powerpoint presentation · §409.44(c)(2)(f)(1,2): a clinically supportable statement why there is...

Not to be copied without permission of KL Miller 1

9/27/2014

Kenneth L Miller, PT, DPT, CEEAA

September 27, 2014

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• Kenneth L Miller, PT, DPT, CEEAA serves as the Chair of the Practice Committee of the Home Health Section of the APTA and as a clinical educator for Catholic Home Care, where he provides staff development, leads the orientation and competency programs, coordinates continuing education and training promoting evidenced-based practice.

• Dr. Miller has published numerous articles in the “The Quarterly Report” publication of the Home Health Section and “GeriNotes” publication of the Section on Geriatrics on evidenced-based practice relating to bone health, heart failure, cancer, balance, dizziness and vestibular rehabilitation.

• He is a member of the Editorial Board of GeriNotes and a manuscript reviewer for JGPT.

Upon completion of this course: 1. The participant will be able to select and administer objective tests appropriate for use with the community-dwelling elderly population in the home health and outpatient physical therapy settings 2. The participant will be able to incorporate the ICF into patient assessment to identify and categorize impairments and justify care provision 3. The participant will have increased competence in the administration and interpretation of standardized objective tests 4. The participant will be able to effectively incorporate the results in goal formation and creation of the plan of care

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Welcome – Background, Pre-Test Regulations ICF

Selecting appropriate objective tests

Hands-On Lab Learn/Practice instruments

Documentation – effective care planning

Knowledge Integration - patient scenarios, documentation & goal writing. Documenting medical need and care provision justification

Conclusion - Q&A; Post-Test; Course evaluation

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True/False. The International Classification of Function, Disability and Health (ICF) is a classification system based on the medical model of disease

True/False. Balance confidence is a metric that is predictive of fall risk

True/False. Home Health and Outpatient therapy settings require objective testing

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Patient Protection and Affordable Care Act (aka ACA) ◦ Signed into law March 2010

◦ Value-Based Purchasing System

◦ Shift from volume-based to value based health care delivery model

Started in Hospitals now moving to Home Health

Scrutiny of Health Care Industry is ramping up ◦ Fraud, Waste and Abuse

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April 26, 2010, WSJ article, “Home Care Yields Medicare Bounty” accelerates ever increasing scrutiny in healthcare, particularly in Home Health

“Gaming” the system – 2011 U.S. Senate Report.

Nationwide therapy usage pattern shifts based on payment tiers

10 visit threshold to 6, 14, 20 visit threshold

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The Health Care Fraud and Abuse Control program, of which OIG is a key partner, returned more than $7 for every $1 invested

Medicare Administrative Contractor (MAC)

Recovery Audit Contractor (RAC) Zone Program Integrity Contractor

(ZPIC) Comprehensive Error Rate Testing

(CERT)

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Daniel R. Levinson Inspector General

July 29, 2014; U.S. Department of Justice Director of Nursing Pleads Guilty in Miami for

Role in $7 Million Health Care Fraud Scheme July 23, 2014; U.S. Department of Justice Owner and Administrator of Miami Home Health

Companies Pleads Guilty for Role in $74 Million Health Care Fraud Scheme

June 19, 2014; U.S. Department of Justice Medicare Fraud Strike Force Case

Former Owner of Physical Therapy Clinic Sentenced to Prison in Connection with Health Care Fraud Scheme

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http://oig.hhs.gov/fraud/enforcement/criminal/index.asp


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The top five states (Florida, Louisiana, Mississippi, Oklahoma, and Texas) account for about 35 percent of all home health care episodes despite accounting for only 17 percent of beneficiaries. The utilization in these five states is 34.7 episodes per 100 FFS beneficiaries, compared with 13.7 episodes per 100 FFS beneficiaries for all other states

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MEDPAC- Report to Congress 2013

Civil War – Lincoln Law Applicable for any claims for which money is

spent on the government’s behalf and/or any of the money is provided by the federal government ◦ This includes claims made with regards to Medicare

and Medicaid

Fraud – intent to deceive “Known or should have known” ◦ Government does not have to prove intent…but

should have known in fraud litigation

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Home Health (Medicare Part A benefit) requires objective testing as per HH PPS Final Rule 2011 ◦ Effective 4/1/2011 ◦ Reassessment requirement @13/19/30

Outpatient Therapy (Medicare Part B benefit) requires functional reporting (G-codes) as per Middle Class Tax Relief and Job Creation Act 2012 ◦ Effective 1/1/2013 (mandatory 7/1/14) ◦ Functional Limitation Reporting

At least every 10th treatment day

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Federal Government ◦ Federal Law – HIPAA, HITECH, ACA

◦ Federal Agency – HHS, CMS, OSHA, CDC

Regulations are dynamic and change

CMS – governs Medicare

Medicare Benefits Policy Manual

Medicare Claims Processing Manual

Transmittals

Medicare Learning Network (MLN) Matters

Medicare Administrative Contractors (MAC)

National Coverage Determination (NCD)

Local Coverage Determination (LCD)

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Moving target – rules change

Proposed rule released in spring and final rule released in fall for following year ◦ Open comment period between proposed and final

rule

Provide your input to CMS!

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Code of Federal Regulations (CFR)

Medicare Benefit Policy Manual (100-02) ◦ Chapter 7. Home Health Services

Medicare Claims Processing Manual (100-04) ◦ Chapter 10. Home Health Agency Billing

Transmittals

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Home Health Prospective Payment System (HH PPS 2011 Final Rule)

◦ Mandated 13th visit and 19th visit and at least every

30 day reassessments

◦ Time point requirements and content requirements

◦ Purpose is to determine the efficacy of the plan of care (POC) towards meeting the established goals

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◦ §409.44(c)(1)(iv): Measurements which assess activities of daily living that may include but are not limited to eating, swallowing, bathing, dressing, toileting, walking, climbing stairs, or using assistive devices, and mental and cognitive factors

§409.44(c)(2)(A): Reassessment to include measurement results and corresponding effectiveness of the therapy, or lack thereof

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http://www.gpo.gov/fdsys/pkg/FR-2010-11-17/pdf/2010-27778.pdf

Question 13: What tools can therapists use to do the objective assessments?

