Category Archives: Geriatrics

Motivational Interviewing

I’m presenting a CEU with a colleague and the director of the residency program tomorrow on balance and falls.  Part of my portion is on adherence to fall risk recommendations – I can’t go in depth in this CEU as I have at other times (when the topic was specifically adherence), and it has been a while since I’ve really dug into the literature on adherence in general other than monitoring it via PubMed’s weekly update email.  One of the adherence models used is the Transtheoretical Model (stages of change), which uses Motivational Interviewing, or MI.  In refreshing my memory, I found two good videos on this that I’ll post here.  Watching them reminded me how I found the TTM and MI intriguing, and that I’d like to take a class on it to get better.

Compendium for teaching professional level PT content (neuro focus)

From an email I received earlier this month.  If you are an instructor this is a great resource for neuro-related coursework ideas.

*************************************************

The Academy of Neurologic Physical Therapy is pleased to announce the
release of the updated *“Compendium for Teaching Professional Level
Physical Therapy Content, v. 2016”*. This compendium is an update of the
previous compendium published in 2000 and edited by Margaret Schenkman PhD,
PT and Kathleen Gill-Body, MS, PT, NCS.

The purpose of the Compendium is to provide examples of high quality
teaching and learning strategies that have been developed and refined by
the contributors. Some activities include detailed patient cases and/or
grading rubrics, which can be difficult and time-consuming to write. These
will be useful for novice faculty who are seeking innovative ways to
deliver content. In addition, experienced educators will find new ideas
and alternative teaching strategies.

The compendium is online, and open access
http://www.neuropt.org/education/compendium. Activities may be searched by
elements of the patient management model, by pathology, or by type of
teaching activity. *Activities can be downloaded individually, and
educators may freely adapt or adopt the learning activities while providing
recognition to the Academy and the original authors*.

The Compendium co-chairs would like to recognize the hard work of authors,
editors, and Academy leaders in developing this resource. We hope you find
it useful in planning your curriculum!

*Jody Cormack, PT, DPT, MS Ed, NCS*
* Sue Perry, PT, DPT, MS*
Compendium v.2016 Co-chairs

Telehealth, tech, and the older adult

64946580_88fb60c7f4_qI received a tweet this morning – “Telerehab+fall predict platform= Game changing. Effective?” (I tried to embed it but it wasn’t working).  The American Telemedicine Association is having their meeting in Minneapolis this week, and it will include telehealth platforms for seniors.  Two quick thoughts about the idea before I get ready for work (I’d love your comments and thoughts in the comments or on Twitter).

First, I agree with the author of the article that cost will be a huge issue.  Those on a fixed income are not going to have much wiggle room, and those who are poorer and rely on SS definitely will not.  This will be an increasing concern with the Baby Boomers given the data out there on their savings (or lack of) for retirement.

Second, will THEY want to wear it/ use it?  There is a great section of dialog in Jurassic Park where the grandfather is defending all he has done to the scientists, that he spared no expense, and Ian (Jeff Goldblum’s character) says something to the effect of your scientists were so busy asking if they could they didn’t ask if they should.  In the same vein, are we so busy asking if we can do all this great tech we aren’t asking whether they want it? Yes, there are those who love tech and will embrace the idea, but are those the ones that are having the falls, experiencing incontinence, not eating well, etc?  It reminds me of the Fitbit – those who use it are often the ones who are already fit.  Will they view it as an invasion of their privacy, of one extra step closer to an ALF or a nursing home, despite assurances that the tech is “to keep them as independent as possible for as long as possible”?

I think the technology has the potential to be effective, and to be a game changer for many.  But I think that for many others the financial cost and the resistance against the tech intrusion will require continued personal monitoring and involvement by family and the home health community.

