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By Deb Bielek, Therapy Education Resource

Currently, several of our facility therapy teams have been supporting efforts toward identifying best practice approaches as well as new tools and resources available to help us continue on our path toward effective and efficient delivery of therapy to our residents and patients. Not only do we see more and more specialty programs popping up where our patients and residents are receiving state of the art care and getting better because of it, but we are also finding effective ways to engage them in care throughout their recovery process. Currently we have facilities who have been participating in Pilot Programs with focus on innovative care delivery systems partnering with technological resources, enhancements to our therapy software system, interdisciplinary assessment processes for measuring functional outcomes through Section GG, leadership of Restorative Nursing programs.

The following Pilot Programs have been used over the recent weeks to help us grow in our understanding of how these tools and approaches can help us succeed in our current operations. We are excited to share some detailed results of the following pilot programs during our Leadership WebEx meeting scheduled for Friday, August 9 from 12:15 – 12:45 pm Pacific:

• Jintronix is a PDPM-ready, “gamified” clinical product that is transforming the therapy experience in both Post-Acute and Long-Term Care. The treatment allows therapists to enhance their skills by customizing specific treatment protocols for individuals, resulting in patients who are much more engaged and applying themselves in a whole new way and we’re seeing the positive impact on outcomes. The results during the pilot program have been exciting.
• Section GG is being used as part of our Quality Reporting System to demonstrate functional outcomes with the Medicare Part A patients, and we are expanding this outcomes tool into all of our post-acute payers beginning August 1! Our recent pilot program with 9 facilities across the organization yielded best practice approaches to accurate Section GG reporting, which will be critical to our Case Mix groupings for PT, OT and Nursing under the new PDPM. There are also some unique findings with the role therapy can play in the accuracy of these results.
• Optima is creating tools to streamline documentation that is relevant for outcomes tracking, clinical pathway implementation and documentation that supports the Case Mix classifications under PDPM. Hear about the exciting results so far as shared by some of our pilot leaders.
• Do you use Home Exercise Programs to enhance your SLP, PT, OT service delivery? Our pilot project with Medbridge is giving us the opportunity to incorporate the HEP experience through some unique offerings to our patients. We are also beginning to integrate the idea of HEP as an extension to the therapy program by incorporating RNA support into the HEP practice prior to discharge. We are analyzing our NOMS and GG Data to begin honing in on best practices for the HEP. Hear directly from some of our therapists using these unique tools!
• Is your facility struggling to maximize the effectiveness of the RNA program to achieve better results with your patients and residents? Our East Texas Market has been trialing a new approach to RNA Management, and we’ll be sharing more about the program, therapy’s involvement, how it works and the status of the early results.

Say your patient had a hip replacement after a fall with a fracture. Coding rules say you code the fracture first, not the aftercare code. But that’s fine — as long as you check the box that says “Hip Replacement” in section J of the MDS, then the fracture code will automatically “bump” up into the Major Joint Replacement, right?

Wrong! The bump is not automatic. The fracture code that’s selected has to be eligible for re-categorization.

But how do I know? you are asking yourself.

Easy! Look at the map!

CMS has mapped every ICD-10 diagnosis to a category (or an RTP!), and the map will tell you if the code you’ve selected is eligible for re-categorization if it gets partnered with a surgery in the MDS. This is true for the bump into the Major Joint or Spinal Surgery as well as the Other Orthopedic Surgery category.

So where’s the map? The PDPM ICD-10 Map is available in the “Resource” tab in the “PDPM Ready 106 — Field Practice, Identifying the Primary Medical Condition” LMS training, or on the CMS.gov website (https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/PDPM.html).

How do I read the map? When you find your diagnosis, look to see what the map says in the “Resident Had a Major Procedure during the Prior Inpatient Stay that Impacts the SNF Care Plan?” column. If it says “NA,” then checking the “hip replacement” box in the MDS won’t do a thing. But if it says, “May be Eligible for One of the Two Orthopedic Surgery Categories,” then checking the box will “bump” the code.

Let’s look at some examples from the map. Here are three femur fracture codes:

Look at the first code: S722.5XD describes a closed left femur fracture with routine healing. By itself, it would qualify only for the Non-Surgical Ortho category. But the box on the right says, “May be Eligible for One of the Two Orthopedic Surgery Categories.” So checking the “hip replacement” box in the MDS will bump this code into the category we should have — Major Joint Replacement.

