That was the message Key Rehab’s Sr. Vice President Mike Gorman and I heard recently from Cynthia Morton, Executive Vice President of NASL (the National Association for the Support of Long Term Care), when she spoke to exhibitors at the Nebraska Health Care Association Spring Conference in Kearney, NE.

The term “lame duck” was first used at the turn of the century to describe the period and opportunity for defeated or retiring lawmakers to “preen their plumage” in November and December before their  departure.  Mike Gorman pointed out that ideally a lawmaker should always represent the will of their constituents, even if at odds with their own conscience (or the interests of lobbys, PACS, polls, or party). So, why is this lame duck session so scary?  

The Congressmen of the 2012 lame duck session can’t just sit back and rest on their laurels. Congress still has to address many big issues including what to do about the so-called “Doc Fix”.  If Congress doesn’t act, physicians will have to endure a huge cut in their Medicare reimbursement, a cut of somewhere around 30%.  If such a cut goes into place many physicians will opt out of the Medicare program and no longer provide services to senior citizens.

In addition, the lame ducks will decide on repealing the Bush Tax Cuts (lowering marginal rates, cutting capital gains and dividend rates, easing exemptions, and child tax credit relief), expiring payroll tax cuts, and again decide the fate of the Therapy Caps and the exception process.

If that’s not enough, decisions on 13 annual spending bills, social security cuts, the estate tax, transportation, highway, and armed services expenditures will all be crammed into just 25 days – the likely number of working days after the November election until year-end.

As one lobbyist said, “this lame duck session is approaching like the Four Horsemen of the Apocalypse”. It is vitally important for all of us to take the time and make the effort now to tell policy makers the stories of our patients.  Tell your Congressmen about what we do and why it’s important that Medicare continue to be adequately funded for the benefit of our senior citizens.  Let Congress know about the successes of our work and the positive impact we make on the quality of life of our patients.  Also, let Congress know about the devastating impact that arbitrary cuts in health care spending will have on patient care.   A lame duck Congress is typically considered a bad thing because it refers to people who no longer have a “horse in the race” (i.e. their own horse – as in running for re-election).  However, this lame duck session still has to tackle some tough issues and for once these politicians do not have to worry about pleasing lobbyists and big money backers.  For once they may be able to simply choose to do what’s right.

Contact US lawmakers through NASL, Leading Age, AHCA, APTA, AOTA, ASHA or your state congressmen and senators.  As, Cynthia Morton of NASL put it, “If we aren’t at the table, we’re on the menu”.

 I don’t mean to disparage used car salesmen.  I know many good people that work in used car sales.  I’m playing off of the old stereotype of used car salesman being shady and lacking in moral character.

 It seems that therapists are now viewed in that light, at least by healthcare payers like Medicare.  It’s an odd thing.  I’d like to argue that therapists are not unscrupulous.  In fact I’d like to make that argument for most professions. There are good and bad people in all walks of life and there is good and bad within all people.  It is easy for me to defend the integrity of therapists because I’ve met many great ones. However, I also have to acknowledge that where there’s smoke there’s fire. Make no mistake, there are crooks out there.

 So, what is the point of this blog article? It is both to condemn and defend. I am saddened by those among us who take shortcuts in life based on greed, laziness and truly being shortsighted. Likewise, I applaud people of integrity of all professions.  There are many.  I consider them heroes for living everyday life with the noble purpose to do good. Well, there’s not much else to say about that so I think I’ll end here.  I’ve got to go buy a car…

Pet therapy is a proactive way to fulfill this need and has been used around the world for many years but you may feel that this is difficult in your situation.

Be creative and think outside the circle to facilitate the person with dementia to interact with animals. As an alternative to a pet, consider introducing someone’s well-behaved pet or bird. You could also organize a regular visit to a local petting farm or maybe even the zoo for a more exotic experience.

 Recalling Someone Special

When people with dementia find it difficult to remember someone special or important in their lives, such as when you mention a son or daughter’s name and they cannot get a mind’s eye picture of that loved person, here is a great way to enable them to remember:

Make a good CLEAR display of photographs of people who visit the person or family and friends whom you talk about often. This can be placed on the fridge, a door, a pin board, or similar. Magnetic photo frames can be attached directly onto the fridge or a magnetic board.

