home Health
• Evidence-based care
“the conscientious, explicit
and judicious use of current best evidence in making
decisions about the care of the individual patient. It
means integrating individual clinical expertise with the
best available external clinical evidence from systematic
research.” – David Sackett
EBP Example:
Knee Osteoarthritis
• Systematic review of the literature
– Efficacious pre- and post-operative interventions
• Preoperative education
• Multimodal pain control
• Accelerated rehabilitation
• Modern wound dressings
• Minimally invasive surgery
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EBP Operationalization
• Addressing “accelerated rehabilitation”:
– Timely admission process
– 7-days/week coverage
– Front-loading visits
– Education materials
• Patient-centered
• Health literacy considerations
EBP Operationalization
• Focused interdisciplinary attention on management of
re-hospitalization risk(s):
–
–
–
–
–
–
–
Day 1 - 87
Falls prevention/risk mitigation
Pain control
Surgical wound management
Medication reconciliation
Anticoagulation management
DVT monitoring
Constipation
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Fall Risk Management as a Team
Intentional Interventions: Mobility
• Consistent use of objective
measurement in assessment,
interventions and goals
–
–
–
–
–
Day 1 - 88
ROM
30 Second Chair Stand
2-Minute Step Test
Gait Velocity
Timed Up and Go
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Intentional Interventions: Self Care Issues
• Do not assume absence of
self care issues for the
CJR population.
– “Do you want OT?”
• Must determine WHY
assistance is needed and
address in the plan of
care.
Pain Management
• Completing the 0 – 10 pain
scale is NOT pain
management.
• Patient specific
interventions include:
–
–
–
–
Day 1 - 89
Medications
Modalities
Positioning
Activity Pacing
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Wound Care
Can therapists do
wound care?
• Two separate issues:
– Routine dressing
changes
– Therapy specific
wound care
interventions
Guide to Physical Therapy Practice
• Outlines precise procedural interventions; stratification
from prevention & risk reduction of integumentary
disorders to superficial skin involvement; partial- and fullthickness wounds; scar formation
• Supports a defined role for the non-wound care PT on the
interdisciplinary home health team
– Reduce incidence and severity of wounds
– Assist in accelerated wound closure
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Minimum Competence – PT Grad
• Screening Expectation:
– Conduct a systems review for screening of the integumentary
system, the assessment of pliability (texture), presence of scar
formation, skin color and skin integrity
– Source Document: Minimum Required Skills of Physical
Therapist Graduates At Entry-Level (BOD G11-05-20-49)
• Def: foundational skills that are indispensable for a new graduate
physical therapist to perform on patients/clients in a competent and
coordinated manner
Minimum Competence – PT Grad
• Examination/Reexamination:
– Perform integumentary integrity tests & measures including:
• Activities, positioning, and postures that produce or relieve trauma to
the skin
• Assistive, adaptive, orthotic, protective, supportive, or prosthetic
devices and equipment that may produce or relieve trauma to the skin
• Skin characteristics, including blistering, continuity of skin color,
dermatitis, hair growth, mobility, nail growth, sensation, temperature,
texture and turgor
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Minimum Competence – PT Grad
• Examination/Reexamination (cont’d):
– Perform integumentary integrity tests & measures including:
• Activities, positioning, and postures that aggravate the wound
or scar or that produce or relieve trauma
• Signs of infection
• Wound characteristics: bleeding, depth, drainage, location, odor,
size, and color
• Wound scar tissue characteristics including banding, pliability,
sensation, and texture
Baseline PT Wound Assessment
• Components:
– Measurement & documentation of the wound characteristics
– Wound cleansing
– Appropriate debridement
•
•
•
•
•
Sharp, selective
Mechanical
Autolytic
Enzymatic
Chemical
– Recommendation & application of wound dressing
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APTA Home Health Section
www.homehealthsection.org
• “The Benefits of Wound Care
Provided by Physical
Therapists in Home Health”
– Authored by: Michelle Abeln,
PT, DPT, WCC and Jean D.
Howard, PT, MS, WCC
– Published in Quarterly Report,
Fall 2014
“Drug Regimen Review”
Identifies if a review of the patient’s medications
indicated the presence of potential clinically significant
problems.
The OASIS captures information for calculation of a
process measure to identify best practices related to
medications.
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“Medication Management”
• This OASIS item is intended to identify the patient’s ability to take all
medications reliably and safely at all times. These items address the
patient's ability to safely take oral medications, given the current physical
and mental/emotional/cognitive status, activities permitted, and
environment. The patient must be viewed from a holistic perspective in
assessing ability to perform medication management.
• Ability can be temporarily or permanently limited by:
– physical impairments (for example, limited manual dexterity)
– emotional/cognitive/behavioral impairments (for example, memory deficits,
impaired judgment, fear)
– sensory impairments (for example, impaired vision, pain)
– environmental barriers (for example, access to kitchen or medication storage
area, stairs, narrow doorways)
Medication Management and Function
Includes assessment of the patient’s ability to obtain the medication from
where it is routinely stored, the ability to read the label (or otherwise
identify the medication correctly, for example patients unable to read and/or
write may place a special mark or character on the label to distinguish
between medications), open the container, select the pill/tablet or milliliters
of liquid and orally ingest it at the correct times.
Assessment areas:
• Ambulation
• Fall Risk
• Vision
• Fine Motor
• Balance ………….
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PT/INR Monitoring

What is the role of
the physical therapist
in monitoring
PT/INR with patients
on anticoagulation
therapy in your state?
PT & PT/INR: New Hampshire
•
Is it within the scope of practice for PT's or PTAs to perform the testing procedure
for monitoring a patient's PT/INR (prothrombin time/international normalized
ratio)?
– This type of testing of itself is not a physical therapy skill. The machine used is similar to using a blood
sugar machine and the results are displayed in digital format. It is the understanding of the Board that the
patient cannot do this testing and report the levels to their physician. The physicians will only accept results
and orders from a licensed health care provider. It is also the understanding that the physical therapist
cannot make recommendations regarding the levels of cumandin in the patient, as the physician makes any
decisions affecting medication adjustment.
– Using available technology and tools to assess the patient's vital signs, is part of the definition of physical
therapy as part of tests and measures. Therefore the Board reasoned that assessing vital signs specifically,
the PT/INR finger stick testing for coumandin levels, would be allowed as a reasonable test and measure as
part of the patient's overall evaluation in preparation of physical therapy treatment.
– The ultimate responsibility rests with the licensed physical therapist or physical therapist assistant to be
appropriately trained and competent in the technique. The Governing Board strongly recommends that
appropriate training and competency be documented for those licensees prior to performing this specific
task.
Day 1 - 95
17
2/9/2017
PT & PT/INR: Wisconsin
• CAN A WISCONSIN PHYSICAL THERAPIST OR PHYSICAL
THERAPIST ASSISTANT DO INR (INTERNATIONAL
NORMALIZED RATIO) MONITORING?
– The scope of practice for Physical Therapy is defined by Wis. Stat. s. 448.50
(4) (a) 1-4 and (b). The Board considers any physical therapist or physical
therapist assistant performing INR monitoring or Prothrombin Time testing to
be acting outside the scope of their practice as stated in the Wisconsin Statutes.
INR is used to monitor the effectiveness of blood thinning drugs. It involves
collecting a blood sample by inserting a needle into a vein or from a
fingerstick. It is typically measured along with Prothrombine Time which is a
lab test used to evaluate the ability of blood to clot properly. Prothrombine
Time or Pro Time is commonly abbreviated as “PT” which can be a source of
confusion if this is misunderstood to mean Physical Therapy.
DVT Monitoring
 Anticoagulation therapy
 Aspirin – does the patient see
this as a medication??
 Graduated compression
stockings
 Compliance?
Clinical Practice Guideline: Role of PTs in the
Management of Individuals at Risk for or
Diagnosed with DVT: PTJ Vol 96:2. 2016
Day 1 - 96
 Screening Options
 Homan’s Sign
 Wells Index
18
2/9/2017
Staple Removal
What is the role of the
physical therapist in
staple removal in your
state?
Day 1 - 97
19
2/9/2017
PT & Suture Removal: California
•
Is staple removal within the scope of practice of a physical therapist?
–
–
–
–
The subject of staple removal was considered by the Practice Issues Committee of the Physical Therapy Board of
California (Board) at their meeting of August 1995. The Practice Issues Committee opined that physical therapists
may not perform invasive procedures; specifically in this instance, that of stapling a wound closed.
The removal of staples, on the other hand, is a non-invasive procedure, which would ordinarily come under the
heading of nursing services, and is not normally associated with the practice of physical therapy; however,
physical therapists may provide any non-invasive physical rehabilitation procedure they have been adequately
trained to perform. Should a facility elect to train physical therapists to do staple removal, the facility would need a
written protocol to be included in their policies and procedures manual, and to be used in the training of each
physical therapist who will perform this procedure.
