Aging in Place

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Maintenance therapy eases the way for in-home care and improved quality of life for patients with chronic and degenerative diseases

For decades, those with chronic and degenerative diseases have been denied access to therapy that can help them “age in place.”

But, a landmark ruling in 2013 changed the Centers for Medicare & Medicaid (CMS) policy, and now providers are setting the bar for effective maintenance therapy programs that keep patients comfortable at home, reduce costs, and increase quality of life.

Jimmo v. Sebelius

The 2013 case of Jimmo v. Sebelius was the impetus for changes in the CMS approach. The Supreme Court found that some Medicare claims were being inappropriately rubber-stamped by contractors with an “Improvement Standard,” thereby denying coverage to others in need.

Medicare has a long history of ruling that improvement is not entirely necessary for authorization of continued therapy, as shown in 42 CFR 409.32(c) (Criteria for Skilled Services and the Need for Skilled Services): “Restoration potential of a patient is not the deciding factor in determining whether skilled services are needed. Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.”

The case’s settlement agreement mandates that CMS update their policy and program manuals to clarify the guidelines for prescribing maintenance therapy, informing stakeholders including contractors and providers through an educational campaign, and performing a claims review to determine trends and identify issues that may be resolved.

In an Opinion and Order released on Aug. 18, 2016, Chief Judge Christina Reiss, who oversees the “Improvement Standard” case (Jimmo v. Burwell, No. 11-cv-17 (D.Vt.)), ordered the federal government, through CMS, to comply with the Settlement Agreement that she had approved in January 2013.

Rehab-Based vs. Maintenance: What’s the Difference?

Rehab-based therapy, whether inpatient or in-home, is designed to improve a patient’s functions. A therapist may focus on strength building, gait improvement, increasing manual dexterity, ambulation and more. The goal is to see improvement at each session.

Maintenance therapy differs in that the therapist isn’t looking for improvement at each session. Instead, the maintenance therapist seeks to help the patient keep their current level of ability for as long as possible. They may adapt a patient’s therapy program at each session to ensure the patient is still able to perform certain tasks, like transferring to and from the bed or toilet, or managing stairs. The goal here is that the patient is able to “age in place.”

Fostering Independence and Lowering Costs

Striving to foster independence for the patient, maintenance therapy can include occupational therapy, which emphasizes instructions and follow through on activities of daily living; physical therapy, which emphasizes ambulation and mobility; and speech therapy, which emphasizes communication and safe swallowing. An initial course of maintenance therapy includes six to nine treatments spread over a 60-day period.

Maintenance therapy can be key to lowering costs for healthcare providers as well. The numbers tell the tale: The average hospitalization episode for a patient costs the healthcare system a minimum of $7,500. In contrast, a 60-day course of in-home maintenance therapy costs $2,000-and can help reduce the chance of expensive future re-hospitalizations.

“There are people who, once discharged from rehab, will go home and forget the instructions they received from their physical therapist. When a therapist visits one day a week and continues the treatment, the patient is less likely to need re-hospitalizations, and more able to age in place, with dignity.

A survey of maintenance therapy patient recently conducted by one home health system found that of 369 patients served over the last 18 months, 350 of them-that’s 95%-did not require follow-up emergency room visits or any hospitalization during their maintenance therapy period.

Our goal is to help patients age in place and minimize their rate of decline, or to even eliminate that decline. If we can help someone stay home an additional six months, versus two months, we’re improving their quality of life, and you can’t put a price on that

Keys to a Successful Maintenance Therapy Program

Many patients thrive in maintenance therapy programs, enjoying greater independence and quality of life for a longer period of time, but not all maintenance therapy programs are created equal. Here are the top three components:

  1. Maintenance is truly maintenance. Goal-oriented therapy got the patient where they are today; the maintenance therapist works to ensure they stay there and are comfortable and safe in their own home. Therapists focus on safety, ambulation and effective transfers.
  2. Every session includes a head-to-toe physical assessment. Traditional therapy looks for improvement each session; in maintenance therapy, providers watch for decline and modify a patient’s program to maintain mobility and safety in spite of it.
  3. Only therapists provide services. Because only licensed therapists, not therapy assistants, can provide maintenance therapy, continuity of service is a key bonus, as well as the ability for the maintenance therapy plan to be effectively modified each visit as necessary.

Maintenance Therapy at Work

Edith, 73, is one patient who is currently benefitting from a  maintenance therapy program. A paraplegic, she suffered a stroke at the age of 71 during a knee surgery and has since needed to use a wheelchair.

“I appreciate having someone to talk to about my case-it made me feel better to talk to someone,” she said. Her maintenance therapist is in close communication with her visiting nurse and doctor, so the whole team is on the same page about her condition week to week. By working with a maintenance therapist, she has been able to strengthen one of her arms, and move her legs a little more-a step toward aging with more dignity in her own home.

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About Author

Jay Neidich, MA, CCC-SLP

Jay Neidich, MA, CCC-SLP, is the vice president of rehabilitative services for VNA Healthtrends. He has more than 35 years of clinical field experience creating and executing acute hospital and in-house skilled nursing facility therapy programs.

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