Answer 13: CMS does not want to be prescriptive regarding which tools should be used and instead recommends that therapists look to their respective national and state associations and accrediting bodies for such resources.

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CMS Q and A Revised March 2012. https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/Therapy_Questions_and_Answers.pdf. Accessed 7/14/12.

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/Downloads/Therapy_Questions_and_Answers.pdf











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§409.44(c)(1)(i): Therapy goals which are consistent with the evaluation of the patient’s function

§409.44(c)(1)(iii): Goals must be measurable, and must pertain directly to the patient’s illness or injury, and the patient’s resultant impairments

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§409.44(c)(1): Therapy services must relate directly and specifically to a treatment regimen designed to treat the beneficiary’s illness or injury ◦ §409.44(c)(1)(ii): Documentation describing how the

course of therapy is in accordance with accepted professional standards of clinical practice

§409.44(c)(2)(E)(1): Objective measurement of the effectiveness of the therapy as it relates to the therapy goals

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§409.44(iii)(A)(1): Material improvement requires that the clinical record demonstrate that the patient is making improvement towards goals when measured against his or her condition at the start of treatment

§409.44(iii)(A)(3): Services are not to be considered reasonable and necessary covered therapy services when a patient suffers a transient and easily reversible loss or reduction of function which could reasonably be expected to improve spontaneously as the patient gradually resumes normal activities

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§409.44(c)(2)(F)(1,2): A clinically supportable statement why there is an expectation that the goals are attainable in a reasonable and generally predictable period of time if patient does not meet maintenance criteria ◦ §409.44(iv):(B)(1) Therapy progress regresses or

plateaus, and the reasons for lack of progress are documented to include justification that continued therapy treatment will lead to resumption of progress toward goals

§409.44(c)(2)(H)(4): In the case of maintenance therapy, the patient is responding to therapy and can meet the goals in a predictable period of time

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Jimmo v. Sebelius

No Improvement Standard

The skills of a therapist are necessary to maintain, prevent, or slow further deterioration of the patient’s functional status,

services cannot be safely and effectively carried out by the beneficiary personally, or with the assistance of non-therapists, including unskilled caregivers

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Code of Federal Regulations (CFR)

Medicare Benefit Policy Manual (100-02) ◦ Chapter 12. Comprehensive Outpatient

Rehabilitation Facility Coverage (CORF)

◦ Chapter 15. Covered Medical and Other Health Services

Medicare Claims Processing Manual (100-04) ◦ Chapter 5

Transmittals

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The severity modifier reflects the beneficiary’s percentage of functional impairment as determined by the clinician furnishing the therapy services for each functional status: current, goal, or discharge. In selecting the severity modifier, the clinician: ◦ Uses the severity modifier that reflects the score from a

functional assessment tool or other performance measurement instrument, as appropriate

◦ Uses his/her clinical judgment to combine the results of multiple measurement tools used during the evaluative process to inform clinical decision making to determine a functional limitation percentage

◦ Uses his/her clinical judgment in the assignment of the appropriate modifier

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Q16) Is there a list of Medicare-approved functional assessment tools?

A16) CMS does not have a list of approved or endorsed functional assessment tools.

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http://www.cms.gov/Medicare/Billing/TherapyServices/Downloads/Functional-Reporting-PT-OT-SLP-Services-FAQ.pdf

Compliance with regulations

OR

Identify impairments, create effective care plans with patient engagement and improved patient adherence in order to achieve better outcomes and justify care provision

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Compliance with regulations

OR

Identify impairments, create effective care plans with patient engagement and improved patient adherence in order to achieve better outcomes and justify care provision

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ICD-9 (soon to be ICD-10) ◦ International Classification of Diseases – diagnosis of

diseases, disorders and other health conditions

ICF ◦ International Classification of Functioning, disability and

Health – human functioning and disability are described as a dynamic interaction between various health conditions and environmental and personal factors

The ICD-10 and ICF are complementary to each other. Using both classification systems provides a broader picture of the health of an individual

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June 2008, the APTA House of Delegates officially endorsed the World Health Organization's (WHO) International Classification of Functioning, Disability and Heath (ICF)

ICF offers a large area of domains that may be considered when evaluating a patient and in determining what other influences may be affecting the patient, such as environmental factors

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Practice Matters: What is the ICF? By Anita Bemis-Dougherty, PT, DPT, MAS February 2009. PT in Motion.

Test selection may be function-based or structure-based

Biopsychosocial model, attempts to integrate the medical and social models of disability. ◦ In the biopsychosocial model, disability is viewed as

a consequence of biological, personal, and social forces Alan Jette, PTJ 2006

http://ptjournal.apta.org/content/86/5/726.full

ICF Beginners Guide ◦ http://www.who.int/classifications/icf/training/icfb

eginnersguide.pdf

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http://ptjournal.apta.org/content/86/5/726.full

http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf



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Classification System of Health/Function (not Disability like Nagi Model)

◦ Body Function ◦ Body Structure ◦ Activities and Participation ◦ Environmental Factors

Framework for describing and organizing info on functioning and disability

Shift focus from disability to the persons level of health

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The physiological functions of body systems (including psychological functions)

Examples include: ◦ Mental functions ◦ Sensory functions and pain ◦ Functions of the cardiovascular, haematological,

immunological and respiratory systems ◦ Functions of the digestive, metabolic, endocrine

systems ◦ Neuromusculoskeletal and movement-related

functions ◦ Functions of the skin and related structures

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Performance Based testing

Mental Functions – MOCA

Neuromusculoskeletal and movement – BERG, TINETTI POMA, DGI, mCTSIB, etc.