The training protocol must be sufficient to ensure the facility's patients that the procedure is being done in a safe
and efficient manner by personnel who are trained specifically to remove staples. The training should also include
procedures for problem situations resulting from staple removal, and for notification of proper medical personnel.
The Board has received multiple inquires as to whether suture removal would be considered a non-invasive
procedure such as staple removal. After consulting with a physical therapist expert consultant, it has been
determined that the removal of sutures would fall under the same category as the removal of staples as indicated
above.
PT & Suture Removal: Florida
•
•
This Order shall become effective upon filing with the Clerk of the Department of
Health. DONE AND ORDERED, this 19 day of, November 2010.
The Board understands the language in the above stated practice act to mean that
physical therapists may use non invasive techniques for the treatment and
prevention of injuries. The Board deems staple removal to be a type of non
invasive, rehabilitative technique allowed under the physical therapist practice act
as long as it is performed under the direction and specified order of a physician
licensed in the State of Florida and the physical therapist receives adequate
theoretical and clinical instruction before engaging in staple removal. Adequate
instruction should be based on the current state of medical literature describing the
proper removal of staples from the human body. Physical therapists providing staple
removal services shall still be held to minimum standard found in Rule 64B176.001, Florida Administrative Code.
Day 1 - 98
20
2/9/2017
Constipation Issues
• Contributing factors:
–
–
–
–
–
Medications
Surgery
Immobility
Diet
Hydration
• Are ALL staff involved in
management of this issue?
EBP Example: Constipation
Day 1 - 99
21
2/9/2017
Moving Beyond CJR
• Other “Bundles” currently up and running:
–
–
–
–
–
CHF
AMI
Cardiac dysrhythmia
Hip and Femur fracture
Stroke
• These populations and much less predictable that planned joint
replacements BUT the concepts of bundling are expected to
continue to expand beyond CJR.
HF and preventing re-hospitalization?
Day 1 - 100
22
2/9/2017
New York Heart Association
Class
Patient Symptoms
Class I (Mild)
No limitation of physical activity. Ordinary physical activity does not
cause undue fatigue, palpitation, or dyspnea (shortness of breath).
Class II (Mild)
Slight limitation of physical activity. Comfortable at rest, but
ordinary physical activity results in fatigue, palpitation, or dyspnea.
Class III
(Moderate)
Marked limitation of physical activity. Comfortable at rest, but less
than ordinary activity causes fatigue, palpitation, or dyspnea.
Class IV
(Severe)
Unable to carry out any physical activity without discomfort.
Symptoms of cardiac insufficiency at rest. If any physical activity is
undertaken, discomfort is increased.
Use of Scale = ADL??
Compliance = Knowledge + Functional Ability
•
•
Day 1 - 101
Knowledge
• When
• How
• Signs
Functional Ability
• Balance
• Strength
• Cognition
23
2/9/2017
Safe & Consistent
Administration
NO
MISTAKES
ALLOWED
Knowledge:
What?
When?
Function:
Where?
How?
Maintenance Therapy?
Management and Evaluation?
Day 1 - 102
24
2/9/2017
Therapy Diagnoses
• “A prescriptive definition of these sorts of conditions,
such as a listing of specific disease states that provide
subtext for these descriptions is impractical, as each
patient’s recovery from illness is based on unique
characteristics.”
• No assumptions can be made about the skilled need,
reasonable and necessary status of a patient because
they present with diagnoses that typically receive therapy
Care Redesign and Maintenance
Skills of a
therapist are
needed to restore
function
Restorative
Day 1 - 103
Patient’s condition
requires a qualified
therapist to design or
establish a
maintenance
program
Skills of a
qualified therapist
are required to
perform
maintenance
therapy
Maintenance
Maintenance
25
2/9/2017
Care Redesign and M&E
• Skilled nursing visits for management and evaluation of a patient's
care plan are reasonable and necessary when underlying conditions
or complications require that only a registered nurse can ensure
that essential non-skilled care is achieving its purpose.
– The complexity of the necessary unskilled services that are a
necessary part of the medical treatment must require the
involvement of skilled nursing personnel to promote the patient's
recovery and medical safety in view of the beneficiary's overall
condition.
Time Limitations?
•
•
Management and
evaluation is not intended
to serve as the primary
mechanism for
providing long-term
care.
However, there are no
time restrictions for
carrying out this skill.
Day 1 - 104
26
2/9/2017
Initial Assessments
Create the Foundation
Measuring Impairments in
Body Structure/Function
Activity
Limitations
Participation
Restriction
Patient
Specificity
Contextual
Factors
Care Redesign and ICF
Disability and functioning are viewed as outcomes of interactions
between health conditions and contextual factors. Diseases, disorders,
conditions
Contextual Factors
Day 1 - 105
27
2/9/2017
Documentation Examples
• “faint periods of forgetfulness”
• “patient is fairly independent with ADLs”
• Referral Dx: L total shoulder replacement
Primary
Dx: pain in unspecified shoulder
• “patient showered this RN in the bathroom”
• Wound #1: proximal to head part of body. Wound #2:
lateral to wound #1
• “Due to fall risk recommend patient get rid of her dog”
• “Patient endorses stress incontinence”
State of therapies . . .
What we “do”
•
•
•
Prescribe individualized, exercise
programs
– Progressive resistive
– Progressive aerobic
Educate on positioning, range of
movement, substitution, delayed
onset of muscle soreness
Monitor both patient & program for
appropriateness
Day 1 - 106
What we document
•
•
•
•
•
“3 x 10 toe tapping and seated
marching”
“I had PT before. They walked me and
did leg kicks.”
1lb weight x 30 reps
Yellow theraband resistance for all
exercises/on all patients
Programs that never change . . . .
28
2/9/2017
State of nursing . . .
What we “do”
•
•
•
•
Instruction in use, administration,
s/s monitoring with specific
medication(s) in use
Pressure ulcer assessment,
monitoring of wound/peri-wound
tissue, infection control
Instruction in dietary restrictions &
weight monitoring for self-mgmt of
chronic disease
•
•
“wound care”
“SN for dressing change”
•
“disease process education”
Miles to Go ?? . . . . .
Systemic deficiencies:
 Deficient internal quality audit
findings
 Limited ability to show
progress/stabilization of patient
 Lack of defensibility in external
audit findings
 Lack patient specificity
 Do not support skilled care
need
 Reasonable & necessary
questioned/services denied
Day 1 - 107
•
•
What we document
“med teaching”
“pill box set up”
Evidence-based
interventions
Patient-specific goal
statements
Outcome
expectations
Service Utilization
29
2/9/2017
The Future of Care Redesign
• Home Health cannot risk
being late to the table.
• Limiting therapy services by
“improvement” impedes care
redesign.
• Utilize evidence based
practice
• Think outside the box Home
Health has been kept in.
Be sure to Follow Us:
@KornettiKrafft
@cindy_krafft
https://www.facebook.com/KornettiKrafftHealthCareSolution
s/
Day 1 - 108
30
Physical Therapy Leadership in Home Health –
Solid Footing in Times of Change DAY 1 Supplement www.homehealthsection.org Home Health Section of the American Physical Therapy Association Day 1 - 109
Alternative Payment Model HH Preparedness Sheet
Ensure Publically Reported Metrics are Satisfactory or Better
Quality of patient care Star Rating: ____ / 5
Patient survey summary Star Rating:_____/ 5
Measure to Improve
Your Agency %
State Average %
Understand Initiatives that are Active in Your Market
Accountable Care Organizations
BPCI
CJR
AMI
CABG
Medicaid / CHIP
Dual Eligible
Understand the Challenges that Each Program Presents to the Risk-Holder
Financial Risk
Bundled Payment Risk
Capitated Risk
Other ___________________
ED Utilization
Complications
Clinical Risk
Re-hospitalizations
BPCI (customized targets): _________________________________________________
Patient Satisfaction: _______________________________________________________
What can your home health agency provide:
Established Protocol to include:
24 hour admission / PT eval
Risk based interventions
Urgent Procedures to address complications
Visit frequency (risk based)
Supplemental Phone Calls
Establishing Communication Processes
Reporting:
Rehospitalization Rate
HHRG Rate
Complications
Clinical Measures (specific to program)
Produced by Daniel Kevorkian, PT, MS
Day 1 - 110
Visit numbers
Page 1
Alternative Payment Model HH Preparedness Sheet
Identify the Key Stake-Holders at the Risk Bearing Entity to Arrange a Meeting to
Present Solutions
Key Person(s) to speak with: ________________________________________________________________
Phone Number: _________________________
Arrange Meeting By What Date: ________________
Once a Partner, Identify Key People with Whom to Communicate
Key Person(s) to communicate (most likely a nurse navigator/case manager): ____________________
Phone Number:___________________________
Email Address: ___________________________
Fax Number: _____________________________
Preferred Method of Communication:
Phone
Email
Fax
Preferred Frequency of Communication:
Daily
Bi-Weekly
Weekly
Every other Week
Monthly
How Will Key Metrics of the Program be Tracked
EMR (must involve IT)
Manual tracking (develop manual tracking form and process)
NOTES: ___________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Establish a Regular Cadence to Review Performance with Key Leaders at Risk
When will follow-up reporting occur?
