Deciding the Principle Medical Diagnosis, By Lori O’Hara, MA, CCC-SLP

Although the PDM only affects therapy buckets, determining the most appropriate diagnosis to put in the first position is an IDT Decision. It is meant to reflect the condition that most strongly explains the reason the patient needs to be skilled in the SNF, and sometimes that is not necessarily the condition for which they need rehabilitation (although it will be often!) The DOR and the therapy team should discuss the reasons the patient needs any therapies they’re receiving, and then the DOR discusses that with the IDT to reach a decision.

Here are few decision making examples:

• A patient admits who had a hip replacement, and then while in the acute hospital had a stroke. Both the hip fracture and the CVA are high-needs conditions and either could legitimately be considered the principle medical condition. When this is true, the facility is allowed to select the best prioritization. In this case, selecting the hip replacement is the best choice. While this does mean that we are opting to miss out on a neuro condition for the SLP case mix index, the benefit to the facility is greater from the hip fracture diagnosis. The patient will still need all the aggressive therapy that comes with those two conditions, so selecting the one that aligns best reimbursement with the amount of resources the patient needs is perfectly fine when it’s clear that the choice is well-supported in the record.
• A patient admits with ulcerative colitis. The patient is on immunosuppressants and close diet monitoring. The patient has suffered significant muscle wasting and is severely debilitated. The patient also has a history of Parkinson’s disease for which they’re receiving a Sinemet regiment that is unchanged in three years. While Parkinson’s would land in a more advantageous clinical category (Acute Neuro) than the ulcerative colitis (Medical Management), that decision is not consistent with the CMS requirement that the principle medical diagnosis reflect the reason the patient needs to be in a SNF. So Parkinson’s disease should not be in the first position, but should be listed as a diagnosis in a later slot.
• A patient admits for pneumonia and also has a fractures of the 4^th toe. The patient is still on antibiotics, requires supplemental oxygen and has an order for a follow-up x-ray. In this instance, while the impact of a toe fracture will certainly need rehabilitation, the patient’s management for pneumonia requires markedly more resources and interventions. So in this instance while the toe fracture would create a more financially advantageous case mix impact, it cannot be validly reported as the principle medical condition.

Congratulations to our newest SPARC Award winner, Brindy Klym, OT, Florida Gulf Coast University, Grad Date: May 2019. Read her winning essay below:

Daily, I do my best to live by Mahatma Gandhi’s words, “Be the change you wish to see in the world.” I envision a world of greater creativity, compassion, and empathy, and strive to embody these traits in order to help others live happier, healthier lives.

My career began as an elementary education teacher. I taught for five years, inspiring children with special needs and those learning English to embrace the world and make a positive impact on others. I strived every day to show up in utmost presence, enthusiasm, and love for my students. I taught over one hundred kindergarteners and first graders, guiding with a sense of adventure and commitment to life-long learning. Each day I was committed to bringing a “spark” to my classroom, a spark that ignited a sense of optimism, confidence, and love for learning in the children that I taught. This spark was evident in my students when they came back to visit me years later, and their families still express gratitude for it to this day as the young children grow into middle schoolers.

While working with students’ with special needs, I discovered occupational therapy (OT) and felt I had discovered my purpose. With my spirit of adventure, sincere care for others, and commitment to personal improvement, I began my pursuit of a career in OT at Florida Gulf Coast University. My commitment to helping others evolved into teaching in a new way: guiding individuals to maximize their functional potential in all aspects of life. OT delights and inspires me because I am able to help others find purpose and independence in their lives. OT is more than a profession; it is an opportunity to teach others holistically and facilitate change at the individual, group, and community level. I feel empowered by my decision to break out of my comfort zone and follow my heart into a new profession, despite the financial and academic challenges it brings. I will never stop learning and will hold strong to my commitment to helping spark a confidence in others that ignites opportunities, happiness, and independence. My purpose is to change the world by inspiring others and teaching a diverse range of individuals to make life better for themselves through occupational therapy.

I appreciate any and all support received and am committed to paying it forward through my commitment to learning so that I may better serve others through OT.

Congratulations to Cody Lemmons, DPT, of Austin, TX, and Runner-up Brent M Giacchetti, COTA, of Pueblo, CO on winning our SPARC Awards! Read their winning essays below!

