Episode 4 of the CORE IM team's Interprofessional Series with the American College of Physicians focusing on learning from physical therapy experts.
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Welcome to Core IM, a virtual medical community! Core IM strives to empower its colleagues of all levels and backgrounds with clinically applicable information as well as inspire curiosity and critical thinking. Core IM promotes its mission through podcasts and other multimodal dialogues. ACP has teamed up with Core IM to offer continuing medical education, available exclusively to ACP members by completing the CME/MOC quiz.
- Pearl 1: Don’t forget to mobilize your inpatients
- During a hospitalization for an acute illness, the majority of patients remain limited to a bed or chair and ambulation occurs infrequently
- Low mobility of older patients in the hospital setting can lead to reduced future functional status and loss of muscle mass
- Even patients that had no contraindications to mobility in the hospital and were completely independent prior to admission spent a small amount of time on their feet
- Commonly perceived barriers to mobility include patient symptoms, restraining medical devices such as catheters and intravenous lines, and concern from patients and providers about falls
- Continue to assess your patients’ functional status daily during hospitalization and encourage them to get out of bed and try walking around, don’t just assume PT will take care of it!
- Instruct patients to get out of bed and try transferring to their chair or ambulating
- Continue to assess the necessity of barriers such as catheters and lines
- Utilize ancillary staff to help mobilize patients and encourage them to do so
- Sometimes all it takes is to simply inquire, “Have you been out of bed today?”
- Pearl 2: Tips on effective documentation
- Start by documenting what a patient’s baseline mobility level
- How far could they walk?
- Did they require any sort of assistive device?
- Were they walking around only inside their house or around their community as well?
- Do they require another person’s help to get around or are they independent?
- Other diagnoses that may relate to ambulatory problems
- Symptoms that limit ambulation
- Documenting a patient's change in functional status from admission in their discharge summaries is often neglected but very useful information for other providers and physical therapists when the patient follows up as an outpatient.
- Some hospitals may discourage physical therapists from recommending site specific locations to allow for more leeway amongst the discharge planners
- If you don’t understand the physical therapy note or need more specific information about potential patient disposition it’s sometimes easiest to just ask them.
- Start by documenting what a patient’s baseline mobility level
- Pearl 3: Don’t be afraid to escalate a patient’s physical therapy
- If a patient didn’t achieve the desired improvements in their functional status after their first few sessions of physical therapy it doesn’t mean that further physical therapy shouldn’t be pursued
- Patients may need additional more intensive physical therapy sessions or a different type of therapy all together
- There are a lot of different types of physical therapy specialists that are underrecognized
- Referral to physical therapy subspecialists may be beneficial for some patients. The American Board of Physical Therapy Specialties (ABPTS) offers board-certification in nine specialty areas of physical therapy: Cardiovascular and Pulmonary, Clinical Electrophysiology, Geriatrics, Neurology, Oncology, Orthopaedics, Pediatrics, Sports, and Women's Health.
- Pearl 4: Tips on ordering durable medical equipment
- Examples of durable medical equipment (DME) include but aren’t limited to wheelchairs, walkers, hospital beds, power scooters, portable oxygen equipment, orthotics, and prosthetics
- Rolling walkers are a good choice for patients with cardiopulmonary conditions because it allows them to brace themselves on their DME for a rest break if needed
- If you are in a skilled nursing facility (SNF) or are a hospital inpatient, DME is covered under Medicare Part A. Otherwise, it is covered under Part B
- Medicare will typically only cover 80% of the cost of DME so patients have to pay the other 20% which can become a financial barrier
- Medicare does not cover:
- Equipment mainly intended to help you outside the home
- Most items intended only to make things more convenient or comfortable. This includes stairway elevators, grab bars, air conditioners, and bathtub and toilet seats
- Modifications to your home, such as ramps or widened doors
- We may sometimes neglect to document things like symptoms that limit ambulation, current assistive devices, or reasons why their current devices aren’t effective in assisting with their ability to perform ADLs.
- Power Mobility Devices (PMD), which includes power scooters (~$800) and power wheelchairs ($1000-3000) are covered under the Medicare Part B Durable Medical Equipment benefit.
- To qualify for a POV:
- The patient must have a mobility limitation that significantly impairs his or her ability to participate in one or more Mobility-Related Activities of Daily Living (MRADLs) in customary locations in the home
- The patient can’t use cane or walker
- The patient does not have enough upper extremity function for a normal wheelchair
- To qualify for a POV:
- Pearl 5: Tidbits about physical therapy reimbursement
- Medicare part A covers inpatient hospital and skilled nursing facility care, home health care, hospice care, inpatient rehabilitation, hospice
- Medicare Part B helps pay for medically necessary outpatient physical therapy. This covers 80% of the Medicare-approved amount. When patients receive services from a participating provider, they pay a 20% coinsurance after meeting the part Medicare Part B deductible ($198 in 2020).
- Outpatient physical therapy includes visits at the physical therapist office, therapy at Comprehensive Outpatient Rehabilitation Facilities (CORFs), outpatient therapy at skilled nursing facilities (SNFs), and home therapy through home health agencies
- If your total therapy costs reach a certain amount, Medicare requires your provider to confirm that your therapy is medically necessary. In 2020, Medicare covers up to:
- Prior to September 2019 skilled nursing facilities were reimbursed based on the volume of services provided, in October 2019 CMS implemented the Patient Driven Payment Model which removed this financial incentive to provide a higher volume of therapy and reimburse based on a comprehensive assessment of patient needs
- This shift to the PDPM model caused some for-profit nursing homes to maintain profits by scaling back on therapy hours, and number of therapists which may impact patient outcomes
Shreya Trivedi, MD, MA - Executive Producer
Christopher Tan, DO - Producer
Jason R. Falvey, PT, DPT, PhD - Guest
Rachel Walton-Mouw, PT, DPT - Guest
Sharon L. Gorman, PT, DPTSc - Guest
Jennifer M. Ryan, PT, DPT, MS, CCS
Kim Levenhagen, PT, DPT, WCC, CLT, FNAP
Those named above unless otherwise indicated have no relationships with any entity producing, marketing, reselling, or distributing health care goods or services consumed by, or used on, patients.
Release Date: August 5, 2020
Expiration Date: August 5, 2023
This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of the American College of Physicians and the Core IM. The American College of Physicians is accredited by the ACCME to provide continuing medical education for physicians.
The American College of Physicians designates each enduring material (podcast) for 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
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