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Anatomical parts of the body such as organs, limbs and their components

Structure of the nervous system The eye, ear and related structures Structures involved in voice and speech Structure of the cardiovascular, immunological and

respiratory systems Structures related to the digestive, metabolic and

endocrine systems Structure related to genitourinary and reproductive

systems Structures related to movement Skin and related structures

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Integrity tests ◦ Ligamentous Laxity Testing – stress testing

◦ Cranial Nerve Testing

◦ Imaging

◦ Vestibular Positional Vertigo Testing

◦ Nerve Testing – impingement testing

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Activity is the execution of a task or action by an individual

Participation is involvement in a life situation

Activity Limitations are difficulties an individual may have in executing activities

Participation Restrictions are problems an individual may experience in involvement in life situations

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Environmental Factors make up the physical, social and attitudinal environment in which people live and conduct their lives

These factors range from physical factors such as climate and terrain, to social attitudes, institutions, and laws

Belief system

Support and relationships

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Knowing what the numbers mean


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Know basic statistics ◦ Know what the numbers mean

Know where to find the tests

Know what tests are appropriate to use

Know how to administer the tests

Know how to use the results

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“… one in which there is reasonable intertester (interobserver) reliability.” – Rothstein

“To determine whether a measurement is objective, one needs to assess the reliability of the measurement.” – Rothstein

Validity – one in which the instrument (test) is measuring what it is intended to measure (the construct)

Psychometric Properties are “those aspects of a test or a measure that say how good the test or measure is” ◦ Reliability ◦ Validity

Rothstein JM: On defining subjective and objective measurements. Phys Ther 69:

577-579, 1989


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Statistical terms are inherent to research and evidenced-based practice

Psychometric Properties

Normative Data

Reliability – consistency in measure (inter and intra rater)

Validity – the measure is measuring what is intended to measure

Objective measurements are measures that have reliability and validity

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True positive: ◦ the patient has the disease and the test is positive

False positive: ◦ the patient does not have the disease but the test is

positive

True negative: ◦ the patient does not have the disease and the test

is negative

False negative: ◦ the patient has the disease but the test is negative

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Sensitivity: ◦ def: measures the proportion of actual positives

which are correctly identified as such (e.g. the percentage of sick people who are correctly identified as having the condition)

◦ If the test is highly sensitive and the test result is negative you can be nearly certain that they don’t have disease

◦ A Sensitive test helps rule out disease (when the result is negative). Sensitivity rule out or "Snout"

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Specificity: ◦ def: measures the proportion of negatives which are

correctly identified (e.g. the percentage of healthy people who are correctly identified as not having the condition)

◦ If the test result for a highly specific test is positive you can be nearly certain that they actually have the disease

◦ A very specific test rules in disease with a high degree of confidence. Specificity rule in or "Spin"

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Sensitivity & Specificity (cont’d): ◦ Perfect = 100%, or the ability to correctly predict

true positives (sensitivity) and true negatives (specificity) all the time

◦ Statistically, however, there always (theoretically) exists some level of error (or . . . “nothing is 100%”)

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BERG POMA - T

Cut-off ≤42/56

Sensitivity – 91%

Specificity – 82%

A negative result means that the person is probably not a high risk for falling

Cut-off =19 Sensitivity – 64%

Specificity – 66.1%

Not a good test to rule in or out a risk for falling

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13.5 second cut-off score Sensitivity = 0.87 means . . . .the TUG accurately

identifies (+) fall risk in the community-dwelling elderly person 87% of the time

OR, 13% of the time, (+) falls risk is incorrectly identified (when, in reality, the individual is not a falls risk)

Specificity = 0.87 means . . . The TUG accurately identifies non-fall risk in the community-dwelling elderly person 87% of the time

OR, 13% of the time no falls risk is incorrectly identified (when, in reality, the individual is a falls risk)

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Minimally Detectable Change (MDC): ◦ def: minimal change that falls outside the

measurement error in the score of an instrument used to measure a symptom

Clinically Significant Difference(CSD)/Minimal Clinically Important Change(MCIC): ◦ def: minimal change in the score that is meaningful

for patients

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What tests do most therapists currently use? ◦ Range of motion (ROM)]

◦ Manual muscle tests (MMT)

◦ Falls risk assessment

Timed Up & Go (TUG)

Missouri Alliance (MAHC-10)

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Resources for finding these instruments: ◦ American Physical Therapy Association (APTA)

www.PTNow.org

◦ Home Health Section of APTA

www.homehealthsection.org

◦ National Institutes of Health (NIH) Toolbox

www.nihtoolbox.org

◦ Rehab Institute of Chicago (RIC)

www.rehabmeasures.org

◦ Geriatric Assessment Tool Kit

http://web.missouri.edu/~proste/tool/

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ROM and MMT are not enough to capture the patient’s functional impairments and the data obtained can be disputed as objective by CMS ◦ ROM and MMT provide data that can be argued as

not meeting the CMS requirement of objective testing as reliability of test results are limited.

◦ Reliability is questionable [as used in research where standardized protocols are used] and even worse when standardized protocols are not followed [as seen in homecare]

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ROM Reliability ◦ Testing is performed without following

standardized test positions

◦ Rounding of values in 5° increments does not indicate use of goniometer for measurement

“eyeball” of ROM; educated estimates

Intertester variability = 5-8° if done accurately

◦ Use of “WFL” without comprehensive assessment of ROM during all necessary functional activities

During self-care, ADLs and IADLs

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http://www.ptnow.org/

http://www.homehealthsection.org/

http://www.nihtoolbox.org/

http://www.rehabmeasures.org/




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Testing is performed without following standardized test positions ◦ Full ROM test vs isometric (break) test

Variability in applied resistance by clinician completing test ◦ What is min resist vs mod resistance?

