We will be holding more clinical instructor trainings in 2013, so make sure you check with your therapy resource for dates and locations.

The University of North Texas Science Center (UNT HSC) provided a state-of-the-art venue for the course. Deb Ellis and Jon Anderson organized the event.  They were able to offer registration to several professors and allowed 4 students to monitor the course. The course was offered to therapists from Keystone North and South Facilities as well as therapists from the surrounding communities, and with the proceeds, we were able to award UNT HSC Student Organization a check for $2000.

Nerida Gerona is the Director of Rehabilitation in Lemon Grove, CA, and her partnership with local universities for ongoing student internships is legendary in Southern California. In the past 12 months, the Lemon Grove center has taken 15 students from six different schools, with two new schools being added in the early summer. What makes her student programs stand apart is how the Lemon Grove team embraces our Core Values and incorporates them into their students’ experience. The students truly become part of the team and have the experience of being part of a dynamic interdisciplinary rehab program. The team celebrates their successes and ensures that each student gets the opportunity to work with a variety of different diagnoses and disciplines. Because of the extraordinary feedback that the students have about their experience at Lemon Grove, Nerida was one of the clinical educators who were asked to be a part of the certification process for a new Physical Therapy Program at San Diego State University. In addition, four of the therapists at Lemon Grove are now certified instructors. Way to go, Team Lemon Grove!

Cynthia poured her heart into her therapy program, and incredibly enough, she walked out of the facility with a FWW and a huge smile of victory on her face! The entire staff was so moved by her inspirational story that they wanted to capture and highlight it in the facility to motivate others during those often difficult hours of therapy. Bobbi Ridge, DOR at Plymouth Towers, and her therapy team put their heads together, and the Journey to Wellness Wall was born. The team hopes to one day cover the entire wall with photos and stories of patients with the drive and determination to overcome limitations and accomplish the unexpected.

Understanding the Rationale for a Balance and Falls Program

• Approximately 30 percent of community living adults fall at least once a year
• Ten to 20 percent of these community living adults have two or more falls a year
• Falls are the most common mechanism for injury in older adults
• 10 percent of those who fall will sustain a serious injury
• Approximately 300,000 hip fractures occur annually in the United States
• 25 percent of these hip fracture patients will die within one year
• Somewhere between $25 trillion to $80 trillion are spent on healthcare related to falls

Emotional impact of falls

• Falls tend to lead to fear, leading to inactivity, leading to loss of confidence, leading to decreased quality of life for patients
• It is a spiraling downward path to decreased independence and mobility
• Initial reactions to falls may be to protect, limit mobility and provide restraints — strategies that may decrease the risk of a fall in the short term but ultimately lead to declined mobility and increased risk of falls
• Forty percent of all nursing home admits are related to a fall. Falls are a major reason for moving up/down the continuum of care provided by hospitals, assisted living facilities, SNF, home health and hospice.

Home health has the ability to make one of the greatest impacts on fall reduction. Being in the patient’s home environment gives us the unique opportunity to identify specific problems, deficits and needs and tailor our approach to treatment to address those needs. Nursing has the ability to identify medical conditions, monitor effectiveness of medications, evaluate/assess vital signs, instruct when there are knowledge deficits and act as a liaison between healthcare provider and patient. Physical, occupational and speech therapists are able to address biological factors that increase the risk for falls, i.e., muscle weakness; gait and balance deficits; visual, vestibular and somatosensory deficits; and cognitive deficits. Physical and occupational therapists can also address environmental risks for falls through home assessment — identifying barriers in the home that might contribute to falls; i.e., clutter, unclear pathways, narrow doorways, throw rugs, insufficient lighting, the need for adaptive equipment, etc. They also provide instruction and training for caregivers and patients as needed to minimize the risk of falls or injury to patients.

How Stepping Stones Improves Quality of Treatment and Outcomes

Quality treatment begins with comprehensive assessment: strength, ROM, posture balance, coordination, cognition and motivation. Traditionally, therapists have been effective at assessing strength, ROM, posture and mobility. A better understanding of balance and the systems that affect it will lead to more targeted treatment plans and strategies to address deficits. Balance assessment should include assessment of sensory input from the visual, vestibular and somatosensory systems as well as strength ROM and posture.

