Patients First: Do the Little Things Right

One positive theme, and there are not many, that we have seen with the COVID-19 pandemic, is that the nation has learned that there are a lot of nursing homes across the nation. Nursing homes in their communities, full of grandparents, and aunts and uncles, moms and dads of people in their inner circles.

AND, these nursing homes patients are vulnerable, present with significant medical  complexities, and are trusting all of us to care for them to our highest ability. Providing the right care for our nursing home should be a little thing.

Not a big thing, not a struggle, not a herculean task battling red tape in your organization, and one that should allow us to use basic human common sense.Common sense for example, that caused many therapists across the nation to question statements such as, “I work in a SNF, and beginning in October I received guidance that my patients don’t need the minutes we used to provide because RUGs was an arbitrary system and we can get the same outcomes with less minutes”

Oh, the wordsmithing that went around….

We all know it did.

Are you getting the same outcomes?

Are your patients coming into sites willingly knowing a new reimbursement model rocked the industry and that their “therapy stay” is going to look very different now?

At the end of the day, we should provide what the person needs, basic human common sense. If your trend was excessive prior to 10-1-2019, I hope we have learned to balance. If your trend shifted to non-person-centered needs, then beware, as new guidance is being shared directly with Medicare beneficiaries and their families to help them understand their rights.

Understanding How Medicare Determines Payment for Your Therapy Services in Nursing Homes or Home Health Care: A Resource for Patients was developed by the therapy tri-alliance, American Physical Therapy Association, American Occupational Therapy Association, and the American Speech-Language Hearing Association and was released on May 15th, 2020.Portions of the document are shared below:

“If you or your loved one is receiving physical therapy, occupational therapy, and/or speech-language pathology services in a nursing home or if you are receiving care at home by a home health agency, Medicare implemented major payment changes for those services that you  should be aware of.

Therapy Services in Nursing Homes: On October 1, 2019, Medicare shifted to a new payment system called the Patient-Driven Payment Model (PDPM) for all skilled nursing facilities or SNFs.

Therapy Services at Home: On January 1, 2020, Medicare applied a similar payment change called the Patient-Driven Groupings Model (PDGM) for therapy services managed by home health agencies (often called HHAs) provided in your home.

Patient-Driven Care: Medicare implemented the payment changes to support and promote patient-focused care as the most appropriate way to pay for services by basing care on the unique characteristics, needs, and goals of each patient. These models for patient-focused care were supported as the most appropriate way to pay for services…..”

To protect your rights and ensure that you are receiving necessary therapy you should be aware of the following:

Common statements shared with patients receiving therapy that are not true.

Statement from provider: Medicare limits the amount of therapy Medicare beneficiaries can receive.

FACT: Medicare does not limit the amount of therapy you can receive in a SNF or from an HHA and the clinical judgment of your therapist should be a key factor in determining the amount of therapy you receive. However, many SNFs and HHAs use computer programs that “predict” the amount of therapy a patient needs in order to dictate visits, without accounting for the clinical judgment of your treating therapist. This may force therapists to restrict the amount of therapy provided….

Statement from provider: A portion of SNF therapy treatment must be provided in a group.

FACT: Medicare does not require patients to receive group therapy in a SNF setting. Group therapy may be clinically indicated for a patient and Medicare allows up to 25% of the patient’s treatment to be provided either in a group (2-6 individuals) and/or as concurrent (two individuals) during the length of stay in the SNF. Medicare expects that the needs of the patient and the clinical judgment of the clinicians for the most effective therapeutic intervention will drive the decision whether to use individual, concurrent, and/or group treatment. The clinician or SNF cannot and should not use group therapy to manage schedules or for the convenience of the clinician or SNF.

Statement from provider: Medicare will only pay for therapy services designed to improve a patient’s condition.

FACT: Medicare will pay for services designed to improve or maintain function for the patient. Improvement or progress is not required. Medicare must cover maintenance therapy, when medically appropriate, under a legal settlement called Jimmo v. Sebelius.

Statement from provider: Medicare does not pay for therapy for certain diagnoses.

FACT: Certain diagnoses or clinical conditions trigger additional payment for therapy, but Medicare requires SNFs and HHAs to provide all medically necessary services, including therapy services, to patients regardless of their diagnoses. CMS has stated:“While these clinical groups represent the primary reason for home health services during a 30-day period of care, this does not mean that they represent the only reason for home health services. While there are clinical groups where the primary reason for home health services is for therapy (for example, Musculoskeletal Rehabilitation) and other clinical groups where the primary reason for home health services is for nursing (for example, Complex Nursing interventions), home health remains a multidisciplinary benefit and payment is bundled to cover all necessary home health services identified on the individualized home health plan of care.”

The document closes by providing beneficiaries and their loved ones with guidance on who to contact if they think that your SNF or HHA has inappropriately restricted access to therapy services including consumer advocacy group such as:

  • Center for Medicare Advocacy: provides education, advocacy and legal assistance to help older people and people with disabilities obtain access to Medicare and quality health care.

  • Medicare Rights Center : helps people with Medicare understand their rights and benefits, navigate the Medicare system, and secure the quality health care they deserve.

  • Senior Medicare Patrol: empowers and assists Medicare beneficiaries, their families, and caregivers to prevent, detect, and report health care fraud, errors, and abuse through outreach, counseling, and education.

  • Local Area on Aging : linking those who need assistance with state and local agencies on aging, as well as community-based organizations that serve older adults and their caregivers.

In closing, it is a stressful time for us all, but I believe caregivers haven’t forgotten why we chose this industry.

Your bravery is second to none, stay steadfast and do the little things right.