Monthly Meetings
Quarterly Meetings
Other: ___________________
How will follow-up reporting occur?
In-Person
Webinar
Other: Conference Call
What will be presented:
Case Studies
Outlier Patients
Clinical Metrics
Financial Metrics
Other: ___________________________________________________________________________________
Produced by Daniel Kevorkian, PT, MS
Day 1 - 111
Page 2
Ensure publically reported metrics are satisfactory or better
Quality of patient care Star Rating: ______ Patient survey summary Star Rating:______
Measure to improve
Your Agency %
State Average %
Understand what initiatives are active in your market
Accountable Care Organizations
BPCI
CJR
AMI
CABG
Medicaid / CHIP
Dual Eligible
Understand the challenges that each program presents to the risk-holder
Financial Risk
Bundled Payment Risk
Capitated Risk
Other ___________________
Clinical Risk
Rehospitlizations
ED Utilization
BPCI (customized targets): _________________________________________________
Patient Satisfaction: _______________________________________________________
What can your home health agency provide:
Established Protocol to include:
24 hour admission / PT eval
Risk based interventions
Urgent Procedures to address complications
Establishing Communication Processes
Reporting:
Day 1 - 112
Visit frequency (risk based)
Supplemental Phone Calls
Rehospitalization Rate
HHRG Rate
Visit numbers
Complications
Clinical Measures (specific to program)
Identify the key stake-holders at the risk bearing entity and arrange meetings to
present your solutions
Key Person(s) to speak with: __________________________________________________________
Once a Partner, identify key people with whom to communicate on a regular
basis:
Key Person(s) to communicate (most likely a nurse navigator/case manager): ____________________
How will you track the metrics?
EMR (must involve IT)
Manual tracking (develop manual tracking form and process)
Establish a regular cadence to review performance with the risk holder
When will follow-up reporting occur?
Monthly Meetings
Day 1 - 113
Quarterly Meetings
Other: ___________________
M2001Drug
RegimenReview
M2001Coded:1
DRR
Completed?
Allmedications
accessiblefor
review?
Issues
Identified?
M2001Coded:0
M2001Coded:
DASH
DRRnot
completed
M2001Coded:
DASH
Patientnot
takingany
medications
M2001Coded:9
Day 1 - 114
M2003Medication
FollowUp
M2003Coded:1
NotificationofMD/
DesigneebyMIDNIGHT
ofnextcalendarday?
MedicationIssue
Identified?
Communicationback
fromMD/Designeeby
MIDNIGHTofnext
calendarday?
Prescribed/
recommendedactions
completedby
MIDNIGHTofnext
calendarday?
M2003Coded:0
M2003Coded:0
M2003Coded:0
M2001Coded:0and
M2003Skipped
Day 1 - 115
Last Updated:05/30/2013
Contact: [email protected]
MEDICATION MANAGEMENT AND PHYSICAL THERAPISTS
Overview – Medication Management
“Medications are involved in 80 percent of all treatments and impact every aspect of a patient’s
life.” 1 Medicare beneficiaries with multiple chronic illnesses see an average
of 13 different physicians, have 50 different prescriptions filled per year, account for 76 percent
of all hospital admissions, and are 100 times more likely to have a preventable hospitalization
than those with no chronic conditions.” 2 Managing medications for optimal patient outcomes
has been the subject of extensive research for decades. Emerging integrated models of care, such
as the medical home, are involving more care team members in the medication management
process.
Medication therapy management (MTM) is defined as a distinct service or group of services that
optimizes drug therapy with the intent of improved therapeutic outcomes for individual patients.
In 2004, this definition was adopted by 11 national pharmacy organizations. “Medication therapy
management includes a broad range of professional activities, including but not limited to
performing patient assessment and/or a comprehensive medication review, formulating a
medication treatment plan, monitoring efficacy and safety of medication therapy, enhancing
medication adherence through patient empowerment and education, and documenting and
communicating MTM services to prescribers in order to maintain comprehensive patient care.” 3
Medication Therapy Management in Pharmacy Practice: Core Elements of an MTM Service
Model Version 2.0 is a model designed to improve collaboration among pharmacists, physicians,
and other healthcare professionals; enhance communication between patients and their healthcare
team; and optimize medication use for improved patient outcomes. The medication therapy
management services described in this model empowers patients to take an active role in
managing their medications. The services are dependent upon pharmacists working
1
http://www.pcpcc.net/sites/default/files/media/medmanagement.pdf accessed 4-1-13
2
Anderson GF. Testimony before the Senate SpecialCommittee on Aging. The Future of Medicare: Recognizing the
Need for Chronic Care Coordination. Serial No. 110-7, pp 19-20 (May 9, 2007).
3
https://www.accp.com/docs/positions/misc/CoreElements.pdf accessed 4-15-13
Day 1 - 116
collaboratively with physicians and other healthcare professionals to optimize medication use in
accordance with evidence based guidelines. 4 5
Medication therapy management includes five core components: a medication therapy review
(MTR), personal medication record (PMR), medication-related action plan (MAP), intervention
and/or referral, and documentation and follow-up. MTM is performed between a patient and
pharmacist. 6
“Comprehensive medication management is defined as the standard of care that ensures each
patient’s medications (whether they are prescription, nonprescription, alternative, traditional,
vitamins, or nutritional supplements) are individually assessed to determine that each medication
is appropriate for the patient, effective for the medical condition, safe given the comorbidities
and other medications being taken, and able to be taken by the patient as intended.
Comprehensive medication management includes an individualized care plan that achieves the
intended goals of therapy with appropriate follow-up to determine actual patient outcomes. This
all occurs because the patient understands, agrees with, and actively participates in the treatment
regimen, thus optimizing each patient’s medication experience and clinical outcomes. 7 8 9
PCPCC This approach has evolved through the emergence of the care team approach in the
medical home. The PCPCC states that “[t]he work of pharmacists and medication therapy
practitioners needs to be coordinated with other team members in the PCMH.” 10
The need for comprehensive medication management by the care team includes, but is not
limited to, (1) the central role of medication use in the treatment of chronic conditions, (2) the
likelihood of multiple prescribers involved in the patient’s care, and (3) the need for patients to
occasionally transition from one care setting to another, even when their care is being
coordinated by a medical home. 11
Physical Therapist’s Limited Role in Medication Management
4
Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical
Practice. 1998;1(1):2-4.
5
Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC:
Institute of Medicine; 2001.
6
Medication therapy Management in Pharmacy Practice. Core Elements of an MTM Service Model. Version 2.0.
American Pharmacists Association and National Association of Chain Drug Stores Foundation. March 2008; .
https://www.accp.com/docs/positions/misc/CoreElements.pdf accessed 4-9-13.
7
American Medical Association. Current Procedural Terminology. Chicago, IL, 2007.
8
CMS. Prescription Drug Coverage 2010 Call Letter. Available at: http://www.cms.hhs.gov/
PrescriptionDrugCovContra/Downloads/ 2010CallLetter.pdf.
9
Minnesota Statute 256B.0625 Subd. 13h, 2005. Available at: https://www.revisor.mn.gov/statutes/ ?id=256B.0625
10
http://www.pcpcc.net/sites/default/files/media/medmanagement.pdf accessed 4-1-13.
11
Ibid.
Day 1 - 117
Under the Guide to Physical Therapist Practice (“Guide”), notation of medications taken for a
current condition, medications previously taken, as well as medications taken for other
conditions physical therapists should be documented during the history portion of patient
management. The Guide further instructs that obtaining a full patient history includes gathering
data “through consultation with other members of the team; and through review of the patient
client record.” 12
Physical Therapist State Practice Acts (SPAs) typically do not contain medication management
provisions. The most express directive relating to physical therapists and medication
management and their allowance to “monitor” medications comes from the Centers for Medicare
and Medicaid Services in OASIS C requirements. The majority of states require licensed
personnel to administer medications. States that permit unlicensed staff to administer
medications generally require that they do so under nurse delegation provisions, though a few
require only consultation with a physician or pharmacist or specific training. Examples include
the following:
Nebraska defines medication administration as providing medications for another person
according to the “five rights” (the right drug to the right recipient in the right dosage by
the right route at the right time); medication provision means giving or applying a dose of
medication to an individual and includes helping an individual in giving or applying the
medication to himself or herself. Adult day service providers must ensure that
medication aides and other unlicensed persons who provide medications are trained and
have demonstrated the minimum competency standards specified in the relevant rules.
Vermont requires an adult day center to have the capacity to administer medications to its
participants and requires a medication management policy that describes a center’s
medication management practices with due regard for state requirements, including the
Vermont State Nurse Practice Act. An adult day center must provide medication
management under the supervision of a registered nurse or a licensed practical nurse
under the direction of a registered nurse.
Wisconsin specifies that if staff administer participants’ medications, non-licensed staff must
consult with the prescribing practitioner or pharmacist about each medication to be
administered, and other conditions related to storage and documentation must be met.
