Therapy Requirements for 2011, Utilizing Best Practices for Patients with Heart Failure, Psychiatric Nursing in Home Health Care
Thursday May 26, 2011
Therapy Requirements For 2011
The CY 2011 Therapy Requirements effective April, 2011 have resulted in many questions after use by therapists.
Therapy Requirements:
Questions are rampant about the reassessments required every 30 days and those required on the 13th and 19th visits. In the March 28, 2011 issue of Home Health Line the journal states “the visit count that will trigger the need for a reassessment is based on the total number of visits when multiple therapy disciplines are involved rather than the visit count for each individual discipline, the fact sheet states.”
The fact sheet referred to is the CMS Therapy Requirements Fact Sheet that can be found at:
https://www.cms.gov/HomeHealthPPS/Downloads/Therapy_Requirements_Fact_Sheet.pdf.
This fact sheet was meant to provide guidance. However weeks of implementation of the new regulations have caused more questions to arise.
The Therapy Requirements Fact Sheet states, “Where more than one discipline of therapy is being provided, a qualified therapist from each of the disciplines must provide the ordered therapy service and functionally reassess, measure, and document the effectiveness of therapy or lack thereof close to or no later than the 13th and 19th therapy visit. The 13th and 19th therapy visit timepoints relate to the sum total of therapy visits from all therapy disciplines. In multi-discipline therapy cases, the qualified therapist would reassess functional items and measure those which correspond to the therapist’s discipline and care plan goals.”
HHL, March 21, 2011 edition cites, “Therapy services won’t be covered after the 13th and 19th visits unless a qualified therapist completes a reassessment.”
In addition, the Fact Sheet identifies:
“Therapy services provided after the 13th and 19th visit (sum total of therapy visits from all therapy disciplines), are not covered until:
The qualified therapist(s) completes the assessment/measurement/documentation requirements.
The qualified therapist(s) determines if the goals of the plan of care have been achieved or if the plan of care may require updating. If needed, changes to therapy goals or an updated plan of care is sent to the physician for signature or discharge.
If the measurement results do not reveal progress toward therapy goals and/or do not indicate that therapy is effective, but therapy continues, the qualified therapist(s) must document why the physician and therapist have determined therapy should be continued.” CMS expects these requirements to be followed or expect no payment for the visits.
The CMS Therapy Requirements Fact Sheet also identifies that “At least every 30 days, for each therapy discipline for which services are provided, a qualified therapist (instead of an assistant) must provide the ordered therapy service, functionally assess the patient, and compare the resultant measurement to prior assessment measurements.” It notes that “The thirty-day clock begins with the first therapy service (of that discipline) and the clock resets with each therapist’s visit/assessment/measurement/documentation (of that discipline).
Per NAHC Regulatory Affairs, ‘the thirty day reassessment count would begin with the initial therapy evaluation through discharge from therapy. The 13th and 19th reassessments are counted per episode since they serve as justification for meeting the therapy threshold.”
Remember, the overall mission of the CY 2011 new rules, for therapy, include continuing or discontinuing treatment or having treatment plan revisions with changes in goals made by a qualified therapist. If therapy is to continue, there must be:
- Clear documentation of objective evidence of patient improvement, or
- A clinically supportable statement of expectations that the patient’s potential to improve is yet to be attained and is expected in a reasonable and generally predictable period of time
CMS clarified regulations at 42 CFR §409.44(c)(2)(iii) by adding that:
- There must be significant improvement
- The clinical record must demonstrate functional improvements that are ongoing and of practical value
- The improvements are to be measured against the patient’s condition at the start of treatment
- Covered therapy services are to be rehabilitative therapy or maintenance therapy (New G-codes for both were included in CY2011).
CMS defines “rehabilitative therapy” as requiring the skills of a qualified therapist, with recovery or improvement in function and, when possible, restoration to the previous level of health. Therapy is meant to assist a patient to improve function and assist a patient to a prior level of well being. The new regulations are meant to capture objective reassessment data at least every 30 days, by a qualified therapist, as well as require a reassessment prior to the higher payment thresholds of the 14thand 20th visits.
