The Sweet and Salty of Return to Normalcy

As the public healthcare emergency (PHE) lightens and with vaccines abundant in the U.S., many businesses are feeling a note of normalcy. Nursing homes have been given the green light to reopen, but continue to be a target of investigation, regulatory ribbon, and reduced consumer trust. This paradoxical environment highlights the sweet and salty of long-term care (LTC). Prior to the pandemic, LTC’s focus was enhancing resident’s outcomes, improving quality of care and quality of life, and fostering a home environment worthy of the residents within.  As difficult as it may have been in the moment, we now know it was truly the sweet stuff.

During the height of the PHE, regulation and policy aligned to create a salty recipe for long-term care. Reporting requirements, acquiring PPE, reduced access to care, and navigating surveys overshadowed previous focuses. Through this pandemic, we’ve learned the necessity of the salty. Salt brings balance and accountability, but when added without first testing the effectiveness of current spices, it can quickly ruin a meal. When regulation, reporting, and accountability metrics are balanced in relation to care needs, quality outcomes, and resident satisfaction, a delightful sweet and salty mix, in high demand for any consumer, is created.

As we emerge into this new era, many are fatigued, short staffed, and considering alternatives to long-term care. Let’s partner together to remember the sweet, learn from the salty, and create an enhanced recipe. Embrace each step of reopening with a dash of optimism and a cup of determination. Give a patient a hug, ignite communal dining and activities with fanfare, have a welcome party in the therapy gym, hype the benefits of group therapy, and celebrate family and friend’s visitation! Talk openly about the expectations for infection control, safety measures, and possible temporary isolation needs. This balance will help achieve a transparent trust with our residents, their loved ones, and care partners.

Don’t let the sweet get lost in the salty, share resident and facility successes with Reliant’s Model 103.0 reports. Spotlight Reliant therapists who exhibit clinical excellence by climbing the Clinical Ladder and facility team who SMILE with purpose. Never hesitate to GROW your brand. Our partnership brings the best ingredients to demonstrate your facility’s value, skill, and compassion in the community. Bon Appetit!

Celebrating SLPs and Their Distinct Role Within the IDT

The field of speech pathology grew in the 1920s as clinicians began to work with soldiers, returning home from World War II, suffering from brain injuries. Since then, speech and language pathologists (SLPs) have helped countless individuals as experts in the field of communication, swallowing disorders, and cognitive impairments in a variety of settings.

As we celebrate Better Hearing and Speech Month, we recognize SLPs and acknowledge their immense influence in improving the quality of our residents’ lives and being key members within our interdisciplinary teams (IDT).

With the introduction of the patient driven payment model (PDPM) in recent years, SLPs are now more than ever actively engaged with the IDT to ensure the MDS accurately portrays the residents’ clinical characteristics and skilled need. Since SLPs are qualified leaders in the areas of cognitive-linguistic impairments and dysphagia, including them in conversations as the MDS coordinator completes sections C, K, and I, can improve the accuracy of these assessment areas, as accuracy of the MDS remains a critical component of the PDPM and ensures resources are available for each resident’s unique needs. By working with the nursing team, SLPs also provide a multi-disciplinary approach to patient care that is focused on patient outcomes, ensuring both quality of life and quality of care expectations are exceeded.

Recently, as a result of SNFs receiving an unintended increase in payments,  CMS has expressed its intention of recalibrating the PDPM “as quickly as possible,” in an attempt to restore it to the original budget-neutral goal. As CMS continues to monitor PDPM and its effects on payments, the IDT will need to ensure accurate and thorough medical documentation is present within the patients’ charts. Due to a sharp change in utilization for speech resources, CMS will be reviewing cases to ensure that speech services were directly linked to a doctor’s order, such as for patients with swallowing issues who require a modified diet.

This month we pause to thank our SLPs and their dedication. Since the inception of the field of speech and language pathology, SLPs continue to rise to the challenge daily. Staying abreast of the latest advances in their field including regulatory changes and requirements, they continue to advocate for the necessity of speech language pathology interventions for the safety and well-being of individuals. SLPs remain a valuable asset to the IDT as a facility leader in dysphagia management, communication and cognitive interventions, and patient and caregiver education.

With Them for the Long Haul

According to Harvard Health Blog, recent studies indicate that 50-80% of patients recovered from COVID-19 continue to have at least one adverse symptom three months after the onset, even if the patient no longer tests positive for the virus.  This emerging condition has been described using a variety of terms including: “Post-Covid-19 Syndrome”, “Long COVID”, “Post-Acute Sequelae of SARS-COV2 infection (PASC)”, and “Long-Haulers”.  As healthcare providers to the most vulnerable population, it is our duty to monitor the evolving evidence in this area and adapt for timely identification and intervention of needs.  

