The Jimmo case is on the agenda for this Thursday’s SNF/Long Term Care Open Door Forum. RehabCare has been closely following the Jimmo vs. Sebelius settlement, which this year established the maintenance standard for Medicare coverage. Prior to the Jimmo case, Medicare only covered skilled care if it improved (rather than maintained) a patient’s condition. CMS is set to provide an update on the settlement with stakeholders and providers this week. Stay tuned to RehabCare Advantage to learn if Jimmo is addressed in the upcoming forum.
For more background about Jimmo vs. Sebelius, please read RehabCare Advantage’s post from January.
Attention, physical therapists: Two orthopedic surgeons at the University Hospitals in Belgium recently discovered a new knee ligament now known as the anterolateral ligament (ALL). The New York Times reported that Dr. Steven Claes and Dr. Johann Bellemans found that the fifth ligament located on the anterior portion of the knee connects the femur to the tibia and helps to control its rotation. As early as 1879, a French surgeon suspected that this additional knee part – a “pearly, resistant fibrous band” – may exist, and the Belgian physicians confirmed existence of the ALL by examining the knees of 41 human cadavers.
The newly discovered ligament may provide insight into why some patients continue to experience knee problems even after anterior cruciate ligament (ACL) surgery. According to NBC News Health, some people with torn anterior cruciate ligaments (ACLs) suffer what is known as “pivot shift,” where the knee gives way when it is moved a certain way. Researchers began to suspect that the knee might have an additional ligament when some of their patients who had undergone ACL surgery experienced this pivot shift, even though the ACL appeared to be healing properly.
“We thought, something is still not right,” said Dr. Claes in the New York Times article. The researchers now believe that the pivot shift may be caused by an injury to the ALL.
Dr. Claes and Dr. Bellemans believe it is very likely that many people with torn ACLs also have torn ALLs and that if the ALL is left untreated, joints could remain unstable. Although they are currently investigating potential surgical treatments for torn ALLs, they admit that there are still many unanswered questions, including whether or not the ALL can heal without surgery.
The findings of this study were published in the Journal of Anatomy, Volume 223, Issue 4.
One of your IRF claims was denied and appealed to the QIC/Maximus with medical record citations and written arguments, yet the decision was still Unfavorable. In fact, the reviewer stated: “The Beneficiary’s impairment, etiology, diagnosis, and comorbidities listed did not require the 24 hour availability, daily monitoring, and frequent management by a physician with specialized training in rehabilitation.”
You read this statement and thought: “Really? But he did!” If you can answer, “Yes, he did” then consider appealing to the ALJ (Administrative Law Judge) level. Why? Because the ALJ is the one level of appeal based not just on the written words of the medical record but also on the oral testimony of the medical professionals, who treated the Beneficiary. Neither the reviewers nor the ALJ can “read between the lines” of our documentation. However, the ALJ level offers the opportunity for the medical professionals to explain to the “trier of fact and decision maker” the unique and complex decision making that occurred at the time of the Beneficiary’s admission.
The medical record “laundry list” of diagnoses, medications, and perhaps an EMR checklist style for the review of systems simply marked, “Stable” may well have different implications to a trained physician or to a reviewer. Thus, at oral arguments, the ALJ may ask specific questions about the care provided or why this Beneficiary needed an IRF and not a SNF level of care. While on the record, take the opportunity to advocate, educate, and justify the Beneficiary’s admission:
- Explain what the “laundry list” of comorbidities and medications in the Beneficiary’s medical record meant to the medical professionals who admitted, treated, and managed the care.
- Explain that “stable” meant the Beneficiary was not in a medical crisis and could tolerate increased stress and activity on their physical system, or the change in medication was helpful and not harmful.
- Explain what complications and barriers to discharge to a lesser level setting were taken into consideration upon review of this Beneficiary’s history and Pre Admission Screen, including social obstacles, such as the Beneficiary was the caregiver for an elderly spouse or the guardian for grandchildren, needed intense rehab in order to return to the home environment quickly due to outside obligations, or lived alone.