People with dementia remember in pictures, just like you and I. We know from research that our long-term memory is more likely to store experiences that are unusual, colorful, humorous or full of sensory experiences. We can apply these same principles to the way we take and select photos of visitors, family or friends to help the person remember them.    

×          A continuation of the Medicare Part B outpatient Therapy Cap Exceptions Process; and

×          An extension of the “Medicare sustainable growth rate formula” commonly called the SGR and a continuation of the “Medicare work geographic floor”.   This prevents the 27% cut to the Medicare Part B fee schedule which sets the reimbursement for all of the therapy CPT Codes. As you can imagine a 27% cut to Part B reimbursement would be significant for Rehab providers.

So we can breathe a sigh of relief for now… but not for too long! February 29^th will be here before we know it.  Please join in the effort to get congress to permanently fix these issues in a way that will not harm patients or our ability to care for them. I recently saw an example from last year where, if the Therapy Cap Exception Process had not been in place, a patient would have started on PT and SLP treatment on January 23^rd and his combined cap amount would have been exceeded by February 6^th! That’s basically two weeks of therapy which was not enough to address his needs at the time and he would not have any additional resources available for additional therapy until the next calendar year!!

As always, you can easily send a letter to your Federal Congressman by using the CapWiz link available on the Key Rehab website.  Simply go to Key’s website and select the “Links” tool and then select www.capwiz.com/nasl.    This will take you to a website that will walk you through sending in a letter to you Congressman.  It’s easy to do, it helps and it’s necessary!  In the meantime, however, its “business as usual”.  There are no caps (financial limitations) in place, and our residents (the beneficiaries) deserve the services when they are needed!  They paid for their Medicare benefits for years and years, they continue to pay for their Part B coverage, and for the time being, we are allowed to deliver them.

“How will I let my caregivers know who I am? …..AT THE MERCY OF STRANGERS Disability obscures individuality like a mask.  When a doctor speaks to the person pushing the wheelchair rather than to its occupant, utter negation occurs.  “How is she feeling today?”  The one who has been negated can always shout, “I am fine, doctor,” thereby declaring her continued status as a person, but the harm has already been done.  To be overlooked, to be discounted even for a moment, wounds even after apologies have been extracted or hasty recognition has been won.  To have to fight to be seen – that is what causes the damage.”

Please visit Key Rehab’s home page, click on “monthly newsletter”, and then click on “Thoughts on the Meaning of Frailty” for the full article.  I hope it helps you slow down and remember the PERSON we are each caring for.

This year’s Medicare changes make me think there is a lack of trust between the people running the Medicare health care system and the providers that try to operate within it. It’s too bad because I believe that for the most part, providers are trying to do the right things, for the right reasons, and I also believe that Medicare is doing the same. In my career I’ve met many providers. Most of them are fine upstanding people who care about their patients. I also have the opportunity and good fortune to meet and interact with many people from Medicare. I’ve also found them to be good people conscientiously trying to do their jobs to manage the Medicare system and protect the rights of the beneficiaries. There are obviously some providers out there who do their best to scam the system and take advantage of the elderly. And likewise there are obviously some people within Medicare who don’t have a realistic understanding of the day-to-day life and operations of the many honest providers out there. In a society as large and complex as ours it is always impossible to come up with “one size fits all” solutions, but it is equally impossible to come up with viable solutions to address the multitude of contingencies that bombard our health care system on a minute by minute basis. And so we all do our best.

So let me say to you that I truly do wish you Happy Holidays this year regardless of which side of the Medicare fence you’re sitting on, bureaucrat or provider. I know we’ve got challenges to face and obstacles to overcome but I know that if we work together, keep the patients in mind, and strive to understand the complex world we live in that we can all be successful.

Happy Holidays everyone!

 Co-treatment

 For Part A:

When two clinicians, each from a different discipline*, treat one resident at the same time (with different treatments), both disciplines may code the treatment session in full. All policies regarding mode, modalities and student supervision must be followed. The decision to co-treat should be made on a case by case basis and the need for co-treatment should be well documented for each patient. (*We have clarified with CMS that co-treatment by two members of the same discipline is not allowed – asterisk added by Key Rehab)

 For Part B:

Therapists, or therapy assistants, working together as a “team” to treat one or more patients cannot each bill separately for the same or different service provided at the same time to the same patient.

