A recent article in Provider Magazine reminds rehab teams that from start to finish, clinicians need to consistently communicate with and listen to all parties involved in the patient’s care.
From the outset, the patient and the multidisciplinary rehab team should take the opportunity to educate each other. Clinicians inform the patient and the patient’s family about the clinical implications of stroke, and the patient gets the chance to explain their goals and their life before their stroke.
“We need to learn a lot more than we usually do about the patient’s personality, life events, and coping skills before they had their stroke,” says David Smith, MD, CMD, president of Geriatric Consultants of Central Texas in Brownwood.
Therapists should capitalize on this chance get to know their patients and uncover their wishes at the beginning of treatment.
“I don’t think we spend enough time asking patients what they want,” says Mary Van de Kamp, MS, CCC, SLP, senior vice president of quality and care management at Kindred Healthcare, RehabCare’s parent company. “We don’t want to make promises we can’t keep, but we also don’t want to discourage aspirations.”
If the stated goal is independence, find out what independence means for that particular patient. Mary recalls a patient who loved to play basketball before his stroke. The physical therapist had doubts, but he worked with the patient to accommodate his goal of getting back in the game. In the end, staff was able to arrange for the patient to join a wheelchair basketball league.
Incorporating patients’ interests and hobbies in therapy can encourage the patient to take an active role in his or her recovery. Once the rehab team understands the patient, they are in a good position to design a care plan that will work.
The rehab team often has to adjust the plan of care as treatment progresses. Therapists must monitor mental health and determine if efforts to engage the patient are working. If the team is struggling to motivate an individual, the patient’s family can be consulted, says Katie O’Shea, PT, DPT, GCS, MBA and rehabilitation manager at PowerBack Rehabilitation in Vorhees, New Jersey. Delivering meaningful therapy requires thorough and ongoing communication with the patient, family and care team. It is important to involve the entire care team in these discussions. When therapists from each discipline are involved, problem solving is more efficient.
A top-notch plan of care also leverages the latest technology with the personal approach. For example, robotic devices can deliver specific repeated exercises to patients with severe weakness. Repeated noninvasive transcranial magnetic stimulation (nTMS) can deliver low or high stimulation to the brain’s hemispheres to assist with motor recovery and pain alleviation. Experts recommend that rehab teams take advantage of these advancements. “Strong departments have both good equipment and a comprehensive approach,” says Mary.
To learn more about stroke rehab, read the full article from Provider Magazine here.
Lack of sleep may increase the risk for Alzheimer’s disease, according to a recent study featured on Medical News Today. Research from the Johns Hopkins Bloomberg School of Health suggests that lack of sleep or poor sleep quality may be linked to an increased buildup of beta-amyloid plaques — a major indicator of Alzheimer’s — in the brains of older adults.
During the study, researchers analyzed self-reported sleep data from 70 adults with a mean age of 76 who did not currently show signs of dementia. Imaging techniques were used to measure beta-amyloid deposition in the brain. The imaging showed that shorter sleep duration and poor sleep quality were linked to an increase in beta-amyloid buildup. According to the study authors, these results “…are consistent with those from animal research in which sleep deprivation increased interstitial fluid beta-amyloid levels.”
Although more research is needed to determine whether or not better sleep patterns can prevent or slow the progression of Alzheimer’s, the researchers believe that these findings could have significant public health implications. Alzheimer’s is the most common form of dementia, and almost half of older adults with Alzheimer’s report symptoms that are related to insomnia.
According to the study authors, “Because late-life sleep disturbance can be treated, interventions to improve sleep or maintain healthy sleep among older adults may help prevent or slow Alzheimer’s disease to the extent that poor sleep promotes Alzheimer’s onset and progression.”
