Why is it important to implement a well-planned restorative nursing program?
The concept of restorative nursing actively focuses on optimal improvement of the resident's physical, mental and psychosocial functioning.  Communication and documentation of resident progress is vital for the success of restorative programs.

Who is responsible for restorative care/programming?
These activities are carried out and supervised by members of the nursing staff.  Other departmental staff may be assigned to work with specific residents.

The Purpose of a Restorative Nursing Program is to increase the patients' independence, promote safety, preserve function, increase self-esteem, promote improvement in function and minimize deterioration.  Specific patient goals, objectives and interventions need to be measurable.  A care plan outlining the program is required.

Restorative nursing programs are initiated when a resident is discharged from formalized physical, occupational, or speech rehabilitation therapy services.  A resident may also be started on a restorative program when a restorative need arises during the course of a custodial stay when the patient is not a candidate for a more formalized therapy program.

To remain in a restorative nursing program, the resident must maintain or retain their level of functioning.  In addition, nursing rehabilitation or restorative care must meet all of the following criteria:

• The individual problem must be clearly identified (ex. AROM, splint or brace assistance, transfer, walking, grooming, etc.).
• Measurable goals (objectives) and measurable interventions (actions) are clearly documented (care planned) for each individual program.
• Goals should be specific, reasonable, and attainable within a prescribed time.  These short-term goals should be seen in the context of a long-term achievement.
• A periodic evaluation by a licensed nurse is present in the resident's record for each individual restorative program.
• Nurse assistants/aides are trained in the techniques that promote resident involvement in the activity.
• A licensed nurse supervises the interventions; however, these interventions may be carried out by restorative nurse aides.
• The technique, procedure or activity practiced total at least 15 minutes during a 24-hour period to report one day of restorative.  To capture revenue for your Restorative Nursing Program, you must provide two separate 15 minute approaches per day provided over 6 days in the 7 day look-back period.

In the interim:

• Medicare Administrative Contractors (MACs) will conduct prepayment review on the claims reaching the $3700 threshold.
• CMS requested MACs conduct these manual medical reviews within 10 days.
• At this time, there is no advance request for an exception process.  Additional information will be provided on the MAC websites.

In light of this recent news, we would like to clarify our company-wide stance on how to approach care delivery for Medicare Part B recipients.  We believe in the clinical decision making skills of our therapists and know that if therapy services are recommended for a resident that exceeds their capitated rate, the resident is in need of the ongoing treatment.  Our current process for MMR will remain in place.  When therapy charges reach $2,200 and is expected they will exceed the $3700 threshold, prior to completion of the therapy episode, all documentation shall be sent to our QA department for review.   It is imperative that we have solid documentation, both therapy and nursing, which accurately reflects the functional progress and the need for skilled intervention.

We will adhere to CMS guidelines for the appeal process should a claim be denied, including ADRs and subsequent appeals. In the event that a claim is not paid by Medicare, we will indemnify our customers as per the indemnification clause in our agreements.   Clinical judgment and the need to improve the resident’s quality of life will always be the primary driver for services for Medicare beneficiaries.  Our goal is to work as partners to assure that all residents receive the necessary therapy services.

Re-cap of HealthPRO’s strategies:

• We will continue to provide all treatment that is medically necessary.  If this takes a patient over the cap, we will go through the pre-payment review process.  If a claim is denied, we will appeal per our current process.
• The QA/Compliance team will continue to review 100% of Part B documentation, pre-threshold, to decrease the risk of denied authorization following the MACs determination

To view the post on CMS.gov, click here. http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/TherapyCap.html

Continuing care retirement communities (CCRCs) in particular have the ability to harness potential revenue from Medicare Part B, which provides coverage and payment for outpatient therapy services, including physical therapy, occupational therapy, and speech-language pathology services, says Richard Boyson, Jr., chief financial officer at Therapy Partners, a division of Baltimore, Md.-headquartered HealthPro Rehab based in Middleburg, Ohio.

Medicare pays the highest rates for residents receiving rehabilitation services, and in 2010 the skilled nursing facilities with the highest Medicare margins were the ones with greater shares of days in intensive rehabilitation case-mix groups, said a 2012 report from the Medicare Payment Advisory Commission (MedPAC).