 

Photo credit: “Old and New” by Sparky

Aging and Population Health

2910912489_bf07d7809b_mI’ve been thinking for some time now (starting during PT school, because of my father and grandfather getting older) about the aging population – including illness, chronic illness, health and wellness, the changing of demographics in the communities and what is needed, or better yet, what might be expected and how to get ahead of the changes.  It was one of the reasons I did the residency and earned my GCS, and with continued changes to healthcare I’m realizing that instead of responding to just a major or minor illness (in my daily practice), I also need to get ahead and do something to help address population health.  From what I’ve seen communities are becoming more aware of this as well as their population ages, including Washington County and the Twin Cities overall.

Dr. Michael Riley has written a great challenging blog post Can We Jump the Fence? which I encourage you to read as a starting point.  One thing he writes is “Given the current health climate we are not seizing the opportunity to work as the entry point to better health. People change for two reasons, desperation or inspiration… I have been inspired to change the way I think about the future of this profession and the value we possess.”

Practice Level:  How can we do this at a provider level?  For PT’s working with older adults, we need to be inspired to be the entry point, and to view our position as a both-and (prehab/wellness, rehab, and post-hab/ wellness so to speak), not as either-or (PT or personal trainer, for lack of a better term).  The issues I see for those working with older adults is that Medicare won’t pay for wellness, there is an annual limit for MedB (and a rather tight scrutiny if you go over), and the limited fixed income most seniors are on create limits in some way.  Even if all these were answered to our patients’ benefit, there is a significant issue with adherence to exercise in the older adult population.  So how can we jump the fence and be “the entry point to better health”? We can advocate on our own, but having the support of other providers and current and former patients will be important.

  • Get buy-in from other providers.  They need to know what we can do, both for injuries and to address chronic diseases.  We need to show we know what we are doing by challenging our patients (which we don’t do often enough) to demonstrate good results.  Two PT’s who stick out in my mind in challenging the strength of their older patients or clients are Dustin Jones of the Senior Rehab Project and Christina Nowak of STAVE Off.
  • Get buy-in from our patients (the customer) that we are THEIR therapist, not just for this POC but anytime the need arises.  How can we do this?  Practice at our best, every, single, time; don’t give out a generic HEP, but target it to the patient’s most significant impairments (and emphasize this); and provide home assessments if they are interested.

Community LevelThis will largely be a pro-bono effort initially (though some customers may come your way through your interactions), but it is greatly needed, though others have found a way for it to work for the general population (see the link below for Pro-Activity Associates).  Having the support of providers and older adults may help you get a program started or give you ideas for promoting healthy aging in your communities.

  • For older adults:  support or even teach programs for falls prevention and strengthening; teach a class at your community center or local gym on a wellness topic or recovery from [x]; make or find and promote low cost technology to encourage physical activity in the older adult population.  An example of a good community program for overall health is Mike Eisenhart’s Pro-Activity Associates (What might a geriatric version of this look like? I’m intrigued and excited by the idea).
  • For their families: advertise how your program or classes can help their loved one function better; offer home assessments to help them age in place.
  • For communities and businesses: first, ask older adults what they see that they will need as they age!  Second, you can provide input at city, county or state meetings (zoning, transportation, and parks are a few areas that come to mind) where issues may come up that relate to older adults.  You can also provide comments to businesses on how to be senior friendly, and offer input to senior centers and ALF’s on design changes and fitness facilities.  Eagan, MN is redesigning their town (which is great for those who can move), maybe your community will redesign a part or all of it to accommodate older adults.  If you aren’t sure where to get started, contact your community’s public health department, and help out where your community may note needs (Washington County seems to have a good grasp of where the needs are and what they have in place already).

With a new baby I’m not taking on anything new at the moment, but I’m mulling all this over in my mind.  How can I help position physical therapy as “an entry point to better health”?  Can we therapists network with each other and with other disciplines and organizations to elevate the health and wellness of our aging population?  I think the answer is yes.  I’d love to hear your ideas either in the comments below, on social media, or via email.

Picture by Mendhak

Part I: “Copious” Therapy in Nursing Homes – Financial Gain or Good Therapy? (or both?)

