I continue to be disappointed in the inadequate therapy intervention that I see occurring for a resident of a long-term care environment who has dementia. During our training sessions and workshops we often discuss the fact that a therapist can get reimbursed to design a maintenance program and train others to implement the program. I continue to hear "concern" about the word "maintenance" and a level of disbelief that this service is actually "billable."
Let's review some of the Medicare guidelines and describe how they can be applied in order to maximize services for the person with dementia.
The Medicare Benefit Policy Manual (Pub 100-02, Chapter 15, Sections 220 & 230) describes skilled therapy, reasonable and necessary, medical necessity, and covered therapy for the development and training of a maintenance program.
C - Rehabilitative Therapy
Covered therapy services shall be rehabilitative therapy services unless they meet the criteria for maintenance therapy requiring the skills of a therapist described below. Rehabilitative therapy services are skilled procedures that may include but are not limited to:
Establishment of treatment goals specific to the patient's disability or dysfunction and designed to specifically address each problem identified in the evaluation;
Design of a plan of care addressing the patient's disorder, including establishment of procedures to obtain goals, determining the frequency and intensity of treatment;
Continued assessment and analysis during implementation of the services at regular intervals;
Instruction leading to establishment of compensatory skills;
Selection of devices to replace or augment a function (e.g., for use as an alternative communication system and short-term training on use of the device or system); and
Patient and family training to augment rehabilitative treatment or establish a maintenance program. Education of staff and family should be ongoing through treatment and instructions may have to be modified intermittently if the patient's status changes.
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. Rehabilitative therapy services are reasonable and necessary services furnished by or under the supervision of qualified professionals.
This description provides us with the following opportunities to serve:
- We can develop a maintenance program (this will be discussed further in the following section).
- We can provide therapy service to improve a "functional limitation."
Alzheimer's disease causes justified functional limitation. However, many people with dementia are living with "excess disability." This occurs when the person's highest practicable level of function is unable to be identified and/or facilitated by family or professionals. This results in the person performing below their functional potential.
Alzheimer's disease and related dementias are considered chronic, irreversible, and progressive. Our interventions will not improve the "impairment" but they will improve the "functional limitation" caused by the cognitive or communication impairment.
In this circumstance of reducing "functional limitations" and "excess disability" the therapist will typically follow this process:
- Perform a comprehensive assessment, including the Allen Cognitive Assessment, to identify current status.
- Translate these results into identification of the person's highest functional potential.
- Observe the patient in their living environment with their caregivers to identify problems/barriers that may prevent the person from reaching their highest functional potential.
- Develop a maintenance program that capitalizes on remaining abilities, compensates for deficits, and reduces any barriers.
- Train caregivers to understand the highest level of function goal and how to deliver the approaches to achieve that goal.
- Make certain the caregivers demonstrate competency before discharge.
- Make certain your discharge summary indicates the "improvement in functional limitation" as a result of your skilled service.
D – Maintenance Programs . . .
Evaluation and Maintenance Plan without Rehabilitative Treatment.
After the initial evaluation of the extent of the disorder, illness, or injury, if the treating qualified professional 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-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.
Once again, Alzheimer's disease and related dementias are classified as chronic, irreversible, and progressive. As a result, the above suggests that even if the therapist determines, through an evaluation, that the person's medical condition does not yet "justify the need for skilled service," it would be a covered service to develop a maintenance program to "prevent or minimize deterioration" of the deficit caused by the progressive medical condition.
This implies that therapist skills are reimbursed to develop a maintenance program for people with Alzheimer's or a related dementia. Think about how many individuals who live in a long-term care environment (nursing home or ALF) currently have this diagnosis. And, how many of these individuals have had the benefit of a therapist who has designed a maintenance program to prevent or minimize their deterioration? In my experience, far too few.
Your Services Are A Win-Win-Win for Everyone
The benefit of your therapy intervention for the resident is obvious. I will discuss this further in a moment. But let us not forget the benefits to the facility and to the therapy organization. The facility would love more "staff education" to better help their activity, CNA, and nursing team maximize the function, quality of life, and safety of their residents. Our services also help to reduce behaviors and falls and to maintain functional abilities and health longer, etc. All of these outcomes have great value to the facility. And, the facility shares in Medicare Part B revenue produced.
The "win" for the therapy company is increased revenue. There are many long-term residents who probably have not been served in this way and yet they are appropriate and waiting for your service. Med B therapy utilization should increase as a result.
And, what is the "win" for the resident? I could write a book about that. And for those of you who know me, you know my eyes are filling with tears as I write this.
The provision of therapy services is a business with a bottom line. Nursing homes and assisted living facilities are also a business. But we are all in the business to take care of our seniors. We must never forget that.
Seniors with dementia don't have to live with excess disability! They don't have to exist instead of live.
We have the gift of knowledge and the support of Medicare to enable each person with dementia to live, love, laugh and prosper . . . despite their diagnosis.
Our seniors deserve emphasis placed on their quality of life. I challenge you to address this need despite any barriers that you may face. Just remember that reimbursement is not the barrier. And, your efforts are worth the reward!!!