“Providers are realizing there’s a revenue stream [in providing therapy services], and it’s also a good wellness component,” says Boyson. A third potential benefit: “If the community has an aging in place philosophy, doing more therapy can keep residents healthier for a longer period of time,” thus improving or maintaining census.

Boyson’s company, which has a large footprint in Ohio, contracts with CCRCs to provide on-site therapy, generally though a full-service model that includes helping communities develop a marketing plan to advertise the availability of services to independent and assisted living residents.

Five years ago, Boyson says his company would ask providers what they were doing with their independent and assisted living residents from a therapy perspective, and would hear ‘We’re not doing anything.’

Now, he says, it’s unusual to go into a CCRC and not see at least some efforts being made to go after those residents. “In the last five years, it has changed dramatically,” Boyson says. “We have some long-time customers who didn’t used to do anything in independent or assisted living. When they realized the market and went after it, they were able to build of a caseload of 20, 30, 35 patients—just in independent and assisted living.”

The marketing pitch to a CCRC’s residents is fairly simple: It’s generally much more convenient to get on-site therapy and rehab rather than having to go on campus, and it provides for great care continuity.

When a CCRC’s independent living residents fall and break their hip, they go to the hospital, get “patched up,” and eventually get sent to the community’s skilled nursing facility, where they’re seen by a therapist.

Typically, then, they’re discharged back to their independent living unit, where they would most likely qualify for at-home therapy under Medicare Part B. More therapy is usually needed even after eligibility for Medicare’s home health benefit runs out.

“Instead of going out for therapy, everything can be on campus, so when a resident comes back to a CCRC’s skilled nursing unit after a hospital stay, they can work with the same therapist through home health benefits and also for outpatient Part B services,” Boyson says.

Feedback from residents indicates a preference for being able to work with the same therapist throughout the recovery process, especially because the therapist is familiar with that particular case, he says, enabling care to be more efficient.

In a CCRC’s independent living component, Boyson’s company has seen anywhere from 5-12% of residents being eligible for the outpatient program. That percentage generally goes up in assisted living, he says, to between 8-16%.

Based on a medium-sized campus of about 400 residents, there could be 30-40 units of eligible Part B beneficiaries, he says. “If you’re seeing them three to five times a week, revenues could be very significant.”

The ability to provide—and get paid for— Part B services depends on state regulations. Communities in states such as Ohio can bill Medicare under their skilled nursing facility’s outpatient services number, while third-party therapy providers in Illinois CCRCs, for example, have to use their own billing number. In those cases, the therapy provider essentially sets up shop on campus and pays the CCRC market rent for the space being utilized.

It’s a revenue stream that’s waiting to be tapped, Boyson says, and it can be at no cost to the CCRC as therapy providers typically aren’t paid unless they’re bringing in revenue to the community. That revenue is split, and while the percentages for sharing revenue vary case by base, Boyson says usually 70-75% is paid to the therapy provider, with the rest retained by the CCRC’s skilled nursing facility.

“The community doesn’t have to put capital at risk [to develop an in-house therapy business] to hire people and keep them busy,” he says. “The onus is on the therapy company to drive that revenue.”

Written by Alyssa Gerace

• PART B REIMBURSEMENT: There is now a delay to the planned cut in Medicare reimbursement for all services paid by the Physician Fee Schedule which include outpatient therapy services. The announced spending cut for payments was to be 26.5% for 2013. Under the legislation, the conversion factor is set at 0, which means payments will remain relatively unchanged for 2013. Specifics related to the impact on therapy CPT codes to follow.
• MULTIPLE PROCEDURE PAYMENT REDUCTION (MPPR): For therapy services furnished on or after April 1, 2013 the 25% multiple procedure payment reduction is increased to 50% for all providers.
• THERAPY CAP
  o Previous legislation set the therapy cap for 2013 at $1900 for PT/ST combined and $1900 for OT.
  o The therapy cap extension process has been extended to 12/31/13.
  o The therapy cap is extended to hospital outpatient settings through 12/31/13.
  o The therapy cap is extended to therapy furnished as part of outpatient critical access hospital services.
  o The Manual Medical Review process is extended through 12/31/13 for claims at or above $3700 for PT/ST combined and a separate $3700 for OT.