• Visual system: the primary system for balance. Therapist will assess for conditions affecting visual acuity, contrast sensitivity, depth perception and visual field deficits.
• Somatosensory system: the ability to feel surfaces below the feet and react appropriately to maintain balance. Therapist will assess for history of peripheral neuropathy and check sensation for light touch and pressure.
• Vestibular system: provides information to central nervous system about movement of head or body, sense of rotation and acceleration. Allows us to stabilize our vision during head and body movement. Therapist will assess for peripheral and central deficits in this system which might cause dizziness, disequilibrium, sensitivity to motion, inability to focus eyes during head movement and benign paroxysmal position vertigo that is the most common cause of vertigo.
• Therapists will also assess patient’s ability to integrate these systems to perform specific balance tasks. An assessment of the central nervous system will be done through oculomotor testing, cerebellar testing and test to determine patient’s ability to multitask.

By identifying the strengths and weaknesses of each of these systems, we can develop a tailored plan of treatment that addresses the specific deficits for each patient. Specific balance, sensory integration and oculomotor tests will be performed at the beginning of treatment to establish baseline, at mid-treatment and at the end of treatment to determine the effectiveness of the treatment plan and determine outcomes.

Our experience has shown that The Stepping Stones program has the potential to improve outcomes, decrease risk of falls in the future, decrease hospitalizations due to falls, save Medicare dollars, maximize patient independence and improve quality of life for our patients in a significant way.

This claims-based data collection system is being implemented to include both 1) the reporting of data by the SNF and the therapists furnishing the therapy services, and 2) the collection of data by the Medicare Administrative Contractors (MACs). This reporting and collection system requires claims for therapy services to include non-payable G-Codes and related modifiers. The non-payable G-Codes and severity/complexity modifiers will provide information about the patient’s functional status at:

• The outset of the therapy episode of care,
• Specified points during treatment (i.e., at least once every 10 treatment days), and
• The time of discharge.

These G-codes and related modifiers are required on all Part B claims provided to residents in our SNF and/or to patients visiting our outpatient treatment centers, regardless of their Part B cap or threshold status.

The functional data reporting and collection system is effective for therapy services with dates of service on or after January 1, 2013. The testing period is in effect until June 30, 2013, to allow us to use the new coding requirements with our Rehab Optima (RO) and Point Click Care (PCC) systems in order to assure that they work. During this testing period, the MACs will continue to process Part B claims without the G-Codes and modifiers. However, claims with therapy services on and after July 1, 2013, will be rejected if they do not contain the required functional G-Code/modifier information.

There are a total of 42 different G-Codes broken down into the following 14 subsections, each including status codes for current status, goal status and discontinuation status:

1. Mobility
2. Changing and Maintaining Body Position
3. Carrying, Moving and Handling Objects
4. Self Care
5. Other PT/OT Primary
6. Other PT/OT Subsequent
7. Swallowing
8. Motor Speech
9. Spoken Language Comprehension
10. Spoken Language Expressive
11. Attention
12. Memory
13. Voice
14. Other Speech-Language Pathology

The Severity/Complexity Modifiers reflect the patient’s percentage of functional impairment as determined by the therapist, physician or non-physician practitioner (NPP) furnishing the therapy services. The patient’s current status, anticipated goal status and the discharge status are reported using the appropriate severity modifiers. The seven modifiers are defined below:

The functional G-Codes and corresponding severity modifiers listed above must be used on the therapy claims beginning July 1, 2013. Only one functional limitation shall be reported at a given time for each related therapy plan of care (POC). However, functional reporting is required on claims throughout the entire episode of care. This means there will be instances where two or more functional limitations will be reported for one patient’s POC, just not during the same time frame. In these situations, where reporting on the first functional limitation is complete and the need for treatment continues, reporting will be required for a second functional limitation using another set of G-Codes. So, the claim may demonstrate a status on more than one functional limitation for a single POC, but the claims would not be used simultaneously.

Rehab Optima has integrated this new functional reporting system into the case manager console, which makes the system very accessible to therapists. In addition, hotlist monitoring has also been added to help with the day-to-day management of the functional G-Code reporting process. Your therapy resource team is testing the new tools and the integration with PCC. We have recorded our Webex trainings from March 26, 2013, so ask your therapy resource if you did not receive the link. The trainings will also be added to our Learning Management System (Brainshark) for those that were unable to attend the Webex. The availability of the functional G-code reporting system is set to go live in Rehab Optima for our facilities beginning April 1, 2013. This will allow our therapists sufficient time to practice using the functional G-codes prior to the July 1, 2013, required date.

If you are interested in reading further about the Functional Reporting System, be sure to check out Medicare Learning Network Matters Number MM8005 on the www.cms.gov website or contact your therapy resource.

