Advocating for those who need us
Providing the best care for our therapy patients has evolved and expanded over the past year. Our roles as therapists have broadened to include advocating for patients as well as providing services for them.
Having been in the therapy field in a variety of settings for almost twenty-five years, the term “Skilled Maintenance Therapy” is quite common to me. When I first started in the field, it was typical to provide therapy for people in skilled nursing facilities who needed to maintain their skills — especially through Medicaid.
As time passed, it seemed the focus of therapy turned more toward sub-acute patients while insurance companies were becoming less inclined to pay for skilled maintenance and in some cases, did not pay at all. It became clear the industry was changing. Because we were asked to treat more patients with increasingly acute needs, I for one, probably became distracted by the new challenges these patients presented.
However, insurance companies continued to make changes, providing coverage for a limited time even for patients in acute care — but only as long as they were making gains from the skilled care provided by therapists. As a result, I couldn't help but wonder about a patient with ALS that I was treating — and about another patient with Parkinson's. They still needed help to maintain the skill level they had achieved; but could not be covered by insurance any longer since they had reached a plateau. If these patients were to continue therapy, they would have to pay privately. This was not an option.
Therefore, patients with chronic illnesses would commonly be seen in therapy and run out of funding due to plateaus. A few months later, we would be called back in to see them, as they had again deteriorated from the level we helped them achieve previously.
On January 24, 2013, Glenda Jimmo and several other plaintiffs won a legal settlement (Jimmo v. Sebelius) in which they challenged Medicare contractors' denials for skilled therapy as “maintenance” therapy, stating that this did not meet the improvement standards. The complaint said Medicare failed to make assessments regarding a beneficiary's “unique condition and individual needs.” It also stated that the contractors relied on internal policies rather than Medicare regulations and federal statutes. The judge agreed and said contractors could not deny this service.
My first thoughts when I heard this were of the patients that could have benefited from ongoing therapy had this regulation been challenged a long time ago. I also realized the significance of caregivers advocating for patients to allow them to “function at their highest practicable level.” As leader of a therapy company, I vowed to make sure my staff was well educated on this issue and to provide training to staff so they could help people who had been underserved in years past. I then looked to my clinical team for interpretation of the regulation.
The new verbiage on skilled maintenance therapy came out in 2014, with requirements for qualification that were easy to implement:
- Therapy must require the expertise, knowledge, clinical judgment, decision making and abilities of a therapist or nurse that qualified personnel, trained caregivers or the patient cannot provide independently. In other words, it must be a skilled service.
- Documentation must support the need for skilled therapy intervention.
- The expected outcome is that the patient's condition will improve significantly in a reasonable and predictable period of time, or that service must be necessary for the establishment of a safe, effective maintenance program required in connection with a specific condition. These services will be covered if the requirements are followed and the outcome is similar to what has been stated here. There should be no time limit on allowable services, as long as a patient meets the established criteria.
As patient advocates, it becomes our responsibility to establish good communication around the topic of skilled maintenance to make sure no one slips through the cracks. Staying in close contact with restorative nursing becomes even more important as some patients could not continue in therapy due to lack of a payor source. This used to be the second best alternative, but is not anymore. If patients meet the criteria stated in the new regulations, it makes total sense to see some of these higher-need patients receive therapy under a billable scenario instead of restorative nursing.
I believe the new ruling will help decrease hospitalizations and disruptions in the daily lives of those who face debilitating diseases. Having more access to therapy may even keep a person at home longer versus being in a skilled nursing center. The new ruling should also enable more health care organizations to preserve people's skills to allow them to be as independent as they possibly can be.
In an environment of ever-changing health care, this latest ruling only sheds more light on our need to do what is right for everyone. We need to take a very proactive stance in each instance and spend money on the living or those facing the end of life. By doing so, we are enhancing the quality of people's lives, regardless of their conditions.
CEO/President Kristy Brown brings more than 25 years of management experience to Centrex Rehab. Brown was the executive director of therapy services at Augustana Therapy Services between 1999 and 2012. A speech language pathologist by training, she developed a passion for management soon after graduating and sought to positively affect patient care.