Serving People with Dementia: An Update "The Barrier to Serve May not Be What You Think!"
Communication Tips for Serving Individuals With Dementia
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By Kim Warchol, OTR/L
As we see the end of 2008 approaching it is time to sit down and review the happenings of the past year, good and bad, related to the provision of Dementia Therapy services. In general much of 2008 saw developments that encourage continued dementia therapy specialization and continued progression of information to help us refine our language and skills. I share this summary list with you to help with your future planning and updates regarding Dementia Therapy.
1. A modification to the name of the model. On a recent call with the board members of the Allen Cognitive Network, we were asked by Deane McCraith to update the name of the model from "The Allen Cognitive Disabilities Theory" to the "Cognitive Disabilities Model developed by Claudia Allen." As an educator, Deane had some very valid reasons for this request. Therefore, we will be moving to integrate this updated name into our materials in the future.
2. New edition of the ACLS/LACLS manual. Around the first of this year, the new and improved version of the ACLS/LACLS manual was published and ready for sale. Please see our January 2008 article entitled "A Review of the New Manual for the ACLS-5 and the LACLS-5" for details. As a clinician you are now required to document what edition of the manual you are administering. For example, if using the latest edition the clinician should document "administered the "LACLS-5" or if using the previous edition document the "LACLS-4", etc. The latest edition is research ready with much improved administration and interpretation guidelines.
3. The adapted placemat test. As you know, we teach and administer an adapted/simplified version of the ADM Placemat Test. Our simplified version was created by Chris Ebell to allow for a more portable and affordable method. However this adapted version does not test all of the cognitive domains to the depth that the original version does, as designed by Catherine Earhart. Therefore we request that the administrator document that this is the "adapted version of the Placemat Test" and that this test be considered more of a "screen" as you are getting broad information. If required, administer the test as designed which calls for gluing and fringing and/or also complete another ADM project for validations. This accuracy of documenting the version tested becomes critical as additional research efforts are in process by different groups.
4. Regulations and Reimbursement Updates
Despite the risk of the cap extension being eliminated in 2008 the congress acted and Alzheimer's disease remains an automatic cap extension.
CMS has begun combining many individual Fiscal Intermediaries into 15 Medicare Administrative Contractors (MAC). This will mean that we will need to become familiar with the new LCDs for the new MACs with relation to the CPT and ICD.9 codes that we are allowed to use in Dementia Therapy. For details, please refer to the September 2008 article "Regulation Updates Impacting Dementia/Alzheimer Therapy Intervention" written by Mary Gennerman.
5. The need grows. The prevalence statistics changed this year. Currently there are 5.2 million people in the United States with Alzheimer's disease (AD). This is up from 5 million. And, currently, 1 in 8 people aged 65+ in the US have AD, which is up from 1 in 10. Also, my personal opinion based upon much interaction with health care company owners and managers is that these leaders are now far more aware of the prevalence of those with AD in various environments.
This Letter Proves We Still Have Much Work to Do!
I recently received a letter that was shared with me by a colleague written by a SLP. This letter contained content about this person's opinion and point of view about being able to serve people who have Alzheimer's disease and related dementias (ADRD). It reminded me of how far we still have to go with regard to spreading the word about the opportunities Medicare has provided us to serve and the importance of providing passionate clinicians with the knowledge to serve people with chronic and progressive dementia types.
Below are some of the statements contained within this letter:
"In a "dementia program" you are talking about totally reprogramming a damaged brain to respond to environmental stressors in a more socially acceptable way AND getting everyone who comes in contact with these people to join you in your quest by reinforcing what you're working on. I just don't see that happening." My Comment: We as clinicians must make our programs with the input of others including the patient, their loved ones, and the facility team members. This is the "may do" component of our model. If we don't create programs that are able to be realistically implemented, the blame lies with us. However, realistic does not mean we have to strip these programs down to nothing. Helping a nurse, CNA, or activity member to use the right communication and care techniques and to modify the environment for success is golden. We should never assume these team members, as a whole, are unwilling to change or learn. I have worked with many who are interested in learning, and in sharing what they know. This collaboration can and does lead to success for all.
Regarding dementia programming in ALFs: "These patients moved from their private homes to the ALF so that they wouldn't have to remember to go grocery shopping, wouldn't get in a car wreck from driving and wouldn't have the lights go out because they forgot to pay the electric bill. For them, moving from their private homes to the ALF where these things were taken care of WAS their strategy. And in doing so, their goal was met: they get 3 squares a day without worry, their medications are given to them, they are driven to activities and their living quarters are safe and comfortable. No deficits exist."
"To me cognitive therapy in the dementia population is like trying to raise the SAT scores in a group home for adults who have developmental disabilities. The disorders are chronic, and in the case of dementia, progressive, so what are we treating? Can we reasonable expect goals being met? Especially those that aim to change abhorrent behaviors?"
My comments: People with ADRD who move to ALFs have many skilled therapy needs. The very fact that they have a chronic, progressive dementia qualifies them for therapy to create a maintenance program to prevent or minimize deterioration (see the reimbursement guideline "a" below).
Also, I can tell you from vast experience that the assessments done by the ALF staff often do not identify the real needs of these clients. Therefore, many problems develop such as isolation and depression due to the inability to get themselves to activities (i.e. can't comprehend the calendar, does not have functional time orientation, can't locate the room) or the activities may not match their cognitive and communication level. And for the same reasons above, weight loss may occur. We often see folks who move into ALFs with dementia who experience many other problems due to the staff not being able to identify their cognitive status and functional needs including falls, over or under medicating, and problems related to poor hygiene. These clients need a skilled therapist to perform a comprehensive evaluation in order to identify their cognitive functional level then to help design their service plan goals and approaches. The therapist will educate staff accordingly so these goals can be met.
In some cases, the person will be admitted to a facility and because of many problems in addition to their cognitive impairment such as communication loss, pain, depression, behaviors or physical complications, the facility is unable to identify the person's best ability to function. Once again, a therapist is enabled to perform comprehensive testing to help tease out this complicated scenario and to discover the person's potential. As a result, functional limitations may be reduced (see guideline "b" below).
The Medicare Benefit Policy Manual (Pub 100-02, Chapter 15, Sections 220 & 230)
(a) The skills of a qualified speech-pathologist may be covered to develop a maintenance program for a patient with multiple sclerosis, for services intended to prevent or minimize deterioration in communication ability caused by the medical condition, when the patient's current medical condition does not yet justify the need for the skilled services of a speech-language pathologist. Evaluation, development of the program and training the family or support personnel would require the skills of a therapist and would be covered. The skills of a therapist are not required and services are not covered to carry out the program.
(b) Rehabilitative therapy occurs when the skills of a therapist (as defined by the scope of practice for therapists in the state), are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation.
We must remember that skilled, reimbursable therapy should not only be provided to those who have acute and reversible diseases or conditions. As you can see in the regulations and by the very nature that Alzheimer's disease is a covered Medicare diagnosis, we are not prohibited to serve those with ADRD. The real barrier may be the prevalence of ill-informed therapists who don't understand the current reimbursement rules and/or have not received the special education to evaluate and treat those with chronic, progressive dementias.
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So as we review and plan ahead, we can clearly see that there is much work to be done and much support for what we do so we can push forward with excitement and energy. Yes, little things change along the way, we may hit bumps in the road such as ill-informed colleagues, and the need for quality documentation to support reimbursement and research is more important than ever before. I hope you join me in continuing your passionate efforts to help make life a better place for those with ADRD.