Sensory Stimulation Programs for Persons in Allen Level 1 and 2

Authored by: Kim Warchol, OTR/L

Person's functioning in Allen level 1 and 2 will greatly benefit from a sensory stimulation maintenance program. The average activity and social climate are not beneficial to a person of this cognitive level. Therefore, we must create a meaningful and therapeutic activity experience by enabling this person to use their remaining abilities while managing their deficits.

Persons in Allen level 1 have similar cognitive functional abilities of the developmental age of an infant. These include:

Key Remaining Abilities

• Can respond to stimuli
• Can track
• Can make vocalizations
• Partial AROM of the upper and lower extremities

Of course this person does not have the ability to talk, walk, use hands, etc.

Persons in Allen level 2 have similar cognitive functional abilities of the developmental age of 12-18 months old. These include:

Key Remaining Abilities

• Can sit unsupported, possibly for only brief periods of time
• Can stand and/or walk
• Can move upper and lower extremities through full range of motion
• Can say a few words
• Can use hands for finger foods

Of course, they have all of the abilities of someone in Allen level 1 but they do not have functional hand use, goal directedness, etc.

Persons in Allen level 1 and 2 have very limited attention and can become quickly overly stimulated. The average activity group is too large and cognitively challenging for this person to be successful. Often, ADL's are done for this individual. Therefore, this individual is at great risk for problems such as depression, contractures, skin breakdown, weight loss and aspiration pneumonia.

Relating Sensory Stimulation Programs to the Medicare Reimbursement Guidelines

A sensory stimulation program can and should be designed for persons functioning at Allen level 1 and 2. The goals should be related to improvement or prevention of high risk areas. Remember, Medicare Guidelines (Chapter 15 in the Medicare Integrity Manual) state the following:

Adapted from Medicare Benefit Policy Manual - Chapter 15 Section 220.2

B. Reasonable and Necessary:

• The skills of a therapist are needed to manage and periodically reevaluate the appropriateness of a maintenance program as described below
• There must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time, or the services must be necessary for the establishment of a safe and effective maintenance program required in connection with a specific disease state. In the case of a progressive degenerative disease, service may be intermittently necessary to determine the need for assistive equipment and/or establish a program to maximize function (see item D for description of maintenance services)

C. Skilled Therapy

Rehabilitative therapy occurs when the skills of a therapist are necessary to safely and effectively furnish a recognized therapy service whose goal is improvement of an impairment or functional limitation.

Evaluation and Maintenance Plan without Rehabilitative Treatment
After the initial evaluation of the extent of the disorder, illness, or injury if the treating qualified profession determines the potential for rehabilitation is insignificant, an appropriate maintenance program may be established prior to discharge. Since the skills of a therapist are required for the development of the maintenance program and training the patient or caregivers, this service is covered. 

Example: The skills of a qualified speech-language pathologist may be covered to develop a maintenance program for a person 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.

We must be aware of these reimbursement guidelines and apply them into our notes and evaluations/reason for referral in order to help justify the need for skilled intervention. For persons in Allen level 1, we are likely providing therapy to "prevent or minimize deterioration". For persons in Allen level 2 we may be providing this therapy service to "prevent or minimize deterioration", or to "maximize function due to the progressive disease of Alzheimer's or a related dementia type" or to "improve an impairment or functional limitation".

Generally speaking, a sensory stimulation program can be created by an Occupational, Physical or Speech therapist. Each discipline is responsible for creating a program that addresses an outcome area that is related to their discipline/practice area.

Tips for a Successful Sensory Stimulation Program

• Create a multi-sensory experience around a highly valued activity
• Include as many highly familiar sensory experiences as possible
• Design a program that is no greater than 15 minutes in length and suggest that this program be delivered 2-3 times per day
• Provide stimulation to 1 or 2 senses at a time
• Provide the intervention in a quiet, distraction free environment
• Create a kit that includes the sensory stimuli (if possible), instructions, and expected responses
• Train caregivers such as family members, activities, social services, CNA's and restorative personnel
• Make sure each of these trained caregivers is aware of the benefits of the responses.

Examples:

• If the resident makes vocalizations in response to the stimulation provided, this can help him/her to clear the airway and reduce the risk of aspiration pneumonia.
• If the resident flexes and extends at the elbows in response to the stimulation, this can help/him her to reduce the risk of developing an elbow contracture
• If the resident turns his/her head in response to the stimulation, this can help him/her to reduce the risk of developing a painful head/neck contracture
• If the resident raises his/her arm up and down through partial range of motion in response to the stimulation, this can help him/her to reduce the risk of skin breakdown and contracture
• If the resident extends the knee in response to the stimulation, this can help him or her to reduce the risk of developing a knee contracture and/or skin breakdown

I believe the ability to connect to long term memory is still present at these Allen levels. The two things that have been said to tap into our memory the best is the sense of smell and music. If possible, try to include familiar smells and music into your program in order to facilitate the greatest responses.

Key Documentation Elements

Writing Goals
The therapy goal should be written so that it clearly identifies the expected outcome. We are not always going to be able to improve function but can reduce the chance that a high risk area will occur and for a person in Allen level 2 we might be "reducing a functional limitation" such as a functional limitation in feeding or transfers.

Example Goals:

• Patient will respond to external stimuli with consistent automatic actions of vocalizations and clearing of airway to prevent or minimize the risk of aspiration pneumonia.
• Patient will respond to external stimuli with consistent automatic actions of partial range of motion of the upper and lower extremities to prevent or minimize the risk of contractures and skin breakdown.
• Patient will respond to external stimuli by extending knees through full range of motion to improve the ability to transfer and to reduce the risk of knee contractures and skin breakdown.

Reasonable Intervention Period
If we are simply developing a maintenance program for one of the reimbursable reasons previously stated the amount, frequency and duration must be reasonable. Generally speaking, I have utilized approximately 6 visits for such a service. I typically spend the first two visits performing evaluation and determining BATF/Allen level. The second two visits I am establishing and implementing the sensory stimulation program. The final two visits I am training caregivers and ensuring their competency. However, this is not a prescription for reimbursement as you must make the decision on the reasonable intervention period based upon your specific evaluation results.

Selecting CPT Codes
As always, you must use your expert clinical reasoning skills to make the decision on what CPT codes to select for your interventions. I am making a few suggestions as to codes that I recommend for consideration for sensory stimulation. Your specific goal and interventions will of course determine the correct coding choice.

97533 - When a deficit in processing from one of the sensory systems (vestibular, proprioceptive, tactile, visual or auditory) decreases ability to make adaptive sensory motor or behavioral responses to environmental demands.

97410 - Manual therapy (joint mobilization & manipulation, myofascial release, PROM, soft tissue mobilization.

97110- Therapeutic exercises to develop strength, endurance, range of motion and flexibility. (The patient participates)

Summary

Typically therapists are very accustomed to intervening for these low Allen levels to provide services such as wheelchair positioning, splinting, PROM education, and diet changes in response to swallowing problems. I am not suggesting that we ignore these important areas of intervention. I am suggesting that the therapist expand their skills to include developing a sensory stimulation maintenance program that can become one additional modality to obtaining outcomes such as contracture prevention, prevention of aspiration pneumonia, etc.

In addition, a sensory stimulation can enhance the quality of life of a person who is often starving for love and attention. The therapeutic benefits are what enable us to be reimbursed by Medicare however the quality of life benefits must become one of our priorities for providing this service to each and every person functioning at Allen level 1 or 2.

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