Guest guest Posted September 26, 2000 Report Share Posted September 26, 2000 In a message dated 09/26/2000 10:34:58 AM Eastern Daylight Time, pkovacek@... writes: << Knowing that PT will not provide any improvement in her function or ability to interact with her environment and that it would strictly be for maintenance ROM which Medicaid will not cover I feel that we do not have to provide these services. >> I feel I need to respond here. Neither the mother, nor the physician, nor the hospital are the ones I would consider here. I have had the pleasure of working with many older CP patients who could communicate. Their explanations on the benefits of being moved, as far as how they feel, reduction of pain, and bodily functions all indicated to me the benefits of working with CP patients that seem to be just maintenance. If you work at a hospital, then your hospital must have a mission statement to serve the people of the community. The hospital also has a indigent fund. Even if this were not the case, there is an humanitarian issue here. I know you can not afford to have a full case load of patients as you describe. Many clinics rarely do. But all clinics will have a case such as yours. My answer is to just do the right thing. Steve Marcum PT, CSCS Kentucky Steve Marcum PT, CSCS Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 26, 2000 Report Share Posted September 26, 2000 We to have experienced situations like this and have dealt with it case by case. If the patient has not been treated for a period of time by the rehab department we feel obligated to evaluate that individual then devise a plan of care in accordance with the assessment. If the plan of care indicates that the patient does not require treatment by a licensed professional after the documented caregiver education the patient is discharged following the education to those involved. The education process, including exercises/procedures to be performed, reasons for continuation or discontinuation of services, or etc., may require both finesse or the direct, don't back down approach. We then follow up immediately with a discharge summary to the physician to document our reasons for discharge. We try to offer as much support through resources as possible by giving our phone number if there are any questions, make follow up calls, offer periodic screens... These offers are also summarized in the discharge plan the the M.D.. These types of patients " cost " us/them at least one visit, maybe two or three depending on what type of education is involved. --The way we operate, for what its worth... B. McCusker, PT Director of Rehab Cole Memorial Hospital _________________________________________________________________________ Get Your Private, Free E-mail from MSN Hotmail at http://www.hotmail.com. Share information about yourself, create your own public profile at http://profiles.msn.com. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 26, 2000 Report Share Posted September 26, 2000 A touch of real life, much removed from the discussions that seem to gravitate to the need for more research. You somehow have to balance the needs of the patient, family, physician, reimbursement and professional ethics while not raising the ire of administration. I'm curious how the list will respond. Todd Freeman, MHSA, PT Director of Rehabilitation Services Sumner Regional Medical Center Gallatin, TN > Clinical Dilemma > > I have been asked to post this for another member who wishes to remain > anonymous. > > Clinical Dilemma > > Please do not respond directly to me but rather to the list with your > comments. > > The problem is this: > We are a small acute care hospital that provides inpatient and outpatient > services primarily to adult/geriatric population. > We have received a referral for PT " strengthening and therex 2x/week " for > an 18 you female with a diagnosis of birth CP/CMV. This patient is well > know to our facility as we have provided PT services for her each summer > while school is out. She is currently w/c bound, blind, ? hearing, > dependent in all ADLs and is contracted x 4 extremities. The mother has > been taught ROM repeatedly and is resistant to performing home ROM stating > that " it's your job " . Mom has now decided that she will no longer be > sending her daughter to school as she is 18 and she expects to have PT > services at our facility. The patient has Medicaid coverage. > Knowing that PT will not provide any improvement in her function or > ability to interact with her environment and that it would strictly be for > maintenance ROM which Medicaid will not cover I feel that we do not have > to provide these services. The referring MD is unsupportive, although he > understands our point of view he feels that " if the mother wants it " we > should provide the services. > If anyone on the list serv has had a similar experience or can offer > suggestions on how to deal with this situation it would be greatly > appreciated. > Visit our EStore at www.RehabBusiness.com > > Rehab Pro - The software solution to controlling your rehab business! Call > to arrange a demo -. > > Rehab Management Solutions can can improve your bottom line - (877) > 552-2996 > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 26, 2000 Report Share Posted September 26, 2000 In situations where we feel the insurance guidelines are not going to be met, we give the patient a letter of financial responsibility stating that the insurance guidelines require.....and that the services being delivered will not meet these guidelines. The patient will be responsible for payment for these services at $xx/ visit.. We require the patient to sign the form before we continue with services. We share this form with our patient financial services department and with the physician. Of course, the patient gets a copy. It is RARE for a patient to sign the form. It is probably RARER for a Medicaid patient to pay an outstanding balance. Good luck. Helene Rosen Beaumont >>> Kovacek 09/26/00 10:26AM >>> I have been asked to post this for another member who wishes to remain anonymous. Clinical Dilemma Please do not respond directly to me but rather to the list with your comments. The problem is this: We are