I will probably ruffle some feathers with this blog- but that is my exact intent…  You may agree with some and you may disagree with some.  Please feel free to open up a discussion with me, that’s the point.  If you have questions/comments/observations/concerns/complaints please comment below or shoot me an email at gameonpt@gmail.com or visit my website-  www.gameonpt.com

I’m taking a page from the book by Jon Goodman of the Personal Training Development Center who recently finished the Free E-Book Titled “101 Personal Trainer Mistakes– and the solutions to each”.

I have been cruising around the web reading blogs, articles, websites, face book pages and everything else possible and I have noticed one common trend.  I am seeing the Fitness world really pushing hard to “better themselves” and learn from each other.  By learning from each others mistakes (and our own) we will only become better at what we do.  I came up with the idea to list what I think the 11 most common mistakes Physical Therapist’s make on a daily basis and how to resolve them.  Here we go from 11 to 1!

11.  Inconsistent Re-Evaluations…
Re-evaluations every 30 days or 10-12 visits is essential to developing proper Physical Therapy routines for patients.  If we are doing a good job, the patient should be progressing consistently and we need to see where their “new baselines are.  In all actuality, we should be reassessing every visit the person comes in for.  Everything manual technique, every movement should be used as a way to evaluate and determine progress.

10. No reasoning for developing certain exercises in a patients program…
When I have students I tell them one simple thing:  I do not care what exactly you do with your patient (to a certain extent) but have a REASON for what you are doing.  Physical Therapy is NOT cookbook so create a program for the patient sitting in front of you!

9. Have the blinders on to other professions…
I believe in chiropractic care, I believe in acupuncture, I believe in strength and conditioning, I believe in anything that works.  PT’s have a tendency sometimes to only believe in what they do.  If you do not have a Strength and Conditioning background, don’t pretend to be a strength coach.  Working together with other professions will only make you better as a practitioner and it will only help your patients get better faster and more effectively!

8. PT’s tend to call themselves “Mulligan” Therapists, “Mckenzie” Therapists, “Maitland”, etc…  Using tools and not the Tool box…
This bothers me a a lot.  Be your OWN therapist.  Yes we must learn from others but there are pros and cons to each tool we use.  A GREAT therapist knows how to use the tools to work with each specific patient.  A GREAT therapist also never stops learning and never stops putting another tool into their box.

7. Utilization of Modalities for time killers or because it can be billed for…
Do I even need to explain this one.  If you know me; you know I hate utilizing modalities such as E-Stim and Ultrasound.  If I need to explain this one to you then you probably fall into a lot of these categories I’m discussing.  There is a time and place for Electrical Stim but US; I’ll battle anyone on this. Steel cage death match anyone?

6. A lack of understanding on how to market and build relationships…
This baffles me?  PT’s build relationships with patients everyday but for some reason have a hard time talking to physicians or other health care providers.  Have confidence in your knowledge and your skills.  Chances are they will respect you more if you have confidence and can be clear and concise.

5. Not having the “cojones” to either question a possible improper diagnosis or make their own diagnosis…
If you think something wasn’t diagnosed wrong- make sure you approach the appropriate person.  Be ready to back your belief with solid data, but if you feel strongly, do not hold back.  But make sure you are respectful.  PT’s (in most states) are allowed direct access and that means we are an entry point into the healthcare system.  Making a proper diagnosis from the start, needless to say, is fairly important.  Now the fun part begins-  you have made the diagnosis, but now you get to figure out WHY!

4. Are just content with being “good” and not “great”…
   Do something great, be something great and don’t settle for just good.  Constantly learn, absorb, be mentored, mentor and teach others.  This will set you apart from the pack.  If you want to “just be good”, you will never get ahead and you are not doing right by your patients.  Strive to be the best and nothing less.

3. Not listening to the Patient sitting right in front of you…
The history is the single most important part of patient care.  Take a proper history, listen to patient and you will gather more information than you could ever imagine.  The history will lead your evaluation and will set you up for success.  Patients also crave this.  So give them what they want!

2. Not educating patients on the “why”…
This really can be 1B.  Just giving someone an exercise is not good enough…  Just doing a mobilization is not good enough…  Just doing post-op rehab is not good enough…  You need to give the why component to the patient.  Explaining why someone is not allowed to do X after a Cuff Repair or why open chain knee extension is the Single. Worst. Exercise. Ever.  Just telling someone is not enough; you must educate them on the why.  If you do this simple task, they will trust you more, listen to you more and get better faster.  Isn’t that what we want?

And #1….  Drum Roll please……….