Therapist scoring does not follow defined conventions ◦ What is 3/5 – 4/5 strength range?

Test position is not defined ◦ Are patients placed in gravity resisted/eliminated

positions?

Muscle(s) tested is/are not defined ◦ What position is forearm in when testing elbow flexors?

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◦ “Manual muscle testing [MMT] is the most widely used method to assess muscle function, however, its reliability and accuracy are questionable. when greater accuracy of results is needed, instruments are available that provide precise readouts of resistive force that muscle works against (i.e., hand dynamometers, pinch grips, and computer-controlled dynamometers).” WK Durfee and PA Iaiazzo

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Durfee, W.K. and Iaizzo, P.A. 2006. Rehabilitation and Muscle Testing. Encyclopedia

of Medical Devices and Instrumentation. Wiley.

http://www.me.umn.edu/~wkdurfee/publications/wiley-chap-2006.pdf. Accessed 7/15/12

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Specific population(s): N/A

Age/gender norms: N/A ◦ Gender differences do exist

Descriptive categories/cut-off scores: ◦ **see slide for muscle test

score definitions

◦ Important to test, when able, in proper test positions Gravity resisted

Gravity eliminated

Psychometric Properties: ◦ Reliability = (ICC) 0.86 – 0.97

Tester consistency best

Study looked at hip and shoulder muscle testing

*½ MMT grade variation is not significant when same tester completes test-retest

*1MMT grade variation is not significant between 2 testers

Protocol for standardized administration

◦ Equipment: NONE ◦ Time: Variable, depending on

number of muscles being tested

http://www.me.umn.edu/~wkdurfee/publications/wiley-chap-2006.pdf






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Gravity Eliminated Grades

Gravity Resisted Grades

2+/5 = < ½ ROM gravity resisted position or minimal resistance/full ROM gravity eliminated position

2/5 = full ROM gravity eliminated position; no resistance

2-/5 = > ½ ROM gravity eliminated position

1+/5 = < ½ ROM gravity eliminated position or palpable AND visible contraction

1/5 = palpable contraction/no ROM completed

0/5 = no palpable contraction/no ROM completed

3-/5 = > ½ ROM gravity resisted position

3/5 = full ROM gravity resisted position; no resistance

3+/5 = full ROM gravity resisted + minimal resistance

4-/5 = full ROM gravity resisted + min-mod resistance

4/5 = full ROM gravity resisted + mod resistance

4+/5 = full ROM gravity resisted + mod-max resistance

5/5 = full ROM gravity resisted + max resistance

The Guide to Physical Therapist Practice identifies 24 Guide categories ◦ ROM [Range of Motion] and Muscle strength [Muscle

Performance] are but two of them

◦ These categories are not appropriate for all patients. [Example, patient with CHF…]

◦ Other category measures seen in audits include:

Gait, Locomotion and Balance

Aerobic Capacity/Endurance

◦ But, are the documented results objective?

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Guide to Physical Therapist Practice. 2nd Ed. APTA. Alexandria, Virginia. 2003

Absence of standardization/competency ◦ Example: The TUG is the baseline tool for falls risk

for your agency.

Have the following been defined?

How to measure test track? (distance)

What marks the distance?

When do you start and stop the timer?

Equipment needs

Scoring method defined

Interpretation of results

Documentation that includes findings

Goals, Opinion Statements

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Independent, Supervision, SBA, CGA, Min A, Mod A, Max A, Total, Dependent levels of assist are not objective measures, but, rather a subjective opinion of the therapist grading the level of assistance required

Mod assist for bathing is not an objective measure. It is a qualitative measure that requires further detail about WHY the level of assist is required

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Assessment of balance and endurance lack objective test measures. ◦ Poor/Fair/Good balance assessments lack:

Correlation to fall risk What is the likelihood that patient with Fair balance is at risk

for falls?

Ability to quantify change/progress What is the “amount” of improvement with an improvement

from Poor → Fair balance?

◦ Poor/Fair/Good endurance assessments are unable to objectively document functional limitations and quantify change/improvements What does Poor+ endurance mean? How is it defined? Is it

the same for all clinicians or at the discretion of each individual clinician?

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“Takes too long. I don’t have time.”

“I am not sure how to do the tests.”

“I don’t know what the results mean.”

“I don’t need to do objective testing.”

“I don’t want to do objective testing.”

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Knowing what the numbers mean

60 y/o patient with recent hospitalization referred for home care following COPD exac.

How do you objectively assess patient to see if progression from rolling walker to single point cane is appropriate?

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Discussion

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Discussion ◦ Assess for balance/gait impairments

Assess for falls risk/mobility

◦ Assess for aerobic capacity/endurance impairments

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Aerobic Capacity/Endurance Arousal/Attention/Cognition Balance/Balance Confidence Gait/Locomotion Mobility/ADL/IADL Strength

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65 y/o patient referred for PT after having knee replacement. Post op day 15. ◦ Rehab course – 3 days acute hospital and 11 days in

SNF.

What objective measures do you use to identify impairments for POC creation?