The middle code (S722.6XD) describes a fracture of an unspecified femur. This is a Return to Provider (RTP) code. And with good reason — we can tell which femur was broken!

The bottom code (S723.01D) describes a closed fracture of the shaft of the right femur. This qualifies for an orthopedic surgery category, but look at the box on the far right — the one that tells you if the code is eligible for the bump. The box says, “NA.” This means if you used this code, even if you check the “Hip Replacement” box, the category wouldn’t change. This makes good clinical sense, since a fractured femur shaft isn’t when a hip replacement would be done. But what if that code got in there by accident and no one noticed? This is why close attention to codes is so important! The input of a therapist whose expertise includes the nature of fractures and joint replacements is a critical support to the team who is selecting the diagnoses.

So, the takeaway is that while CMS is happy to provide us with reimbursement commensurate with taking care of a major joint replacement or spinal surgery, we need to watch how we’re coding carefully so that we build the case in such a way that CMS can know that that’s what we’re doing.

By Lori O’Hara, MA, CCC-SLP, Therapy Resource – ADR/Appeals/Clinical Review

As we move closer to the October 1st changes with PDPM, many therapy programs have made concerted efforts to implement Group and Concurrent modes of treatment and have noted how their patients are enjoying them. Since January of 2019 we can see a significant shift to adding multi-patient treatment programming across several affiliated companies. The chart below shows a steady increase month-over-month for 2019.

So the real question is: What is the impact of group treatment to our organizations? Let’s briefly look at how these modes of treatment have an effect on Financial, Clinical and Cultural outcomes.

Financial:

Below is an example of CPM and Productivity several markets. As you can see, being focused on providing multi-participant therapy programs created a LOWER Cost per Minute with a HIGHER Productivity (working smarter…not harder)!

Also, by providing multi-patient clinically appropriate treatment approaches, we create additional time to ensure we are providing care to our LTC residents and grow our outpatient programs. Note the trend from the first 4 months of 2018, to the first 4 months of 2019, as we increased our “Moments of Love” (Ciara Cox) for those that reside within our facilities and our communities from 14% to 19%!

Clinical:

Within Optima we assess each patient’s Initial and Discharge Functional status through our CARE Items sets (Physical and Occupational Therapy). Another trend we can see is a general increase in the Mobility and Self Care improvement for all patients. This is a snap-shot and requires additional study; however it is interesting to see our clinical outcomes improving as our modes of treatment are changing…

Another area that would be great to study is the impact of Long Term Care therapy programming compared to changes in facility Quality metrics. Some markets already have been working on this and we would love to see your results!

Cultural:

How does one measure culture? Very tough question, however I believe we can look at some anecdotal evidence from the massive number of emails we all have been sharing demonstrating the creativity, functionality and joy from our therapy professionals, residents and patients. Dozens and dozens of emails from Directors of Rehab and Therapy Program Managers have been shared across all companies AND dozens more have been shared just within each market.

For those still looking for ideas about groups or evidence for the effectiveness and benefits of group programming, below is a Link to our Portal for Therapy Group list of published articles.

Portal:

Group Therapy Programming

Modes of TherapyPOSTette1

Please continue to share your ideas, reach out for support and focus on ensuring each patient and resident receives the BEST care. Thanks for all you do!

By Chad Long, Therapy Resource

Sources for the Effectiveness of Group Treatment:

Flora M. Hammond,,2 Ryan Barrett, MS, Marcel P. Dijkers, PhD, FACRM,4 Jeanne M. Zanca, PhD, MPT,5 Susan D. Horn, PhD,3 Randall J. Smout, MS,3 Tami Guerrier, CTRS,1 Elizabeth Hauser, OT,1 and Megan R. Dunning, PT, DPT, NCS6Group therapy use and its impact on the outcomes of inpatient rehabilitation following traumatic brain injury: Data from TBI-PBE project ArchMed Rehabil 2015 Aug; 96(80):S28 Phys-S292.e.5

De Weerdt W, Nuyens G, Feys H, Vansgronsveld P, VandeWinckel A, Nieuwboer A, Osaer J, Kiekens C. Group physiotherapy improves time use by patients with stroke in rehabilitation. Aust J Physiother. 2001;47:53–61. [PubMed]

Kurasik S. Group dynamics in the rehabilitation of hemiplegic patients. J Am Geriatr Soc. 1967;15:852–5. [PubMed]