1.  Go straight to the site of pain…  To take a phrase from a friend and colleague, Perry Nickelston: “Stop Chasing Pain”!…
Man has he this nailed on the head.  Simply speaking just because someone has knee pain, doesn’t mean the problem is coming from the knee.  By understanding human movement and how the body functions you can pick out and find the Non-Painful Movement Dysfunction that’s causing the Painful Dysfunction.  It’s as simple as that.  Systematically assess human movement and assess the patient- I promise you will find things that will blow you away and will blow your patient away.  In other words:  Treat the Problem and not the symptoms.  You also must be able to explain to the patient why a sprained ankle 3 months ago is the reason for their neck pain.  You have to get it first before the patient gets it.  If you can answer this question, then you are on the right path.  ”Why would a rigid great toe with decreased extension on the lead leg of a pitcher lead to medial elbow pain in the throwing arm?”

CMS had posted the most recent version of the OASIS C manual for users. Title is “2011 OASIS C Manual”.

Also posted is the file “OASIS C Guidance Manual Errata 12-11″.

http://www.cms.gov/HomeHealthQualityInits/14_HHQIOASISUserManual.asp

The item by item guidance for OASIS C items that was previously found in Chapter 3 is now found in each section of the guidance manual.

Best wishes from the home health setting!

Eileen Bach PT, M.Ed, DPT, COS-C

CMS has released the final PPS rules for home health care. Link and brief summary posted here.

The 2012 CMS Home Care PPS rules can be found at: www.ofr.gov/OFRUpload/OFRData/2011-28416_PI.pdf.

Medicare Program; Home Health Prospective Payment System Rate Update for Calendar

Year 2012

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Final rule.

SUMMARY: This final rule sets forth updates to the home health prospective payment system

(HH PPS) rates, including: the national standardized 60-day episode rates; the national per-visit

rates; and the low utilization payment amount (LUPA) under the Medicare PPS for home health

agencies effective January 1, 2012. This rule applies a 1.4 percent update factor to the episode

rates, which reflects a 1 percent reduction applied to the 2.4 percent market basket update factor,

as mandated by the Affordable Care Act. This rule also updates the wage index used under the

HH PPS, and further reduces home health payments to account for continued nominal growth in

case-mix which is unrelated to changes in patient health status. This rule removes two

hypertension codes from the HH PPS case-mix system, thereby requiring recalibration of the

case-mix weights. In addition, the rule implements two structural changes designed to decrease

incentives to upcode and provide unneeded therapy services. Finally, this rule incorporates

additional flexibility regarding face-to-face encounters with providers related to home health

care.

EFFECTIVE DATE: These regulations are effective on January 1, 2012.

Pasted below is from National Association for Home Care and Hospice (NAHC) who posted the question and answer from CMS regarding single therapy in terms of 30 days/13th visit re-assessment. This only reinforces the importance of scheduling, know ing how many rehab visits  are made and adherence to CMS expectations regarding re-assessments.

Hope this is helpful to those of you working in home care!

Best, Eileen

The Centers for Medicare and Medicaid (CMS) responds to an inquiry about physical therapy and visit assessments, and clarifies its policy about re-evaluation requirements.

Question: Can you please clarify this for me? If we are only doing physical therapy (PT) and the 30-day re-evaluation not only falls on the 12 visit and on a Friday and then come Monday is the 13 visit, do I have to send out the PT for another re-evaluation? We are concerned that a 30-day reassessment conducted on the 12 th PT visit in single therapy cases will not suffice to meet the 13 th therapy visit assessment. If it doesn’t meet requirements, there would be a large financial impact based on non-coverage of subsequent PT visits.

CMS Response: You are correct that for a single therapy case, the therapist must do the reassessment visit exactly on the 13 th and 19 th visits, unless the rural or documented circumstances outside the control of the therapist exceptions apply as stated in 42 CFR § 409.44(c)(2)(i)(C). If neither exception applies, the PT would need to do the reassessment on the 13 th visit as required by the regulations.

Hello, home care therapists! In the past few days, CMS updated the written questions and answers for therapy. A new 16th question/answer was added regarding 30 day re-assessments.

You can access this information by going to http://www.cms.gov/snfpps/03_RUGIVedu12.asp  for the Q&A therapy file. You can also find this (and many more CMS documents) by going to the Home Health Agency center at CMS, under “Therapy and Skilled Nursing” – http://www.cms.gov/center/hha.asp

Happy and safe summer to all!

Eileen Bach PT, M.Ed, DPT, COS-C

The FDA site noted here has some helpful information. http://www.fda.gov/MedicalDevices/      The case study for July is pasted below.