• SEQUESTRATION CUTS: Postponed until March 1, 2013. Under these cuts Medicare providers would see a 2% reduction in payment.

Additional information will be provided as clarification is received from our national associations.

If you have questions related to these changes, please contact your Regional Vice President for clarification.

What Are The New Therapy Provisions Anyways? At Therapy Partners we know that it is important as your partner to keep you informed of all industry changes, which is why we have recently asked to meet with our partners to discuss the upcoming therapy provisions. On November 1, 2012 CMS released the CY 2013 Physician Fee Schedule Final Rule. Key provisions are as follows: 1. Final rule contains a 26.5% across the board reduction to Medicare payment rates effective 1/1/13. Congress has overridden the required reduction every year since 2003. 2. Therapy cap amount for 2013 is $1900 for PT/ ST combined and $1900 for OT. 3. An exceptions process to the caps has been in effect since 1/1/2006. If Congress does not act to extend the exceptions process, the exceptions process for the $1900 cap and the manual medical review for claims over $3700 expires 12/31/2012. If you’re current provider hasn’t met with you to discuss these provision, we would be more than happy to walk you through these changes. Simply contact Shelly Grisik at sgrisik@therapypartnersohio.com.

McKnight’s LTC Magazine Asks US…How Do We Do It?? Staying on top of the industry changes is what we are all about at Therapy Partners which is why we were asked to be featured in the October print and online addition of the national publication McKnight’s news.  “Offering McKnight’s the information on the article, How Do We Do It…Rehabilitation, was the perfect opportunity to assist educating our industry how to identify on the need for therapy services” states Jim Rogerson, COO at Therapy Partners.  We also were honored once again when they asked our very own Tom Conrad, Behavioral Specialist, to educate on strategies to decrease antipsychotic usage in the long term care industry. Conrad never takes away from the fact that medications are necessary, but did offer evidence on the success that has occurred with residents when offering non pharmaceutical interventions in place of unnecessary medications. We truly are the experts in the field… don’t believe us? Just asks McKnight’s!!!

Our MDS Division Just Got Bigger and Better... Therapy Partners would like to welcome Carol Ashdown to the team! Carol will be stepping into a consulting role within our MDS Division as of Jan. 1^st.  “Carol comes to us with a diverse background in healthcare and has the expertise to assist our customers in meeting the challenges the industry brings” states Sheri Tomlinson, VP of Quality Assurance at Therapy Partners. We are elated to open our arms to another team member who will assist us in redefining therapy!       

For more information visit us at therapypartnersohio.com

or call us at 216-410-5062

We are currently hiring therapists full time, part time, and PRN. If interested in joining this elite partnership, please visit contact Amanda Hite, Regional Director of Recruiting at 216.870.4036 or via email ahite@therapypartnersohio.com.

Don’t forget to visit the organizations web page at www.birchaven.org!

There are four basic keys to utilizing alternatives to chemical restraints with this unique population. Understanding, Communication, Attitude, and Willingness. Each area needs to be addressed to achieve successful outcomes.

Understanding

Understanding, is critical: understanding the diagnosis that increases the potential for adverse, agitated, even combative behavior; understanding role delineation with nursing and therapy regarding chemical restraint reduction; understanding the triggers for the behavior; understanding that behavior is a form of communication often times resulting from an unmet need; understanding adverse behavior occurs when the demand on a person exceeds the person's ability at any given time; understanding the importance of resident centered approach strategies.

Communication

Communication can be the basis for implementing resident specific approach strategies. Communication is as important among direct care staff, nursing, dietary, therapy, physician, social services, and other departments, as it is with the resident and family members. Communication is effective when each member of the interdisciplinary treatment team has the opportunity to provide feedback throughout the entire day. This resident centered care approach empowers all staff to take ownership and share strategies to decrease the risk of adverse behavior.

Attitude

Attitudes can negatively, as well as positively, affect the work place. "When people look at the past, they feel regret. When they look at the future, they feel anxiety and pessimism. In the moment they're bound to find something unsatisfactory. They are suffering from automatic negative thoughts, ANTS, which are cynical, glooming, and complaining thoughts A "Can-do", positive attitude is critical to the success of any organization, effecting all departments.

