An interdisciplinary approach to rehab maintenance
The January 24, 2013 Jimmo versus Sebelius ruling of claims involving skilled care which were being inappropriately denied by contractors based on a rule-of-thumb “Improvement Standard” set into motion a flurry of conversations in skilled nursing facilities across the nation.
The ruling determined that services provided to Medicare beneficiaries could not be denied due to a beneficiary's lack of restoration potential and the that deciding factor would be related to whether or not a skilled level of care would be indicated in order to prevent or slow further deterioration of their clinical condition.
Discussions at the facility level following the ruling often tried to piece together what appeared at the time to be an oxymoron of sorts, we can skill, however we do not have to rehab or restore as updates to Medicare regulations following this ruling required therapists to state at the start of care (SOC) whether services were to be Maintenance Based or Rehabilitative/Restorative Based in nature.
- Maintenance Based- includes programs established by a therapist that consists of activities and/or mechanisms that will assist a beneficiary in maximizing or maintaining the progress he or she has made during therapy or to prevent or slow further deterioration due to a disease or illness.
- Rehabilitative Based- includes therapy services designed to address recovery or improvement in function and, when possible, restoration to a previous level of health and well-being.
Step One: Back to the basics
To begin, in order to understand how we can met individual resident needs by slowing deterioration begins with going back to the regulations which have been long standing in Chapter 15 of the Medicare Benefit Policy Manual related to what specifically encompasses skilled care.
Skilled reasonable and necessary care per the MBPM must meet the following criteria:
- Rehab therapy providers must follow evidenced based practice standards;
- Determinations for skilled care must not be based on diagnosis alone;
- Care must be provided at the appropriate level of frequency and duration of care; and
- Services must be at such as level of complexity and sophistication that the services can only be provided by a skilled therapist.
Additionally, the Omnibus Budget Reconciliation Act of 1987 (OBRA '87) mandated that facilities “provide necessary care and services to help each resident attain or maintain their highest practicable physical, mental, and psychosocial well-being” and “ensure that the resident obtains optimal improvement or does not deteriorate within the limits of a resident's right to refuse treatment, and within the limits of recognized pathology and the normal aging process.”(Code of Federal Regulations [CFR] Title 42, Part 483.25).
While this language is often applied to nursing care, facilities should remain cognizant that these regulations apply to the entire interdisciplinary team including rehab therapy providers. What sets rehab clinicians apart is the definition of skill and the fact that care they provide and the documentation completed must be reflect intervention that is complex and sophisticated. Therefore therapists have to be able to show WHY? their presence was needed. Such as, what specifically did their trained eye see that they adapted, modified, or altered in order to make the individual patient more successful? What individualized intervention, exercise based program, or compensatory based technique was selected based on evidenced based practice.
Step Two: Putting regulations in action
Treatment planning and care provided for all beneficiaries receiving therapy services should be individualized in nature. Adhering to the criteria of reasonable and necessary care it can be summarized as simply: Right Service, Right Patient, Right Time.
Rehab clinicians, nursing teams, and other facility interdisciplinary team members should have conversations related to scope of practice for physical, occupational, and speech therapy services and how services can be provided irrespective of medical diagnosis but based solely on need for services.
Additionally, explanations related to individualized frequency and duration of services can provide insight on how flexibility in regards to the number of visits over a specific time frame can assist with maintaining levels of function for individuals at risk for declines.
Take for example an individual with hypokinetic dysarthria and reduced vocal function associated with progression of Parkinson's disease. Following a period of intense skilled rehabilitative therapy with frequency of 5 times per week aimed at restoring vocal function as prescribed by evidence based practice standards, the patient has achieved functional voice at the structured conversational level. Transition at this point to maintenance based interventions prescribed at a reduced frequency of one time per week accompanied by individualized home exercise program which patient completes alongside caregivers, could be clinically appropriate in order to reduce risks for reduction of overall vocal function.
Or consider an individual who due to progression of chronic neurological condition is receiving primary nutritional via external means, however with implementation of skilled dysphagia therapy is able to receive prescribed therapeutic oral feedings in order to honor wishes and preserve quality of life.
Dysphagia as clearly defined per the MPBM related to scope of practice for speech–language pathology is as follows:
Swallowing assessment and rehabilitation are highly specialized services. The professional rendering care must have education, experience and demonstrated competencies.
Competencies include but are not limited to: identifying abnormal upper aerodigestive tract structure and function; conducting an oral, pharyngeal, laryngeal and respiratory function examination as it relates to the functional assessment of swallowing; recommending methods of oral intake and risk precautions; and developing a treatment plan employing appropriate compensations and therapy techniques (MBPM, 2016).
Therefore, when providing therapeutic interventions to an individual who is at increased risks for aspiration a clinical eye is need to make on demand modifications of which cannot simply be outlined in the standard functional maintenance programs which are often developed when transitioning a patient from skilled to non-skilled professionals.
Step Three: Identifying residents for maintenance care
Diagnosis alone does not determine the need for skilled or maintenance based interventions, however often the individuals who are appropriate for this level of care are the ones with chronic conditions, multiple complexities, and progressive neurological degenerative disease processes which complicate not only care but the level of clinical reasoning needed on a consistent basis in order to help them attain and maintain function.
Skilled nursing facility team members should assesses their processes for providing skilled maintenance based base by asking:
What key areas should we consider when making referrals for maintenance based care? Consider for example the benefit of rehab reviewing MDS Section G: Functional Status sub-categories with nursing and MDS to discuss potential maintenance based care which would prevent ADL declines. Take for example an individual patient who has complicated history of Multiple Sclerosis with referral to therapy due to increased tone in their upper extremities with resultant pain causing difficulty with dressing. Occupational therapy may be reasonable and necessary to integrate tone inhibition techniques and promote dressing abilities.
How can our rehab team provide service which is therapeutic and not “repetitive in nature” which would be indicative of the need for transition to non-skilled care?
What clinical considerations should be made for individualized frequency and duration when transitioning from restorative care to maintenance based care?
Do we have certain residents who are repeatedly referred back to rehab after a short period of restorative nursing due to the nature of the patient's condition not being conducive to a static plan with the need for a skilled eye to make adjustments to interventions?
Renee Kinder, MS, CCC-SLP, RAC-CT, is the Director of Clinical Education for Encore Rehabilitation. In addition she serves as editor for Perspectives on Gerontology, a publication of the American Speech Language Hearing Association.