News

As we are all well aware, CMS has begun penalizing hospitals for unplanned readmission of certain diagnoses, including acute myocardial infarction (AMI), heart failure (HF) and pneumonia (PN). This new rule brought into focus specialty areas where the post-acute care settings could partner with the hospitals for improved outcomes. Many skilled nursing and rehabilitation programs have always accepted patients with cardiac conditions, but they are now talking about their role in relation to reducing hospital readmissions. In many cases, the SNF, HH and outpatient programs are providing therapy to these patients under the general rehabilitation program.

We have seen the opportunity in some of our markets to further develop well-defined cardiac specialty programs with quality outcome measures in place (such as the CARE Item Set and NOMS), for the primary purpose of enhancing the transition of care for this highly specialized population. By implementing this type of specialty program, we believe that hospital readmissions, greater patient satisfaction and higher success with transitions of care will be achieved. When we add in the fact that we will be able to provide measurable outcomes using standardized tools such as CARE and NOMS, measuring the overall effectiveness of the program and evaluating opportunities for further development will be more distinguishable.

In 2012, your therapy resource team developed a tool that could be used to help facilitate the steps for developing a specialty program. In 2014, we refined it using the specialty of cardiac wellness as an example, sharing it through leadership meetings and the Therapy Portal. Three of our facilities took the information from the meeting and identified cardiac specialty physicians who were eager for a program that could help transition their patients from the acute hospital stage and back into the community. The facilities reached out for therapy resource support with development, and as we dug in with these three programs, we began to see the opportunity to create something special that could be shared across the organization. We then turned this support into a collaborative program development pilot, where we are asking them to be a part of creating a packaged program that can be implemented by our facilities throughout the organization. The pilot facilities are Sabino Canyon Rehabilitation & Care Center in Tucson, Brookside Healthcare Center in Riverside, and Victoria Care Center in Ventura.

Together with service center resource support, the three facilities have each identified the facility IDT interested in the program and developing the skills necessary to enhance expertise, identified a need in their communities by talking with health partners, invested in some of the equipment deemed essential for getting started with a post-acute cardiac wellness specialty program, helped to refine components of the guidelines being created, and are contributing to the development of clinical pathways relevant to our cardiac diagnoses and setting. One of the consistent questions that the teams were struggling with as they embarked on this specialty program development was where to start once they had secured internal interest and a potential need within their healthcare communities. Therapy Resource support was helpful with how to have those initial conversations for the facility to springboard into the next steps.

At Sabino Canyon Rehabilitation and Care Center, administrator Eli Robbins, DNS Quinny Mazzola, DOR Valerie Berg and a therapy resource met together with Dr. Tirrito, a local cardiologist, to discuss the need in the community for a transitional program such as this one. Dr. Tirrito was instantly intrigued, as he identified a significant need for the patients within his own practice. Dr. Tirrito is well-established in the Tucson community, working with Pima Heart and a variety of hospitals and health plans. He has helped us consider different definitions to the program. He provides rounds on a regular basis, he provides ongoing in-service education to the facility staff, and he assists with creating in-roads to various health partners for Sabino to spread their message. They are taking his patients and using the experience to continue to help with the development of the program. During the development phase, the Sabino Canyon Therapy Team was in need of more specific expertise. We are working with Ellen Strunk, who not only holds an Expert on Exercise with the Aging Adult and Geriatric Specialty Certification, but also has extensive experience with developing cardiac rehab and wellness models. Ellen has helped us to create and deliver a training and competency program for our own therapists.

At Brookside Healthcare Center, Matt Stevensen, in partnership with Vangie Bravo, Ron Layos and a therapy resource, began conversations with the Dignity Health Partners and local Hospital Liaisons about a need for this type of program. Dr. Slayyeh, a local Cardiovascular Surgeon, is a great partner and has helped to further define our admission criteria. He and the Dignity Health Partners are also helping to create a transition from the acute hospitalization to our setting, as well as transitions beyond the Skilled Nursing and Rehab stay.

