Dr. Kristine Yaffe, a professor at the University of California, San Francisco, and her colleagues followed more than 2,500 individuals between the ages of 70 and 79 over an 11 year period. At baseline, none of the participants had dementia, but 15 percent had anemia. Participants were cognitively assessed in the course of the study, and researchers found a correlation between anemia and the development of dementia.
“During the investigation period, 18 percent of all study participants developed dementia. Those who had anemia at the start of the study had a 41 percent higher risk of developing dementia than those who were not anemic,” said Lois Bowers of Long-Term Living Magazine.
Dr. Yaffe points to low oxygen levels in anemic patients as a possible reason for compromised brain health.
The researchers say that further investigation is warranted in this area and that anemia may one day be treated as a means of improving cognition.
The same day CMS issued the final IRF rule, they issued the SNF Medicare Prospective Payment System update for the fiscal year 2014. In large part the final rule was in line with our expectations and close to the proposed rule issued earlier this year. The final rule includes a 1.3 percent Market Basket Increase for SNF Medicare payments beginning October 1 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.
Regrettably, CMS ignored much of the stakeholder comments and will require new reporting through item O0420 to the MDS 3.0 to capture distinct therapy days provided by all the rehabilitation disciplines to a beneficiary over the seven-day look-back period. CMS asserts that there was no change in policy, rather this is merely adding an item to the MDS to enable the agency to implement and track existing policy.
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.
The SNF final rule also includes the requirement to report co-treatment minutes provided by therapy.
Co-treatment minutes are currently captured and reported on the MDS but not as a separate item. Co-treatment is a technique where two therapists from two different disciplines both treat the patient at the same time.
RehabCare currently records this treatment as part of documentation in the medical record. Reporting of this as a new item on the MDS is expected to be managed through our software vendors. CMS is expected to release specifications in the MDS 3.0 RAI manual.
We are working with our technology and software partners to ensure that we have the best tools and programs in place prior to October 1, 2013 to enable our therapists and customers to easily and appropriately implement the new requirements.
On July 31, 2013, the Centers for Medicare and Medicaid Services (CMS) issued the final 2014 Medicare payment and regulatory update for Inpatient Rehabilitation Facilities, which includes a 2.3 percent increase in Medicare payments effective on October 1, 2013. The final rule also included several updates including changes to the list of diagnosis codes that are used to determine presumptive compliance with the “60 Percent Rule,” changes to the IRF Patient Assessment Instrument (IRF-PAI), and revised quality measures and reporting requirements.
We were pleased that in preparing the final rule, CMS took into consideration some of the formal comments that RehabCare and other stakeholders provided. While we had specifically advocated CMS withdraw the proposed changes to the presumptive compliance criteria methodology, we also commented that if CMS decides to move forward with the changes, it should allow providers adequate time for implementation, establish modifiers for arthritis, appropriately target record review, and preserve certain codes. In an improvement over the proposed rule, and consistent with RehabCare’s comments, CMS has removed fewer codes than originally proposed from those that may count toward presumptive compliance of the 60% Rule threshold. Additionally, this portion of the update will not take effect until October 1, 2014, which gives providers time to prepare.
The changes to the IRF-PAI and to the IRF quality reporting program are also delayed by a year, effective as of October 1, 2014.
A recent study conducted by American and German scientists found that vitamin D deficiency not only inhibits the formation of new bone but also accelerates aging of existing bone, according to an article in Medical News Today. The study appears in the journal Science Translational Medicine.
Robert Ritchie, leader of the American team from the University of California, Berkeley, said, “The assumption has been that the main problem with vitamin D deficiency is reduced mineralization for the creation of new bone mass, but we’ve shown that low levels of vitamin D also induce premature aging of existing bone.”
Vitamin D helps the body absorb calcium. When a person becomes vitamin D deficient, his or her body takes calcium from the bone to replenish blood calcium levels, which can lead to rickets (in children), osteomalacia, or osteoporosis. According to Björn Busse, leader of the German team and a scientist at the University Medical Center in Hamburg, “Unraveling the complexity of human bone structure may provide some insight into more effective ways to prevent or treat fractures in patients with vitamin D deficiency.”