Willingness

Willingness is the key to changing our understanding of resident specific triggers. Willingness is the key to always challenging, while striving to improve our understanding of residents entrusted to our care. Willingness helps to improve our communication with each other, with our residents, families. Willingness ties to ongoing staff training and trying new approaches including interdisciplinary treatment team regular weekly meetings. This treatment team may consist of the medical director, consultant, pharmacist, director of nursing, unit nurse manager, MDS nurse, social services and therapy representative.

The focus of this team is to review each dementia resident on antipsychotic medications to determine if the need still exists. Resident concerns and adverse drug reactions - negative side effects should be discussed, along with recommendations to reduce or discontinue the use of psychotropic drugs, while ensuring that each psychotropic drug used has a specific diagnosis linked to it.

While psychotropic medications can decrease the need for physical restraints, they aren't the only or necessarily the first treatment strategy. It is effective to incorporate intervention strategies including therapy, effective communication, environmental modifications to manage the behavior, instead of medicating the behavior to fit in the environment. Look to identify the cause of the behavior, first, and then determining how to proceed.

--You have it easily in your power today, to increase the sum total of this world happiness, now. How, by sharing a few words of sincere appreciation, to someone who is lonely or discouraged. Perhaps tomorrow, you will have forgotten the kind words you said today, but the recipient will cherish them for a lifetime." Dale Carnegie.

--You CAN make a difference in the care and life of the person with dementia!

Below are recommendations that afford the opportunity to use alternatives to chemical restraints with this unique population.

1. Approach is everything...make the resident your focus, determine what he/she likes as a reward.

2. Build rapport; help resident to recognize you as a person who is friendly and supportive.

3. Modify the environment- eliminate distractions to increase focus, know the residents personal, cultural history.

4. Work closely with staff; know what works, and what doesn't.

5. Use multi-sensory cues.

6. Use positive statements and praise for efforts leading to completion of task.

7. Do not use terms of endearment; honey, sweetie, sugar, or dear.

8. Problem solve with caregivers to find effective strategies.

9. Use non-threatening body language.

10. Use calm, audible voice, use one step requests, avoid giving too much information, don't ask yes or no questions...the answer most of the time will be "no".

11. Realize your thoughts are real, and automatic negative thoughts - ANT's - don't always tell the truth.

12. Train your thoughts to be positive and hopeful.

13. Replace the negative with the positive.

14. Psychotropic medications are among the most frequently prescribed agents for elderly nursing home residents.

15. Older people, and people suffering from a dementing illness are susceptible to overmedication and negative reactions from a combination of drugs.

16. To get the needed results, doctors can't always eliminate the side effects. You and your doctor must work closely to achieve a balance.

17. Ask what side effects to watch out for, and communicate what you see.

18. The focus should be to eliminate the underlying cause of the behavior rather than medicate the behavior.

19. In cases where medication cannot be eliminated, the focus should be to; maximize the resident’s potential and wellbeing, and minimize the hazards associated with medication side effects.

20. Increase understanding of non-medication treatment, and approach strategies.

21. Change the approach, redefine the problem, if the behavior doesn't cause harm, don't medicate the behavior.

22. Ask yourself, "What's my goal," this is to improve resident’s quality of life.

23. Ask resident "What is troubling you, and how can I help"... if you find you are getting impatient or angry, leave.

24. Remind caregivers they can make a difference.

25. Decide how to respond, rather than react, to the behavior., don't take behavior personally.

26. Be confident, yet flexible in your approach, avoid frustration and negativity.

27. Think safety first.

28. Staff training regarding antipsychotic medications is key to any efforts to reduce drug use in long term care.

29. Resident quality care improves with staff empowerment.

30. We can't change the person, so we have to change our approach.

"Antipsychotic medications pose a great risk for elderly residents, especially those with dementia. They can increase the risk of death in these residents and may put elders with dementia at greater risk for a stroke. They also have many negative side effects such as weight gain, agitation, sleepiness, gastrointestinal problems, dry mouth, worsening cognitive problems, and fatigue to name a few.