At Victoria Care Center, the team has created a very strong physician advisory board with a variety of physician expertise. John Gardner, Juvie Lopez and Sacchin Bhatia, along with therapy resource support, began seeking areas of potential need for more post-acute care expertise within the community. Dr. Patel, a cardiologist and one of the board members, agreed with our suggestion of the need for a transitional post-acute cardiac wellness program. He brought the idea back to a group of surgeons and partners in the practice. As we were moving through the development phase of the program, he suggested involving an expert from the Cardiac Rehab Program at Henry Ford Hospital, Dr. Steve Keteyian. We have partnered with Dr. Keteyian to add his expertise in further development of the clinical aspects of the program. In addition to directing Henry Ford Hospital’s Cardiac Rehab Program, Dr. Keteyian is also a very accomplished educator and author on the subject of cardiac rehabilitation and is interested in helping with the work we are doing in the post-acute care settings.

Before the end of 2014, your therapy resource, clinical resource and PAC resource teams, in collaboration with the pilot facilities, expect to have a well-defined, fully executable cardiac wellness program guideline, training pieces and clinical pathways developed for sharing throughout the entire organization. There will be a Cardiac Wellness Guidelines Manual, clinical pathways for the program diagnoses, an educational training for the Clinical Program Coordinators, a CEU training and competency-based education program for the therapists, educational flyers for patients on subjects such as smoking cessation, dietary considerations, exercise and self-assessment, as well as a marketing and education campaign for use with the local healthcare community and potential consumers. If you and your team are interested in getting started with a specialty program, please reach out to your local therapy resource for assistance with how to get started. We are here to support you and your interdisciplinary team with living your vision.

By Deb Bielek, Therapy Resource

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act signed by President Barack Obama on Oct. 6, 2014, directs the U.S. Department of Health and Human Services (HHS) to standardize patient assessment data, quality and resource use measures for PAC providers, including home health agencies (HHAs), skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs) and long-term care hospitals (LTCHs).

It is believed that the standardization of patient data across Post-Acute Care settings will allow HHS to compare quality across PAC settings, improve hospital and PAC discharge planning, and use this standardized data to reform PAC payments in the future.

The new law will:

• Require PAC providers to begin reporting standardized patient assessment data at times of admission and discharge by Oct. 1, 2018, for SNFs, IRFs and LTCHs and by Jan. 1, 2019, for HHAs.
• Require new quality measures on domains beginning Oct. 1, 2016, through Jan. 1, 2019, including functional status, skin integrity, medication reconciliation, incidence of major falls, and patient preference regarding treatment and discharge.
• Require resource use measures by Oct. 1, 2016, including Medicare spending per beneficiary, discharge to community and hospitalization rates of potentially preventable readmissions.
• Require the secretary of HHS to provide confidential feedback reports to providers. The secretary will make PAC performance available to the public in future years.
• Require MedPAC and HHS to study alternative PAC payment models, with reports due to Congress in 2016 for MedPAC and 2021–2022 for HHS.
• Require the secretary to develop processes using data to assist providers and beneficiaries with discharge planning from inpatient or PAC settings.

CMS and other entities have worked together to strategically identify an efficacious tool for collecting quality measures in PAC settings. The CARE (Continuity Assessment and Record Evaluation) Item Set is the frontrunner as the tool for collecting data on self-care and mobility. The CARE Item Set was developed by a PAC Outcomes Workgroup being led by Dr. David Gifford, with members from the National Association for Support of Long Term Care (NASL), American Health Care Association (AHCA), American Physical Therapy Association (APTA), American Occupational Therapy Association (AOTA) and others. Extensive research has been collected on the tool using over 12,000 cases. There is overwhelming support for this tool.

The tool for measuring swallowing, cognition and communication has not yet been determined by the PAC Outcomes Work Group. The National Outcomes Measurement System (NOMS), developed by the American Speech-Language Hearing Association (ASHA), is felt to be the frontrunner at this time.