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Discussion

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Discussion ◦ Knee ROM flexion and extension – use of

goniometer, describe test position (describe end feel)

◦ Flexibility testing – Hamstrings, Calves

◦ Knee strength MMT flexion and extension – describe test position

◦ Chair stand test

◦ One leg stance test

◦ Gait speed

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Specific population(s): ◦ None defined

Age/gender norms: N/A Descriptive

categories/cut-off scores: ◦ Perception of exertion

depends mainly on the strain and fatigue in muscles and on feeling of breathlessness or aches in the chest

◦ 6-20 scale (original) 11-14 = mid-range

◦ 1-10 scale (modified) 3-6 = mid-range

Psychometric Properties: ◦ Reliability = (ICC) .91

Protocol for standardized administration ◦ Equipment: rating scale

◦ Time: < 5 minutes

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Borg Modified Borg

Rating Perception of effort Rating Perception of Effort

6 No exertion at all 0 Nothing at all

7 Extremely light 0.5 Very, very weak (just noticeable)

8 1 Very weak

9 Very light

10 2 Weak

11 Light

12 3 Moderate

13 Somewhat hard 4 Somewhat strong

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15 Hard (heavy) 5 Strong (heavy)

16 6

17 Very Hard 7 Very strong

18 8

19 Extremely hard 9

20 Maximal exertion 10 Very, very strong (almost maximal)

Specific population(s): ◦ Community-dwelling older

adults

Age/gender norms: ◦ 5-yr increments from 60-94

years of age

◦ Male/female norms

Descriptive categories/cut-off scores: ◦ Average range of steps

◦ Below & above average designations

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Psychometric Properties: ◦ Reliability = .90

◦ Criterion Validity = .73 - .74 with 1-mi. walk, treadmill

Moderate correlations

Protocol for standardized administration ◦ Equipment: stop watch;

tally counter; tape measure or 30inch string; masking tape

◦ Time: approx. 5 minutes


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adults

Age/gender norms: ◦ 5-yr increments from 60-

94 years of age ◦ Male/female norms

Descriptive categories/cut-off scores: ◦ Average range of steps ◦ Below & above average

designations

Psychometric Properties: ◦ Reliability = .90 ◦ Criterion Validity = .73 -

.74 with 1-mi. walk, treadmill Moderate correlations

Protocol for standardized administration ◦ Equipment: stop watch;

tally counter; tape measure or 30inch string; masking tape

◦ Time: Approx. 5 minutes

Age Men Women

60-64 87-115 75-107

65-69 86-116 73-107

70-74 80-110 68-101

75-79 73-109 68-100

80-84 71-103 60-91

85-89 59-91 55-85

90-94 52-86 44-72

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adults ◦ Parkinson’s Disease ◦ TIA/CVA

Age/gender norms: N/A Descriptive categories/cut-off

scores: ◦ Normal = > 26/30 ◦ Mild Cognitive Impairment

(MCI) = < 26/30 Range: 19-25 (avg: 22)

◦ Alzheimer’s Disease = < 26/30 Range: 11-21 (avg: 16)

Psychometric Properties: ◦ Sensitivity:

MCI = 90%

AD = 100%

◦ Specificity: 87%

Protocol for standardized administration ◦ Equipment: instructional

guide; score form; pencil/pen; stopwatch

◦ Time: 15-30 minutes

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adults Age/gender norms: N/A Descriptive categories/cut-

off scores: ◦ Normal:

> HS Education: > 27/30

< HS Education: > 25/30

◦ Mild Neurocognitive Disorder (MNCD): > HS Education: 21-26/30

< HS Education: 20-24/30

◦ Dementia: > HS Education: 1-20/30

< HS Education: 1-19/30

Psychometric Properties: ◦ Sensitivity and Specificity

*category dependent

◦ 95% Confidence Intervals

*category dependent


guide; form; pencil/pen

◦ Time: 7 minutes


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Specific population(s): ◦ Community-dwelling adults (age

range 18-89 years)

Age/gender norms: ◦ Age (11 categories) and education

(2 categories) variances

Descriptive categories/cut-off scores:

Increasing age + decreasing education resulted in ↓ scores

Not equivalent on Trail A and B Higher scores = greater

impairment Trail A: avg = 29 secs.

abnormal = > 78 secs. Trail B: avg = 75 secs.

abnormal = >273 secs.

Psychometric Properties: ◦ Not described in research

literature reviewed ◦ Commonly used in research

published in peer-review journals


guide; score form; pencil/pen

◦ Time: Trail A ~ 90 seconds Trail B ~ 3 minutes

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Specific population(s): ◦ Elderly persons with/without

mild-moderate dementia and/or physical illness

Age/gender norms: N/A

Descriptive categories/cut-off scores: ◦ 1-4 Score = No cause for

concern

◦ 5-9 Score = Strong probability of depression

◦ 10+ Score = Indicative of depression

Psychometric Properties: ◦ Sensitivity (at 4/5 cut-

off): 92.7%

◦ Specificity (at 4/5 cut-off): 65.2%

Protocol for standardized administration ◦ Equipment: scoring

guide; form; pencil/pen ◦ Time: 5 minutes

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Specific population(s): ◦ Elderly persons with suspected

depression; with/without dementia


Descriptive categories/cut-off scores: ◦ Final ratings represent the rater’s

clinical impression rather than informant responses.

