Recovery from a debilitating neurological or musculoskeletal condition can be a long and costly process. Patients suffering from such conditions can continue to benefit from therapy for many months, and sometimes years. They may be treated in as many as five different rehab settings during one diagnostic episode, for which therapy information often is neither standardized nor flows from setting to setting. Each therapy setting (i.e, acute inpatient, skilled nursing facility, home health, outpatient, and inpatient rehab facility) has its own set of documentation regulations and reimbursement structures. There is no standardized, functional outcome tool used throughout the various therapy settings to measure a patient’s functional improvement from the start of the diagnostic episode to when the patient has reached their maximum benefit from therapy. Therefore, the value of the therapy across the continuum of care is rarely fully understood.
To better understand just how disconnected the continuum of care for physical therapy (PT), occupational therapy (OT) and speech-language pathology (SLP) is in the U.S., we will follow a fictional Medicare patient, Ella, a 78-year-old black female who suffered a stroke, as she moved through four different therapy settings until she reached her restorative potential.
After being medically stabilized upon suffering the stroke, Ella was admitted to a hospital’s inpatient acute unit for several days. Doctors, nurses, social workers, and therapists worked together to determine the best place for her to receive rehab after she was discharged from the hospital. The PT, OT and SLP departments all performed their respective evaluations, established a plan of care specific to their discipline, and began therapy. Ella’s acute inpatient stay was covered by Medicare Part A.
Next, Ella was admitted to a skilled nursing facility to receive PT, OT and SLP for 21 days under Medicare Part A. A therapist from each discipline performed a brand-new initial evaluation, with little information as to what goals were set or functions measured in the acute care setting. Once again, her functional baselines were not measured by a standard system, providing little meaningful information to her future therapists.
After three weeks in the skilled nursing facility, Ella was discharged and allowed to go home. She received additional PT, OT and SLP through a certified home health agency under Medicare Part A. Like in the previous therapy settings, therapists from each discipline performed new initial evaluations with little information on goals previously set and functions measured. When Ella reached the point of no longer being homebound, she was discharged from home health and began to receive outpatient therapy under Medicare Part B. No one involved in the delivery of that care can possibly understand the functional progress she has made since her admission to the inpatient acute unit four therapy settings ago.
Ella’s story will be repeated millions of times as baby boomers begin to require extensive rehab services for a myriad of acute and chronic orthopedic and neurological conditions. If we cannot measure functional improvement consistently across diagnostic episodes that involve multiple settings, we will not be able to manage it. Billions of dollars and the quality of patient care are at risk if a better system to measure the true functional benefit and value of therapy throughout an entire diagnostic episode is not introduced.
The root of the problem is found in the billing requirements, documentation regulations, and reimbursement structures that are specific to each therapy setting. Those requirements, regulations, and billing structures are not going away anytime soon. Another issue is the number of commercial functional measurement tools used in many therapy settings today. There is little correlation between them to produce a clear picture of the effectiveness of therapy when disparate measures are used in different settings for a patient across the continuum of care. So, what can be done now or in the future to change this fragmented cycle?
For one, entities such as accountable care organizations (ACOs) definitely need to understand the dynamics and interplay between the various therapy settings to maximize outcomes and control costs. For the most part, the same therapy techniques, interventions, exercises, functional training, and modalities are used throughout the various PT, OT and SLP settings. In other words, therapy is therapy.
Instituting a program that requires each therapy discipline in each setting to use one standard, valid, and reliable functional outcome tool could go a long way in solving this growing, currently unmanageable problem.
One such tool is the International Classification of Function (ICF) established by the World Health Organization (WHO), which already is being used in more than 40 countries. This tool could revolutionize therapy in the U.S. The ICF classifies health and health-related domains from body, individual, and societal perspectives by using two lists – one a list of body functions and structure, the other a list of domains of activity and participation. The ICF, which happens to be WHO’s framework for measuring health and disability at both individual and population levels, also takes environmental factors into consideration.
In a scenario in which the ICF becomes the universal functional outcome tool, every therapist in each setting would complete the ICF and send it on down the line. By using diagnostic groups, ACOs could compare the effectiveness of therapy in each setting, apples to apples. Best practices then can be established based on standardized information gathered around the world.
Most importantly, though, is the effect that the ICF could have on patient experience. The ICF casts the notions of “health” and “disability” in a new light. It reflects the idea that every human being can experience a decrement in health and thereby experience some degree of disability. That is, disability is not something that only happens to a select few. The ICF redefines the experience of disability and recognizes it as a universal human experience. By shifting the focus from cause to impact, it places all health conditions on an equal footing and allows them to be compared using a common metric. Furthermore, ICF takes into account the social aspects of disability and does not see disability only as a medical or biological dysfunction.
A common standard of measurement and evaluation also detaches some of the stigma associated with disability from the therapy experiences of patients like Ella. When ACOs become more involved and the therapy settings employ a standardized test like the ICF, rehabilitation will become more streamlined and best practices more thoroughly understood. Each patient’s recovery and cost containment are of the upmost importance. So, all organizations and therapy settings should support one another through standardized data collection and reporting mechanisms. For more information on the World Health Organization’s International Classification of Function, go online to http://www.cdc.gov/nchs/icd/icf.htm.
About the Author
Gerry Stone is a physical therapist and the founder/chief clinical officer of The Rehab Documentation Company, Inc., makers of ReDoc Software. He served on the Neuro-Muscular panel of American Physical Therapy Association to help to write The Guide to Physical Therapist Practice, Volume 1, (1995-1997). He has extensive knowledge of the CMS and TJC regulations and billing structures pertaining to rehab settings.
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