Optima Health Care Solutions (Optima HCS), the maker of our rehab software, Rehab Optima, has been selected to serve as a national repository for the collection of data from the CARE Item Set, which will be used to collect data regarding self-care and mobility at admission and discharge. Optima HCS has also worked with the ASHA and has been authorized to build NOMS into the documentation for use by our SLPs certified in NOMS. Ensign has been selected as one of three organizations nationally to test the external NOMS collection site in Optima. As an organization, greater than 50 percent of our therapists have been certified in NOMS and/or CARE and we are collecting data on our Post-Acute Care admissions. We are also beginning to use the data to speak to our healthcare partners, including those affiliated with hospitals, home health agencies and outpatient treatment centers. By using CARE Item Set and NOMS to measure outcomes, our programs are preparing for the requirement to measure and improve quality of service delivery to our Skilled Nursing Facility rehabilitation patients.

The data collected during the CARE Item Set demonstrations completed by the PAC Outcomes Workgroup will be presented to the National Quality Forum on Nov. 7.

Read more information about CARE Item Set.

Read more information about ASHA NOMS.

Congratulations to Trevor Pettigrew of Medford, Oregon, our second winner of Ensign Therapy’s SPARC. To assist him in completing his Physical Therapy education, he will receive a check for $2000.00. Trevor is a student who will graduate from the DPT program at the University of Washington in June of 2015. He is recognized by his academic mentors as someone who is ethical, caring, conscientious, thorough and personable. He is also the kind of student who consistently requests feedback and constructive criticism and is able to apply it to his practice. The SPARC judges unanimously chose Trevor and were touched and impressed by his personal story, a “must read” (below).

Essay by Trevor Pettigrew

Staring at the run-down “single-wide” in the middle of nowhere, I could barely believe my parents as they told my siblings and me that this would be our home for awhile. We had just moved from a pleasant neighborhood in a suburb of Los Angeles. The move itself had been stressful–caravanning up north, with merely the hope of a job and a home, and our pared-down belongings left in storage.

My dad’s company had been bought out and the employees laid off while I was in elementary school. While not extravagant, our comfortable lifestyle disappeared as my family was caught in the country’s economic downturn. After thousands of resumes, several low-paying jobs, and depleted savings, my parents decided to take a leap of faith and move to an area where my dad had often dreamed of living: southern Oregon.

The stark contrast of these two locales highlighted the fact that I had spent my early years in an area that in itself was filled with individuals of rich diversity. Unlike my mom’s stories of culture shock when she moved from a small town with a fairly homogeneous population in upstate New York to an inner-city neighborhood in Los Angeles she could afford as a graduate student/teaching assistant, I was, in fact, shocked by the relative homogeneity of my new surroundings.

Perhaps it was the fact that I had been homeschooled and had participated in activities with students from a widespread, metropolitan area. Unlike public school students who went to school with the same children they played with at home, my friends were spread out in various towns whose neighborhoods, homes, and families often varied drastically from mine. Quite frankly, because of the changes in my family’s circumstances, my lifestyle quickly changed from that of my neighborhood friends.

All these factors resulted in feelings of frustration, restlessness, and a subconscious, smoldering desire, a desire as yet un-named. The spark that ignited this desire came at a high price. It involved bigger losses than before, beginning with the incarceration of my older brother shortly before I started college. As devastating as that was, it paled in comparison to the losses to come. One week after I started college, my father died of a massive heart attack while out for a morning run–the first half of an incredible one-two punch that I felt would level me. And as stressful as it was when my mother underwent open-heart surgery a little over two years after that, the final blow of that one-two punch came several months afterwards when my younger sister passed away in her sleep due to an undiagnosed congenital heart defect. While certainly dazed, I am thankful I was not knocked out and I didn’t submit. Instead, these devastating personal losses were the spark that caused that un-named desire that had been smoldering since after my earlier life circumstances to burst into full flame: I wanted to pursue life in a career that would allow me to make a positive difference in people’s lives by encouraging others not to lose faith and to keep on “keeping on” when they have been dealt blows in life, and I wanted to do that in a career that would not only allow me to be physically active but would also engage my mind as well.