◦ Scale Range of Scores from 0-2 (19 items)

◦ Scores > 10 = probable major depression

◦ Scores > 18 = definite major depression

Psychometric Properties: ◦ Correlative status with GDS

◦ Convergent Validity: High

◦ Sensitivity: 93% (at > 6)

◦ Specificity: 97% (at > 6)

Protocol for standardized administration ◦ Equipment: scoring guide;

score form; pencil/pen

◦ Time: 20 minutes


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adults (> 65 yrs and older)

◦ Parkinsonism


Descriptive categories/cut-off scores: ◦ < 45/56 = impaired

balance; (+) falls risk

◦ > 45/56 = impaired balance; (-) falls risk Sensitivity ↑’s with cut-off

score >48/56

**PTJ S Muir 2008 article – discourages use of dichotomous score for fall risk determination

Psychometric Properties: ◦ Reliability = (ICC) > .90 ◦ Sensitivity: 91% ◦ Specificity: 82% ◦ Clinically significant

difference/minimally detectable change: 6, 8 pts

Protocol for standardized administration ◦ Equipment: score sheet,

stopwatch, shoe, ruler, stepstool


96


adults


Descriptive categories/cut-off scores: ◦ 25-28 = low falls risk ◦ 19-24 = medium falls risk ◦ < 19 = high falls risk

Sensitivity and specificity vary based on individual studies

Psychometric Properties: ◦ Reliability = (ICC) 0.93 ◦ Sensitivity:

Gait (8/12 cut-off) = 21% Balance (12/16 cut-off) = 24%

◦ Specificity: Gait (8/12 cut-off) = 95% Balance (12/16 cut-off) = 91%

◦ Clinically significant difference/minimally detectable change: 5 points (PTJ)

Protocol for standardized administration ◦ Equipment: hard, armless chair;

stopwatch, 15ft walkway ◦ Time: 20 minutes


adults (> 65 yrs and older) ◦ Vestibular

Descriptive categories/cut-off scores: ◦ > 15 seconds = impaired

balance; (+) falls risk – community dwelling older adult

◦ >12 seconds = impaired balance; (+) falls risk – vestibular population

97

Psychometric Properties: ◦ Reliability = (ICC) > .99

◦ Sensitivity: 85%

◦ Specificity: 88%

Protocol for standardized administration ◦ Equipment: stopwatch, 4

canes



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Start by standing in square 1, facing square 2 (imagine that direction is facing “north”)

Begin in a clockwise direction, i.e. 2-3-4-1; then immediately move counterclockwise, i.e. to squares 4-3-2-1.

Clock starts when first foot contacts box 2 and stops when last foot returns to box 1.

98

99

Specific population(s): ◦ Older adults (60+ yrs. of

age)

Age/gender norms: available (Springer et al.)

Descriptive categories/cut-off scores: ◦ < 5 seconds is predictive

of an injurious fall according to Vellas et al.

Psychometric Properties: ◦ Inter-rater reliability =

ICC=0.994


◦ Equipment: Instruction sheet, stop watch/timer

◦ Time: <5 minutes

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101

Specific population(s): ◦ Older adults (ranging from

65-95 yrs of age) ◦ > 1 yr post-stroke ◦ Parkinsonism; PD


Descriptive categories/cut-off scores: ◦ > 80% = balance

confidence WFL; no probable fear of falling

◦ < 80%: impaired balance confidence; (+) fear of falling

Psychometric Properties: ◦ Reliability = (ICC) 0.92

◦ Correlation with FES = 0.84


◦ Equipment: instruction sheet; score sheet; pencil/pen


102

Many adaptations made to FES. FES- I

Specific population(s): ◦ Older adults (age ranges 66-

89 yrs of age) ◦ With/without cognitive

impairments


Descriptive categories/cut-off scores: ◦ > 80% = balance confidence

WFL; no probable fear of falling

◦ < 80%: impaired balance confidence; (+) fear of falling

Psychometric Properties: ◦ Reliability = (test-retest) 0.71

◦ Correlation with ABC = 0.84


◦ Equipment: score/instruction form; pencil/pen



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104

Specific population(s): ◦ Adults/Older adults

(ranging from 45-90 yrs of age)

◦ Parkinson’s Disease

◦ Post-stroke

◦ Vestibulopathy


Descriptive categories/cut-off scores: ◦ < 22/30 predictive of falls

Psychometric Properties: ◦ Reliability = (ICC) 0.93; (test-

retest) 0.91

Sensitivity: 72%

Specificity: 78%

◦ Vestibulopathy = (ICC) 0.86; (test-retest) 0.74

Protocol for standardized administration ◦ Equipment: score sheet;

stopwatch; shoe box; steps; pencil/pen

◦ Time: 5 minutes ◦ Space: approximately 20

feet

105

Specific population(s): ◦ Adults/Older adults (ranging

from 21-77 yrs of age)

◦ Parkinson’s Disease; MS

◦ > 3 mos post-stroke ◦ Vestibulopathy


Descriptive categories/cut-off scores: ◦ < 19/24 = (+) falls risk in

community-dwelling older adult

◦ < 12/24 = (+) falls risk in MS

Psychometric Properties: ◦ Reliability = (ICC) 0.96

◦ Correlation with TUG = 0.80

◦ Validity (construct/concurrent) = 0.68 – 0.83

◦ MDC/CSD: 2.9 pts


◦ Equipment: score sheet; 2 obstacles (same size); stairs; 20ft path; pencil/pen


106

Psychometric Properties: ◦ Reliability = (ICC) 0.96-0.97

◦ Correlation between 8ft and 20ft = 0.933

◦ Clinically significant/meaningful change:

Meaningful: 0.05m/second

Substantial: 0.10m/second

Protocol for standardized administration ◦ Equipment: stopwatch;

measuring tape ( > 10ft) ◦ Time: < 5 minutes ◦ Acceleration and

Deceleration zone ◦ Test Track: Any distance

between 8 and 20 feet

Specific population(s): ◦ Older adults (ranging from

50-98 yrs of age) ◦ Post-stroke; OA; CHF;

post-fracture

Age/gender norms: multiple studies available

Descriptive categories/cut-off scores: ◦ Various distances; can be

measured in ft/sec or m/sec.

