Month: September 2018

The land swelled below the wing of the plane in gentle shades of green and brown, revealing ample squares defining crops, and the perimeter of a small community where various creeks meander through town before combining to become the Walla Walla River, which drains into the Columbia River about 30 miles west of town. Park Manor Rehabilitation Center is nestled in the farmlands of eastern Washington.

One sweltering hot morning, Sonya, DOR and Zewdi, DON and the IDT team calmly evacuated over two dozen residents to the dining area to preempt any issues with dehydration in a seamless flow of activity. The team identified that the temperature in one wing was too high for the medical well-being of their residents and made the decision as a group during the morning Standup Meeting. Within minutes, people self-organized to provide a pleasant alternative to the overheated area of the building for the patients in the affected wing. Soon the residents were seated comfortably in the dining room, offered beverages and provided with activities to engage them for the morning. Being a part of this particular morning left me with a powerful experience of Ownership, a core value for us at Ensign.

In practice, ownership takes many forms, reflecting the composition of the people who form those teams. As I reflected on why this team seemed so special, I realized that while their location set them apart in very practical terms, the quality of their interactions were definitively harmonious, often uplifting and consistently grounded in sound clinical and operational practice. These lovely people had figured out how to keep the fire lit and love one another through the usual travails of long-term care. I was struck by the balance of utter focus and levity during the morning meetings. This created the critical element of mutual understanding for each patient’s current medical and functional status for a better quality of patient care.

I was particularly struck by the level of individualized attention to ensure that each patient was situated well and individual or family needs were considered. The objective aspects of patient care were navigated skillfully while the personal needs of each patient were also thoroughly respected.

Over the course of a few days, there were many opportunities to get to know this team, and I found myself pondering how to describe what I was experiencing. There were eight factors that seemed to play a part in this team’s capacity to work so well together.

• Relationships — These folks had healthy working relationships. They worked out their differences, held each other accountable and genuinely enjoyed working together. They even went to the movies together after work.

• Finances — While any facility has opportunities for improvement, and the external market factors play a role in that, the basic metrics were in place and well- Census was above average and key metrics were in good shape.

• Calm — There was a quality of calm. While the challenges were quite real, with case mix index, productivity and/or admissions, overall, this was not an anxious group. If tension arose in an interaction, there was a tendency to deal with it directly or let it go altogether. Trust played a huge role in this.

• Creativity — On more than one occasion, I heard the IDT team generate multiple solutions to various patient issues, and then choose one, together, to solve it. This was most notable when a vociferous member of the residential community requested space that was scarcely available, yet a solution was provided that worked for everyone involved.

• Health — If we’re looking at the collective level of function of a team or teams, the overall health of the Interdisciplinary team partners and the therapy department partners was remarkable. While any one of these folks would admit that their work could be challenging, on the whole, they knew that they had each other’s backs and found ways to express that easily and frequently, often in simple ways. For example, they’d share food to create a group lunch, or bring tea or coffee for all to enjoy; express words of appreciation and silent exchanges of support; clean a certain mug for a friend; or draw a picture for each other when documentation was completed.

• Intelligence — In and of itself, the sheer experience of simplicity was part of the intelligence of the way that ownership was enacted within Park Manor. I felt as if the common courtesy and willingness that these partners extended for their work and for each other possessed a quality of coherence that was palpable and easily observed in patient/therapist interactions.

• Flow — The innate intelligence of the team could be seen in the way they addressed the temperature in the south wing being too high on the morning that I visited the building. There was calm but decisive decision-making happening with a seamless flow of activity and an unflustered interdisciplinary team swiftly evacuating two dozen residents to a cooler area. That’s flow.

• Generosity — The consistency of the integrity, accountability and genuinely generous performance that these leaders modeled, coupled with their mutual respect for each other as functional counterparts created a very visible absence. There was no silo. Each leader understood and acted as though they comprised the whole well-being of the facility. They fully supported each other within the scope of their roles, and they took every action possible to ensure continual success to whatever degree they could actuate, one day at a time.

This generosity was the spirit of ownership. It was so seamlessly implicit in the functional performance of this team that I almost missed it. The word “ownership” in our secular culture has come to mean possession, yet here, the opposite is true. When we consciously choose to open up and own more, to bring awareness and act as if our collective results are actually our own, new possibilities open up. New perspective. New hope.

By Willow Dea, Leadership Development

By Lori O’Hara, MA, CCC-SLP – Therapy Resource, ADR/Appeals/Clinical Review

CMS doesn’t define a lot of requirements for what needs to be in a daily note, understanding that it’s what happens during the session that drives the content. But one of the places where they do define a requirement is on the day of the evaluation. Because evaluation minutes don’t count towards the calculation of a RUG score, but treatment minutes do count, they want to be able to see easily that those things were different when they occur on the same day. That means a narrative entry is always required when treatment occurs on the day of the evaluation.

What needs to be in the note? Content that describes how activity billed to the treatment codes was clearly not activity that should have been billed to the evaluation code. So the content in the therapy CPT boxes should describe skilled activity associated with the specific treatment code being billed.

Content that is providing detail on the evaluation findings, interpreting scores or risks associated with testing performance with the patient or family, or describing goal setting is evaluation related. So this cannot be billed towards a therapy code and should not be documented in therapy CPT boxes.

Education about the patient’s conditions or limitations, trialing devices or attempting environmental adaptations, and specific therapeutic interventions are treatment related and should be billed to and recorded as their corresponding CPT codes. Content should be detailed enough that it’s evident to anyone reading that those activities were clearly distinct from the evaluation activity.

Reviewers are starting to look for this – managed care organizations too! So, protect your minutes on your evaluation day content that is just as amazing as the services you provide.