Maine allows unlicensed employees to administer medications only if they have completed,
at a minimum, an approved medication course within the previous 12 months or were
employed in a health care setting during the previous 12 months where medication
administration was part of their responsibilities.
Most states require providers to have written policies for medication management and
administration and policies may differ based on health care setting. For example, Georgia
requires adult day care programs to have a written policy for medication management
12
Guide to Physical Therapist Practice (2003).
Day 1 - 118
designating specific staff to be authorized and trained to assist with the administration of
medications and designating the program’s role in the supervision of self-administered
medications and/or staff-administered medications. 13
APTA Official Statement
In 2010, The American Physical Therapy Association (APTA) issued an official statement on the
Role of Physical Therapists in Medication Management:
The Role of Physical Therapists in Medication Management
As States continue to formulate their policies on the role of physical therapists in
medication management as related to homecare, APTA would like to clarify our position, as
well as, provide reference to the federal Medicare home health policy.
APTA believes and it has been acknowledged in federal guidance that it is within the scope
of the physical therapist to perform a patient screen in which medication issues are assessed
even if the physical therapist does not perform the specific care needed to address the
medication issue. The physical therapist is competent and qualified to serve as case
manager and facilitate coordination of care with physicians and nurses.
APTA has a position statement adopted by its House of Delegates which states:
“Physical therapist patient/client management integrates an understanding of a
patient’s/client’s prescription and nonprescription medication regimen with consideration
of its impact upon health, impairments, functional limitations, and disabilities. The
administration and storage of medications used for physical therapy interventions is also a
component of patient/client management and thus within the scope of physical therapist
practice.
Physical therapy interventions that may require the concomitant use of medications include,
but are not limited to, agents that:
Reduce pain and/or inflammation
Promote integumentary repair and/or protection
Facilitate airway clearance and/or ventilation and respiration
Facilitate adequate circulation and/or metabolism
Facilitate functional movement”.
In addition, within the Normative Model of Physical Therapist Professional Education:
Version 2004, Pharmacology is a primary content area and includes:
Pharmacokinetic principles
Dose-response relationships
Administration routes
Enhancement of transdermal drug absorption
13
Many states also specify requirements related to self-administration of medications. For example, Texas requires
individuals who self-administer their medications to be counseled at least once a month by licensed nursing staff to
ascertain if they continue to be capable of self-administering their medications.
Day 1 - 119
Absorption and distribution
Biotransformation and excretion
Factors affecting pharmacokinetics
Potential drug interactions
Pharmacodynamics
Also, within the Guide to Physical Therapist Practice (included in the Patient/Client
Management Model), medications are gathered from the patient/client history. This
includes: medications for current condition; medications previously taken for current
condition; and medications for other conditions.
The position of APTA has been formally recognized and adopted into the Medicare Home
Health Outcomes Assessment Instrument, known as OASIS-C. In March 2009 OASIS-C
training materials and conferences, the Center for Medicare and Medicaid Services (CMS)
specifically addressed the question of whether the physical therapist could complete OASIS
item M2000 regarding medications. In its response, CMS consistently referred to APTA’s
position as laid out in the above paragraphs. In fact, a link to APTA’s position is readily
accessible in the Medicare OASIS tools and resources provided on the CMS website:
(http://www.cms.gov/HomeHealthQualityInits/06_OASISC.asp#TopOfPage).
Therefore, APTA strongly urges State entities to duly note and recognize the role of the
physical therapists in medication management (i.e. screening, evaluation, collection of
information, identification of adverse events/reactions, and education) in the home. APTA
is more than willing to work with any State entity to ensure that all home health policies
reflect the appropriate role of physical therapists in medication management.
Physical therapists, Medication and State Law
Below are additional examples of state statutes and other directives that are either permissive or
restrictive in relation to medication and physical therapists, some specific to OASIS:
California
Physical Therapy Board of California
In August of 2012 a decision was rendered by Board Staff and the acting Board President that
the ability to review and identify the ·implications of a patient's current medications is not within
the scope of practice for the Physical Therapist.
In February 2014, the Board held a meeting on whether to withdraw this position.
http://www.ptbc.ca.gov/about_us/meetings/materials/20130213.pdf
Colorado
Colorado Physical Therapists Practice Act
Day 1 - 120
Effective July 1, 2011 14
12-41-103. Definitions.
…
(D) The administration of topical and aerosol medications consistent with the scope of
physical therapy practice subject to the requirements of section 12-41-113;
12-41-113. Special practice authorities and requirements-rules.
…
(2) Administration of medications. Physical therapists or physical therapist assistants
under the direct supervision of a physical therapist may administer topical and aerosol
medications when they are consistent with the scope of physical therapy practice and
when any such medication is prescribed by a licensed health care practitioner who is
authorized to prescribe such medication. A prescription or order shall be required for
each such administration.
Connecticut
Restrictive:
Connecticut General Statutes
Chapter 376
Physical Therapists
Sec. 20-66. Definitions. As used in this chapter, unless the context otherwise requires:
(1) "Physical therapist" means a person licensed to practice physical therapy in this state;
(2) "Physical therapy" means the evaluation and treatment of any person by the employment of
the effective properties of physical measures, the performance of tests and measurements as an
aid to evaluation of function and the use of therapeutic exercises and rehabilitative procedures,
with or without assistive devices, for the purpose of preventing, correcting or alleviating a
physical or mental disability. "Physical therapy" includes the establishment and modification of
physical therapy programs, treatment planning, instruction, wellness care, peer review, [and]
consultative services and the use of low-level light laser therapy for the purpose of accelerating
tissue repair, decreasing edema or minimizing or eliminating pain, but does not include surgery,
the prescribing of drugs, the development of a medical diagnosis of disease, injury or illness, the
use of cauterization or the use of Roentgen rays or radium for diagnostic or therapeutic purposes.
As used in this section, "low-level light laser therapy" means low-level light therapy having
wave lengths that range from six hundred to one thousand nanometers.
Idaho
14
http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheadername1=ContentDisposition&blobheadername2=ContentType&blobheadervalue1=inline%3B+filename%3D%22Colorado+Phy
sical+Therapists+Practice+Act%2C+Effective+July+1%2C+2011.pdf%22&blobheadervalue2=application%2F
pdf&blobkey=id&blobtable=MungoBlobs&blobwhere=1251832458565&ssbinary=true accessed 4-1-13.
Day 1 - 121
“As the agency authorized by the Kentucky General Assembly to regulate the practice of
physical therapy in this Commonwealth, the Board is empowered to interpret its statutes and
regulations. In summary, while a physical therapist may complete a drug regimen review as
required on the OASIS, any questions from the patient should be referred to another health care
professional as mandated by 201 KAR 222:053 Section 3.” (from ID OASIS Guidebook)
Kentucky
“As the agency authorized by the Kentucky General Assembly to regulate the practice of
physical therapy in this Commonwealth, the Board is empowered to interpret its statutes and
regulations. In summary, while a physical therapist may complete a drug regimen review as
required on the OASIS, any questions from the patient should be referred to another health care
professional as mandated by 201 KAR 222:053 Section 3.” (Kentucky General Assembly
statement, March 18, 2010)
Missouri
APRIL 1, 2010
The Most Frequently Asked Questions of the Bureau
M2000 Drug Regimen Review
1) Q: Is it correct that Physical Therapists now have it in their scope of practice to do the Drug
Regimen Review?
A: NO. A Physical Therapist cannot do the complete drug regimen review as outlined in the
Conditions of Participation CFR 484.55(c). The Bureau has recently contacted the State Board
for Physical Therapists and received confirmation that drug regimen review is NOT part of the
physical therapist scope of practice. Therefore, the complete drug regimen review, in a therapyonly case, must still be performed by the registered nurse.
I think some of the confusion has been the result of misinterpretation of the information on the
OASIS-C; specifically in regards to whether it is still expected that a therapist should be able to
do the OASIS-C with all the new data items that have been added. CMS has made it clear that
the Conditions of Participation have not changed. In a therapy-only case, the therapist can do
the OASIS-C assessment; however, there has to be documentation in the medical record that the
drug regimen review was performed by the registered nurse. The physical therapist will then
answer M2000 and the M0090 date would be the date that the therapist and the registered nurse
collaborated.
Further confusion stemmed from CMS's trainings on OASIS-C in which a slide that is titled
"What about PTs?" In this slide they shared the comments from the American Physical Therapy
Association regarding whether PTs can respond to the new items in OASIS-C. It states, "It is
within the scope of the PTs to perform a patient screen in which medication issues are assessed,
even if the PT does not perform the specific care needed to address the medication issue." This
does not say that it is within the scope of practice of the therapist to conduct a complete drug
regimen review.
Questions #32 and #32.1, Category 2-Comprehensive Assessment, from the CMS Q&As
somewhat address this issue.
