Raising children, like providing patient care, requires a plan.

The older our children become, like when patients show progress, the more freedom they should be allowed.

The guide book for plan of care development for patients is clearly outlined in Medicare Benefit Policy Manual Chapter 15 Section 220.1.2, Plans of Care for Outpatient Physical Therapy, Occupational Therapy, or Speech-Language Pathology Services

For children, parents know we make the plan, and the best approach to ensure consistency and expectations is to stick to the plan.

Sunday, June 2, at the Railbird Festival in Lexington, KY,  we were tasked with developing a plan of care for supervising our teenagers, ages 16 and 17.

You see, our 16-year-old daughter, Kathryn, is a rule follower. Leading up to the event, I had joked with other parents that if you need a rule book on Railbird, “just ask Kathryn Kinder.” She knows the entire layout of the event, she knows who plays when on each of the three stages, she knows when the doors open, she knows what you can and cannot bring in. She even knows the exact measurement of a purse that is not clear that will be allowed entry. 

This girl loves rule books. 

Most importantly, however, she told us, “When we get in here, you can’t call me because there is no cell service.” Her solution with her friends was also planned as they used walkie-talkies to communicate throughout the long day. 

From 1 p.m. to 11 p.m., however, Mom and Dad had to trust she would stick to the plan for touching base as we could throughout the day, and connecting at the end of the night. 

Under the green Railbird sign, we decided, Kathryn would meet us after the final act.

Our 17-year-old son, Lawson, had a friend with a parking pass, and had zero plans in mind for parental guidance.

How it should be done

Step one of creating a therapy treatment plan under Centers for Medicare & Medicaid Services guidelines begins with who writes the plan.

The plan (also known as a plan of care or plan of treatment) must be established before treatment begins. The plan is established when it is developed (e.g., written or dictated). 

The signature and professional identity (e.g., MD, OTR/L) of the person who established the plan, and the date it was established, must be recorded with the plan. 

Furthermore, therapists must understand that simply establishing the plan is not the same as certifying the plan, which is described in §§220.1.1 and 220.1.3.

For example, establishing the plan — meet under the green sign — is separate from certifying the plan (i.e. getting the official seal of approval from parents), which in CMS’ eyes for a therapy plan of care would be a physician’s certification of the plan.

Next, we must understand what should be included in the plan.

The plan of care shall contain, at minimum, the following information as required by regulation (42CFR424.24, 410.61, and 410.105(c) (for CORFs)). (See §220.3 for further documentation requirements): 

• Diagnoses; 

• Long term treatment goals; and

 • Type, amount, duration and frequency of therapy services. 

The plan of care shall be consistent with the related evaluation. 

The plan should strive to provide treatment in the most efficient and effective manner, balancing the best achievable outcome with the appropriate resources. 

Long-term treatment goals should be developed for the entire episode of care in the current setting. 

Long-term goal (stay safe today and meet under the green sign at 11 p.m.).

Goals should be measurable and pertain to identified functional impairments. 

The long and the short

Therapists typically also establish short-term goals, such as goals for a week or month of therapy, to help track progress toward the goal for the episode of care.

To use our example, that would mean:  

Measurable short-term goal: Hydrate once an hour every hour to avoid dehydration.

Measurable short-term goal: Stay in a group always and never go anywhere alone. 

Step two after a therapy plan is treatment. The evaluation and treatment may occur and are both billable either on the same day or at subsequent visits. 

It is appropriate that treatment begins when a plan is established.

So, Kathryn knows the rules, we have a plan, and her treatment day begins bouncing stage to stage, walkie-talkies in hand with her crew. 

Meanwhile, we have no idea what Lawson is up to. 

Frequency and duration is the next consideration for therapists. The frequency refers to the number of times in a week the type of treatment is provided. 

It may be appropriate for therapists to taper the frequency of visits as the patient progresses toward an independent or caregiver assisted self-management program with the intent of improving outcomes and limiting treatment time. Depending on the individual’s condition, such treatment may result in better outcomes. 

Similarly, with our teenager touchpoints we made a plan to check often early in the day. Then as we observed the large number of friends in their group and evidence of responsible behavior, even for Lawson, we tapered our check-ins. 

Then comes the true test of the plan: the long-term goal. 

As 10:30 p.m. approaches, I see the panic growing in my husband. There are 40,000 people here, he tells me. “There is no way we will ever find her. This is not good. This is really, really a bad situation and we should go find her now.” 

“Now?” I replied. “In this crowd? Good luck trying.”

Try he did, weaving in and out of the massive crowd, outside of the plan of care, and without success. 

“You will find me under the green sign at 11 p.m. and you will see me there until I have Kathryn. Stick to the plan,” I told him. 

Then, as the evening ended, and Chris Stapleton sang the final lines of “Tennessee Whiskey,” I stood under that neon green sign only to see a familiar cowboy hat, floral shirt and jean shorts emerge from the crowd. 

“Come on, Dad,” she says. “I know the best way out of here.”

Of course she does … 

Kathryn Kinder, a girl who sticks to the plan.

Renee Kinder, MS, CCC-SLP, RAC-CT, serves as the Executive Vice President of Clinical Services for Broad River Rehab. Additionally, she contributes her expertise as a member of the American Speech Language Hearing Association’s (ASHA) Healthcare and Economics Committee, the University of Kentucky College of Medicine community faculty, and an advisor to the American Medical Association’s (AMA) Current Procedural Terminology CPT® Editorial Panel, and a member of the AMA Digital Medicine Payment Advisory Group. For further inquiries, she can be contacted here.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

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