Many of us focus on losing weight as the New Year begins, but it can be hard to know the best way to reach our goals. Everywhere we turn there is a new, “guaranteed” weight loss program or exercise fad vying for our attention and our dollars. Although there is a lot of solid research available to assist us in identifying a good program, that information is often in the shadows of the highly marketed money-making programs. We typically focus on what looks to be a quick and easy fix.
67% of the US population is currently overweight or obese1. This epidemic has increased the need for research into what works and what doesn’t work to guide people to safe weigh loss strategies. Recent findings support much of what we already know: There are still no quick fixes that are sustainable.
Lifestyle improvements, through cognitive and behaviour change, increasing physical activity and improving dietary intake is fundamental to weight management. To achieve and maintain a healthy weight you must burn off more calories than you consume. That remains the underlying principle. How you do that most effectively is the dilemma.
Here are facts and tips from current research that you should consider year round when selecting your weight loss strategies2,3,4:
Fat: Energy balance is critical to maintaining healthy weight and ensuring optimal nutrient intake, regardless of whether it is a carbohydrate, fat or protein. Eat a balanced diet.
Protein: Protein contains calories, and consuming too much protein can actually make losing weight more difficult — especially if you drink protein shakes in addition to your usual diet. The average adult needs 46 to 56 grams of protein a day, depending on weight and overall health. If we eat a balanced diet, we don’t require additional protein and the calories it brings. We get more than enough from eating a regular balanced diet.
Glycemic index: Glycaemic index and/or glycaemic load are not associated with body weight. Modifying either of these does not lead to greater weight loss or better weight management. Follow physician’s advice related to medical conditions.
Vegetables and fruit: Eating vegetables and fruit is associated with a reduced risk of weight gain. Eating fruit is also associated with a reduced risk of obesity. Do not eliminate fruits and vegetables.
Grains: There is a probable association between eating three to five servings/day of grain (cereal) foods (mainly wholegrain) and a reduced risk of weight gain. Watch out for added sugar and salt in these products.
Nuts: Eating nuts does not cause undue weight gain. Nuts provide important protective effects on our hearts that you won’t get if you don’t eat them. 5 Include nuts, as they are an important part of your balanced diet.
Physical activity (to maintain weight) 4: Updated international recommendations are for a minimum of 45–60 minutes of moderate intensity (usually a 5 or 6 of 0–10 on a scale relative to an individual’s personal capacity) daily physical activity versus the previous recommendation of 30 minutes. This increase is due to the fact that we now, as compared to when the previous guidelines were created, eat higher calorie foods more often and in greater quantities. Just get moving! Start with what you enjoy doing. To help patients identify the best physical activity for their age and condition, RehabCare created our Smart Moves wellness program.
Apps: A recent study compared thirty popular mobile weight loss applications.6 Weight loss apps can be very helpful, but keep these findings in mind when you use them. On average, the apps included just three or four of the twenty strategies used in an evidence-based program—often missing are strategies that help patients with adherence and motivation.The researchers also concluded that “Free apps were just as likely as paid apps to include evidence-based strategies.” You do not necessarily get a better app by paying for it. The two top-rated apps, according to the study, are MyNetDiary PRO ($3.99,) and MyNetDiary (free.)
Summary of guidelines for weight management*2,3
|Overall most effective||Dietary change plus improved physical activity; reducing total calorie intake (variety of means)|
|Somewhat effective||Increasing intake of low calorie foods (especially fruit/vegetables); Reducing intake of sweetened beverages; Limiting number of high calorie snacks; Reduced time spent in sedentary behaviour; Mediterranean-style diet|
|Insufficient or inconsistent||Exercise in the absence of dietary change; Increased incidental or occupational physical activity|
What to do to get started:
- Identify which changes to work on first.
- Start by making small changes and work up to your targets.
- Involve family and friends if appropriate.
- Identify activities and healthy foods that you enjoy.
- Monitor your progress (e.g. keep a food and/or exercise diary).
- Weigh yourself regularly (e.g. each week).
- Reward yourself for meeting each goal (not with food).