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New Jersey
NEW JERSEY STATE BOARD OF PHYSICAL THERAPY EXAMINERS
PUBLIC SESSION MINUTES
March 25, 2008
A regular meeting of the New Jersey State Board of Physical Therapy Examiners was held at 124
Halsey Street, Newark, New Jersey, in the Somerset Conference Room, 6th Floor, on Tuesday
March 25, 2008. The meeting was convened in accordance with the provisions of the Open
Public Meetings Act. Nancy Kirsch, Chairperson of the Board, called the meeting to order at
9:35 A.M. and a roll call was taken.
C. Letter from Princeton HomeCare Services
RE: Medication Reconciliation
Princeton HomeCare Services asked whether a physical therapist can complete medication
reconciliation. Medication reconciliation consists of listing prescription medications that are in
the home of a home care patient in the patient’s chart.
The Board will advise Princeton HomeCare Services that a physical therapist can complete
medication reconciliation.
New York
Medication Review:
Medication Reviews by PTs
The State Board for Physical Therapy has recently received many questions about the role of the
physical therapist in completing all the assessments, including the drug regimen reviews, for
certified home health agencies (CHHA) and long term home health care programs (LTHHCP),
specifically the OASIS-C form. The Board has worked diligently to come to an agreement as to
the methods, policies and procedures that have to be followed that will allow the physical
therapists to complete the review. Please see the guidance letter ( 183K) from the Department
of Health.
http://www.op.nysed.gov/prof/pt/ptfaq.htm
North Carolina
Position Statement – North Carolina Board of Physical Therapy Examiners
Physical Therapist’s Role in Managing and Recording Medications
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Adopted – June 28, 1999
Revised – September 23, 2010
Gathering information on the medication a patient is taking and the patient's ability to take the
proper dosage would be considered within the scope of practice for a physical therapist. It would
also be appropriate for a physical therapist to provide basic information on medications that may
have an impact on the PT plan of care; however, to provide an educational intervention,
especially on medications unrelated to the PT plan of care, would not be considered within the
scope of practice for a physical therapist.
It is also appropriate for a PTA to document medication changes if all the PTA is doing is simply
recording changes in medication orders from the physician, PA, or nurse practitioner, but it is not
appropriate for the PTA to make any interpretations or recommendations regarding medications.
However, if a PTA believes that a medication change could result in harm or injury to the
patient, the PTA should immediately notify the PT, who will then contact the referring
practitioner.
If a PT identifies a discrepancy between the discharge medication order and the prescription on
the bottle or the amount that the patient says he/she is taking, it is the physical therapist’s
responsibility to contact the appropriate health care practitioner to let him / her know of the
discrepancy. As always, the PT should document the conversation or correspondence.
If there is to be a change in the medication, this information should be forwarded to the home
health nurse. If the health care practitioner asks the PT to confirm the patient the medications
that the patient taking and there are no changes in the dosages, etc., the physical therapist may do
so.
Regarding PRN Standing Orders that have been approved by the Medical Director: It would
not be a violation of the North Carolina Physical Therapy Practice Act or Board’s rules for a
PT to advise a patient as to what PRN standing orders involving the medications exist.
Ben F. Massey, Jr., PT, MA, Executive Director
NC Board of Physical Therapy Examiners
18 West Colony Place Suite 140
Durham, NC 27705
Phone: 1-919-490-6393 / 800-800-8982
Fax: 1-919-490-5106
Email: [email protected]
Web: www.ncptboard.org
Ohio
Ohio Occupational Therapy, Physical Therapy, and Athletic Trainers Board Physical
Therapy Section, March 8, 2012, 9:30 a.m.
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JB2. Lyndi Schwab, PT: Ms. Schwab asked the Occupational and Physical Therapy Sections
whether it is acceptable for occupational and physical therapists to sign the medication sheets in
a client’s chart.
Reply: There is nothing in the Ohio Occupational Therapy Practice Act that prohibits an
occupational therapist from completing medication reconciliation provided that the occupational
therapist has received training, demonstrated and documented competence in this activity. There
is nothing in the Physical Therapy Practice Act that prohibits a physical therapist from
performing a medication reconciliation that includes interviewing a patient about current
medications, comparing those to the list of prescribed medications, and implementing a
computerized program or referring the lists to other practitioners to identify suspected drug
interactions. Even though not part of the physical therapy plan of care, the reconciliation may be
performed as an administrative task of any health care professional. Other such administrative
tasks that are not part of a physical therapy plan of care but that may be performed by physical
therapy personnel include removal of staples, coaguchecks, listening for bowel sounds, and
other patient assessments. However, no procedure should be performed by a physical therapist
or physical therapist assistant unless the practitioner demonstrates competence in that
procedure. You may also wish to view the APTA’s Home Health Section FAQ regarding
medication reviews.
Pennsylvania
Permissive:
§ 40.51a. Transdermal administration of drugs.
A physical therapist may perform transdermal administration of drugs through the use of
modalities such as ultrasound and electrical stimulation. If a prescriptive medication is used, the
medication must be prescribed by the referring physician and dispensed in the name of the
patient by the referring physician or pharmacist. Between treatment sessions, drugs must be
properly stored in a manner consistent with pharmaceutical practice. After the patient is
discharged, the remaining drugs must be disposed of by the physical therapist or returned to the
patient.
Restrictive:
§ 40.2. Practice of medicine prohibited.
The license issued to those practicing physical therapy does not authorize the right to use the title
‘‘Doctor of Medicine,’’ or the right to use drugs administered internally. Except as authorized in
section 9 of the act (63 P. S. § 1309), a person licensed under the act as a physical therapist may
not treat human ailments by physical therapy or otherwise except upon the referral of a physician
or other person authorized by law to order the same.
Disclosure:
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(b) Use of patient disclosure forms.
(1) It is the physical therapist’s responsibility to disclose to the patient a financial or ownership
interest when making a referral covered by the act of May 26, 1988 (P. L. 403, No. 66) (35 P. S.
§ § 449.21—449.23). The Board believes that meaningful disclosure shall be given to each
patient at the time a referral is made. The disclosure may be made orally or in writing. In either
event, it is recommended that the disclosure be memorialized, dated and signed at the time of
referral by the physical therapist and the patient, and that the physical therapist maintain written
evidence of the disclosure. If the physical therapist delegates the disclosure to another person in
the therapist’s office, the disclosure shall be memorialized, dated and signed by the person
making the disclosure and the patient.
(2) The memorialization of the disclosure shall be substantially in the following form:
I ACKNOWLEDGE THAT I HAVE BEEN ADVISED BY MY PHYSICAL
THERAPIST THAT HE HAS A FINANCIAL OR OWNERSHIP INTEREST IN THE
FACILITY OR ENTITY TO WHICH HE HAS REFERRED ME, AND THAT HE
HAS ADVISED ME THAT I AM FREE TO CHOOSE ANOTHER FACILITY OR
ENTITY TO PROVIDE THE SERVICE, DRUG, DEVICE OR EQUIPMENT.
(3) Written evidence shall constitute presumptive evidence that the physical therapist made the
required disclosure in an enforcement proceeding before the Board. The disclosure to the patient
is not the act of the patient signing the form, but is the act of the physical therapist disclosing to
the patient the therapist’s financial or ownership interest and advising the patient of the patient’s
freedom of choice.
…
(c) Guidelines for disclosure. If the patient is a minor, unconscious, of unsound mind, or
otherwise incompetent to understand freedom of choice in the selection of a facility or entity,
disclosure shall be made to the guardian, spouse or closest adult next of kin. A physical therapist
may not disclose his interest unless the patient is competent to understand his freedom of choice.
A physical therapist will not be disciplined for failure to disclose if an emergency prevents
consulting the patient or the patient’s next of kin.
(d) Posting notice of disclosure requirement. It is recommended that compliance with the
disclosure requirement include the prominent posting of a printed notice, at least 8 1/2" x 11" in
the physical therapist’s waiting room in all office locations, substantially in the following form:
TREATMENT IN THIS OFFICE MAY INCLUDE A RECOMMENDATION FOR
FURTHER DIAGNOSTIC TESTING, FOR VARIOUS FORMS OF THERAPY OR
TREATMENT, OR FOR DRUGS OR DEVICES. PENNSYLVANIA LAW
REQUIRES YOUR PHYSICAL THERAPIST TO DISCLOSE TO YOU ANY
FINANCIAL INTEREST HE HAS IN TREATMENT FACILITIES, TESTING
LABORATORIES, MEDICAL EQUIPMENT SUPPLIES, PHARMACEUTICAL
COMPANIES AND PHARMACIES TO WHICH HE REFERS YOU. HE MUST
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ALSO ADVISE YOU THAT YOU ARE FREE TO CHOOSE ANOTHER FACILITY
OR ENTITY TO PROVIDE THE SERVICE, DRUG, DEVICE OR EQUIPMENT.
(ACT 66-1988)
Utah
Utah Physical Therapy Practice Act
58-24b-403. Administration of a prescription drug.
(1) A licensed physical therapist may purchase, store, and administer topical and aerosol
medications that require a prescription only as provided in this section.