 Therapists may utilize this technique when selecting treatment approaches for their Part A patients if it is clinically appropriate and when it is performed according to the definitions listed above.  The treatment provided by each therapist must be directly related their own plan of care and it must be distinct from the other discipline’s treatment. Keep in mind that the documentation must support that the skills of each discipline were required for the entire time the activities are being performed.  Some examples of clinically appropriate uses of co-treatment are as follows:

*Example from CMS: A SLP and an OT do a meal with a patient. The OT is working on feeding skills and fine motor coordination of the utensils and the SLP is working on swallowing skills. Both disciplines may code the full treatment session.

 Other Suggestions from Key Rehab:

Low-functioning patients-

•  Sit to stand transfers up to the sink to perform ADL’s.  (PT and OT)
• Edge of bed activities for sitting balance and dressing tasks. (PT and OT)
• Gait training from bed to bathroom. (PT and OT)
• Static standing activity with UE reaching tasks. (PT and OT)
• Meal time activity with safe swallow techniques and self-feeding instruction. (ST and OT)
• Standing activity with word finding or problem solving activity (ST and PT)

 Cognitively Impaired patients- 

• Problem solving/sequencing tasks during an ADL. (ST and OT)
• Gait training around obstacles while sequencing or problem solving. (PT and OT/ST)
• Gait training to closet for clothing retrieval and dressing task. (PT and OT)

High functioning patients-

• Standing/balance activity on uneven surface while working on “brain games”. (PT and OT/ST)
• Dynamic sitting balance on Swiss ball while performing UE exercise. (PT and OT)
• Obstacle course navigation and problem solving task. (PT and OT/ST)

U.S. Representatives Jim Gerlach (R-PA) and Xavier Becerra (D-CA), Senator Ben Cardin (D-MD) have introduced the Medicare Access to Rehabilitation Services Act (H.R. 1546/S. 829). This legislation would repeal the cap on therapy services for Medicare beneficiaries. If Congress does not take action by December 31, 2011, therapy caps will be imposed on Medicare-covered physical therapy, occupational therapy, and speech language pathology services.

Congress needs to hear from front-line health care providers within the long-term care community that the therapy cap is bad public policy that would be especially hard on patients in long-term care settings.  With congressional focus on debt reduction and recommendations from the “Super Committee”, we need to ensure that Congress does not lose sight of Medicare extenders that are set to expire at the end of the year. Please contact your member of Congress today on this critical issue – we need to take action NOW to ensure the cap does not go back into place.

Please log onto the NASL (National Support for Long Term Care) website and with just a few clicks, you can send letters to your Legislators today.   http://capwiz.com/nasl/issues/alert/?alertid=42500531&type=CO

(Notes taken from ASHA and NASL websites)

 Later in the day, Tracy visited the exhibitor booths of some of our fellow therapy companies and asked them what changes they’re making in response to the Medicare cuts.  Some said they were making cuts. Others said they were following the same course as Key, taking a measured approach and focusing on productivity.      

 I think some perspective can come from the words of the conference’s general session’s second speaker, Maya Angelou.  When, as a child, she would complain about something – if you’re familiar with her story, you know her young life was tragic – her grandmother would say, “When you whine or complain you let a brute know there is a victim in the neighborhood”. 

 So, to feel inspire and to stay focused…Google Maya Angelou.

“I’ve learned that no matter what happens, or how bad it seems today, life does go on, and it will be better tomorrow.  I’ve learned that you can tell a lot about a person by the way he/she handles these three things: a rainy day, lost luggage, and tangled Christmas tree lights.  I’ve learned that regardless of your relationships with your parents, you’ll miss them when they are gone from your life.  I’ve learned that making a “living” is not the same thing as making a “life”.  I’ve learned that every day you should reach out and touch someone.  People love a warm hug, or just a friendly pat on the back.  I’ve learned that I still have a lot to learn.  I’ve learned that people will forget what you said, people will forget what you did, but people will never forget the way you made them feel”.                                 ~Maya Angelou