Essay by Cody Lemmons, DPT, University of St. Augustine, Austin, TX, Grad Date: 8/23/19

A spark can be defined physically as transferal of energy or symbolically as “a new beginning” or “hope”. Therefore, it is crucial that every physical therapist embed themselves with a spark to change each of our patient’s lives. In a world infiltrated with pessimism, deceit, poverty and carelessness, we very well maybe the only ignition to provide meaning and purpose to our patients. Patients come from many walks of life, various generations and cultures with a multitude of diagnoses who desperately need the hope, faith and spark that therapists can provide. While I come from the lens of a physical therapist and athletic trainer specifically, every patient can benefit from a multidisciplinary team of professionals in order to produce physiological and psychological change.

This past Spring, I was blessed to be given the opportunity to travel abroad to underdeveloped regions of Guatemala City, Guatemala in order to provide physical therapy and general medical services. I remain humble while writing about this heartwarming and rewarding experience to share my spark with many individuals that have lived their entire lives without hope or motivation. The primary goals and mission were to teach others about general health conditions, educate the community with exercise prescription/benefits, train other medical professionals and provide medical advice/treatment daily to those with no access to healthcare. My experience in Guatemala was to say the least the most humbling and enlightening adventure of my life. I aspire to return that same experience to my patients wherever I practice in the future. My goal is to restore hope, faith, life, meaning and spark to patients that otherwise wandered from their path by providing education, training, treatment and habitual change to carry on long past discharge.

Clinically, my journey has taken me around the states and abroad to learn from mentors and professionals, share my knowledge and skills, and gain experience with patient care. My journey began about 10 years ago when my undergraduate assignment prior to graduation was held at an inpatient rehabilitation hospital. Then, it was uncertain where my career path would take me; however, at the end of that rotation, I knew that I enjoyed patient care and improved their lives and “human experience”. While attending this rotation, I also had the privilege of working with sports medicine professionals at the local college in which I developed much of my patient and hands-on skills with emergency medicine and orthopedics. To this point, I was involved with the medical management, treatment and physical therapy to one of my classmates and football athlete that suffered a severe SCI. I was fortunate to work with him for the duration of his inpatient rehabilitation and witnessed the power of therapy and “spark” that allowed him to walk and enjoy life with his family again. He now travels to give motivational speeches and involved with the Fellowship of Christian Athletes to share his story and provide that spark.

I continued my education to become an athletic trainer and assisted with physicians in office treating a myriad of patient populations. In many ways my duties included patient care and education but did not feel that was my purpose. Patients were effectively treated but often returned for recurrent treatment in order to improve their quality of life short term. In some cases, these recurrent in-office treatments were warranted as options were limited; however, a majority of patients could have simply required the self-management education for their injuries. I decided that further education was warranted to be able to share my knowledge and skills to improve my patients’ quality of life.

I am currently beginning my final year of physical therapy school and had the privilege to attend a skilled nursing facility for my initial rotation. I had the pleasure of seeing patients admitted in our facility with severe functional decline and discharged with modified independence with all ADLs. Many of our patients often felt hopeless, helpless and without direction. My mentor and I not only provided essential physical therapy with enthusiasm but also education/training that could be used long after discharge. Patients often discharged with new life goals, new skills and friends/support that could provide a path to better quality of life and return to share their knowledge one day.

I have been blessed with so many opportunities, experiences, knowledge, mentors, students, peers, family and support in order to become a strong future clinician. These experiences have provided a strong foundation and will create opportunities to grow as a professional and person. Although my schooling is nearing its end, my learning is ceaseless. I hope that I can provide the same knowledge, skills, opportunities, foundation and “spark” that so many have given me and change every patient’s life one step at a time.

Essay by Brent M Giacchetti, COTA, Pueblo Community College, Pueblo, CO, Grad Date: 5/1/19

I am writing to you to apply for the Spark Scholarship. It has taken me many years of my life in and out of college, traveling the world, volunteering, and working many different seasonal jobs to realize my calling is where I am currently at in the Occupational Therapy Assistant Program. I look forward to doing so many things as a Certified Occupational Therapy Assistant (COTA) to give back to the community here in Pueblo or Colorado Springs, CO.