The study highlights the importance of continually monitoring and maintaining vitamin D levels in patients who are at risk for vitamin D deficiency. The article suggests that vitamin D deficiency is a growing problem in the United States.
It is not too late to start adding vitamin D to your daily regimen. Patients 65 and older stand to benefit from everyday vitamin D supplementation. In 2012, the U.S. Preventive Services Task Force suggested that supplemental vitamin D combined with exercise can reduce the risk of falls in individuals who are at an increased risk. To reap the benefits, it is crucial that patients take a high enough dose as determined by a physician. The American Geriatrics Society recommends that patients with proven vitamin D deficiency take at least 800 IUs a day.
- BMJ-British Medical Journal (2009, October 3). Over 65s Should Take High Dose Vitamin D To Prevent Falls, Say Researchers. Accessed on July 31, 2013 from ScienceDaily.
- Virginia A. Moyer, on behalf of the U.S. Preventive Services Task Force*; Prevention of Falls in Community-Dwelling Older Adults: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine. 2012 Aug;157(3):197-204.
- The American Geriatrics Society. 2010 AGS/BGS Clinical Practice Guideline: Prevention of Falls in Older Persons. American Geriatrics Society. Accessed on July 31, 2013 from http://www.americangeriatrics.org/files/documents/health_care_pros/Falls.Summary.Guide.pdf.
Physical activity has been shown to minimize the losses in physical and mental resources that accompany aging. But if the goal is to increase physical strength and conditioning while improving cognition and spatial memory, aerobic exercise is ideal. Recent research from Medical News Today builds on previous studies and shows that aerobic exercise in particular may be a best choice of intervention for patients with mild cognitive impairment.
To boost cognitive performance, elderly patients should focus on aerobic exercise and weight training over toning or balance training. Research demonstrates that aerobic exercise:
- Shows a significant correlation between spatial memory performance and overall physical capacity;
- Greatly increases the number of new neurons that are produced in the area of the brain that influences mental functioning whereas mental training (via skill learning) increases the numbers of neurons that survive, particularly when the training goals are challenging;
- Benefits cognitive performance, brain function and brain structure in elderly adults;
- In late life preferentially benefits executive functions, including multi-tasking, planning and inhibition; and
- Improves the aging brain’s ability to effectively engage task-relevant resources, particularly under cognitively challenging conditions.
For addressing therapy goals related to memory, cognition and physical functioning, especially if treatment time or resident/patient cooperation or ability is limited, focusing on aerobic interventions may be the most effective and efficient use of the treatment session.
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. Curlik DM 2nd, Shors TJ. (2013). Training your brain: Do mental and physical (MAP) training enhance cognition through the process of neurogenesis in the hippocampus? Cognitive Enhancers: molecules, mechanisms and minds 22nd Neuropharmacology Conference: Cognitive Enhancers. Neuropharmacology,64, 506–514. http://dx.doi.org/10.1016/j.neuropharm.2012.07.027
2. Lindsay S. Nagamatsu, et al. (2013) Physical Activity Improves Verbal and Spatial Memory in Older Adults with Probable Mild Cognitive Impairment: A 6-Month Randomized Controlled Trial. J Aging Res, doi: 10.1155/2013/861893.
3. Schaefer S, Schumacher V. (2011). The interplay between cognitive and motor functioning in healthy older adults: findings from dual-task studies and suggestions for intervention. Gerontology, 57(3):239-46. http://www.ncbi.nlm.nih.gov/pubmed/20980735.
Since the requirement to include G-codes and severity/complexity modifiers to indicate a patient’s functional status on all therapy claims began on July 1, 2013, there has been confusion among providers. In a recent McKnight’s Long Term Care News column, Shelly Mesure, MS, OTR/L, addressed the three most common areas of confusion for providers.
First off, it is important for therapists to recognize that the cognition/memory code of G9168 – G9170 is only to be used for speech therapy – and does not apply to either physical or occupational therapies as it was not included in the PT/OT code list.
In addressing the confusion over whether physical and occupational therapists can use the same G-codes at the same time, Shelly indicated that it is okay to do so as they related to each discipline’s goals, but recommended that the therapist clearly indicate the difference in the scope of practice so as to avoid an appearance of duplication of services.