(2) A licensed physical therapist may purchase, store, and administer:
(a) topically applied medicinal agents, including steroids and analgesics, for wound care and
for musculoskeletal treatment, using iontophoresis or phonorphoresis; and
(b) aerosols for pulmonary hygiene in an institutional setting, if a licensed respiratory
therapist is not available in, or within a ten mile radius of, the institution.
(3) A licensed physical therapist may only purchase, store, or administer a medication
described in this section pursuant to a written prescription issued by a practitioner who is
licensed to prescribe that medication.
(4) This section does not authorize a licensed physical therapist to dispense a
prescription drug.
http://www.dopl.utah.gov/laws/58-24b.pdf
General Medication Management Laws
California
California Code of Regulations
ARTICLE 12. TOPICAL MEDICATIONS
1399.75. Compliance with Regulations.
A physical therapist may apply or administer topical medications to a patient as set forth in this
article.
Note: Authority cited: Sections 2615 and 2620.3, Business and Professions Code. Reference:
Section 2620.3, Business and Professions Code.
History:
(1.) New Article 12 (Sections 1399.75-1399.79) filed 2-11-81; Register 81, No. 7.
1399.76. Topical Medications Defined.
As used in this article "topical medications" means medications applied locally to the skin or
underlying tissue where there is a break in or absence of the skin where such medications require
a prescription or order under federal or state law.
Note: Authority cited: Sections 2615 and 2620.3, Business and Professions Code. Reference:
Section 2620.3, Business and Professions Code.
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1399.77. Administration of Medications.
Topical medications may be administered by a physical therapist by:
(a) Direct application;
(b) Iontophoresis; or
(c) Phonophoresis.
Note: Authority cited: Sections 2615 and 2620.3, Business and Professions Code. Reference:
Section 2620.3, Business and Professions Code.
1399.78. Authorization and Protocols Required.
Topical medications shall be applied or administered by a physical therapist in accordance with
this section.
(a) Any topical medication applied or administered shall be ordered on a specific or standing
basis by a practitioner legally authorized to order or prescribe such medication.
(b) Written protocols shall be prepared for the administration or application of each of the
groups of medications listed in Section 1399.79 for which a prescription is required under
Federal or State law, which shall include a description of the medication, its actions, its
indications and contraindications, and the proper procedure and technique for the application or
administration of medication.
Note: Authority cited: Sections 2615 and 2620.3, Business and Professions Code. Reference:
Section 2620.3, Business and Professions Code.
History:
(1.) Amendment of Note filed 3-8-2000; Register 2000, No. 10.
1399.79. Authorized Topical Medications.
A physical therapist may apply or administer those topical medications listed in this section in
accordance with the provisions of this article:
(a) Bacteriocidal agents;
(b) Debriding agents;
(c) Topical anesthetic agents;
(d) Anti-inflammatory agents;
(e) Antispasmodic agents; and
(f) Adrenocortico-steroids.
Note: Authority cited: Sections 2615 and 2620.3, Business and Professions Code. Reference:
Section 2620.3, Business and Professions Code.
History:
(1.) Amendment of subsection (f) and Note filed 3-8-2000; Register 2000, No. 10.
http://www.ptbc.ca.gov/laws/regulations.shtml
Illinois
Medication therapy management services
(aa) "Medication therapy management services" means a distinct service or
group of services offered by licensed pharmacists, physicians licensed to
practice medicine in all its branches, advanced practice nurses authorized in a
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written agreement with a physician licensed to practice medicine in all its
branches, or physician assistants authorized in guidelines by a supervising
physician that optimize therapeutic outcomes for individual patients through
improved medication use. In a retail or other non-hospital pharmacy,
medication therapy management services shall consist of the evaluation of
prescription drug orders and patient medication records to resolve conflicts
with the following:
(1) known allergies;
(2) drug or potential therapy contraindications;
(3) reasonable dose, duration of use, and route of
administration, taking into consideration factors such as age, gender, and
contraindications;
(4) reasonable directions for use;
(5) potential or actual adverse drug reactions;
(6) drug-drug interactions;
(7) drug-food interactions;
(8) drug-disease contraindications;
(9) identification of therapeutic duplication;
(10) patient laboratory values when authorized and
available;
(11) proper utilization (including over or under
utilization) and optimum therapeutic outcomes; and
(12) drug abuse and misuse.
"Medication therapy management services" includes the following:
(1) documenting the services delivered and
communicating the information provided to patients' prescribers within an
appropriate time frame, not to exceed 48 hours;
(2) providing patient counseling designed to enhance
a patient's understanding and the appropriate use of his or her medications;
and
(3) providing information, support services, and
resources designed to enhance a patient's adherence with his or her prescribed
therapeutic regimens.
"Medication therapy management services" may also include patient care
functions authorized by a physician licensed to practice medicine in all its
branches for his or her identified patient or groups of patients under specified
conditions or limitations in a standing order from the physician.
"Medication therapy management services" in a licensed hospital may also
include the following:
(1) reviewing assessments of the patient's health
status; and
(2) following protocols of a hospital pharmacy and
therapeutics committee with respect to the fulfillment of medication orders.
Other Medication References in Guide to Physical Therapist Practice (2003):
Interventions:
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Electrotherapeutic Modalities
Electrotherapeutic modalities are a broad group of agents that use electricity and are intended to
assist functional training; assist muscle force generation and contraction; decrease unwanted
muscular activity; increase the rate of healing of open wounds and soft tissue; maintain strength
after injury or surgery; modulate or decrease pain; or reduce or eliminate soft tissue swelling,
inflammation, or restriction. Modalities may include biofeedback, electrical stimulation (muscle
and nerve), and electrotherapeutic delivery of medication.
Physical therapists select, prescribe, and implement these modalities when the examination
findings, diagnosis, and prognosis indicate the use of electrotherapeutic modalities to decrease
edema and swelling; enhance activity and task performance; enhance health, wellness, or fitness;
enhance or maintain physical performance; enhance wound healing; increase joint mobility,
muscle performance, and neuromuscular performance; increase tissue perfusion; prevent or
remediate impairments, functional limitations, or disabilities to improve physical function; or
reduce risk factors and complications.
The use of electrotherapeutic modalities in the absence of other interventions should not be
considered physical therapy unless there is documentation that justifies the necessity of their
exclusive use.
…
Interventions
Electrotherapeutic modalities may include:
•
Biofeedback
•
Electrotherapeutic delivery of medications
o
•
iontophoresis
Electrical stimulation
o
o
o
o
o
o
Day 1 - 130
electrical muscle stimulation (EMS)
electrical stimulation for tissue repair (ESTR)
functional electrical stimulation (FES)
high voltage pulsed current (HVPC)
neuromuscular electrical stimulation (NMES)
transcutaneous electrical nerve stimulation (TENS)
Case 5:11-cv-00017-cr Document 115 Filed 02/01/17 Page 1 of 11
U.S. DISTRICT COURT
DISTRICT OF VERt10NT
UNITED STATES DISTRICT COURT
FOR THE
DISTRICT OF VERMONT
GLENDA JIMMO, et al.,
Plaintiffs,
v.
SYLVIA MATHEWS BURWELL, Secretary
of Health and Human Services,
Defendant.
)
)
)
)
)
)
)
)
)
)
)
FILED
2011 fEB -I PH
CLERK
BY
t&L
OEFUTY CLERK
Case No. 5:11-cv-17
OPINION AND ORDER ADOPTING DEFENDANT'S CORRECTIVE ACTION
PLAN AND MANDATING TWO ADDITIONAL REQUIREMENTS
(Doc. 111-114)
This matter comes before the court on the parties' submissions regarding the
appropriate corrective action plan to be ordered in light of the court's conclusion that the
Secretary breached the parties' Settlement Agreement. See Doc. 106 (August 17, 2016
Opinion and Order GRANTING IN PART and DENYING IN PART Plaintiffs' motion
for resolution of noncompliance with the Settlement Agreement) (the "August 17, 2016
Opinion and Order"); Jimmo v. Burwell, 2016 WL 4401371 (D. Vt. Aug. 17, 2016).
Plaintiffs are represented by David J. Berger, Esq., Matthew R. Reed, Esq., the
Center for Medicare Advocacy, Inc., and Vermont Legal Aid, Inc. The Secretary is
represented by Assistant United States Attorney M. Andrew Zee, Assistant United States
Attorney Steven Y. Bressler, and Special Assistant United States Attorney Tamra Moore.
I.
Factual and Procedural Background.
A.
The Jimmo Class Action.