Though what predisposes an individual to developing “Long COVID” is still unknown, a number of those with even mild symptoms have continued to experience lingering effects. Some of the troublesome symptoms that have been observed with “Long COVID” include many of the same musculoskeletal, cardiopulmonary, oral/respiratory, neurological, and psychological dysfunctions that are seen with active COVID-19. Furthermore, it has been noted that some individuals recovering from COVID-19 develop new conditions or complications of pre-existing conditions as a result of the illness.

Rehabilitation’s distinct role in COVID recovery and “Long COVID” is clear. Therapy can intervene to assist “Long Hauler” patients by maximizing their participation and performance in daily function with the use of the following:

  • Referral to the IDT when changes in clinical presentation emerge
  • Patient-specific musculoskeletal and neurological re-training
  • Individualized cardiopulmonary programming
  • Dysphagia analysis and treatment
  • Compensatory strategies to assist with cognitive re-training
  • Environmental modifications to facilitate increased participation and decreased risk of injury
  • Trauma-informed approaches to care when addressing the psychological effects of prolonged isolation
  • Patient and caregiver training on adaptive techniques and equipment
  • Patient education to promote health literacy

Reliant is actively engaged with the therapists in the field by developing resources such as Reliant’s Post COVID Clinical Considerations in order to equip the care team to positively impact patients and residents. Evidence continues to emerge, but the tools and knowledge do exist to address the physical, cognitive, and psychosocial needs that COVID-19 has introduced. Whether newly diagnosed as COVID positive, challenged by long-term effects of “Long COVID”, or facing an entirely new condition as a result of COVID-19, a patient or resident will never feel alone as they can rest assured that we’re with them for the long haul.

References:

Anthony Komaroff, MD. “The Tragedy of Long COVID.” Harvard Health Blog, 1 Mar. 2021, www.health.harvard.edu/blog/the-tragedy-of-the-post-covid-long-haulers-2020101521173.

AOTA. “Research: Occupational Therapy and Physical Therapy Provide Significant Rehabilitative Value in Post-Acute Care.” American Occupational Therapy Association, 5 Apr. 2021, www.aota.org/Advocacy-Policy/Federal-Reg-Affairs/Therapy-Outcomes-Post-Acute-Settings.aspx.

Cutter, Matthew. “COVID Long-Haulers: An End in Sight?” ASHAWire, 5 Mar. 2021, leader.pubs.asha.org/do/10.1044/leader.FTR1.26032021.42/full/.

Royal College of Occupational Therapists. “A Quick Guide for Occupational Therapists: Rehabilitation for People Recovering from COVID-19.” Rcot.co.uk, Apr. 2020, www.rcot.co.uk/files/guidance-quick-guide-occupational-therapists-rehabilitation-people-recovering-covid-19-2020.

WHO. “COVID-19 Clinical Management: Living Guidance.” World Health Organization, World Health Organization, 25 Jan. 2021, www.who.int/publications/i/item/WHO-2019-nCoV-clinical-2021-1.

The Distinct Value of Physical Therapy in Trauma-Informed Care

About 70% of adults in the U.S. have experienced at least one traumatic event in their life.1 COVID-19 may have resulted in a traumatic experience for many, while for others it may have triggered re-traumatization from past experiences. The experience of trauma or re-traumatization during a patient’s rehab stay cannot only result in physical, psychological, and emotional health conditions, but also impede therapeutic rapport, the patient’s feelings of safety, and the overall healing and recovery process.  By putting into practice the core principles of trauma-informed care (TIC): patient empowerment, choice, collaboration, safety, and trustworthiness, physical therapists can help prevent trauma and re-traumatization while increasing overall patient health and well-being.

Physical therapists have a responsibility to become trauma-informed and respond to each patient’s needs with a holistic approach by preventing re-traumatization and creating a supportive and safe environment for a patient’s rehabilitation journey. When the therapy team has been alerted to a history of trauma or is aware of a particularly stressing event such as loss or isolation during the pandemic, consider this history during the development of goals and treatment approaches.  For example, provide education on the impact and empowerment associated with improving the level of independence with bed mobility or transfers. Assess and modify environmental factors that trigger re-traumatization. Other tips to implement through interventions may include identifying alternative approaches to physical assistance (i.e., sit to stand assistance with equipment support instead of hands-on approach), clearly communicating the purpose and process of the activity before providing manual interventions (i.e., explaining hand placement before intervention initiated), and identifying and respecting preferences (i.e., gender preference with close interactions such as bed mobility tasks).

Many of the patients we serve have a history of trauma or may be experiencing a traumatic experience through their illness or injury.  Some have faced loss through COVID-19, while others may internalize fear and uncertainty through prolonged hospitalization and isolation in response to the pandemic.  Trauma has lasting implications on an individual’s health and well-being. The physical therapist that approaches each individualized plan of care with function and the emotional well-being of the patient first and foremost will demonstrate the distinct value of physical therapy in trauma-informed care.