a small acute care hospital that provides inpatient and outpatient services primarily to adult/geriatric population. We have received a referral for PT " strengthening and therex 2x/week " for an 18 you female with a diagnosis of birth CP/CMV. This patient is well know to our facility as we have provided PT services for her each summer while school is out. She is currently w/c bound, blind, ? hearing, dependent in all ADLs and is contracted x 4 extremities. The mother has been taught ROM repeatedly and is resistant to performing home ROM stating that " it's your job " . Mom has now decided that she will no longer be sending her daughter to school as she is 18 and she expects to have PT services at our facility. The patient has Medicaid coverage. Knowing that PT will not provide any improvement in her function or ability to interact with her environment and that it would strictly be for maintenance ROM which Medicaid will not cover I feel that we do not have to provide these services. The referring MD is unsupportive, although he understands our point of view he feels that " if the mother wants it " we should provide the services. If anyone on the list serv has had a similar experience or can offer suggestions on how to deal with this situation it would be greatly appreciated. ! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 26, 2000 Report Share Posted September 26, 2000 In my opinion, you have two separate issues here. The first being whether or not you are ethically required to provide services upon request, and the second being a billing issue. The first question will need to be addressed within your own guidelines, but the second will default to Medicaid's guidelines, in that they will not cover maintenance therapy. These two considerations need to be kept separate. One cannot base recommendations for therapy on third-party reimbursement. Clinical Dilemma I have been asked to post this for another member who wishes to remain anonymous. Clinical Dilemma Please do not respond directly to me but rather to the list with your comments. The problem is this: We are a small acute care hospital that provides inpatient and outpatient services primarily to adult/geriatric population. We have received a referral for PT " strengthening and therex 2x/week " for an 18 you female with a diagnosis of birth CP/CMV. This patient is well know to our facility as we have provided PT services for her each summer while school is out. She is currently w/c bound, blind, ? hearing, dependent in all ADLs and is contracted x 4 extremities. The mother has been taught ROM repeatedly and is resistant to performing home ROM stating that " it's your job " . Mom has now decided that she will no longer be sending her daughter to school as she is 18 and she expects to have PT services at our facility. The patient has Medicaid coverage. Knowing that PT will not provide any improvement in her function or ability to interact with her environment and that it would strictly be for maintenance ROM which Medicaid will not cover I feel that we do not have to provide these services. The referring MD is unsupportive, although he understands our point of view he feels that " if the mother wants it " we should provide the services. If anyone on the list serv has had a similar experience or can offer suggestions on how to deal with this situation it would be greatly appreciated. Visit our EStore at www.RehabBusiness.com Rehab Pro - The software solution to controlling your rehab business! Call to arrange a demo -. Rehab Management Solutions can can improve your bottom line - (877) 552-2996 Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 26, 2000 Report Share Posted September 26, 2000 I have been there/done that in similar situations. There are many things to consider here. Here a just a few to chew on: If the client is contracted x 4, are these contractures impeding her caregiver's ability to provide personal care? If so, she should be referred for an orthopedic consult regarding releases to assist with caregiving. Post surgically, PT would then be appropriate for short term to train caregiver(s) in positioning, seating, ROM, and adaptive or orthotic needs. Has anyone ever referred this family to a Cerebral Palsy Center for resources? Having worked with CP clients for years, I have always dealt with these issues as a professional ethics issue. Ethically, would I be OK with providing a service that I know will not affect any positive functional outcomes and at best, in the long run, slow the inevitable continued loss of motion and billing ANYBODY for that service? (Let's face it, ROM a few times a week will not win the battle of 24/7 spastic muscle activity.) Have you put that question to yourself or any other therapist that may be asked to work with this individual? Most third party reimbursers have made it abundantly clear that ROM is considered a non-skilled service by a PT unless there is a mitigating factor such as an healing fracture or other situation that would necessitate skill and judgement to perform. If the Mother is refusing to perform ROM even after being trained, is it because she is otherwise overwhelmed emotionally and/or physically in caring for this child. Has she been counseled to seek assistance from and training for other family members and friends who could also perform this service? These are just a few things to consider when making your final decision. Good Luck. I hope this was helpful. Tammy PT Director of Rehab Friendship Rehabilitation tkelly1@... Clinical Dilemma I have been asked to post this for another member who wishes to remain anonymous. Clinical Dilemma Please do not respond directly to me but rather to the list with your comments. The problem is this: We are a small acute care hospital that provides inpatient and outpatient services primarily to adult/geriatric population. We have received a referral for PT " strengthening and therex 2x/week " for an 18 you female with a diagnosis of birth CP/CMV. This patient is well know to our facility as we have provided PT services for her each summer while school is out. She is currently w/c bound, blind, ? hearing, dependent in all ADLs and is contracted x 4 extremities. The mother has