- Explain, if appropriate, why no local SNF was able to accommodate this Beneficiary’s immediate medical needs, i.e., he needed specialized bariatric equipment, respiratory therapy services 24/7, further diagnostic re-assessments, required expensive IV medications, or needed more physician oversight that typically occurs with SNF level care.
The ALJs may at their discretion ask for their own expert witness to testify as well as to the standard of care for IRF type Beneficiaries. That “expert” may testify as to what is customary in a particular setting or within a theoretical community. Thus, take the opportunity to fully explain your program in your community—you know it best. For example, the standard of care often varies from region to region with regard to availability of resources in a SNF, transportation barriers for outpatient services especially in the winter months, and the limits to your own local community social service resources. By educating the “expert” as well as the Judge you will advance their understanding for future ALJ hearings of the issues that are unique to your community.
“Opposing” reviewers from the MAC, RAC, or Maximus are also invited to attend the ALJ hearing and a representative or two or three may choose to do so at your hearing. Take this opportunity to advocate and educate about your program. These representatives will, of course, advocate from their agency perspective that the documentation did not support the admission and care and a lesser level of care would have been appropriate, often based on the admitting diagnosis. Take the opportunity to review all of the above implications, risks, availability of services in the community, and to explain what influenced the medical professional, who personally met and cared for the Beneficiary, and knew of the family/caregivers’ goals and barriers. Above all, explain the quest to improve that Beneficiary’s quality of life, both medically and functionally, post this injury or illness, while under that professional’s care in the IRF setting.
Regardless of whether you are simply speaking directly to the ALJ Officer, comparing standard of care in your community with that of the “expert” witness, or refuting an agency reviewer’s decision, be prepared and thorough in your advocacy. By fully describing the Beneficiary’s medical condition, the inherent risks, barriers and implications of other care options, and by advocating for specialized intense rehab because it was best for this Beneficiary, you too can get to a YES/Favorable decision at the ALJ level.
By Emily Morgan, Appeal Specialist for RehabCare.
Please join RehabCare and McKnight’s Long-Term Care News this afternoon for our webinar on data utilization with Ron Scarff, MSPT, Assistant Vice President of Research for RehabCare. From our presentation, “How Data Components Drive Optimal Rehab Services,” attendees will learn to communicate key demographic data that articulates changing patient diagnosis within the post-acute environment, understand key utilization metrics for rehab services and use strategies to engage rehab teams in the care of medically complex patients.
Join us today at 2:00 PM Eastern Standard Time. To register, visit: www.mcknights.com/webinarNovember13.
Were you unable to attend this year’s American Physical Therapy Association (APTA) National Student Conclave? You can still catch the keynote address here, delivered by RehabCare physical therapist Aaron Scheidies. Aaron spoke to students about transcending limitations on disability as it relates to both his career and his patients.
As a child, Aaron was diagnosed with Juvenile Macular Degeneration and has less than 20% vision. But Aaron has gone on to complete his doctorate in physical therapy and make an indelible mark in sports. Aaron is a world-class athlete who has competed in more than 250 triathlons all over the world. Aaron recently completed the 2013 Boston Marathon in a remarkable two hours and 44 minutes. He was a 2011 Espy Award finalist and is a member of the Disabilities Hall of Fame.
Aaron is also a devoted RehabCare therapist at our Emerald Heights facility in Washington state. Utilizing technology, always being resilient and relying on other senses has empowered Aaron to adapt to the demands of his physical therapy career and his athletic endeavors. Aaron’s unique perspective enables him to motivate his patients to overcome their impairments, too. “It’s about looking at disability in a different way and never putting a ceiling on anybody’s potential,” said Aaron. “When I get a patient, I don’t think about what this person can’t do. I think about what I can do to get them from unable to do something to being able to do what they want, about bridging the ability gap.”