National Council for Behavioral Health. (2015, Jan 8). Retrieved March 8, 2021, from https://www.thenationalcouncil.org/BH365/2015/01/08/strengthening-personal-community-resilience-mitigate-impact-disaster-trauma/.

Intentional Ideas to Fuel Your Residents with Unintended Weight Loss

To those working on the front lines in nursing homes and skilled nursing facilities, it comes as no surprise to hear that CMS is directing state surveyors to be alert and investigate those residents experiencing a significant decline in their condition during the pandemic particularly those residents with weight loss and/or a decline in mobility. As we know, weight loss and changes in mobility can be a direct effect of increased social isolation resulting from the healthcare emergency.  Essential quarantine and social distancing come with a high cost for our seniors who already experience higher incidences of loneliness and isolation. Healthcare professionals have the skills to address the wide range of challenges that increased isolation has introduced to our long-term care residents.

Decreased taste and smell and diminished appetite can lead to poor eating habits and weight loss, and unfortunately these are often devastating side effects that isolation and various illnesses generate. Weight loss can cause complications ranging from dehydration and increased confusion to increased risk of skin breakdown, all of which inadvertently lead to decreased ADL and functional mobility independence.

There are many ways appetite can be encouraged within your facilities, including the following:

  • Offer small meals often including protein packed small meals/snacks several times a day.
  • Trend meal intake and maximize snack or mealtimes reflective of better appetite. If you know that a resident traditionally eats more in the evening, use that time to offer favorite, protein-rich foods.
  • Train and engage all staff in meal assistance including administrators and activities staff to assist with meal set up and feeding (opening cartons, cutting meat, self-feeding, encouragement).
  • As infection control allows, offer the structure of eating at a table as opposed to alone in the room or in bed.
  • Remove wrappings, boxes or covers and move food to an actual plate/bowl so that food looks homemade and appetizing.
  • Fortify food with things like yogurt, cream, honey, butter, and/or oats to meals to increase caloric intake and boost energy.
  • Always have snacks and beverages handy. Make eating a communal event as much as possible while following infection control precautions. Meals should be enjoyable and not rushed.
  • Enlist family member support when able.  Have them join the resident virtually for meals.
  • Remember that food has to be eaten to count. Honor resident choice and encourage selection of favorite foods, even if it’s cereal for supper!
  • Coordinate opportunities with therapy and activities to encourage exercise and activity to help stimulate a healthy appetite.  
  • Timing therapy sessions to assist patients in routine daily functions including getting dressed and out of bed for meals to improve alertness and mobility for safe intake of meals/snacks.
  • Refer for speech or occupational therapy screening when safe chewing/swallowing or self-feeding or positioning are of concern.

Fun fact: Did you know that the scent of cinnamon, citrus, spearmint, and peppermint can all stimulate appetite and alertness?

As the public health emergency continues, we must continue to rise to our residents’ needs. It is crucial to be diligent about monitoring weight and enriching resident care plans with nutritional and physical activity interventions to prevent weight loss. The keys to successful resident outcomes during a pandemic are knowledge, communication, and collaboration. Reliant Rehabilitation is proud to partner with you, your staff, and your residents!

COVID-19 Vaccine Resources

With the increasing availability of COVID-19 vaccinations on the horizon and updated information being released almost daily, organizing the pertinent material into a concise usable format can be daunting. Below are the most up-to-date resources from the CDC, CMS, and FDA regarding the COVID-19 vaccine.

CDC Vaccine Resources

CMS Vaccine Resources

FDA Vaccine Resources

CMS Provides Updated Guidance for Use of Waivers

CMS has updated its guidance and provided specific instructions for using the Qualified Hospital Stay (QHS) and benefit period waivers, as well as how this affects claims processing and SNF patient assessments.

  • To bill for the QHS waiver, include the DR condition code. To bill for the benefit period waiver:
    • Submit a final discharge claim on day 101 with patient status 01, discharge to home.
    • Readmit the beneficiary to start the benefit period waiver.
  • For ALL admissions under the benefit period waiver (within the same spell of illness):
    • Complete a 5-day PPS Assessment. (The interrupted stay policy does not apply.)
    • Follow all SNF Patient-Driven Payment Model (PDPM) assessment rules.
    • Include the HIPPS code derived from the new 5-day assessment on the claim.
    • The variable per diem schedule begins from Day 1.
  • For ALL SNF benefit period waiver claims (within the same spell of illness), include the following:
    • Condition code DR – identifies the claims as related to the PHE
    • Condition code 57 (readmission) – this will bypass edits related to the 3-day stay being within 30 days
    • COVID 100 in the remarks – this identifies the claims as a benefit period waiver request

Note: Providers may utilize the additional 100 SNF benefit days at any time within the same spell of illness.