- Do not expect to meet all of your lifestyle change targets right away.
By resolving to follow sound dietary and fitness principles continuously, you can safely maintain a healthy weight. Be sure to consult your physician before undertaking and new or revised strategies. Here’s to your health in 2014!
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. World Health Organization. WHO global database on body mass index. http://apps.who.int/bmi/index.jsp.
2. Australian Government’s Department of Health and Ageing . Clinical Practice Guidelines for the Management of Overweight and Obesity in Adults, Adolescents and Children (2013). https://www.nhmrc.gov.au/guidelines/publications/n57
3. CP Guidelines for the Management of Overweight and Obesity Systematic Review. http://www.nhmrc.gov.au/_files_nhmrc/publications/attachments/n57a_obesity_systematic_review_130601.pdf. Accessed on November 30, 2013 at https://www.nhmrc.gov.au/guidelines/publications/n57
4. World Health Organization web site. Global Strategy on Diet, Physical Activity and Health. Accessed on November 30, 2013 at http://www.who.int/dietphysicalactivity/factsheet_adults/en/
5. Ros E. Health Benefits of Nut Consumption. Nutrients. 2010 July; 2(7): 652–682. Published online 2010 June 24. doi: 10.3390/nu2070652
6. Pagoto et Al. Evidence-based strategies in weight-loss mobile apps. American Journal of Preventive Medicine, October 2013. http://www.ajpmonline.org/article/S0749-3797(13)00426-1/abstract
7. Villareal DT, et al. Weight loss, exercise, or both and physical function in obese older adults. N Engl J Med. 2011 Mar 31;364(13):1218-29. doi: 10.1056/NEJMoa1008234.
8. Rejeski WJ, et al. Translating weight loss and physical activity programs into the community to preserve mobility in older, obese adults in poor cardiovascular health. Arch Intern Med. 2011 May 23;171(10):880-6. doi: 10.1001/archinternmed.2010.522.
9. Pagoto S, Schneider K, Jojic M, DeBiasse M, Mann D. Evidence-Based Strategies in Weight-Loss Mobile Apps. Am J Prev Med 2013;45(5):576–582.
10. Federal Trade Commission web site. Consumer information. Weighing the Claims in Diet Ads. Accessed on November 30, 2013 at http://www.consumer.ftc.gov/articles/0061-weighing-claims-diet-ads
11. The Weight-control Information Network (WIN) website. Accessed on November 30, 2013 at http://win.niddk.nih.gov/index.htm
12. Eat for health website. Accessed on November 30, 2013 at http://www.eatforhealth.gov.au/guidelines
The nation’s post-acute care system continues to be highly scrutinized within the context of access, quality outcomes, efficiency and reimbursements. In order to provide context to factors related to the provision of care and rehabilitation across the entire continuum, RehabCare has compiled the following regulatory review to help provide clarity for 2014.
Rehab Therapies in Skilled Nursing Facilities
- CMS SNF Rule for FY 2014: On October 1, 2013, the CMS Medicare final rule for Skilled Nursing Facilities went into effect for the fiscal year. The final rule includes a 1.3 percent Market Basket Increase for SNF Medicare payments as well as several regulatory changes including the reporting of discreet therapy days on the MDS and the requirement to report therapy co-treatment minutes on the MDS. At RehabCare, we have been tracking distinct calendar days for therapy as part of our protocol for a long time and ensuring the needs of our patients are met remains our primary objective. Continued compliance will require close attention to detail in order to ensure that patients remain in the appropriate RUG that accurately best represents their medical and rehabilitative needs rather than changing based solely on an arbitrary day count and a rolling 7-day calendar. Additionally, the SNF rule will require the reporting of co-treatment minutes as a separate item on the MDS.