After passing my National Exam I will work part-time and plan to return to Pueblo Community College for their Nursing or Radiology Tech program. With these Associates degrees I will have the means to work abroad and improve health conditions of under privileged communities with disabilities. I would love to go back to India, return to the Himalaya’s and live there for a few years, and network through my Catholic Priest friends to be of assistance in small mountain towns where a COTA/RT/RN is needed. Using this experience from being in the mountains it will be enriching and humbling to bring those experiences back to Colorado and integrate more yoga and meditation into therapies with children and adults so they have behavioral coping mechanisms through Heavy Work yoga motions and breathing. I think it would be extremely beneficial to those in the school systems so as a whole, these holistic approaches with evidence based research and practice could bring more peace to the kids and faculty as a whole. With the success of this kind of program, it would be implemented into the routine of the teachers to do this for children, since many are sitting all day for hours in a chair, would decrease joint and ligament stress from repetitive motion fatigue and make school increasingly fun through movements that are silly, fun, and relaxing.

As I have lived my adult life in poverty and continually struggle in school due to a learning disability, it is increasingly challenging to make ends meet. I have taken to being a homeless student out of my Subaru Forester. It would be nice to lift myself out of this homelessness to afford some comforts, pay off school loans and credit card debt that have accumulated trying to complete my formal education over the past many years. Working part-time for Pikes Peak Community College as a Pre-Nursing tutor helps me manage my finances some, though the real financial support is from loans, grants and scholarships to make car payments, pay for insurance, and food. Starting Spring 2019 in January, I will have to let go of working due to the intensity and long hours of school and with clinical field work. With your generous support it will help me stay afloat from the concerns of financial instability. I appreciate your time, and I thank you for reading this.

Warm Regards!

Congratulations to our newest SPARC Award Winner, Jane Song! She is an Occupational Therapy student at Dominican University of California, and plans to graduate in May 2019.

Read her winning essay below:

In late 2012, I watched my father be nursed back to health after a serious automobile collision left him barely able to move on his own. Though the accident was difficult to deal with, the positive experience with his medical team thereafter led me to believe in the value of occupational therapy. Watching him regain the ability to engage in the functional activities that were important to him was an emotional experience. I still remember the proud look on my father’s face after he used the bathroom independently for the first time since the accident. I, too, felt extremely proud of his accomplishments. This experience led me to pursue a career in occupational therapy. The experiences I’ve had since then continue to validate my decision and reinforce my passion for this profession.

Initially, I had a desire to work in pediatrics. I first-handedly witnessed the benefits of early intervention when I worked as a volunteer with a young girl who was born with an orthopedic disorder that disallowed for fluid movements of her extremities. After several months of therapy, she was able to independently perform various functional tasks such as taking off her jacket. Her progress was remarkable to watch, but seeing her become more confident in herself was what left a lasting impression of this entire experience. This was the first time I had played a role in facilitating progress as a healthcare provider, and I felt the same, incredibly proud feeling I had felt with my father for this young girl and her accomplishments.

As my clinical knowledge and skills continued to develop throughout graduate school, the want to help individuals discover their potentials and feel more confident remained the same. This desire was especially strong during my recent level two fieldwork experience in an inpatient acute mental health setting. An experience I had with a patient not only reinforced this passion but also enabled me to gain real-life experience of the importance of engagement in functional activities. This patient spent all day in his room and refused to speak with the staff for the first three days of his stay. On the fourth day, I briefly made his acquaintance in the hallway when he momentarily stepped out of his room. I introduced myself and welcomed him to find me in the occupational therapy office if he needed anything. The next day, I invited him to group therapy. A full week nearly passed before he took his first steps into the occupational therapy room to join us for art group. With much encouragement, he picked up a paintbrush and painted his first picture. He, then, painted everyday until he was discharged. Not only did he start coming out of his room more often, but he also began to open up to the staff, making jokes and laughing. The positive changes in his behavior when he discovered this leisure activity was an eye-opening experience that demonstrated the effectiveness of occupational therapy. I, again, found myself feeling proud of this individual and the progress he had made.

Throughout the pursuit of my professional career, I am constantly reminded of the incredible potential that people have to achieve their goals. My experiences continue to solidify the notion that I am undoubtedly in a field that not only enables me to meet my professional goals but also incorporates values that I hold most dear: serving others and making a difference.