RehabCare is thankful to call Aaron one of our own. For his speech and introduction by Paul Diaz, chief executive officer of RehabCare’s parent company, Kindred Healthcare, skip to 54:00 minutes into the video titled “Opening Ceremonies.”
To learn more about RehabCare Student Programs, visit www.rehabcarestudents.com.
Together with McKnight’s Long-Term Care News, RehabCare is presenting a webinar on November 13: “How Data Components Drive Optimal Rehab Services.” Ron Scharff, MSPT, Assistant Vice President of Research for RehabCare, will explain why utilizing core data components is vital for optimal operation of rehabilitation services within the care continuum.
Attendees will learn to communicate key demographic data that articulates changing patient diagnosis within the post-acute environment, understand key utilization metrics for rehab services and use strategies to engage rehab teams in the care of medically complex patients.
Join us on Wednesday, November 13 at 2:00 PM Eastern Standard Time. To register, visit: www.mcknights.com/webinarNovember13.
You have surely noticed in your professional practice that we are seeing more and more people developing and being diagnosed with chronic conditions and illnesses. The incidence of chronic diseases and the related disabilities is expected to rise, especially as the “Baby Boomers” (more than 37 million people in this age group within the US) turned 65 in 2011. 1 Older adults are at high risk for developing chronic illnesses and related disabilities. As these older adults age and the diseases progress, the medical complexity increases, requiring focused and patient-centered care that includes therapy interventions, prevention and health promotion and wellness strategies.
The Centers for Medicare and Medicaid Services report that “…more than two-thirds, or 21.4 million beneficiaries, had at least two or more chronic conditions… and 14% [have] 6 or more chronic conditions.” 2 Additionally, it is projected that levels of obesity will be at 41 percent by 2015 bringing with it the sequelae of conditions.3 As a clinician, working with this population can be challenging, and it may be difficult to determine the focus areas. Following these tips can help ensure that these older adults receive everything they need for all of their conditions:
- Examine and evaluate all involved systems (cardiac, pulmonary, etc.).
- Ensure full understanding of the existing diseases and conditions (etiology, pathophysiology).
- Determine the impairments that need to be addressed.
- Take care to address aerobic capacity as indicated.
- Select the correct objective Tests and Measures to best assess and monitor change.
- Consider the use of a Rating of Perceived Exertion scale.
- Establish a baseline and use guidelines to determine appropriate treatment intensity levels.
- Educate patients about their diseases, “red flags” to look out for and self management.
- Set goals specific to the individual.
Once you have the impairments selected and all baselines from the tests and measures compiled, it will be easier to see where the deficits are (compare to norms/physician guidelines) and to determine the exact areas to address. Working closely with the therapy team (PT, OT, SLP) to make sure all needs are met and not duplicated is essential.
Before discharge from skilled care, ensure all assessments and recommendations are clearly documented and communicated and that any needed follow-up care and referrals are established. All older adults, especially those with chronic conditions, benefit from continued exercise and activity after skilled treatment. Formal establishment of an exercise plan combined with a thorough hand-off and teaching of those who will continue the care is critical. Following these suggestions will help produce optimal results from treatment and therapy.
Mary Moretti, DPT, PT, is RehabCare’s Director of Clinical Operations and supports the development of clinical programming, protocols and evidence-based practice across all of RehabCare’s clinical settings. Mary also oversees Smart Moves, RehabCare’s wellness program.
1. American Hospital Association; First Consulting Group. When I’m 64: How boomers will change health care. Chicago: American Hospital Association; 2007. 23 p.
2. Centers for Medicare and Medicaid Services. Chronic Conditions among Medicare Beneficiaries, Chartbook, 2012 Edition. Baltimore, MD. 2012. Retrieved at http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/Downloads/2012Chartbook.pdf on October 16, 2013.
3. Wang Y, Beydoun MA. The obesity epidemic in the United States—Gender, age, socioeconomic, racial/ethnic, and geographic characteristics: A systematic review and meta-regression analysis. Epidemiologic Reviews. 2007;29:6–28. Available at PubMed: 17510091