Trahey PJ. A comparison of the cost-effectiveness of 2 types of occupational-therapy services. Am J Occup Ther. 1991;45:397–400. [PubMed]

Coulter CL, Weber JM, Scarvell JM. Group physiotherapy provides similar outcomes for participants after joint replacement surgery as 1-to-1 physiotherapy: a sequential cohort study. Arch Phys Med Rehabil. 2009;90:1727–33. [PubMed]

Zanca JM, Dijkers MP, Hsieh CH, Heinemann AW, Horn SD, Smout RJ, Backus D. Group therapy utilization in inpatient spinal cord injury rehabilitation. Arch Phys Med Rehabil. 2013;94:S145–S153. [PubMed]

Oouchida Y, Suzuki E, Aizu A, Takeuchi N, Izumi S. Applications of Observational Learning in Neurorehabilitation. Int J Phys Med Rehabil. 2013;1(5):1–6.

Gauthier L, Dalziel S, Gauthier S. The benefits of group occupational therapy for patients with Parkinson’s disease. Am J Occup Ther. 1987;41:360–5. [PubMed]

Dobrez DG, Lo Sasso AT, Heinemann AW. The effect of prospective payment on rehabilitative care. Arch Phys Med Rehabil. 2004;85:1909–1914. [PubMed]

Fuller PR. Matching clients to group therapies. J Psychosocial Nursing. 2013;51:22–27. [PubMed]

The land swelled below the wing of the plane in gentle shades of green and brown, revealing ample squares defining crops, and the perimeter of a small community where various creeks meander through town before combining to become the Walla Walla River, which drains into the Columbia River about 30 miles west of town. Park Manor Rehabilitation Center is nestled in the farmlands of eastern Washington.

One sweltering hot morning, Sonya, DOR and Zewdi, DON and the IDT team calmly evacuated over two dozen residents to the dining area to preempt any issues with dehydration in a seamless flow of activity. The team identified that the temperature in one wing was too high for the medical well-being of their residents and made the decision as a group during the morning Standup Meeting. Within minutes, people self-organized to provide a pleasant alternative to the overheated area of the building for the patients in the affected wing. Soon the residents were seated comfortably in the dining room, offered beverages and provided with activities to engage them for the morning. Being a part of this particular morning left me with a powerful experience of Ownership, a core value for us at Ensign.

In practice, ownership takes many forms, reflecting the composition of the people who form those teams. As I reflected on why this team seemed so special, I realized that while their location set them apart in very practical terms, the quality of their interactions were definitively harmonious, often uplifting and consistently grounded in sound clinical and operational practice. These lovely people had figured out how to keep the fire lit and love one another through the usual travails of long-term care. I was struck by the balance of utter focus and levity during the morning meetings. This created the critical element of mutual understanding for each patient’s current medical and functional status for a better quality of patient care.

I was particularly struck by the level of individualized attention to ensure that each patient was situated well and individual or family needs were considered. The objective aspects of patient care were navigated skillfully while the personal needs of each patient were also thoroughly respected.

Over the course of a few days, there were many opportunities to get to know this team, and I found myself pondering how to describe what I was experiencing. There were eight factors that seemed to play a part in this team’s capacity to work so well together.

• Relationships — These folks had healthy working relationships. They worked out their differences, held each other accountable and genuinely enjoyed working together. They even went to the movies together after work.

• Finances — While any facility has opportunities for improvement, and the external market factors play a role in that, the basic metrics were in place and well- Census was above average and key metrics were in good shape.

• Calm — There was a quality of calm. While the challenges were quite real, with case mix index, productivity and/or admissions, overall, this was not an anxious group. If tension arose in an interaction, there was a tendency to deal with it directly or let it go altogether. Trust played a huge role in this.

• Creativity — On more than one occasion, I heard the IDT team generate multiple solutions to various patient issues, and then choose one, together, to solve it. This was most notable when a vociferous member of the residential community requested space that was scarcely available, yet a solution was provided that worked for everyone involved.

• Health — If we’re looking at the collective level of function of a team or teams, the overall health of the Interdisciplinary team partners and the therapy department partners was remarkable. While any one of these folks would admit that their work could be challenging, on the whole, they knew that they had each other’s backs and found ways to express that easily and frequently, often in simple ways. For example, they’d share food to create a group lunch, or bring tea or coffee for all to enjoy; express words of appreciation and silent exchanges of support; clean a certain mug for a friend; or draw a picture for each other when documentation was completed.