Disclaimer before I go further – I work at a wonderful place that listens to its therapists’ recommendations regarding level of minutes. They respect our professional recommendations and we work together to deliver what is appropriate, adjusting levels as needed. I am very thankful to be working there; this blog especially this post and the next one are my thoughts and do not reflect the thoughts, positions, or practice of the staff or management.

***************************************************************************

On Monday August 17th, The Wall Street Journal had a page 1 article entitled “Nursing-Home Rehab Raises Medicare’s Tab” with the subtitle online of “Medicare pays top dollar for patients in heavy rehab; the pivotal 720-minute mark” and in the paper “Federal rules can give homes financial incentive to provide ‘ultra high’ therapy.” For those who don’t have access, I will give you an overview in this post [along with a few comments], then provide a few thoughts on the article.

The article leads with a story of a 96-year-old gentleman in California who had fallen and broken his hip, had it surgically repaired, and then went to a SNF/TCU for rehabilitation. He “became severely dehydrated… in part because staff did not follow written plans for his nutrition or facility policies… still, during many of his 21 days there, the 96 year old man suffering from dementia received 2 hours or more of [PT and OT] combined.” This gave the nursing home an “ultra-High” level for rehab, billing Medicare “top dollar for his entire stay.”

Medicare use to pay based on costs, but in 1998 it adopted a new payment system based on categories, which the article points out has been billed at higher levels with increasing frequency. In 2002 the average use of RU for billing was 7% nationwide, and in 2013 it was up to 54%. The categories with corresponding minutes/week and 2013 reimbursement rates are below (I added the minutes per day per discipline).

Category Number of minutes/wk Reimbursement in 2013 (WSJ) Minimum minutes/day with 2 therapies (5 days a week) Minimum minutes/day with 3 therapies (5 days a week)
RL 45-149 $325/day
RM 150-324 $341/day
RH 325-499 $383/day 33 each
RV 500-719 $445/day 50 each 33 each
RU 720 $560/day 72 each 48 each

According to Vincent More (Brown University health services professor, and chairman of the independent quality committee at HCR ManorCare Inc), the new system “‘changed the incentives which changed the culture… playing to the max has a long tradition in health care – that tradition is based on the number of minutes of therapy given, so people give therapy up to the max.’ He says factors such as a trend of sicker patients getting admitted to nursing homes may also contribute to rising therapy.” While he acknowledges the benefits of therapy he admits that we don’t know if outcomes are better with higher minutes. The article notes that this payment system causes problems, with dozens of interviews (former and current therapists, rehab directors and others who provide care in 17 states) revealing pressure to reach the 720 minute mark. This delivery of therapy even occurs “when patients are unresponsive, aren’t likely to benefit or have declined such services” [some therapists talk about this pressure; more about this in my next post].

This high level of billing occurs across the country, in small sites and large chains, with several chains mentioned (Genesis, Kindred, HCR, and Five Star Quality Care); HCR is being sued by the DOJ for allegedly pressuring employees to provide unnecessary therapy and overbill Medicare (HRC “refutes the basic claims” and states that they provide care “based on [patients’] individual clinical needs.”).

Industry defenders such as David Gifford (senior VP at the American Health Care Association) believe the WSJ analysis “is incomplete because it doesn’t examine patient outcomes but ‘shows we are trying to provide as much therapy as possible to get people better.’ Patients generally want as much therapy as possible [in my experience this is not common] and Medicare doesn’t set quantity guidelines he says…. Factors beyond money drive increased therapy, says Kim Blunt, an nursing home consultant and former nursing-home administrator at HCR and other organizations. Patients are more educated about health care than a generation ago, she says, and demand more therapy [again, in my experience this is not common]. Providers more thoroughly document treatment she says [point of service documentation is feasible, but would not justify the increase in RU, and can be an ethical issue depending on how it is done in my opinion], and hospitals send patients to nursing homes sooner after surgeries” [true, but often they can’t tolerate an RU when they are more sick].