Claims are not required to contain the above coding for ALL benefit period waiver claims.

Example: If a benefit waiver claim was paid utilizing 70 of the additional SNF benefit days and the beneficiary either was discharged or fell below a skilled level of care for 20 days, the beneficiary may subsequently utilize the remaining 30 additional SNF benefit days as along as the resumption of SNF care occurs within 60 days (that is, within the same spell of illness).

Additional instructions can be found in the article if you previously submitted a claim for a one-time benefit period waiver that rejected for exhausted benefits.

CLICK HERE to view the MLN Matters article.

CLICK HERE for the updated list of blanket waivers available.

CMS to retire the original Compare Tools on December 1

Use Medicare.gov’s Care Compare to find and compare health care providers.

In early September, the Centers for Medicare & Medicaid Services (CMS) released Care Compare on Medicare.gov, which streamlines the eight original health care compare tools. The eight original compare tools – like Nursing Home Compare, Hospital Compare, Physician Compare – will be retired on December 1st. CMS urges consumers and providers to:

  • Use Care Compare on Medicare.gov and encourage people with Medicare and their caregivers to start using it, too. Go to Medicare.gov and choose “Find care”.
  • Update any links to the eight original care tools on your public-facing websites so they’ll direct your audiences to Care Compare.

With just one click on Care Compare, easy-to-understand information about nursing homes, hospitals, doctors, and other health care providers is available.

Information about health care providers and CMS quality data will be available on Care Compare, as well as via download from CMS publicly reported data from the Provider Data Catalog on CMS.gov.


Direct links to the tools & additional resources

Care Compare on Medicare.govhttps://www.medicare.gov/care-compare/

Provider Data Catalog on CMS.govhttps://data.cms.gov/provider-data/

Care Compare resources for consumers and partners – Medicare blog, Promotional video, Conference card  

Full Press Release: https://www.cms.gov/newsroom/press-releases/cms-care-compare-empowers-patients-when-making-important-health-care-decisions

Triumphs During Trying Times

The holiday brings with it an important time of reflection. As we gather around our proverbial table with you as part of our Reliant family, we pause to remind ourselves that despite the profuse and unique challenges of 2020, there were numerous successes for which to be grateful. While the list of obstacles at times seemed insurmountable, we continued to be a light to our patients – constantly adapting, advocating, evolving, leaning on our interdisciplinary team members, and showing up despite unsettling moments, and at times, heartbreaking losses.

Essential staff have risen as infection control heroes. We protected our residents, ourselves, and our loved ones through diligent processes as vigilance became a top priority. We met these challenges by solidifying our knowledge of infection prevention and control, provision of care for those in isolation, and proper use of personal protective equipment. The procedures and protocols developed this year will, no doubt, continue to ensure everyone’s safety in the long run.

Isolation and quarantine became a daily reality in an attempt to prevent and mitigate infection spread. Reliant clinicians continue to combat this by brainstorming and executing some impressive, heart-warming, therapeutic activities that provide much needed social interactions, safely. For example, our Sterling Oaks Rehab team built an actual lemonade stand to help the residents celebrate the end of summer, Northern Nevada Veterans Home created a resident carnival for their patients, and there were many more examples. They also incorporated daily care needs into their skilled treatment sessions to assist nursing staff. Countless other interdisciplinary teams facilitated “visits” through video calls or even through windows with patients and their families during quarantine.

This year, thousands of long-term care providers and therapists banded together to make their voices heard. Our respective, discipline-specific associations and The National Association for the Support of Long Term Care (NASL) enabled a multitude of health care providers to voice their concerns creating a powerful advocacy force and gateway to facilitate action. Advocacy measures impacted bipartisan legislation to continue to fight against cuts that would affect service provision for those who need it the most, proving that advocacy does matter!

As vaccine and treatment options appear imminent, even on the cusp of again increasing cases, we can go forward with knowledge, confidence, and determination to continue to protect and fight for our residents.  So this year, as we sit around our “Reliant table” and share feelings of gratitude with and for one another, despite having to hold each other’s gloved hands and speak through masks, we hope you feel and sense accomplishment and gratitude, and that you are smiling under those masks, knowing that we stood together on the precipice of the unknown and found resilience, meeting daily demands with continued hope beyond the present circumstances. 