On January 18, 2011, six individual Medicare beneficiaries (the "Individual
Plaintiffs") and seven national organizations (the "Organizational Plaintiffs")
(collectively, "Plaintiffs") filed a class action suit in the District of Vermont against the
Secretary, alleging, among other things, that the Secretary "impose[ d) a covert rule of
Day 1 - 131
35
Case 5:11-cv-00017-cr Document 115 Filed 02/01/17 Page 2 of 11
thumb that operate[ d] as an additional and illegal condition of coverage and result[ ed] in
the termination, reduction, or denial of coverage for thousands of Medicare beneficiaries
annually." (Doc. 13 at 2,
1.) Plaintiffs alleged this covert rule of thumb improperly
imposed an "improvement standard," whereby coverage for certain home health care
services was denied if a beneficiary's condition had not improved (the "Improvement
Standard"). !d. at
2. Plaintiffs further alleged that because of the Improvement
Standard, Medicare contractors and adjudicators were denying Medicare coverage merely
because a patient was unlikely to improve, or in retrospect failed to improve, even when
the patient needed skilled care to maintain his or her condition or prevent or slow further
deterioration.
The Secretary moved to dismiss Plaintiffs' claims on a number of grounds,
including that they failed to allege a plausible ground for relief. The court granted the
motion to dismiss in part and denied it in part. See Jimmo v. Sebelius, 2011 WL
5104355, at* 1 (D. Vt. Oct. 25, 2011). Thereafter, without admitting liability or any
wrongdoing, the Secretary agreed to settle Plaintiffs' claims in accordance with the terms
and conditions of the Settlement Agreement. The court approved the Settlement
Agreement at a January 24,2013 fairness hearing under Fed. R. Civ. P. 23(b)(2).
B.
The Settlement Agreement.
Pursuant to the Settlement Agreement, the parties agreed to a "maintenance
coverage standard" which provides that "[ s]killed nursing services would be covered
where such skilled nursing services are necessary to maintain the patient's current
condition or prevent or slow further deterioration so long as the beneficiary requires
skilled care for the services to be safely and effectively provided." (Doc. 82-1 at 13,
§ IX.7.a.) (the "Maintenance Coverage Standard"). 1
1
To receive Medicare benefits for home health care services, a beneficiary must be: (a) confined
to the home; (b) under the care of a physician; (c) in need of skilled services; and (d) under a
plan of care. 42 C.F.R. § 409.42(a)-(d). "Nothing in [the] Settlement Agreement modifies,
contracts, or expands the existing eligibility requirements for receiving Medicare coverage[.]"
(Doc. 82-1 at 9, § IX.2.)
2
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Case 5:11-cv-00017-cr Document 115 Filed 02/01/17 Page 3 of 11
The Settlement Agreement required the Secretary to make certain revisions to the
Medicare Beneficiary Policy Manual ("MBPM") to reflect the Maintenance Coverage
Standard. In its August 17, 2016 Opinion and Order, the court concluded that the
Secretary has fulfilled these obligations.
The Settlement Agreement also required the Secretary to "engage in a nationwide
educational campaign" through the Centers for Medicare and Medicaid Services
("CMS "), and in this "Educational Campaign," "use written materials and interactive
forums with providers and contractors, to communicate the [skilled nursing facility
("SNF")], home health, and [outpatient therary services ("OPT")] maintenance coverage
standards and the [inpatient rehabilitation facility] coverage standards[.]" (Doc. 82-1 at
14, § IX.9.) The Settlement Agreement provided that although Plaintiffs' counsel would
be consulted and could provide input, "CMS shall retain final authority as to the ultimate
content of the written educational materials" and the "PowerPoint slides" used in the
Educational Campaign. Id. at 16-17, §§ IX.12, IX.14.
The Settlement Agreement provides that the court will retain jurisdiction for
thirty-six months after the conclusion of the Secretary's Educational Campaign to
"enforc[ e] the provisions of the Settlement Agreement in the event that one of the Parties
claims that there has been a breach of any of those provisions[.]" Id. at 6, § Vl.3.
On March 1, 2016, after complying with the Settlement Agreement's dispute
resolution process, Plaintiffs filed a motion to enforce the Settlement Agreement. In
support of their motion, Plaintiffs argued that the Secretary did not adequately disavow
the Improvement Standard or disseminate the Maintenance Coverage Standard and that
the Secretary's Educational Campaign was so confusing and inadequate that little had
changed as a result of the Jimmo settlement. Among other things, Plaintiffs asked the
court to require the Secretary "to carry out additional educational activities to address the
inaccuracies and inadequacies of the original [Educational] Campaign." (Doc. 94-1 at
25.)
In its August 17, 2016 Opinion and Order, the court granted in part and denied in
part Plaintiffs' motion to enforce, holding that:
3
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Case 5:11-cv-00017-cr Document 115 Filed 02/01/17 Page 4 of 11
the Secretary failed to fulfill the letter and spirit of the Settlement
Agreement with respect to at least one essential component of the
Educational Campaign. Plaintiffs have provided persuasive evidence that
at least some of the information provided by the Secretary in the
Educational Campaign was inaccurate, nonresponsive, and failed to reflect
the maintenance coverage standard.
(Doc. 106 at 18.)
Thereafter, the parties negotiated extensively at arms-length and in good faith to
reach an agreed upon corrective action plan. When they were unable to reach a
consensus, each party submitted a proposed corrective action plan accompanied by a
memorandum explaining why the court should adopt the party's plan.
C.
The Proposed Corrective Action Plans.
1.
Plaintiffs' Proposed Corrective Action Plan:
1.
Jimmo Webpage: CMS will develop and launch a webpage
dedicated exclusively to the Jimmo Settlement and its implementation. The
webpage would include, inter alia, a web portal to which questions could
be submitted for consideration by CMS and a section of Frequently Asked
Questions (F AQs ), which would be updated on a scheduled basis.
2.
Written Statements about Jimmo: A clear statement about the
changes (not mere "clarifications") created by the Jimmo Settlement,
including an explicit statement that the maintenance coverage standard is a
change in policy and practice for providers and adjudicators and an
announcement of a new "Jimmo webpage," would be transmitted to
stakeholders immediately after initiation of the webpage. The same
statement would appear at the beginning of the webpage.
3.
Oral Statements at Open Door Forums: A statement similar to that in
No.2 above would be read at the beginning of at least eight Open Door
Forums scheduled after the website was launched.
4.
National Call: A new National Call for contractors and adjudicators
would be held.
5.
New Trainings: New trainings would be held for the staffs of
Medicare Administrative Contractors (MACs) and Medicare Advantage
Organizations (MAOs), for which plaintiffs' counsel would have the
opportunity to review the training materials and to make suggestions about
them and to listen in on the training.
6.
Additional Monitoring: Monitoring of the corrective action plan
would continue beyond January 2017 and would include in-person
4
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Case 5:11-cv-00017-cr Document 115 Filed 02/01/17 Page 5 of 11
meetings of counsel to review questions that have been raised and to
develop appropriate new FAQs.
(Doc. Ill at 6-7.)
2.
The Secretary's Proposed Corrective Action Plan:
1.
CMS will disavow the application of the so-called "Improvement
Standard" as improper under Medicare policy for the SNF, HH, and OPT
benefits, while making clear that CMS has consistently denied the existence
of such an "Improvement Standard." This disavowal would appear on the
forthcoming Jimmo webpage and in the transmittal message notifYing
stakeholders of the webpage.
2.
CMS is willing, through counsel, to notifY Plaintiffs and the [c]ourt
once the Technical Direction Letter and Health Plan Management System
memorandum have been issued to, respectively, Medicare Administrative
Contractors (MACs) and Medicare Advantage Organizations (MAOs).
3.
CMS will publish on its website cms.gov a new webpage dedicated
to the Jimmo settlement. The Jimmo webpage will, in one location, provide
access to public documents related to the settlement that have been
previously posted on the cms.gov website. In addition, the Jimmo webpage
will direct providers and suppliers with questions regarding individual
claims to the appropriate MAC. CMS will include at the top of the new
Jimmo webpage a message about the settlement. This message will
summarize the clarifications to Medicare policy that CMS has issued as
part of the settlement. Once the Jimmo webpage is published, CMS will
notifY stakeholders of the webpage through existing communication
channels and advise stakeholders seeking information about the settlement
to visit the webpage. Before the new Jimmo webpage message is finalized,
CMS will provide Plaintiffs' Counsel with a two-week period in which to
provide comments on an advance version of the message. CMS will
consider any comments received from Plaintiffs' Counsel.
4.
CMS will post on the forthcoming Jimmo webpage one set of
Frequently Asked Questions (F AQs ). This document would be developed
by CMS and would include multiple questions and answers regarding the
policy clarification resulting from the Jimmo settlement. CMS will provide
Plaintiffs' Counsel with an opportunity to suggest potential questions for
inclusion in the FAQ posting, which CMS will consider but would not be
bound to accept.
5.
CMS will include a message regarding the Jimmo settlement when it
announces the publication of the Jimmo webpage to providers, adjudicators,
contractors, and other stakeholders.
5
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Case 5:11-cv-00017-cr Document 115 Filed 02/01/17 Page 6 of 11
6.