Critics of the high billing practices report pressure to get as many patients as possible to the 720 minute mark, but not to go over it. Therapists are asked to provide therapy to those who refuse it, don’t need it, or are in “advanced stages of illness.” WSJ analysis of data showed that from 2010 to 2013, nursing homes billed Medicare at the RU level for at least 51,000 patients “until they went on hospice… and about 110,000 patients died within five days” of RU billing. Mr. Gilford “says many patients may need lots of therapy to prepare for home-based hospice care” [they may need therapy to be able to get up stairs or improve strength to make it home, but I haven’t seen it take an RU to do it].

The billing system was developed by Dr. Brant Fries at the University of Michigan, “using statistical methods to determine categories based on examining patients at the time because there wasn’t good science predicting how much therapy was needed. There still isn’t good science, he says, adding that he named the ultrahigh category after determining patients getting 720 minutes were “a very rare group.” Responding to the Journal’s findings, he says there may be “excesses of people getting rehabilitation””. In January the Medicare Payment Advisory Commission (independent congressional agency) and the Urban Institute released a report, stating that “the present payment system continues to encourage providers to furnish clinically-unnecessary services for financial gain.” [emphasis mine]

The article closes with more to the story of the 96 year old gentleman, with snippets of information from the OT and SLP notes over the last week of his stay there, including “no understanding or recall” of OT’s fall prevention instruction and the SLP’s report that he “is unable to hold his head up for longer than several seconds.” The day before he was sent to the hospital he became agitated and tried to hit a therapist, and received 61 minutes of PT, 50 of OT, and 60 of SLP.

**************************************************************************

I’d love to say that numbers don’t matter in healthcare rehabilitation, but this is a business and if you run your business without thinking of the numbers to some extent you won’t be around long. But has evidence for more rehab supported this dramatic increase? That is a tough question; I haven’t seen any study looking at discharge location, re-admittance rates, falls, or anything like that relating to RUG levels. But it is questionable to me with the financial incentives to provide more, and the pressures put on therapists at times to get minutes/ levels, and I don’t know that research would support the extent that RU is billed (if anyone has data, please share and enlighten me!).

So where might we go from here? This article may spur quicker changes at CMS; paying by minutes doesn’t seem to work, and MPAC/ UI’s report acknowledges the financial conflict of interest. Paying strictly by outcomes won’t work (sicker patients take longer and won’t recover as much), though G-codes make me think they are heading that way. I like the idea of FOTO, which allows comparison of patients to others with similar conditions (it is mostly an OP tool, but apparently has a SNF version). Let’s hope whatever CMS adopts is something that all parties can get behind. According to an article in the new GeriNotes, the IMPACT Act of 2014 (Improving Medicare Post-Acute Care Transformation) requires the implementation of standardized assessment data by October 1, 2018 (Home Health is extended until January 1, 2019). These data are functional status, cognitive function/ mental status, special treatments, interventions, and services, medical conditions/ comorbidities, impairments, and an “other” (any category required by the Secretary of HHS). It will be interesting to see what they will do with the data and how they will tie it into payment.

You can read the APTA’s response in this PT in Motion article.

Orthotics to improve balance?

Selection of good footwear is important in balance for older adults, and a fall reduction/ prevention program should include a review and discussion of footwear. In going through an older journal I had set off to the side, I came across this interesting article examining “Effects of Foot Orthoses on Balance in Older Adults” (JOSPT July 2012). This is definitely something to consider, and it would be interesting to see a prospective RCT for looking at the impact of orthotics on falls in older adults.

Two compendiums (mobility and falls), and free access to a journal issue on frailty

A few interesting links came across my desk recently, and I thought I would pass them on.

  • Mobility Compendium Focused on Older Adults – “…a compendium of measures to support research and practice addressing the mobility of community-dwelling older adults with cognitive impairment or physical disabilities. The compendium includes self-reported, performance-based, and instrumented measures.”