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Utilizing Best Practices for Patients with Heart Failure
Best practices are expected when providing quality home health care to heart failure patients. According to the American Heart Association, there are over 5 million cases of heart failure (HF) in the US, with an average 500,000 cases, diagnosed annually. It ranks as the primary and secondary diagnoses for all hospitalizations over the age of 65. The financial burden is in excess of $40 billion, annually, in direct and indirect costs.
Heart failure patients are among those most visited in home health care and among the five most prevalent diagnoses of homecare patients (per VNAA Chronic Care Clearinghouse). A cardiac assessment is often the primary nursing skill for homebound patients diagnosed with heart failure and involves specific knowledge of nutrition, pharmacotherapy, exercise, coping skills, and risk management. Because caring for cardiac patients is frequent, many agencies rely on the clinician’s expertise regarding assessment and planning, yet research is suggesting the establishment of agency protocols is in order.
Pathophysiology
Heart failure may occur when damage is done to the heart preventing it from adequately pumping blood to tissues to meet required metabolic needs. Because the circulatory system carries oxygen and necessary nutrients, a decreased blood flow limits needed tissue nourishment, resulting in compensation by the body as it seeks balance or homeostasis. The body is forced to stimulate the sympathetic nervous system to increase both the heart rate and blood pressure to meet oxygen and nutrient requirements. The kidneys will assist, by a process of vasoconstriction, within the tubules, to increase blood pressure and secondarily retaining and reabsorbing sodium to increase vascular pressure that will aid in also raising blood pressure. In the short term, this is effective. However, long term effects include cardiac decompensation and increased symptoms of heart failure.
Symptoms frequently seen during exacerbations
Per HHQI, Best-Practice Disease Management: Heart Failure Intervention Package, expect to see
- Shortness of breath
- Decreased urination
- Chest pain or heaviness
- Increased weakness or fatigue
- Edema of the feet, ankles, hands, abdomen, or sacrum (anasaca)
- Increase in weight of 2-3 pounds in 24 hours or 3 pounds in one week
- Dry hacking cough or cough producing a white foamy sputum
- Orthopnea (the number of pillows needed propped up to breath comfortably)
- Paroxysmal nocturnal dyspnea (feeling of smothering or fullness in the chest when lying down and resolves when standing up).
An effective in-home prevention and treatment plan helps the patient control symptoms. It also helps control the costs associated with heart failure by reducing the need for emergent and/or inpatient care. Since heart failure patients are among those most often seen in emergent and inpatient settings, a home health clinical specialty heart failure program is necessary for cardiac patients to reduce this incidence. This care is a focus of CMS. New Survey Protocols, effective May 1, 2011, focus on data gathering and outcomes seen, as opposed to the focus on structure and process orientation of past surveys. Care planning and delivery with resulting outcomes of all patients will be the focus, but because heart failure is of growing incidence, expect scrutiny.
As the OASIS process measure begins to produce data, one can expect to see the evaluation and adjustment of processes brought to the forefront. Agencies must consider a specialized episode and disease management plan for heart failure patients under care. This program will assist the agency reach its goals clinically, operationally, and financially.
The CMS OASIS data items were created to measure processes of care in several areas to reflect Institute of Medicine (IOM) goals and Medicare Payment Advisory Commission (MPAC) recommendations. It was felt there is a need to focus on high-risk, high-volume, chronic conditions seen in the home health setting and although CMS indicates that the integrated OASIS-C process items are optional practices, it is believed by industry specialists and content experts that identified best practices are critical to providing efficient quality home health care with expected/predictable outcomes.
Evidence-based best practices
The rationale behind process data elements is to encourage agencies to incorporate evidence-based practices (EBP) into processes. One definition of EBP is to use the best scientific evidence available as a tool to guide clinical decision-making for the purpose of attaining the best outcomes.