Core Principles of COVID-19 Infection Prevention

  • Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms
  • Hand hygiene (use of alcohol-based hand rub is preferred)
  • Face covering or mask (covering mouth and nose)
  • Social distancing at least six feet between persons
  • Instructional signage throughout the facility and proper visitor education on COVID-19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face covering or mask, specified entries, exits and routes to designated areas, hand hygiene)
  • Cleaning and disinfecting high frequency touched surfaces in the facility often, and designated visitation areas after each visit
  • Appropriate staff use of Personal Protective Equipment (PPE)
  • Effective cohorting of residents (e.g., separate areas dedicated COVID-19 care)
  • Resident and staff testing conducted as required at 42 CFR 483.80(h) (see QSO-20- 38-NH)

Interrupted Stay Policy

Under the Patient-Driven Payment Model (PDPM), there is a potential incentive for providers to discharge skilled nursing facility (SNF) patients from a covered Part A stay then readmit the patient in order to reset the variable per diem schedule. To mitigate this potential incentive, an interrupted stay policy is included within the PDPM. 

This policy combines multiple SNF stays into one single episode in situations where the patient’s discharge and readmission occur within a prescribed window. If a patient is discharged from a SNF and readmitted to the same SNF no more than three consecutive calendar days after discharge, then the subsequent stay is considered a continuation of the previous stay.  In this instance, the variable per diem schedule continues from the point just prior to discharge.

If the patient is discharged from a SNF and then readmitted more than three consecutive calendar days after discharge or admitted to a different SNF, then the subsequent stay is considered a new stay.  In this instance, the variable per diem schedule resets to day one.

CLICK HERE for more information in the PEPPER User’s Guide Update.

Speech Language Pathology’s Role in COVID Recovery

The novel coronavirus and resulting pandemic have altered our lives in many ways. The combination of  isolation, physical and social distancing, as well as an economic crisis have all impacted our personal and professional lives. Juggling the ever-changing responsibilities during a healthcare emergency may be overwhelming. The lack of social connections with family and friends as well as in-person visits with your patients can lead clinicians to feelings of loneliness and isolation. Now consider the impact that continued social distancing and isolation may have on the residents and patients within our long-term care facilities. In some instances, isolation of residents has been ongoing for the entirety of the pandemic, entering nearly 6 months!

Prior to this healthcare emergency, a 2019 University of Michigan study on healthy aging noted that 34% of adults aged 50-80 years reported feeling lonely. This current period of social isolation will only exacerbate the number of adults feeling disconnected and lonely and disproportionately affect the elderly population, especially those whose primary social contacts were within their long-term care facility. Furthermore, according to the National Academics of Sciences, Engineering, and Medicine, “Seniors who are experiencing social isolation or loneliness may face a higher risk for mortality, heart disease, and depression.”

As experts on communication, SLPs know the value and need for social interaction for the mental health and well-being of our patients. We are a major factor in the identification of patient needs and educating patients and caregivers on appropriate and personalized techniques to improve and maintain cognitive, speech-language, and executive functioning. We can start by educating on the importance of social interaction and modeling how to achieve this safely during the pandemic.

In the absence of cognitive stimulation and routine, patients may have trouble maintaining prior levels of cognition. We can encourage and educate on the use of daily orientation techniques and maintaining daily routines – targeting problem solving, reasoning, memory, and sequencing during morning and evening self-care routines. Engage with each patient on a personal level and encourage all caregivers to do the same. Provide insight to caregivers on personal preferences that may enhance engagement.

Socialization and purpose play a critical role in feelings of self-worth and success in everyday life. Encourage the use of personal electronic devices. Provide education on increasing socialization through communication and social media. Encourage residents to write letters to family or “neighbors” within the facility. Foster conversation between residents and caregivers during meals and invite family or friends to “dine” with residents via videoconferencing.

Incorporate training on personalized “home” exercise programs to give purpose and focus to each resident’s day. Develop exercises that capitalize on the routines the resident has already established, such as oral motor exercises and/or breathing exercises during a TV commercial break.

As we evolve as professionals during a pandemic, we must continue to protect and advocate for our most vulnerable residents. With the continuation of the healthcare emergency there is a fine line between protecting those that are medically fragile from this virus while continuing to encourage and promote socialization that is vital to their well-being. As visitor restrictions are lessened we continue to be the lifeline that can bring awareness to the effects of social isolation on our residents in long-term care, and by supporting the facility and promoting each caregivers’ strengths as well as educating in areas of opportunity we are creating a more understanding and supportive environment for our residents.  

https://www.asha.org/Practice/Connecting-Audiologists-and-Speech-Language-Pathologists-With-Mental-Health-Resources/

https://time.com/5833681/loneliness-covid-19/

https://www.nationalacademies.org/news/2020/02/health-care-system-underused-in-addressing-social-isolation-loneliness-among-seniors-says-new-report

Occupational Therapy’s Role in COVID Recovery

As we all have become acutely aware of, COVID-19 and the response to the pandemic have resulted in adverse outcomes to residents of skilled nursing and long-term care facilities. These adverse outcomes range from reduced physical function, including decreased muscle strength and endurance, to cognitive and psychosocial impairments, including delirium, neurological dysfunction, depression, and occupational deprivation. In combination, these symptoms paint a clear picture for the need of occupational therapy (OT) intervention. As OT practitioners, we must identify and champion our unique role in not only the physical rehabilitation of our patients but also in their psychological well-being.