- MedPAC Proposals: Adding to the pressure, the Medicare Payment Advisory Commission (MedPAC) staff has once again – as they have since 2008 – recommended that the PPS be revised to discourage the provision of “unnecessary rehabilitative therapy services.” In fact, the Commission continues to recommend revising the PPS to “raise payments for medically complex care (and the SNFs that provide it) and lower payments for high-intensity therapy (and the SNFs that provide it).” These staff recommendations will be officially voted on by the Commissioners in January and submitted to Congress in March as their official recommendations on changes to Medicare policy – though it is important to recall that MedPAC has no weight of law, just the ability to submit recommendations to lawmakers.
Medicare Changes for Inpatient Rehabilitation Facilities
On October 1, 2013, the CMS final rule for the IRF prospective payment system went into effect for all exempt-bed acute rehabilitation facility discharges occurring on or after October 1, 2013. Key provisions include:
- Medicare Reimbursement Changes: The final rule contained multiple routine revisions to the current payment system including: revised base rate, updated wage indexes, updated CMG weights, updated CMG lengths of stay, and an updated outlier threshold. Generally, we estimate the overall impact of the rule to be favorable in comparison to the current base rate which went into effect October 1, 2012; however, the impact to specific individual units varies.
- Tweaks to the “60 Percent Criteria:” The CMS rule imposes changes to the way inpatient rehabilitation facilities comply with the 60% Rule – specifically changing the way that a hospital meets “presumptive compliance.” After these changes go into effect on October 1, 2014, it is anticipated that some IRFs may no longer meet the presumptive compliance threshold and therefore will be automatically subject to the medical review methodology which will increase the administrative burden to providers and MACs.
- Quality Reporting: Beginning in October 1014, new elements on the IRF-PAI will allow for risk adjustment of the current pressure ulcer measure and allow for a new measure to track the percent of IRF patients given the seasonal flu vaccine. Two new, non IRF-PAI related quality measures will be added including rehospitalization within 30 days of discharge and percentage of staff receiving the flu vaccine.
The 2014 U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) work plan is scheduled to be published in January of 2014. The OIG is tasked to “protect the integrity of HHS programs and operations and the well being of beneficiaries by detecting and preventing fraud, waste, and abuse; identifying opportunities to improve program economy, efficiency, and effectiveness; and holding accountable those who do not meet program requirements or who violate Federal laws.”
The current work plan continues to focus on timely submissions of the Inpatient Rehabilitation Facility Patient Assessment Instruments (IRF-PAIs) and the examination of the level of therapy being provided in IRFs and the appropriate utilization of concurrent and group therapy in the IRF setting. Additionally, the current work plan will focus on identifying and pursuing questionable billing patterns for Part B covered services – including rehabilitative therapies – during a nursing home stay.
We expect that the 2014 plan will continue to pursue its 2013 work plan and build upon it with its revised 2014 plan. RehabCare will continue to monitor for the revised work plan and provide timely updates.
Additionally, in 2014, we expect to see the increased scrutiny and overall activity seeking improper Medicare payments to post-acute care providers – including activity by RACs, MACs and ZPICs.
With 2014 already set to continue a trend of increased regulatory activity regarding the provision of rehabilitative care in a whole host of settings, it is also speculated that as Congress addresses a permanent “Doc Fix” and the potential for comprehensive post-acute care payment and delivery reform, they will touch on issues of critical importance to our service line. RehabCare will continue to closely monitor and report any and all legislative activity as it relates to the provision of medically necessary therapy care.
We don’t want to dampen your holiday spirit, but we at RehabCare do want you to be safe this holiday season. The holidays are notorious for coronary trouble, and it is critical to be vigilant about heart health and self-care in December. According to the American Red Cross, the likeliest time of the year for heart attacks to occur is the holidays. A 2004 study in the journal Circulation even found that there are more heart attacks on December 25 than any other day of the year.