Research supports that a combination of proper acute care discharge planning and post discharge care for patients with heart failure can significantly reduce hospital readmission rates, improve quality of life, and reduce cost of care. Heart failure evidence-based standards of care per the American College of Cardiology/American Heart Association (ACC/AHA) include:
- Assessment for fluid retention via monitoring weight and abdominal girth.
- Assessment of activity level, perceived dyspnea, fatigue, reduced exercise tolerance, sleep patterns, and patient’s activity that triggers dyspnea.
- BP standing/sitting, heart rate (HR), respiratory rate (RR), jugular venous distention (JVD) every visit.
- Assess edema and instruct the patient as to obtaining daily weight and complete a patient assessment of abdominal and peripheral swelling, focusing on feet/ankles, hands, sacrum, scrotal area, and abdomen.
- Complete auscultation of heart and lung sounds; identify S3 or S4. Assess for new or recurrent dysrhythmias or murmurs. Per HHQI “changes in heart rhythm can lead to poor cardiac output and worsening heart failure. Note: Extra sounds can be a warning of impending heart failure exacerbation.”
- Assess lung sounds to identify any changes or note wheezes, crackles, rhonchi, or diminished breath sounds.
- The physician may well monitor serum electrolytes/renal function every 6 months.
- Assess appetite. Expect the physician to order a low-fat, low-sodium diet; fluid restriction. When assessing appetite, look for signs of abdominal fluid retention such as feelings of abdominal fullness and early satiety. Refer to girth baseline and successive measurements.
- Assess for orthopnea and paroxysmal nocturnal dyspnea. Verify number of pillows used when lying down. Both of these symptoms are usually intermediate signs of fluid retention and per HHQI, “intervention at this point could still prevent re-hospitalization.”
- A thoracic impendence reading (ZO) may be ordered. Fluid status changes can signify need for intervention and possibly prevent a hospitalization.
- Assess urinary output. Decreased output could signal impending signs of renal failure or heart failure decompensation, as the body attempts to raise blood pressure.
- Assess diabetes control, if applicable.
- Assess psychosocial coping and note symptoms of depression. Assess family and support systems. Depression intervention may be necessary to maintain optimum self care-management.
- If ordered, encourage regular walks progressing to 1 hour per day 3-5 days per week..
- Smoking: Discourage first-hand and second-hand smoke.
Agency Administrators
Administrators who are looking to establish a cardiac program in their agency should review the HHQI “Best Practice Disease Management: Heart Failure.” This Nurse Track is a Best-Practice Disease Management intervention package that supports the implementation, education, and application of current assessment and symptom management modalities with clinical processes to decrease active symptoms in heart failure patients. It discusses providing a structured plan for care, and supports EBP. The package describes nursing actions that support an effective disease management program.
The administrator should also include an assessment of current standards of care in relation to the number of visits incurred as well as type and depth of education provided to patients, along with early intervention for symptoms of heart failure. Once the assessment plan is completed, a review of nursing education gaps assessed, agency-wide education must occur to ensure that all clinicians are familiar with best-practice standards and provide opportunity for feedback. After that education is provided and the standards are implemented, outcomes should be analyzed, and ongoing auditing for compliance should be established to ensure the best practice standards are maintained.
Guidelines in Best-Practices for Administrators
There are many programs available regarding best-practices for care of patients with heart failure. The HHQi site offers RNs a free 2.0 Continuing Nursing Education units after completion of the 115 minute five activities for the Heart Failure Track. In addition, there are tools and podcasts to aid in reducing hospitalizations as well as a Decision Support Tool: Heart Failure
Once the program is underway, data analysis becomes an important practice allowing the administrator to review statistics and trends within the agency-specific patient populations. For the administrator planning to survive present and anticipated future changes in regulation, care delivery, and reimbursement models effective decision-support software providing data aggregation, benchmarking, and analysis opportunities for operational management will be essential.
Administrators should monitor specific patient populations for trending and analysis that include:
- Hospitalization rates by diagnoses
- Disciplines utilized within an episode
- Visit patterns and scheduling
- Number of days from SOC before therapy began care
- Average number or recertifications
- Therapy utilization for energy conservation training
- Changes in patient education between SOC and recertification episode
In addition to monitoring heart failure outcomes through OASIS-C data, reduced hospitalization rates, compliance with the structured heart failure disease management program the agency should find ways to motivate personnel to continue use of the enhanced heart failure education. Administrators should be certain a specific skilled staff competency review regarding heart failure symptoms is administered regularly.