All these circumstances–my homeschooling, the change in my family’s socioeconomic status, our move, and our losses—have helped me develop not only an ease with, but an interest in, widely disparate people as well as unique friendships that have enriched my life. They have driven me to pursue learning how to attain one’s best overall health through nutrition, exercise, stress management, and other lifestyle changes so that in addition to helping people in need of rehabilitation, I can contribute to the well-being of my patients by approaching them holistically.

At this point in my life and after these past two years of physical therapy education, when I think of how I hope to be a unique spark in the lives of my patients, I recall myself watching the evening news the day after Steve Jobs, the founder of Apple, died. I find myself agreeing with a man in Tokyo who said, “Someone who did so much makes me want to do more.”

Just as the news story described Jobs as having “democratized” the digital world with his ideas and products, I would like to “democratize” the world of physical therapy, making it more directly accessible to everyone. This has many implications from the idea of integrated practices of physical therapists and other medical providers and the accompanying expansion of patient choices in treatments to the development of more cost-effective interventions which would open up direct access to physical therapists to the uninsured, for example. One of my goals is to be running a pro bono physical therapy program helping to promote primary injury prevention and wellness in our community as well as to educate the general population about the physical therapy profession as a whole.

In addition, based on my student experiences working with patients in physical therapy settings as well as on witnessing my mother’s past experiences in physical therapy, I envision promoting investigation into and consideration of the effects of factors such as a patient’s personal life and environment when developing a plan of care to better insure the patient’s adherence to the plan and thereby improve the prognosis. Every patient’s story and background is different, and I believe my life’s diverse experiences in combination with my physical therapy training have given me a unique well of expertise on which to draw to serve my patients with skilled physical therapy care, understanding, and compassion to the highest ability.

Anar Veliyev is the inaugural winner of Ensign Therapy’s SPARC. To assist him in completing his Physical Therapy education, he will receive a check for $2000.00. Anar is a student in his final year of the DPT program at the University of Washington and is recognized by his academic mentors as someone who is ethical, caring, conscientious, thorough and personable. He is also the kind of student who consistently requests feedback and constructive criticism and is able to apply it to his practice. The SPARC panel of judges was touched by Anar’s personal story as well.

Anar and his family are refugees from Azerbaijan. As he describes it, “being half Armenian and half Azeri is the deadliest split ethnicity one can have when living in either Armenia or Azerbaijan.” Anar and his family transformed themselves from struggling refugees sharing a one-bedroom apartment to a family that has worked hard to support themselves financially and obtain degrees in healthcare. Anar’s mother is completing an advanced degree in Nursing while working as a registered nurse, and Anar’s older brother is a college graduate who continues to help support his family in achieving their goals.

Anar decided early on that it was his manifest destiny to use his skills to help the elderly through rehabilitation. “Giving the elderly help by strengthening their muscles, bones and tendons greatly increases their chances of living a longer and better life. Bringing awareness to their diets and activities is a vital process. Simply showing the elderly that we care could be all the difference in convincing them to voluntarily receive the assistance that they need,” writes Anar.

Ensign Therapy is proud to demonstrate our support of Anar and the excellence we are sure he will bring to caring for our elderly patients.

written by Ellen Strunk, PT, GCS, CEEAA

The Program for Evaluating Payment Patterns Electronic Report (PEPPER) provides SNF-specific data statistics for Medicare services by provider. Each report compares a SNF’s Medicare billing practices with other SNFs in the states, MAC jurisdiction and nationwide, so the SNF can determine the level of risk for improper payments. The 2013 reports contain statistics for episodes of care ending between October 1, 2009 and September 30, 2012.

The type of information that can be obtained from these reports include:

• Proportion of days billed in the highest ADL categories (X, L, and C)
• Proportion of assessments completed as a change of therapy assessment
• Proportion of days billed in the RU and RV RUGs
• Proportion of episodes with a length of stay of 90+ days

The reports were mailed to each SNF individually on or before August 30, 2013 and are not available to the public; CMS is providing these reports “freely” to all SNF providers nationwide. SNFs are encouraged to use the data to support their own internal auditing and monitoring activities.

Ellen Strunk is owner of Rehab Resources and Consulting and a partner to the Therapy Resource Team at Ensign Services, Inc.