• Intelligence — In and of itself, the sheer experience of simplicity was part of the intelligence of the way that ownership was enacted within Park Manor. I felt as if the common courtesy and willingness that these partners extended for their work and for each other possessed a quality of coherence that was palpable and easily observed in patient/therapist interactions.

• Flow — The innate intelligence of the team could be seen in the way they addressed the temperature in the south wing being too high on the morning that I visited the building. There was calm but decisive decision-making happening with a seamless flow of activity and an unflustered interdisciplinary team swiftly evacuating two dozen residents to a cooler area. That’s flow.

• Generosity — The consistency of the integrity, accountability and genuinely generous performance that these leaders modeled, coupled with their mutual respect for each other as functional counterparts created a very visible absence. There was no silo. Each leader understood and acted as though they comprised the whole well-being of the facility. They fully supported each other within the scope of their roles, and they took every action possible to ensure continual success to whatever degree they could actuate, one day at a time.

This generosity was the spirit of ownership. It was so seamlessly implicit in the functional performance of this team that I almost missed it. The word “ownership” in our secular culture has come to mean possession, yet here, the opposite is true. When we consciously choose to open up and own more, to bring awareness and act as if our collective results are actually our own, new possibilities open up. New perspective. New hope.

By Willow Dea, Leadership Development

By Lori O’Hara, MA, CCC-SLP – Therapy Resource, ADR/Appeals/Clinical Review

CMS doesn’t define a lot of requirements for what needs to be in a daily note, understanding that it’s what happens during the session that drives the content. But one of the places where they do define a requirement is on the day of the evaluation. Because evaluation minutes don’t count towards the calculation of a RUG score, but treatment minutes do count, they want to be able to see easily that those things were different when they occur on the same day. That means a narrative entry is always required when treatment occurs on the day of the evaluation.

What needs to be in the note? Content that describes how activity billed to the treatment codes was clearly not activity that should have been billed to the evaluation code. So the content in the therapy CPT boxes should describe skilled activity associated with the specific treatment code being billed.

Content that is providing detail on the evaluation findings, interpreting scores or risks associated with testing performance with the patient or family, or describing goal setting is evaluation related. So this cannot be billed towards a therapy code and should not be documented in therapy CPT boxes.

Education about the patient’s conditions or limitations, trialing devices or attempting environmental adaptations, and specific therapeutic interventions are treatment related and should be billed to and recorded as their corresponding CPT codes. Content should be detailed enough that it’s evident to anyone reading that those activities were clearly distinct from the evaluation activity.

Reviewers are starting to look for this – managed care organizations too! So, protect your minutes on your evaluation day content that is just as amazing as the services you provide.

By Lori O’Hara, MA, CCC-SLP – Therapy Resource, ADR/Appeals/Clinical Review

One of the most common reasons for denials in both the Medicare and managed care areas is removing e-stim minutes because the documentation doesn’t support a skilled service.

Reminder! No one pays the machine, so the amount of time the machine is running has nothing to do with how much time is billed. What is reimbursed are the minutes that required a skilled brain — so clearly describing the minutes when the brain was engaged is critical!

Typically, the skilled time includes: assessing and prepping the patient for treatment (including a skin check), applying the electrodes, selecting and inputting the parameters, time spent during the treatment assessing for tolerance or accommodation and making any adjustments, and the post-treatment take-down (including another skin check) and assessments.

Patients who rapidly and frequently accommodate to the current, or roll over from sensory response into a pain response, may require skilled attendance the entire duration of the delivery — but that is not common, so when it occurs it must be very well-documented.

Also remember to put billed minutes in the right place! If you’re using e-stim as an adjunct to neuromuscular re-education or therapeutic exercise, make sure you record the minutes properly. Lumping your treatment minutes into the e-stim code creates an artificially high delivery that the documentation will almost certainly not support.

And finally, the cherry on top: Conclude your narrative entry with a summary statement about the billed time for one-on-one skilled intervention, e.g., “Total number of one-on-one skilled time = 16 minutes.” This is even stronger if the run time is detailed in the description of the e-stim parameters.

Please see the Supervised Modalities POSTette on the portal for more details and examples.