The last issue of whether assistants can complete the G-codes is still a bit unclear. While a therapist must determine the G-code and appropriate modifiers, it is noted that the therapy assistant may be able to document the updates in accordance with the schedule set forth in the regulation. However, as is stated in the column, as with most significant changes to reporting regulations, there are many areas that still need to be addressed and “ironed out.”
At RehabCare, we are continuing to work to establish best practices regarding the inclusion of G-codes, and we will continue to partner with other national stakeholders to develop industry standards.
Although the majority of RehabCare’s patients are adults, RehabCare has experience and can offer pediatric rehabilitation at any of our facilities. One of RehabCare’s sites, Therapy Connections for Kids, has been providing pediatric rehabilitation for 19 years. Located in Coon Rapids, Minnesota, Therapy Connections for Kids offers occupational therapy, physical therapy and speech-language pathology services for children. Beth Sorenson, program assistant at Therapy Connections for Kids, described developmental complications that are unique to children and how pediatric therapy is different from adult rehabilitation.
The disorders pediatric therapists come across range in severity, and the staff at Therapy Connections for Kids is trained to treat children for a wide range of behavioral and physical conditions. Therapy Connections for Kids most commonly sees children for autism, Asperger’s, ADD/ADHD, articulation disorder, oppositional defiant disorder, developmental delay, anxiety, obsessive compulsive disorder, fine and gross motor delay and sensory processing disorder. Since opening its doors in 1994, Therapy Connections for Kids has also treated kids with Angelman Syndrome, Cornelia de Lange Syndrome, Wiedemann-Rautenstrauch (WR) Syndrome, Down Syndrome and brain injury.
Therapy Connections for Kids often sees children whose motor, language and/or emotional skills are not developing at a regular pace, a condition known as developmental delay. Developmental delays such as autism spectrum disorders may present themselves within months or several years after a child is born and are considered lifelong conditions. “We generally see that all activities of daily living are affected,” said speech-language pathologist Amy Bergsbaken. Therapists develop individualized treatment plans that may consist of neurodevelopmental treatment, oral motor facilitation, functional communication skills, self-care skills and behavioral management.
Along with treating developmental delays, people are often surprised to learn that pediatric therapists can help kids with feeding disorders. Occupational therapists and speech-language pathologists at Therapy Connections for Kids collaborate to treat children with food aversions. Therapists approach feeding disorders from a sensory side and introduce new foods by associating them with the colors, shapes and textures the child prefers. They also motivate kids to face their food fears by engaging them in messy play and other tactile activities.
Uncovering what motivates a patient is a common denominator of therapy regardless of the patient’s age, but inspiring children to cooperate and want to succeed requires special understanding. (Imagine a child who refuses fruits and vegetables, for instance.) Therapy sessions must be fun and comfortable. Therapy Connections for Kids has a sensory gym with a trampoline, ball pit, water table, scooterboards and swings, and offering gym time is usually enough to motivate “even the toughest kiddo,” said Sorenson. Therapists incorporate games and activities into treatment to make children feel at ease. “We go to great lengths to make each child feel comfortable and supported,” said Sorenson. To calm possible anxiety, parents are invited into therapy sessions.
In pediatric therapy, parents play an instrumental role from start to finish. Compared to patients in a skilled nursing facility or inpatient rehabilitation facility, children who visit Therapy Connections for Kids are not in-house, and parents must commute with their kids often more than once a week for as long as therapy is needed. “Without parents’ support and belief in what we do, we would not be here,” said Sorenson. “We commend our parents for their dedication to their children.”
Therapy ends with “graduation” from the program once a child achieves his or her goals, scores within 1.5 standard deviations below the mean on standardized assessment or stops making progress. Therapy Connections for Kids implements home programming and caregiver training to ensure that graduates continue to benefit from therapy long after they leave.
Thank you to Megan Appelwick, OTR/L; Amy Bergsbaken, MA, CCC-SLP; Stacy Leidholt, MA, CCC-SLP; Alicia Marten, OTR/L; Beth Sorenson, program assistant and Mary Jo Theis, COTA for contributing to this article.