Results are predictive of falls, adverse health outcome


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Gait Velocity Distance

Score Categories/Cut-off Feet/Meter Conversion

10 Feet

<1.97ft/sec = predictive of hospitalization risk < 1.86ft/sec = (+) falls risk

______________

4 Meter

0.0-0.4m/sec = household amb. 0.4-0.6m/sec = limited community amb < 0.57m/sec = (+) falls risk 0.6 – 1.0m/sec = lmtd – safe community amb > 1.0m/sec = functional community amb > 1.2m/sec = safe to cross streets

13 feet 1.48

inches

107

Start Walk Stop Walk

Start Timer Stop Timer

NOTE: There are additional distances that can be utilized for testing – establish internal consistency in your agency. NOTE: The shortest distance found reliable/valid in the research literature is 8 feet. Distances greater than 20 feet become difficult to establish in the home setting.

Fritz S. and Lusardi M. “Gait Velocity: The 6th Vital Sign” Journal of Geriatric Physical Therapy Vol. 32;2:09:2-5.

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110


adults ◦ Vestibulopathy

◦ Parkinson’s Disease ◦ Post-hip fracture

◦ Alzheimer’s Disease

Age/gender norms: see next slide

Descriptive categories/cut-off scores: ◦ Mobility impairment

categories (ref next slide)

◦ > 14 seconds = (+) falls risk

Psychometric Properties: ◦ Reliability = 0.98 – 0.99 ◦ Sensitivity: 0.80 ◦ Specificity: 0.934 ◦ Correlates mod-high with:

Berg, gait velocity, Barthel

Protocol for standardized administration ◦ Equipment: stopwatch;

tape measure; standard-height chair with arms


Time to Complete Test Mobility Impairment Category

Falls Risk

< 10 seconds Independent NO

10-20 seconds Mostly Independent YES, if > 14 seconds

20-30 seconds Moderately Impaired YES

> 30 seconds Severely Impaired; probable ADL dysfunction

YES

111

Variations in measurement: 10ft distance measured from either front leg of test chair or front of individual’s foot when seated in chair Variations in test setup – cone vs. tape on floor

112

Pondal M and del Ser T. J Geriatr Phys Ther. 2008.


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TUG 8 foot up and go

A Shumway Cook

10 feet distance

Fully seated

Falls risk predictor and mobility indicator

Use tape or cone

Rikli and Jones 8 feet distance Fully seated Age/Gender Normative

data available for 60-94 y/o

Use cone

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114

Variations exist – seated v standing and multi-directional reach

Specific population(s): ◦ Disease specific and age

specific population data available

Age/gender norms: available: YES

Descriptive categories/cut-off scores: ◦ < 18.5 cm (7.3 inches)

indicates fall risk (75% Sensitivity, 67% Specificity)

Psychometric Properties: ◦ Inter-rater reliability =

ICC=0.994


◦ Equipment: Instruction sheet, yardstick and tape

◦ Time: <5 minutes

Age Men Women

20-40 16.73 in. 14.64 in.

41-69 14.98 in. 13.81 in.

70-87 13.16 in. 10.47 in.

115

(Duncan et al. 1990)


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118

Normative Data for Arm Curl Test.

Women 60 - 64 65 - 69 70 - 74 75 - 79 80 - 84 85 - 89 90 – 94

Arm Curl Test (# of reps)

13-19 12-18 12-17 11-17 10-16 10-15 8-13

Men 60 - 64 65 - 69 70 - 74 75 - 79 80 - 84 85 - 89 90 – 94

Arm Curl Test (# of reps)

16-22 15-21 14-21 13-19 13-19 11-17 10-14

Arm Curl Test: Assesses upper-body strength

Equipment: Stopwatch, folding chair without arms, 5-lb.dumbbell for women,

8-lb dumbbell for men. Scoring: The score is the total number of arm curls completed in 30 seconds. If the arm is more than halfway up at the end of 30 seconds, it counts as a curl.


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adults

Age/gender norms: ◦ 5-yr increments from 60-

94 years of age ◦ Male/female norms

Descriptive categories/cut-off scores: ◦ Average range of

completed stands ◦ Below & above average

designations

Psychometric Properties: ◦ Reliability = (ICC) 0.90;

(test-retest) 0.96

◦ Correlates to leg press performance for LE strength (0.78 men; 0.71 women)

Protocol for standardized administration ◦ Equipment: test chair;

stopwatch; tally counter


Age Men Women

60-64 14-19 12-17

65-69 12-18 11-16

70-74 12-17 10-15

75-79 11-17 10-15

80-84 10-15 9-14

85-89 8-14 8-13

90-94 7-12 4-11

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Choose objective tests based on the patient’s history, systems review, diagnoses, and functional impairments

Document the results of the chosen objective tests

Give meaning to the results. ◦ Make professional opinions based on the

results ◦ For example, what does a Tinetti POMA

score of 12/28 mean for falls risk? Use test results to form goals Use results of objective tests to assist in

creating plan of care

123

Use the ICF model to identify barriers for an effective plan to be implemented

◦ Is there non-adherent or non-compliant behavior?

◦ Is there underlying depression?

◦ Cognitive status?

◦ Adequate support system?

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Expectations for the Home Health Therapist

Justifies that the care being provided is: Reasonable and necessary

Skilled

Medically necessary

Inherently complex that must be provided by nursing and/or therapy

Answer the question, WHY? ◦ Why should you CMS pay you?

◦ What are you providing that only you can provide?

◦ Are the interventions you provide able to be handed off to a caregiver to perform?

126

Requirements: ◦ Reasonable & necessary

An expectation that improvement will occur, and without it, possibility of decline/deterioration (i.e., injury) is real

◦ Interventions according to clinically accepted standards of practice

Evidence-Based Practice approach

◦ Requires the skills of a therapist to be present/complete

Knowledge, training, clinical decision-making, etc.

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So, what does a therapy “skilled” visit look like? ◦ Answer the following questions:

What was taught? (and who was it taught to?)