Why can the season of merrymaking be dangerous? Experts offer several reasons for the increased risk as well as strategies to minimize the hazards:
- Travel: Patients cannot let travel disrupt medicine schedules, cautions Dr. Sharonne N. Hayes from the Cardiovascular Diseases department at the Mayo Clinic. Be sure to stay on track with your medications if you spend the holidays away from home. Set up reminders or enlist others to help you remember.
- Emotional stress: Financial expenses and time spent with family can contribute to increased stress. Keep seasonal stress in check. Know when to give yourself a break, and keep expectations reasonable.
- Postponement of medical treatment: There is a tendency to delay treatment at this time of year. “People just tend to put off seeking medical help during the holidays. They tend to wait till afterwards, which I think is a mistake,” says Dr. Robert Kloner of the Good Samaritan Hospital in Los Angeles. If you experience symptoms during a gathering, seek help and do not worry about disrupting an event, advises Dr. Hayes of the Mayo Clinic.
- Inclement weather: Frigid temperatures may pose dangers to your heart. “Breathing cold air can constrict the blood vessels and therefore increase the pressure, causing clots to form,” says the American Red Cross. Avoid extreme cold temperatures and dress warmly. Be smart about shoveling snow, which can cause undue strain on the heart. For those who live in snow-prone areas, Chicago-based Advocate Health Care created this video about snow shoveling safety.
- Overindulgence: Excessive caloric intake can lead to greater stress on your heart. Enjoy the specialties of the season, but eat normal portion sizes and watch alcohol consumption. It is especially important for individuals with heart failure to be mindful of sodium intake. Ask the cook about salt content if you dine out or eat in someone else’s home. Avoid sauces and gravies. Finally, don’t ditch your exercise routine.
RehabCare wishes everyone a safe and happy holiday season!
- Katherine Kam: The Truth Behind More Holiday Heart Attacks. WebMD. September 28, 2011. Accessed from http://www.webmd.com/heart/features/the-truth-behind-more-holiday-heart-attacks on December 17, 2013.
- The Mayo Clinic Medical Edge Newspaper Column. “Self-care Steps Can Keep Your Heart Healthy During the Holidays.” Accessed from http://www.mayoclinic.org/medical-edge-newspaper-2012/nov-30b.html on December 17, 2013.
A group of therapists at Timberlake Care Center in Kansas City, MO who are originally from the Philippines organized a fun run on November 17 to raise money for victims of typhoon Haiyan.
It began as a small Facebook event but grew into an event attended by dozens. The run at Loose Park was covered by two TV crews. Fox 4 News interviewed OTR Mary Elizon, who said, “A lot of us from the Philippines do feel their pain, we’re miles and miles away but we want them to know that we do hear them.”
The group of therapists raised $1,895 by the end of the event, and our parent company Kindred Healthcare will make a matching contribution.
Watch the story from Fox 4 News here.
Medicare recently proposed expanding coverage of cardiac rehabilitation services for cardiac patients, reports MedPage Today. Prior to the proposal, announced online last week, CMS claimed there was insufficient evidence to support cardiac rehab to patients with chronic heart failure (CHF). Medicare currently only covers such services for patients who have experienced major events like coronary bypass surgery, heart or heart-lung transplant, or an acute myocardial infarction.
CMS is now asking for public comments on increasing coverage to a wider range of heart patients. After reviewing existing literature on cardiac rehab service, the agency stated, “With the accumulated evidence that supports the benefits of the individual components of cardiac rehabilitation programs, the evidence is sufficient to determine that participation in these multi-component programs improves health outcomes for Medicare beneficiaries with chronic heart failure.”
The proposal includes Medicare coverage for cardiac rehab services including exercise, personal counseling, health education, and behavioral risk factor reduction.
The American Heart Association commended CMS for the move. Dr. Ileana Pina, vice chair of the clinical cardiology council at the AHA, said, “Even though we know all the good things exercise can do, a lot of physicians were not recommending it because the patients would have to pay out of pocket for a cardiac rehab program.”
To read the official proposal, visit CMS.gov here.