According to the American Journal of Occupational Therapy’s (AJOT) OT Practice Framework, our profession, in its fullest sense, is facilitating achieved “health, well-being, and participation in life through engagement in occupation.” We identify the areas of occupation that our residents value, consider their context, and recognize the unique performance patterns and skills that affect the individual’s ability to engage and participate. This is clearly a client-centered, holistic process—one that considers physical function, cognition, and psychosocial impairments that may be impacted. Who better to address the wide range of outcomes that have resulted with our residents in skilled nursing and long-term care facilities?

As we continue to care for our residents who have been affected directly or indirectly by COVID-19, it is imperative that we implement this client-centered, holistic approach. How has the individual’s physical function been affected? Consider implementation of a cardiopulmonary program that includes respiratory strategies, postural control exercises, and exercise prescriptions. To address changes in cognition, complete a standardized cognitive assessment to identify specific processing skills for intervention during activities of daily living. Equally important, and even more important in some cases, are the psychosocial challenges that residents face during the pandemic. As patients are isolated to reduce transmission risks, unintended negative consequences present, including disruption of daily routines and restrictions to leisure and social participation. Recent studies suggest that isolation- associated loneliness has contributed to swift health declines in residents with dementia during the COVID-19 pandemic. Recognize and affirm residents in the challenges they face and use creative technological outlets to enhance participation in meaningful daily activities. Are there opportunities for virtual conferencing with friends or family? Are audio books, online games, or learning modules an option for leisure?

As OT practitioners, we are equipped to meet the tidal wave of challenges that COVID-19 has introduced to residents in skilled nursing and long-term care facilities. The tenets of our profession prepare us to respond to the physical, cognitive, and psychosocial changes that may occur. Though relaxed restrictions to nursing home visitation are on the horizon, the time is now to take hold of our unique, distinct role in facilitating health, well-being and participation in the lives of our residents.   

References:

American Occupational Therapy Association. (in press). Occupational therapy practice framework:

Domain and process (4th ed.). American Journal of Occupational Therapy, 74 (Supplement 2). Advance online publication.


De Biase, S., Cook, L., Skelton, D. A., Witham, M., & Ten Hove, R. (2020). The COVID-19 rehabilitation

pandemic1. Age and ageing, 49(5), 696–700. https://doi.org/10.1093/ageing/afaa118

Gitlow, L., PhD, ATP, FAOTA, OTR/L, Lee, S., OTR/L, Hemraj, R., OTR/L, Sheehan, L., OTD, OTR/L, & Ambroze, G., OTS. (2020). Occupational Therapy and Older Adults: Combating Social Isolation through Technology. PDF. American Occupational Therapy Association.

Lasek, A. (2020, September 18). Dementia mortality skyrockets since lockdowns; CMS loosens visitor restrictions – Clinical Daily News. Retrieved September 18, 2020, from https://www.mcknights.com/news/clinical-news/dementia-mortality-skyrockets-since-lockdowns-cms-loosens-visitor-restrictions/?utm_source=newsletter

Physical Therapy’s Role in COVID Recovery

For over 100 years, physical therapists have specialized in human movement using skilled interventions to maximize health and function.  During periods of critical illness, such as moderate to severe cases of COVID-19, it is common for patients to experience a loss of physical function which can lead to the development of new impairments or worsening of existing ones.

Long-term recovery from COVID-19 may be complicated by lasting effects due to deconditioning, restrictive lung disease, post intensive care syndrome, or neurological disorders. After 10 days of bed rest healthy older adults may lose up to 2.2 pounds of muscle mass from the legs with 2-5%/day loss of muscle strength.  Recovery of physical function may take an extended period of time with impairments that may persist up to 2 years post infection. 

As practitioners of movement, physical therapists are essential in early mobility during and following a critical illness in order to minimize the effects of immobility.  Through skilled interventions such as functional mobility, balance training, endurance activities, posture training, and strengthening, physical therapists are equipped to help residents achieve their optimal level of function as quickly and effectively as possible.

Along with debility, residents in nursing homes that remain quarantined during the public health emergency face another silent threat: social isolation. Even with the recent relaxation of nursing home visitor guidelines, the effects of social isolation may be long lasting.

Restricted access to family and friends may affect even those who have not contracted the virus itself and may include severe fatigue, anxiety, post-traumatic stress disorder, depression, and cognitive dysfunction. 

The effects of patients remaining in their room, the cessation of communal dining, and restricted access to common areas (i.e. the therapy gym and equipment) pose significant barriers not only to successful intervention and outcomes, but also overall resident well-being. The interdisciplinary team should assess and re-assess situations, analyze tasks, make changes, and consider a holistic plan of care to help reduce the lasting effects of social isolation and provide person-centered, specialized care which emulates Reliant’s motto of Care Matters.