Best regards,   Eileen Bach

Case Study of the Month

The FDA encourages consumers and health care professionals to report problems they have with their devices while they are using them. This could be anything from an injury or death to a malfunction or near miss with a device while it is being used. Users should report these problems to the FDA so that we can accumulate information on products in our national database and take any action if needed. The reporting number you should use is 1-800-FDA-1088.

Case Study for July 2011: Dangerous Purchase
Consumer ordered a knee walker/leg caddy from an online shopping website. This device was unsuitable and even dangerous because the knee platform was unsteady and the pads were slick. The steering did not turn 120 degrees as advertised, the brake did not work well and the handlebars collapsed (weight was not a factor). As a result, the consumer experienced a fall. At first, the online seller refused a refund, but the buyer appealed to PayPal and PayPal secured a full refund on the basis that the device was unsafe and not as described. Consumer later learned that this device was an imitation to a superior product. This cheaply-made imitation is extremely dangerous and could further injury and/or result in additional surgery for many people. Unfortunately, products as such are still being sold on at the shopping website.

CMS released the proposed rules – you can see full text at http://federalregister.gov/inspection.aspx

A few significant changes are – a 3.35 % decrease in payment, lower payment amounts and changes to case-mix for select  diagnoses and the therapy payment structure, OT serving as a qualifying service and flexibility in MD face-to-face process by allowing physicians in acute or post-acute setting to inform the certifying MD of the patient encounter. Face-to-face MD requirements would be extended to Medicaid patients.

Additional clarification for Medicaid beneficiaries around homebound, services in the home and DME are in the proposed rules.

Comments are due within 60 days, after which CMS will review and submit the final rule. I expect to see the 2012 in final rule format by November.

Happy reading!

Eileen Bach

Pasted below is a summary from an update from HCA of NY (www.hcanys.org). The timing of the required therapy reassessments (13th and 19th visits, 30 days) is important and based on the CMS response below, when the re-assessments are late, the visits from due date to actual are not only not covered but need to be reported as non-covered in the submitted claim. Another reason for those of us working in home health to be super-organized about visits!

Happy summertime!  Eileen

The U.S. Centers for Medicare and Medicaid Services (CMS) recently responded to an inquiry from the National Association for Home Care and Hospice (NAHC) about requirements related to the reporting of non-covered billing visits on Medicare claims, specifically in the case of late therapy reassessments. The required re-assessment at the 13th and 19th visits and/or 30 days have prompted questions as to the reporting of covered and non-covered services on the claim. Such questions have specifically centered on billing for late therapy reassessments and other non-covered situations. Providers have asked if it would be acceptable to omit from a claim visits that were made prior to a late therapy reassessment visit, as it has been a longstanding practice to exclude such non-covered visits from home health claims. According to CMS, “Therapy would be covered again for the visit which occurs after the qualified therapist(s) completes all the assessment, objective measurement, and documentation requirements … Asking which visit to omit [from the claim] is asking the wrong question. No visits should be omitted. The visits that are not payable should be reported with non-covered charges and will be assigned provider liability. Reporting non-covered charges is required per the Claims Processing Manual, Chapter 10, Section 40.2.”

CMS further states that when providers do not meet reassessment requirements by visits 13 and 19, non-coverage will apply to visits starting on 14 and 20 (respectively) and non-coverage will continue up to and including the visit during which required reassessments were conducted. Coverage resumes on the visit following the final reassessment visit for each respective therapy threshold. (A similar policy applies when therapists do not reassess a patient by the 30th day, with resumption of coverage on the visit following the visit on which the required reassessment is conducted.)

CMS pointed out that its intent has been for home health agencies to include all non-covered visits and charges on claims to ensure a better representation of all home health costs. Therefore, the reporting of non-covered charges shouldn’t be limited to missed therapy reassessments. Home health agencies should include all non-covered visits and charges on their claims, such as for nursing assessments, aide supervisory visits, etc.

Welcome to June!

June is the month when the weather pulls us outdoors; when we are attending graduations, weddings, barbecues and concerts and when we celebrate our Dads. There are a few unusual events recognized such as June 3^rd ‘Repeat Day”, June 11^th “National Hug Day”, June 15^th “Smile Power Day”, June 18^th “International Panic Day” and June 30^th “Meteor Day”. June is also when we enjoy the Summer Solstice (on 6/21/11), the day the sun is highest in the sky at noon as well as the longest day of the year, and summer officially begins!

Two June recognition events that all of us working in healthcare can bring into the lives of our patients and clients are: National Safety Month and Home Safety Month and Prevention and Wellness Month. Working in home health care, I have a unique opportunity to see the home environment and identify specific ways to increase safety. Some safety measures will span the generations, addressing small children and older adults needs such as non-skid mats, decluttering, lighting. Here’s a top 10 list from the Home Safety Council that covers home safety areas.