These drugs must help stabilize or improve the person's clinical outcomes, quality of life, and functional capacity. The FDA regulations indicate that these drugs cannot be used simply for behaviors of wandering, poor self-care, restlessness, impaired memory, mild anxiety, insomnia, unsociability, fidgeting, nervousness, uncooperative behavior, verbal outbursts, and behaviors that don't endanger the resident or others.

They should be used to treat an enduring condition only when target behaviors are clearly and specifically identified and monitor, and usage must be documented over time. The behavioral issues must be re-evaluated periodically to determine if medication dose reduction or discontinuation are viable options."

Article by Tom Conrad, OTA/L, is a Clinical specialist for Cognition and Behavioral Approach strategies for HealthPRO Rehabilitation. In addition to providing daily treatment for clients with dementia and other psychiatric disorders, he develops and delivers continuing education seminars nationwide.

From July 2012 issue of Provider; The Troubling Role of Antipsychotics. Solving The Mystery, Providers are finding alternatives to antipsychotics by doing some old fashioned detective work. by Joanne Kaldy

Therapy Partners is grateful to be aligned with such a stellar organization. Boyson states “They are one of the best not-for-profits out there and deserve to be recognized for the supportive services they offer to keep the communities thriving.”

For more information, contact Shelly Grisik, VP of Company Relations, Therapy Partners at 216.410.5062 or via email at sgrisik@therapypartnersohio.com.

Welcome to the Therapy Partners Advisor

This newsletter is a service to our valued customers, offering updated information about industry issues, as well as news regarding Therapy Partners programs and services.

CMS Clarifies the Coding of Start and End of Therapy

On the most recent SNF Open Door Forum, CMS clarified how to code the start and end of therapy.  The MDS coding systems have the ability to simply copy everything over so that the MDS coordinators can change the items that need to be changed.  The start and end of therapy dates will carry over until there is a new start and end of therapy.  This pertains to both Part A and Part B start and end dates.

Please see the CMS clarification below:
CMS reiterated that the start and end date of therapy must be coded, even if there were no minutes of therapy.  If there are no minutes of therapy, the latest start and end dates of therapy should be used.   

CMS QUALITY MEASURES FOR NURSING HOMES: CHANGES AND CHALLENGES

CMS created the Five-Star Quality Rating System to help consumers, families, and facilities evaluate performance of nursing homes. Included in the ratings are Quality Measures which are derived from resident assessment data collected at specified intervals during a stay in the nursing home. The intended purposes of the Quality Measures are:

•  Provide information about the Quality of Care at nursing homes to help the public choose a nursing home
• Prompt consumers to talk to nursing home staff about the Quality of Care
• Provide data to the nursing home to help with Quality Improvement efforts
• Provide data to the State Survey Agency for Inspection

With the implementation of the MDS 3.0, Quality Measures have changed.  The new Quality Measures will become an enhanced set of publicly reported information available on Nursing Home Compare in mid-July. Providers will have a 1-month preview before the data is publicly released.

The Quality Measures continue to be categorized into two types: short stay (or post-acute) and long stay (or chronic) measures.

Short stay measures are related to:

• Self-reported moderate to severe pain
• Provision of flu vaccine
• Provision of pneumococcal vaccine

Long stay measures are related to:

• Provision of flu vaccine
• Provision of pneumococcal vaccine
• Self-reported moderate to severe pain
• High risk residents with pressure ulcers
• Utilization of physical restraints
• Falls with major injury
• Depressive symptoms
• Urinary tract infection
• Catheter inserted and left in bladder
• Low risk residents who lose Bowel/Bladder control
• Excessive weight loss
• Increase in need for help with ADL’s

Although the measures do not appear to be significantly different from those based on the MDS 2.0, there are changes in the resident and record selection processes.

Resident Sample Selection

An episode is a period of time consisting of one or more stays. It starts with a new admission and ends with a permanent discharge.  During that time, the resident may be out of the facility for a hospitalization, leave of absence, etc.  These days are not counted in calculating Cumulative Days in Facility (CDIF).

A stay is the time that a resident is physically in the facility or CDIF. When the resident leaves the facility for any reason, this completes a stay and when the resident returns a new stay begins.