References:

https://www.bsrm.org.uk/downloads/covid-19bsrmissue1-published-27-4-2020.pdf.

https://academic.oup.com/ptj/article/100/9/1458/5862054

https://www.aannet.org/initiatives/choosing-wisely/immobility-ambulation

The Impact of Isolation and New Guidance from CMS

As healthcare providers, it has been our priority to encourage and maintain as much “normalcy” as possible while following all guidelines issued to protect our residents from COVID-19 over the last 6 months. We have seen firsthand the impact these regulations have had on our residents, and have used creativity to modify the environment, teach our residents how to utilize technology to speak to their family members, and encourage continued mobility and activity. Even with exhaustive efforts to bridge family communication and daily support and love from staff, depression and loneliness among residents continues to rise.

Recently, the Centers for Medicare and Medicaid Services (CMS) has announced new guidance for long-term care facilities in relation to visitation stating, “we recognize that physical separation from family and other loved ones has taken a physical and emotional toll on residents. Residents may feel socially isolated, leading to increased risk for depression, anxiety, and other expressions of distress. Residents living with cognitive impairment or other disabilities may find visitor restrictions and other ongoing changes related to COVID-19 confusing or upsetting.” While allowing visitation will certainly improve resident morale, CMS has also opened the door to increased social interaction between residents throughout the day.

Deep within this guidance, CMS advises to resume communal activities and dining while adhering to infection prevention recommendations. For example, residents may eat in the same room with social distancing. Group activities may also be facilitated with social distancing among residents and use of appropriate hand hygiene and face covering. Facilities may also be able to offer a variety of activities while taking the necessary precautions. CMS further states that “facilities may not restrict visitation without a reasonable clinical or safety cause.”

The detailed memo largely outlines visitation for indoor, outdoor, and compassionate care situations. CMS advises that visitation should be person-centered, taking into consideration each resident’s physical, mental, and psychosocial well-being. Outdoor visitation is preferred and should be utilized whenever practicable as it poses a lower risk of transmission. Facilities should also accommodate and support indoor visitation as safety and risk assessment allow utilizing data from the COVID-19 county positivity rate, found on the COVID-19 Nursing Home Data website. Facilities should continue to reduce transmission risk while allowing visitation through the use of physical barriers (i.e. clear Plexiglas dividers or curtains).  Among these guidelines, CMS emphasizes the need to follow core principles of COVID-19 infection prevention and use of social distancing.

Although this is not a return to normal, the new guidelines from CMS provide hope for our residents and caregivers by allowing them to have time with their loved ones and other residents within their facility. As healthcare providers, we continue to be the lifeline that can bring awareness to the effects of social isolation on our residents in long-term care. By promoting safe interaction among residents and their families, friends, or neighbors, we are creating a more understanding and supportive environment for our residents.

The CMS guidance for visitation can be found here.

https://www.nationalacademies.org/news/2020/02/health-care-system-underused-in-addressing-social-isolation-loneliness-among-seniors-says-new-report

Clinical Appeals Corner: Sept. 2020

Earlier this year, the U.S. Centers for Medicare and Medicaid Services (CMS) deleted certain Correct Coding Initiative (CCI) edits related to physical, occupational, and speech therapy during the public health emergency. Recently, CMS announced that effective October 1, it will reinstate previously deleted coding edits for code pairs that represent common and appropriate therapy practice (i.e. 97116 and 97530 or 92526 and 97129).

The reinstated edits will require the use of the 59-modifier when these code pairs are provided on the same date of service. For clinicians, data entry within Optima will remain the same. The 59-modifer will automatically be added by Optima when appropriate and viable on the Service Delivery Logs.

CLICK HERE for the list of edits from CMS.

Take CARE with Infection Control

With frequently updated guidance from federal and state agencies, we are continuously hearing the most current information on how to protect our residents from COVID-19 with best practice infection control. Keeping all members of the team informed of the most recent processes may appear to be a daunting task; however, with the uptick in COVID-19 cases in nursing homes and CMS administrator Seema Verma stating concern, it’s a great time to review how we can keep our residents, staff, and selves safe.

Reliant has created a 4-step approach to Take CARE with Infection Control:

When considering implementation, identify appropriate hand hygiene frequency, PPE based on type of precautions, and items and equipment that need routine cleaning and disinfection.  Be attentive to sequenced steps and processes for hand hygiene, donning and doffing PPE, and cleaning.  In order to ensure reliability, commit to self and peer accountability and implementing PPE peers using return demonstration. To monitor effectiveness of implementation, assess and adjust processes as necessary.

Download and review CMS’ latest Infection Control Survey Guidance (released 8/26/2020) as a guide.