By Willow Dea, Therapy Resource

“Comfort is not the objective in a visionary company. Indeed, visionary companies install powerful mechanisms to create /dis/comfort — to obliterate complacency — and thereby stimulate change and improvement /before/ the external world demands it.” -James C. Collins

We take tremendous care to achieve our mission every day: To dignify and transform long-term care in the eyes of the world. We do that by enacting a pledge to our core values, which foster a culture of integrity and compassion for our patients and their families.

These commitments ask everything of us. They require each of us to explore a profound, and continuously evolving understanding of leadership. Every Ensign affiliate is a leader; it’s part of the agreement we made when we accepted our respective positions. As partners in this endeavor, we are offered an opportunity to be part of something much greater than ourselves. It’s in this context that I find myself wondering how to be a better partner to each of you and a better leader, especially in practical terms. What does it actually look like, as a set of behaviors and outcomes, to be a leader?

Good to Great^[1] revealed the traits of great leaders, and we’ve benefited from learning from these examples. We know that taking responsibility, being humble, getting the right people on the bus, being able to ask for help and leading with passion are essential characteristics and skills for building great organizations and realizing our mission.

Yet the question of how to develop those traits remains somewhat elusive for me, even with such clear stories. In practice, this means we get to cultivate new habits and practice new behaviors. To do that, we need to get comfortable with the uncomfortable. Easier said than done, right? Where do we start? It’s been said that habits are more powerful than fear and that “life begins at the edge of your comfort zone.”

Fortunately, many people are asking similar questions, in every industry sector. Extensive research has been done to help us grapple with these central concerns and effectively answer them. Leadership Agility is based on the rigorously researched developmental framework presented in the award-winning book Leadership Agility: Five Levels of Mastery. The three dimensions of this framework are summarized below.

The Developmental Model^[2]

Agility Levels

The first aspect is a description of the “leadership agility levels” that came out of the research. As managers develop, they grow through stages or levels of agility that can be clearly defined and measured. Teams and leadership cultures have the potential to evolve through parallel levels of agility. The three levels of leadership agility most relevant to the vast majority of today’s organizations are:

• Expert: Managers who operate at this level of agility use their technical and functional expertise to make tactical organizational improvements, supervise teams, identify and solve key problems, and sell their solutions to others. Research indicates that approximately 45 percent of today’s managers operate at this level of agility.
• Achiever: Managers who function at this level of agility use their managerial skills to set clear organizational objectives, lead strategic change, motivate and orchestrate team performance, and engage in challenging cross-boundary conversations. About 35 percent of today’s managers operate at this level of agility.
• Catalyst: Those rare managers who have developed this level of agility are visionaries who can lead transformative change, develop high participation teams, and collaborate with others to develop creative, high-leverage solutions to tough organizational issues. About 10 percent of today’s managers operate at this agility level.

As change accelerates and the world continues to become more complex, the need increases for more Experts to become Achievers and for more Achievers to develop the capacities and skills needed to operate at the Catalyst level. In this increasingly turbulent environment, teams and leadership cultures are challenged to undergo parallel developments.

Action Arenas

As leaders develop through the levels of agility described above, their capacity for taking leadership in all three key leadership arenas expands and becomes more effective:

• Leading organizational change
• Improving team performance
• Engaging in pivotal conversations

The Agility Compass: Four Types of Agility

Joiner and Joseph’s research found that agile leaders employ four types of agility, which work together to increase the effectiveness of leadership initiatives in each of the three arenas. The four types of agility are briefly summarized below:

• Context-settingagility determines how leaders scan their environment, select key initiatives, then scope and set objectives for these initiatives
• Stakeholderagility determines how leaders identify and understand key stakeholders, as well as their ability to create greater alignment with different stakeholder groups
• Creativeagility determines a leader’s ability to identify the key problems an initiative needs to solve, get to the underlying issues, and develop creative solutions that work for multiple stakeholders
• Self-leadershipagility determines how proactive leaders are in experimenting with new leadership behaviors and in learning from their experience

If your curiosity is sparked and you’d like to learn how to reach your next level, reach out to Willow Dea at WDea@EnsignServices.net to take a self-assessment. It takes about 10 minutes, and you’ll leave with a clear understanding of exactly what you can practice to become the leader you aspire to be.

Remember, “The job isn’t to catch up to the status quo; the job is to invent the status quo.” — Seth Godin

^[1] Good to Great, James C. Collins, Harper Business; 1st edition (October 16, 2001)

^[2] Leadership Agility, William B. Joiner and Stephen A. Josephs, Jossey-Bass; 1 edition (October 20, 2006)