The Cumulative Days in Facility (CDIF) defines the resident sample, with Short Stay CDIF up to 100 days and Long Stay CDIF counting from 101 days. As a result of the methodological shift, more residents are included in the Short Stay measures. The MDS 2.0 measures were limited, using PPS assessments to Day 14. Now all assessments, including OBRA and PPS assessments for residents are included for Short and Long Stays.

Record Selection

Requirements for a qualifying assessment are not based on having an ARD within the Target Period, but are based on the resident’s Episode. Due to this, as assessment can be included even if the ARD is not in the Target Period.  In addition, some measures include a look-back scan, in which all assessments within an episode are included. For example, the measure for falls with major injury could include assessments going back to one year if they are contained in an episode.

As a result of these changes, it is critical that providers know where residents are in terms of episodes and stays. Providers must have a reliable, effective means of using clinical data to determine trends, challenges and risks, and promote quality improvement. Being quality focused will improve clinical outcomes, reduce professional liability claims, potentially lower insurance premiums, and improve resident satisfaction. Well performing facilities benefit from fewer survey deficiencies, higher occupancy rates and a positive public perception.

Summer 2012

Got Compliance?  Therapy Partners, a HealthPRO® Company, would like to congratulate our very own Alissa Vertes, VP of Clinical Services & Compliance, in successfully passing the Compliance Certification Board Exam! Alissa is now officially certified in Healthcare Compliance by the Health Care Compliance Association, one of only a handful in the country!  We work in a high risk and challenging environment that demands a proactive approach. Being certified as a Health Care Compliance Professional will help achieve the most optimal results. Alissa is now known nationwide as professional with knowledge of relevant regulations and expertise in compliance processes sufficient to assist the health care industry to understand and address legal obligations, and promote organizational integrity through the operation of effective compliance programs.  Way to rock the world of compliance Alissa!

Road Trip!!!  Therapy Partners team hit the road to present at this year’s 2012 OHCA Annual Convention. Michele Kramer, Sr. VP of Operations, presented in conjunction with Rehab Optima’s experts to present, “Reconnect with Technology to Optimize Reimbursement.” CMS continues to implement changes that impact patient care and reduce revenue for skilled nursing and assisted living providers, the role of innovative software/technology in patient care and team management becomes more apparent. This presentation offered practice ready‐to‐implement‐today strategies to ensure financial and clinical success within an industry of change. Go Electronic! We also delivered awesomeness to the attendees by offering insight from one of the industry’s leading Clinical Behavioral Specialists, Tom Conrad. Conrad presented, “Alternatives to Chemical Restraints without Changing the Floor Plan.” In this powerful presentation, Conrad educated the attendees on how to modify the environment of residents with Dementia by focusing on approaches rather than solely medicating the behavior to fit the environment. He empowered the attendees on not only the importance of effective communication but how to produce positive outcomes through collaboration of the entire interdisciplinary team.

Lost in Translation?! Not exactly… Frank Gargano PT, DPT, OCS, MCTA, the Vice President of Outpatient Services, for Therapy Partners/Rehabilitex Inc. came back from Brazil this past May.  Gargano was invited to the 5^th International Conference on Manual Therapy being held in Fortaleza-Ce, Brazil with speakers and participants from all over the world. The attendees came together to become better informed of unique therapy practices that are being implemented internationally. With the main language being Portuguese, Gargano had an interpreter by his side throughout the conference so he wouldn’t get “lost in translation.” Gargano presented 2 lectures: Differential Diagnosis and Treatment Concepts of Vestibular Dysfunction and Differential Diagnosis and Treatment Concepts of Cervicogenic Dizziness.

CLICKABILITY?  Yep, you have that ability…Clickability! Click away to “like” or “follow” us on Facebook, LinkedIn, and Twitter! You can also sign up for our blog by navigating to our website www.therapypartnersohio.com, and subscribe to the RSS feed. We ask you to utilize your clickability skill to not just support us, but allow us to SUPPORT YOU! We will find industry updates that are pertinent to you or someone you know. Go ahead; you know you want to…click away!!!

For more information visit www.therapypartnersohio.com

Sgrisik@therapypartnersohio.com  216-410-5062