Best practices disease management programs can be very successful as seen in Dominion Care Home Health agency in San Antonio, TX. Their acute care hospitalization (ACH) rate declined from 41% to 28% after initiating such a program. With pay for performance in our future, newly instituted Survey Protocols, and higher expectations for improved patient outcomes, a disease management program targeting heart failure is a must.
Sources:
www.homehealthquality.org
HHQI Best Practice Intervention Practice, 8SOW-PA-HHQ07 467 App, 1/2008
http://mhcc.maryland.gov/consumerinfo/hospitalguide/hospital_leaders/best_practices/hf..h
www.chronicconditions.org/ClearingHouse/cat/Heart%20Failure,61.aspx
Heart and Ling Sounds by 3M
http://solutions.3M.com/wps/portal/3M/en_US/Littmann/stethoscope/education/heart-lung-sounds
Decision Support Tool: Heart Failure Publication # 8SOW-PA-HH05.187
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Psychiatric Nursing in Home Health
During these past few weeks, we have seen an increase in questions regarding psychiatric nursing services. More agencies are considering new programs. One agency has shared that Palmetto is no longer asking to see resumes of psychiatric nurses, but agencies must verify with EVERY MAC before beginning a psych program.
The CMS Publication 100-2, Chapter 7, §40.1.2.14, simply says, “Psychiatrically trained nurses are nurses who have special training and/or experience beyond the standard curriculum required for a registered nurse.” MACs can establish the special training and experience required. A home health agency should contact its MAC and look at the MAC website for any special qualifications needed.
Introduction
CMS has recognized psychiatric home care as a reimbursable service since 1979, but nationwide, proportionately fewer home health agencies actually provide this service. The exact number of agencies that include psychiatric home care is unknown. There has been a reluctance of agencies to implement psych programs and there are many reasons for these decisions.
First of all, the skills of a psychiatric nurse are required and this specialist is usually more difficult to find. Second, the psychiatric patient is frequently more disorganized and needy than other patients causing the case management responsibilities to become time consuming and complex. Third, this patient is frequently homebound questionable.
CMS Publication 100-2, Chapter 7, §430.1.1, states that a patient with a psychiatric problem may be considered homebound if “the illness … is of such a nature that it would not be considered safe to leave home unattended, even if he or she does not have any physical limitations.” The homebound status of patients with psychiatric needs require well written, clearly stated clinical visit notes, because there may not be physical impairments, and homebound status must be clearly delineated. Any patient in a certified home health program may leave their home for specific reasons, as identified in Chapter 7 of the Medicare Provider Benefits Manual. Homebound status for a patient suffering from a mental health issue may be just as painful and debilitating, but may not manifest itself with physical symptoms or behaviors.
Homebound status (for a patient suffering from a mental illness) may need to be evaluated as a clinician would evaluate a patient suffering from dementia or Alzheimer’s diseases That patient may have few or no physical limitations and yet would be deemed unsafe to leave his/her home unattended. The patient, in this example, could be considered homebound.
However, if the patient with a psychiatric condition leaves home regularly for reasons other than to visit the physician, he/she may not be considered homebound; the same as any other home health patient in the certified agency. An example may be that of patient with a mental health issue attending partial hospitalization.
Partial Hospitalization
In 1999, CMS, then known as HCFA, stated that a patient in a partial psychiatric hospitalization program does not qualify for psychiatric home care services. The partial hospitalization program should be able to provide necessary psychiatric services. The homecare services must be psych-related. If they are not focused on a psychiatric issue, the home health agency must evaluate the patient’s needs, just as it would normally do with any other patient, and evaluate whether home care services are in keeping with medical necessity and homebound status.
What is Psychiatric Home Health Nursing?