By working together as an interdisciplinary team and holding each other accountable for best practice infection control practices, we can minimize the spread of COVID-19 within our facilities.  Practice extreme diligence and caution with infection control and prevention processes.

CLICK HERE for more information on Reliant’s Take CARE with Infection Control initiative.

MACs Resume Medical Review on a Post-Payment Basis

In the August 6, MLN, CMS announced Medicare Administrative Contractors (MACs) are resuming fee-for-service medical review activities. Beginning August 17, the MACs resumed with post-payment reviews of items/services provided before March 1, 2020. The Targeted Probe and Educate program (intensive education to assess provider compliance through up to three rounds of review) will restart later. The MACs will continue to offer detailed review decisions and education as appropriate.

CLICK HERE to review the MLN Connects newsletter.


Although medical review has not been initiated at this time for dates of service during the public health emergency, future RAC and MAC reviews are forthcoming. According to an article posted on RAC Monitor on 8/25/20, high priority audits may include claims with

  • Positive COVID-19 diagnoses to ensure testing results are accurately documented. 
  • Remote patient monitoring codes

Providers should be reviewing claims and supportive documentation now to identify potential areas of improvement.

Additionally, the introduction of remote audits is anticipated. The remote audits allow for the current work-from-home, travel-restricted business climate.

CLICK HERE to view the article in its entirety.

What’s GG Got to Do With It?

Despite the many adaptations and additional considerations that have been adopted in the battle against COVID-19, healthcare providers in skilled nursing facilities (SNFs) maintain their primary focus of quality patient rehabilitation and care. In the midst of planning and delivering care in a pandemic, some may ask, Does data collection really matter right now?  What’s GG got to do with it? The answers are Yes and everything!

CMS has indicated the value of data collection of our patient’s functional abilities (i.e. Section GG) by signaling it as a key comparison of quality across post-acute settings, an indicator of resource use impacting reimbursement, and critical to guiding patient-centered care planning. Although CMS stated exceptions and extensions were granted because data collection may be greatly impacted by the response to COVID-19, beginning July 1, SNFs are expected to report their quality data to meet the SNF QRP requirements for the third quarter of 2020. (Download CMS’ SNF QRP Tip Sheet)

Knowing this data eventually will be publicly posted, the question now becomes Does it reflect our exhausting efforts to deliver care during this public health emergency? That answer is yet to be determined, but it is never too late for a review and refresh of Section GG content as well as considerations for coding and patient identification in the current environment.

Accuracy of Section GG coding depends not only upon the healthcare professional’s familiarity with the objective scales, but also with each item’s definition, intent and parameters for coding. For example, walking items may be completed within separate sessions. A single walking item may include a brief rest, as long as the resident does not sit down. These considerations may assist in completing a thorough assessment in isolation. CMS provides training videos on the SNF QRP Training webpage for instructional purposes.

Facilities can use Section GG data to capture potential changes in function that may require skilled intervention by completing interim assessments. It is the role of the interdisciplinary team to identify potential impacts of isolation on a patient’s biopsychosocial wellbeing and intervene as appropriate.

Finally, review the submission requirements for the SNF-QRP, so a technicality does not overshadow the successful outcomes your teams are creating. Avoid dashes, utilize the activity not attempted codes as necessary, incorporate at least one goal into the patient’s care plan and submit the completed data for at least 80% of your Medicare A claims.

The interdisciplinary team should champion the role of data collection, even in a pandemic, to ensure that we are facilitating the appropriate plan of care, capturing the true picture of the resident’s needs and maintaining the highest quality of rehabilitation and care. Our patients are counting on us!

Medical Review Audits Suspended

Reliant has worked closely with the National Association for the Support of Long Term Care (NASL) to raise awareness of the activity associated with Medicare’s medical review process during this pandemic, including pre-pay targeted probe and educate (TPE) activity and post-pay recovery audit contractor (RAC) reviews. At this time, Novitas, First Coast and CGS have suspended TPE activity until further notice. Our contacts indicate current pre-pay TPEs will be released and paid in the coming weeks.

According to an FAQ released on 3/30/2020, CMS indicates suspension of most Medicare Fee-For-Service (FFS) medical reviews during the emergency period due to the COVID-19 pandemic. The FAQ states that both pre-payment medical reviews such as the reviews for TPE and post-payment reviews conducted by the MACs, Supplemental Medical Review Contractors (SMRCs) and Recovery Audit Contractors (RACs) are suspended for the duration of the Public Health Emergency (PHE).

The FAQ also notes that “no additional documentation requests will be issued for the duration of the PHE for the COVID-19 pandemic.” Current post-payment review by the MACs, SMRCs, and RACs will be suspended and released from review as well. CMS is suspending these medical review activities for the duration of the PHE, but could conduct medical reviews “during or after the PHE if there is an indication of potential fraud.”