Nursing homes were one of the first settings to graciously open their doors to the concept of pet therapy, which was developed by Therapy Dogs International (TDI) more than 30 years ago. Today, therapy dogs and cats are registered from all types of breeds, and many are rescue animals. In 2012, there were roughly 25,000 therapy dogs registered. All therapy dogs and handlers are volunteers and are located in all 50 states. The typical therapy dog is at least 1 year of age, and each dog must pass a temperament evaluation and demonstrate appropriate behavior around people with the use of some type of service equipment (e.g., wheelchairs or crutches) in order to become a therapy dog.

It is profoundly moving to see how dogs and cats have the ability to help calm and soothe agitated individuals while lifting the spirits of those who are sad and lonely. They provide a medium for physical touch and display unconditional affection for those who may live isolated lives. Therapy pets elicit responses from some nursing home patients who are typically withdrawn and limited in their abilities. Stroking the back of a dog leads to more movement from the patient and, consequently, increased physical activity. The introduction of dogs and cats increases interaction among individuals and promotes a positive change in self-esteem.

Over the last several decades, multiple studies have measured aspects of human interactions with pets (Katcher, Friedman, Goodman & Goodman, 1998; Millot & Filatre, 1986; Stallones, Marx, & Johnson 1990) and demonstrated validity and reliability. Evidence suggests that pets may enhance self-esteem in patients/people and may assist them in socializing with one another (Zimmer, 1996). Several studies report positive social behavior changes after introducing an animal into the nursing home environment or hospital. The Australian Joint Advisory Committee on Pets in Society conducted a six-month study of the interaction of 60 nursing home residents with a dog. Using pre- and post-test questionnaires, they found positive behavior changes in interest and conversation and an increase in participation in activities of daily living (Salmon, Hogarth-Scott & Lavelle, 1982).

Studies show that pets can aid in relaxation, lower one’s blood pressure, promote healing and prolong life. With the addition of a well-trained handler/health-care worker, the mere presence of a dog may facilitate therapeutic intervention with the non-communicative patient, assist in recall of memories and help sequence temporal events in patients with head injuries or chronic degenerative diseases of the brain such as Alzheimer’s disease, as well as teach appropriate behavior patterns to those with emotional disabilities (Brickel, 1991). According to the National Institutes of Health, among older people, the ownership of pets does not help the general illness status but does act in combating depression. Pet therapy has had a more positive response in nursing homes in comparison to arts and crafts or visitors coming in for the day. Indeed, visits with therapy pets encourage reminiscence and social interaction and result in stress relief and incidental physiotherapy (Island, 1996).

Furthermore, Lynch, Thomas and Weir (1993) examined marked physiological responses in patients who had a dog to pet. The heart rate of a patient with dementia decreased by five beats per minute when he was introduced to a dog and was allowed to pet him. Even managed care organizations are studying the idea of price breaks for pet owners. In a prospective yearlong study of 938 Medicare Advantage enrollees, beneficial effects of pet ownership on the general health of senior citizens were suggested (Siegel, 1990). Improvements in the quality of life in nursing homes have been suggested by a survey of the effectiveness of a pet therapy program with monthly visits to nursing homes in Florida. Commonly reported effects of the visits included shared experiences among residents and greater socialization among residents, and it gave them something to anticipate. A pet therapy program appeared to improve the quality of life for some residents (Yates, 1987).

The scientific evidence is plentiful that pet therapy is a great adjunct to improve the quality of life of older adults. It may not be possible to have a therapy dog or cat that lives at every facility, but it might be possible to have a therapy dog visit your facility periodically. Luckily, Therapy Dogs International (TDI) has 25,000 U.S. dog/handler teams whose purpose is to provide comfort and fulfill this need of therapy pets for each facility. A visit by a therapy dog/handler is absolutely free, and TDI will work with an individual facility to identify the best days and times for visits. TDI also provides liability and accident insurance to its volunteer teams. The teams have been carefully tested by qualified evaluators to ensure the well-being of those being visited, and all dog records are reviewed continuously and updated as recommended by the American Animal Hospital Association.

To request a TDI dog/handler team visit, send a request on facility letterhead with information about the facility and the type of visits you are seeking. Include a contact name and number. Fax to (973) 252-7171. Therapy Dogs International , 88 Bartley Road, Flanders, NJ 07836, Phone: (973) 252-9800, Email: tdi@gti.net, website: www.tdi-dog.org

By Jon Anderson, PT, Keystone Therapy Resource