CMS will clarify the responses in the document entitled "Summary
of the questions posed and answers provided during the December 16, 20 13
Jimmo vs. Sebelius National Call for contractors and adjudicators" to
address the concerns identified by the [c]ourt in its August 17,2016
Opinion and Order. CMS will disseminate the Clarified Summary to
contractors and adjudicators using the same communication channels as
were used for the original Summary. CMS will make clear to contractors
and adjudicators that the information contained in the Clarified Summary
supersedes the information contained in the original Summary. Before the
Clarified Summary is finalized, CMS will provide Plaintiffs' Counsel with
a two-week period in which to provide comments on an advance version of
the Clarified Summary. CMS will consider any comments received from
Plaintiffs' Counsel but would not be bound to accept them.
7.
CMS will issue a Technical Direction Letter to MACs directing
them to conduct, within a specified timeframe, additional training on the
Jimmo manual clarifications. CMS would provide the MACs with
materials for use in conducting this training.
8.
CMS will issue a Health Plan Management System memorandum to
MAOs requesting that they conduct, within a specified timeframe,
additional training on the Jimmo manual clarifications. CMS would
provide the MACs with materials for use in conducting this training.
9.
CMS will disavow the application of the so-called "Improvement
Standard" as improper under Medicare policy for the SNF, HH, and OPT
benefits, while making clear that CMS has consistently denied the existence
of such an "Improvement Standard." This disavowal would appear on the
forthcoming Jimmo webpage and in the transmittal message notifying
stakeholders of the webpage.
10.
CMS is willing, through counsel, to notify Plaintiffs and the [c]ourt
once the Technical Direction Letter and Health Plan Management System
memorandum have been issued to, respectively, Medicare Administrative
Contractors (MACs) and Medicare Advantage Organizations (MAOs).
(Doc. 112-1 at 3-4.)
II.
Legal Analysis and Conclusions.
The court's authority to enforce the Settlement Agreement is not unlimited. It
cannot impose new obligations
parties have not bargained for, correct any disparity in
bargaining power, or devise its own scheme for implementing the Jimmo settlement. The
Secretary has offered to undertake certain educational activities beyond those required by
the Settlement Agreement in order to correct the deficiencies the court found in the
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Educational Campaign. Plaintiffs offer a more expansive list of educational activities and
ask the court to order that certain obligations be continuing in nature. For example,
Plaintiffs argue that CMS should be required to create a Jimmo webpage that is
"dynamic, not static, with [P]laintiffs participating in the creation ofFAQs and new
FAQs as developments demand. A web portal for questions should be added to the
webpage." (Doc. 114 at 7.) Plaintiffs were free to negotiate for this relief in the
Settlement Agreement. No reasonable interpretation of the Settlement Agreement could
be deemed to include it. It is therefore beyond the court's authority to require it.
Plaintiffs' suggestion that "additional training should not be left to the Secretary
for her unilateral development; [P]laintiffs should be allowed to participate" warrants a
similar response. !d. The court does not have the authority to order the Secretary to
allow Plaintiffs to participate in her training. Provided the Secretary offers accurate
guidance regarding the Maintenance Coverage Standard and affirmatively disavows the
Improvement Standard, she retains the discretion to determine the content of the training
she has agreed to undertake.
Finally, the court's jurisdiction over the Settlement Agreement does not extend to
monitoring of indeterminate duration. It is therefore sufficient if the Secretary certifies
the completion with the relief ordered herein. The court has considered each of
Plaintiffs' remaining requests for corrective action and concludes that those requests
require a different and more extensive Educational Campaign than the Settlement
Agreement authorizes.
For the foregoing reasons, with the exceptions set forth, the court hereby ADOPTS
the Secretary's proposed corrective action plan and ORDERS its completion on or before
September 4, 2017. The court hereby ORDERS the Secretary's corrective action plan to
including the following two additional requirements.
First, the parties agree that a statement disavowing the Improvement Standard and
explaining the Maintenance Coverage Standard is an essential component of any
corrective action plan. They have, however, been unable to reach a consensus as to the
content of this statement. The Secretary's proposal that she draft a statement and then
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solicit the non-binding comments of Plaintiffs' counsel is unlikely to resolve the parties'
dispute as it merely replicates the negotiations that have prompted the current stalemate.
Simply put, in light of the parties' dispute resolution history, the court finds little
likelihood that the parties will reach an agreement as to the content of the corrective
statement.
Plaintiffs propose a statement that is generally accurate. To date, Defendant has
not pointed to any aspect of Plaintiffs' proposed statement that is either inaccurate or
misleading. Instead, Defendant asserts only that "there is no need to include a subjective,
history critique of allegedly 'erroneous' beliefs of certain providers, adjudicators, and
contractors" and there is no need to "stray from the terms of the [Settlement] Agreement
to introduce such undefined concepts as 'equal coverage' for so-called 'improvement and
maintenance' care." (Doc. 113 at 7-8.) The court agrees with the latter contention and
disagrees with the former.
The concept of "equal coverage" may add an element of confusion without
clarifying whether and when the Maintenance Coverage Standard applies. It is therefore
both unnecessary and potentially confusing surplusage. In contrast, the Secretary's
disavowal of the Improvement Standard should be part of any corrective statement.
Plaintiffs' proposed statement reflects this disavowal in non-inflammatory terms that
accurately reflect the confusion over the use of the Improvement Standard which gave
rise to their lawsuit. In their motion to enforce the Settlement Agreement, Plaintiffs
persausively demonstrated that confusion over the Improvement Standard persists. In
such circumstances, an affirmative disavowal of the Improvement Standard in an accurate
historical context is warranted.
Accordingly, subject to Defendant's right to object within fourteen (14) days of
this Order, the court hereby ADOPTS IN PART Plaintiffs' proposed statement as
follows:
The Centers for Medicare & Medicaid Services reminds the Medicare
community of the Jimmo Settlement Agreement (January 2014), which
clarified that the Medicare program will pay for skilled nursing care and
skilled rehabilitation services when a beneficiary needs skilled care in order
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to maintain function or to prevent or slow decline or deterioration (provided
all other coverage criteria are met). Specifically, the Jimmo Settlement
adopted a "maintenance coverage standard" for both skilled nursing and
therapy services:
Skilled nursing services would be covered where such skilled
nursing services are necessary to maintain the patient's
current condition or prevent or slow further deterioration so
long as the beneficiary requires skilled care for the services to
be safely and effectively provided.
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 ("skilled care") 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.
The Jimmo Settlement may reflect a change in practice for many providers,
adjudicators, and contractors, who may have erroneously believed that the
Medicare program pays for nursing and rehabilitation only when a
beneficiary is expected to improve. The Settlement correctly implements
the Medicare program's regulations governing maintenance nursing and
rehabilitation in skilled nursing facilities, home health services, and
outpatient therapy (physical, occupational, and speech) and maintenance
nursing and rehabilitation in inpatient rehabilitation hospitals for
beneficiaries who need the level of care that such hospitals provide. These
regulations are set forth in the Medicare Benefit Policy Manual.
(Doc. 111 at 8-9) (the "Corrective Statement"). The Corrective Statement shall be
included on the Jimmo webpage, in the FAQs, and in the written materials and oral
statements the Secretary has agreed to disseminate as part of her corrective action plan.
Second, because the Secretary's "Summary of the questions posed and answers
provided during the December 16, 2013 Jimmo vs. Sebelius National Call for contractors
and adjudicators" (the "Summary") (Doc. 94-15) gave rise to the court's determination
that the Settlement Agreement had been breached, the errors in the Summary must be
corrected. The Secretary argues that a corrected Summary will suffice. She further
argues that, in light of the passage of time, a corrective national call will only increase
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confusion. Plaintiffs counter that because the Summary merely highlights the erroneous
information provided in the December 16, 2013 national call, a new and accurate national
call should take place.
A transcript of the national call was not provided to the court. The court must
therefore proceed on the assumption that the Summary reflects certain erroneous and
misleading information provided by the Secretary in the national call. Based on this
assumption, the court agrees that a corrected Summary will not cure the deficiencies in
the national call. The court therefore ORDERS that, after providing at least fourteen (14)
days' notice to Plaintiffs' counsel, the Secretary shall hold a national call in which the
Corrective Statement is orally disseminated. Nothing precludes the Secretary from
including other subject matters in the national call. Notice of the national call shall
include the following statement: "This call will include corrective action mandated by the
court overseeing the Jimmo settlement, clarifying the rejection of an improvement
standard and explaining the maintenance coverage standard now included in the
Medicare Beneficiary Policy Manual." Such notice will alleviate any potential confusion
regarding the purpose of the national call.
In all other respects, the court finds that the Secretary's corrective action plan will
cure its breach of the Settlement Agreement and fulfill its remaining obligations for an
Educational Campaign set forth therein.
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CONCLUSION
For the foregoing reasons, the court hereby ORDERS the Secretary to implement
her corrective action plan with the two additional requirements: (1) the inclusion of the
Corrective Statement; and (2) a national call that includes the Corrective Statement and
the notice required by the court. The Secretary shall certifY compliance with this court's
Order no later than September 4, 20 17.
sf-
SO ORDERED.
Dated at Burlington, in the District of Vermont, this _l_ day of February, 2017.
United States District Court
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