What did the patient do?

Was there assistance required?

Was there cueing/supervision, etc. required?

If so, how much and for what?

How did the patient respond?

What is your clinical opinion (“assessment”) of the visit? What improved? What didn’t? If not, why not?

What can patient now do (functional relevance)?

Clinical Plan:

What can’t the patient do and why does it continue to require a therapist to visit?

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129

Case Scenario – Skilled Visit Note Writing

Requirements: ◦ Objective measurement

Evaluation – provides a baseline

Reassessment – progress compared to baseline (IE)

◦ Quantifiable

Allows measurement/comparison

◦ Related to patient impairment(s)/function

Individualized to need

Reasonable for prior level of functioning and in light of current injury/illness or disease/condition

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So, what does a “well written” goal look like? ◦ Answer the following questions:

Who is the focus?

Patient?

Caregiver?

What objective test/measure was utilized?

What improvement is expected?

What quantifiable change in score?

Consistent with score interpretation

What functional improvement is expected to result from this change?

Optional: What time frame should this occur in?

131

Goals should be:

Objective

Measureable

Meaningful

Functional

Realistic

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Case Scenario – Goal Writing


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134

Be inherently complex, which means that they can be performed safely and/or effectively only by or under the general supervision of a skilled therapist;

Be consistent with the nature and severity of the illness or injury and the patient’s particular medical needs, which include services that are reasonable in amount, frequency, and duration; and

Be considered specific, safe, and effective treatment for the patient’s condition under accepted standards of medical practice.

135

At defined points during a course of treatment, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must perform the ordered therapy service. During these visits, the therapist must:

Assess the patient using a method that allows for objective measurement of function and successive comparison of measurements; and Document the measurement results in the clinical record ◦ 13th visit/19th visit/30 day Reassessments

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Recovery Audit Contractors, or RAC, a program was created through the Medicare Modernization Act of 2003(MMA) to identify and recover improper Medicare payments paid to healthcare providers under fee for service (FFS) Medicare plans

◦ RAC paid on % of recovered improper payments . . . .

137

Zone Program Integrity Contractors (ZPIC audits) are organizations hired indirectly (or in connection with other CMS affiliated contractors) by CMS to perform a wide range of medical review, data analysis and Medicare audits looking for Medicare fraud.

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Patient is receiving home physical therapy. 1-3x per week and has received 25 visits and is about to be recertified

Prior level of function – Amb with Mod assist

No objective tests were performed

Visit #1. Amb 5’ with Mod Assist

Visit #25. Amb 10’ with Min Assist

Is this reasonable? Is this skilled?

140

Patient is receiving outpatient physical therapy 3x per week and has received 10 visits for R knee arthritis.

Prior level of function – Indep. Amb with intermittent use of cane. Works full time.

Pain level has remained consistently at 5/10.

Lower extremity functional scale improved 3 points from visit 1 to visit 10

Is this reasonable?

141

True/False. The International Classification of Function, Disability and Health (ICF) is a classification system based on the medical model of disease

True/False. Balance confidence is a metric that is predictive of fall risk

True/False. Home Health and Outpatient therapy settings require objective testing

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Contact information: [email protected]

Q & A

World Health Organization. 2002. Towards a Common Language for Functioning, Disability, and Health. Available at: http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf. Accessed 7/22/14.

World Health Organization. 2013. How to use the ICF. A Practical Manual for using the International Classification of Functioning, Disability and Health (ICF): Exposure draft for comment. Available at: http://www.who.int/classifications/drafticfpracticalmanual2.pdf?ua=1. Accessed 7/22/14.

144

Powell, LE & Myers AM. The Activities-specific Balance Confidence (ABC) Scale. J Gerontol Med Sci 1995; 50(1): M28-34

Myers AM, Fletcher PC, Myers AN, Sherk W. Discriminative and evaluative properties of the ABC Scale. J Gerontol A Biol Sci Med Sci. 1998;53:M287-M294.

Lajoie Y, Gallagher SP. Predicting falls within the elderly community: comparison of postural sway, reaction time, the Berg balance scale and ABC scale for comparing fallers and non-fallers. Arch Gerontol Geriatr. 2004;38:11-26.

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Rothstein JM: On defining subjective and objective measurements. Phys Ther 69:577-579, 1989.

NIH Toolbox. http://www.nihtoolbox.org/RFP/NIH%20Toolbox%20Overview%20and%20Instruments%202-2012.pdf. Accessed 9/4/2012.

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Guide to Physical Therapist Practice. 2nd Ed. Phys Ther. 2005;81:9-744.

Rosenbaum S. Law and the Public’s Health. Public Health Report. 2011;126:130-135.

Lalkhen AG, McCluskey A. Clinical tests: sensitivity and specificity. Contin Educ Anaesthesia, Crit Care Pain . 2008;8 (6 ):221–223. doi:10.1093/bjaceaccp/mkn041.

Binkley JM, Stratford PW, Lott SA, Riddle DL, Network TNAORR. The Lower Extremity Functional Scale (LEFS): Scale Development, Measurement Properties, and Clinical Application. Phys Ther . 1999;79 (4 ):371–383. Available at: http://ptjournal.apta.org/content/79/4/371.abstract.

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Faber MJ, Bosscher RJ, van Wieringen PCW. Clinimetric Properties of the Performance-Oriented Mobility Assessment. Phys Ther . 2006;86 (7 ):944–954. Available at: http://ptjournal.apta.org/content/86/7/944.abstract

Pondal M and del Ser T. Normative Data and Determinants for the Timed "Up and Go" Test in a Population-Based Sample of Elderly Individuals Without Gait Disturbances. J Geriatr Phys Ther. 2008;31(2):57-63

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