What is unique about psychiatric home care? Although psychiatric home care is bound by the same CMS regulations that define other types of home care, these regulations are largely non-specific for the psychiatric patient. This means the clinician must be specific as to symptoms and document those plans and interventions, as well as work closely with the physician.
On the surface, psychiatric care appears to be very eclectic, but there is much depth of choice for intervention strategy. Although psychiatric nurses may draw upon crisis intervention techniques as noted by Duffy, Miller, and Parlocha (1993) and Beck’s or Montgomery-Asburg Depression Inventories, Young Mania Scale, Sheehan Anxiety Scale along with Cognitive Restructuring therapy, there are a number of other psychiatric intervention models that can be very useful: psycho-education, interpersonal reflective, supportive, individual, and/or brief therapy, as well as behavior therapy, relaxation, contract, and reward provisions.
The psychiatric nursing home care plan must be intermittent. This short term program frequently focuses on improved problem-solving, stronger ego boundaries, and enhanced self-concept. This is important with patients of all ages, but the need is seen often with elder patients who are suffering significant losses in life.
With patients suffering from depression, the psych nurse frequently seeks ways to displace internalized anger outwardly. Activities designed by an occupational therapist can augment the skills of the psych nurse. An increasing number of home health agency psych programs are adding this discipline because of the physical activities that can be beneficial.
Stress management and education of stress strategies are commonly taught. Many patients have weak or fragile coping mechanisms that require reinforcement or a new approach.
Forming linkages between the patient and needed community services is a vital component of the role of the psychiatric home care nurse. This type of nursing brings an existential/spiritual concern and dimension to patient care. The clinician frequently provides support to a patient with low self esteem and a belief that the community has prejudged them. The clinician can assist the patient to cope with behaviors and approaches patients with an attitude of respect, reinforcing or assisting to rebuild worth and dignity.
Demoralized individuals are frequently seen in this program. Patients may lack energy, frequently because of losses; losses of friends, of family, of job, of status, of money, of respect, and others. This patient frequently requires a nurse whose plan with the patient requires assessment of the patient, their role within the family, the family support system, teaching use of psychotherapeutic techniques to facilitate change, medication management, and supervising their care in a supportive fashion that sustains physical, emotional, and spiritual life,
Relationship Building and Trust
The clinician will build relationships established on trust, caring, compassion, empathy, education, and hopefulness. The RN will use verbal and non-verbal communication techniques to convey interest in the patient, to assess what the patient wants to accomplish, to assist with care planning and goal achievement, and to clarify the boundaries of the relationship, and lastly to affirm the patient has value and worth.
Medication Management
Medication management is frequently a need for patients and is one of the main reasons for hospitalization. CMS identifies a significant portion of hospitalizations are due to poor medication management. Some patients do not understand the reasons they has been prescribed certain medication. Sometimes, patients do not like the side effects and feel those effects are nearly as bad as the psychiatric condition. Some patients cannot afford their meds and still others do not wish to take their meds as they provide a constant reminder of a condition many wish could be forgotten. One patient once shared, “I look in the mirror, put the pill in my mouth, bring the glass to my lips, and know I am ill.” Unless this issue is addressed, the chance that this patient will become medication non compliant is great.
Medication management intervention must be individual. Certain patients may require a contract by which they contractually agree to take their medications as prescribed. It is this tangible “document” that assists with compliance reinforcement. Teaching about major effects of the medications can be an empowering experience. For those patients whose cognitive impairment is apparent, modified pictorial teaching tools may be necessary. Role-playing, coaching, and teaching can be a part of an empowering strategy.
Summary
Patients with stressors, depression, and cognitive impairments can frequently benefit by a psychiatric nurse. The program must be comprehensive aiding the patient through stabilization, caring, and reinforcement of strengths. A therapeutic relationship built upon trust can provide acceptance to teaching and compliance with medication. Leaving the patient more calm, organized, stronger, and knowledgeable can assist the individual to improve links with family, friends, and the community and be more compliant with their medication regime.
The psychiatric program can be a strong support to total quality care and improved outcomes.
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