• Prevent Falls
  • Bathroom – install grab bars for tub/shower and use non-skid mats
  • Stairs/Steps – have bright lights over stairs/steps and on landings
    • Remove clutter everywhere especially on stairs
• Prevent Poisoning
  • Products such as cleaners, beauty, medications should be stored where children cannot reach them. Use child safety locks.
    • Note: This is also true for cognitively impaired adults
  • Poison Help – call 1-800-222-1222
    • Note: Know when to call 911
• Prevent Fires and Burns
  • Install Smoke Detectors and check that they are working; practice evacuation
  • Cooking Tips:
    • Never leave the stove when food is cooking on it
    • Turn pot handles towards the back of the stove or use back burners
  • Set the hot water heater to 120 degrees
  • Carry hot items carefully – use pot holders, travel mugs, choose insulated handles or easy to grip handles on pots, pans, oven trays
• Prevent Choking and Suffocation
  • Small children:
    • Use the dimension of a toilet paper tube – anything that fits through can cause choking in a child. Keep “tempting” items (coins, balloons, hard candy or food, etc) out of reach.
    • Place babies on their backs to sleep, remove toys, pillows, etc from crib
    • Always supervise around water (tub, toilet, buckets or pool)

Prevention and wellness is a key element in improving care outcomes and engaging patient self-care management.  Medicare offers specific advice and tips, including covered services – see details at http://www.healthcare.gov/law/provisions/medicare/preventiveservices.html

Resources, brochures and safety checklists to improve home safety can be found at:

http://www.homesafetycouncil.org/AboutUs/ResourceCenter/rc_bwtips_w001.asp

http://www.nsc.org/nsc_events/Nat_Safe_Month/Pages/home.aspx

http://www.cdc.gov

http://www.workingcaregiver.com/articles/safetytips/homesafetytips

Wishing everyone a wonderful summer ahead!

Eileen Bach

I have to start this entry by first apologizing for not posting for a while.  I have been extremely busy  soaking up the sun here on Hilton Head Island, South Carolina.  If you have never been here it is worth the venture.  I am actually here in a work capacity, at the 2011 Cincinnati Sports Medicine Conference.  It has been several days of well organized and very informative educational sessions on many of the recent advances in the treatment of upper and lower extremity pathology.  It has been a well justified trip to the beach!!!

There is one part of the conference that I wanted to talk about today.  The main reason to take the trip here was to obtain a certification in the Sportsmetrics™ ACL prevention program.  I came here with luke warm expectations about the program, but I am looking to implement a prevention program in our area and I thought this would be a great place to start.  Well, let me tell you that I was nothing short of impressed with the 2 day certification course.  Simply stated this is a brilliantly organized, evidence based course that has me excited to get home and get started with a program of our own.

If you are unfamiliar with this program, it was designed by Dr. Frank Noyes at Cincinnati Sports Medicine as an effort to address the growing issue of non-contact ACL injuries in female athletes.  It is an exercise based program with one simple concept in mind – neuromuscular control.  It involves teaching and reinforcing proper movement patterns in sport specific activities.  The primary focus is jump training, with strengthening and stretching to ensure the ability to control the jump.  For those of you that have been to my course or have heard me speak, you know that this is right up my ally.

It has long been my philosophy that the inability to control multiplanar movements throughout the lower extremity are the basis for most injuries we see.  Whether it is a non-contact ACL, patellofemoral pain, posterior tibialis tendonitis, lateral hip issues, etc., the mechanics of the individual and their inability to control the motion in all planes is often the source of the injury.  I talk a lot about the use of external devices to assist with this control (i.e. orthotics, shoeware, etc.) but that is always secondary to or in conjuction with a neuromuscular education and strengthening program.  The Sportsmetrics™ program is ideal for this.  I have yet to formally use the program, but I know with my experience with these injuries and these types of exercises that this will be successful for me and the local athletes that we serve.

The program itself is so well organized.  Its coordinators Stephanie Smith and Tommy Campbell do wonderful job with teaching the program.  However the real benefit is how they help you implement it.  From well organized handouts and forms to marketing tools to get up and running, they have really thought of it all.  They also provide you with much of the evidence to back up the results of the program.

Bottom line is this.  If you are looking to start a program, work with local high schools/colleges, or simply improve your exercise prescription in the clinic, this is a great program.  This patient population is one that I work very closely with and am very passionate about.  I hope you get the opportunity to check this course out.