been taught ROM repeatedly and is resistant to performing home ROM stating that " it's your job " . Mom has now decided that she will no longer be sending her daughter to school as she is 18 and she expects to have PT services at our facility. The patient has Medicaid coverage. Knowing that PT will not provide any improvement in her function or ability to interact with her environment and that it would strictly be for maintenance ROM which Medicaid will not cover I feel that we do not have to provide these services. The referring MD is unsupportive, although he understands our point of view he feels that " if the mother wants it " we should provide the services. If anyone on the list serv has had a similar experience or can offer suggestions on how to deal with this situation it would be greatly appreciated. << File: ATT00007.htm >> Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 26, 2000 Report Share Posted September 26, 2000 > I do not see much mention of the patient - only her mother. As annoying as the mother may be, it appears she is not a viable option for providing care, so some other means must be sought. Another family member, a student looking for community service, local support groups and volunteers, a hospital auxiliary group for funding, pro bono work by the PT facility or local PT students....I do not think an ethical choice would be to leave the patient in care of someone you know will not provide the needed care. Perhaps the PTs could educate someone else to provide the maintenance ROM if the mother will not do it. What would this patient's care options be if/when her mother dies or becomes unable to care for her? This will eventually happen and future planning needs to be considered. While one could not fill a whole case load with patients like this, surely it would not be too time consuming if the staff shared these exercises? As you point out, it need not be provided by the PT if a less expensive employee could be made available. Sandy Curwin Bangor, Maine > > > Clinical Dilemma > > Please do not respond directly to me but rather to the list with your > comments. > > The problem is this: > We are a small acute care hospital that provides inpatient and > outpatient services primarily to adult/geriatric population. > We have received a referral for PT " strengthening and therex 2x/week " > for an 18 you female with a diagnosis of birth CP/CMV. This patient is > well know to our facility as we have provided PT services for her each > summer while school is out. She is currently w/c bound, blind, ? > hearing, dependent in all ADLs and is contracted x 4 extremities. The > mother has been taught ROM repeatedly and is resistant to performing > home ROM stating that " it's your job " . Mom has now decided that she > will no longer be sending her daughter to school as she is 18 and she > expects to have PT services at our facility. The patient has Medicaid > coverage. > Knowing that PT will not provide any improvement in her function or > ability to interact with her environment and that it would strictly be > for maintenance ROM which Medicaid will not cover I feel that we do > not have to provide these services. The referring MD is unsupportive, > although he understands our point of view he feels that " if the mother > wants it " we should provide the services. > If anyone on the list serv has had a similar experience or can offer > suggestions on how to deal with this situation it would be greatly > appreciated. > Visit our EStore at www.RehabBusiness.com > > Rehab Pro - The software solution to controlling your rehab business! > Call to arrange a demo -. > > Rehab Management Solutions can can improve your bottom line - (877) > 552-2996 > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 26, 2000 Report Share Posted September 26, 2000 In addition to working in home care part-time, I also work at a school for multi-handicapped children and have been exposed to your situation/dilemma. My advice would be 1) contact the child's casemanager for MEDICAID (if waiver program and/or straight Medicaid), 2) involve a social worker who is familiar with community resources for respite care workers/equipment funding/rehab aides, 3) contact any other casemanager the child may have (i.e where I live in addition to being " waiver " they can be part of the County (or State) Board of Mental Retardation/Developmental Disabilities), 4) Find out if there are any Parent Support Groups for the mother to get in touch with, 5) contact CP Society for any leads/funding, and 6) contact the Easter Seal's Society (i.e where I live the students/adults can use the pool for a few bucks to perform supervised home/maintainence rehab programs -- but only after HEP instruct has been provided for say 6 visits. I do not consider myself to be insensitive to the mother's plight, nor more importantly, insensitive to the child's needs, but the mother must assume some responsibility for care: dare I say child/adult protective services if she is withholding essential PROM (provided she is physically capable)?. As holistic? altruistic? as I would like to think hospitals are with regard to providing pro bono visits (which could be an option parlayed into any of the above recommendations), the mother does have to realize there are certain laws of the land regarding progress vs maintenance. Trust me on this...there are some services available out there, but it just takes some aggravated investigating. Hope this is of some help. Babich, MS, MS-PT, CSCS Ohio State University Medical Center: Home Care Services, and lin County Board of MR/DD Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 27, 2000 Report Share Posted September 27, 2000 Great ideas! Thanks for sharing. >>> 09/26/00 09:29PM >>> In addition to working in home care part-time, I also work at a school for multi-handicapped children and have been exposed to your situation/dilemma. My advice would be 1) contact the child's casemanager for MEDICAID (if waiver program and/or straight Medicaid), 2) involve a social worker who is familiar with community resources for respite care workers/equipment funding/rehab aides, 3) contact any other casemanager the child may have (i.e where I live in addition to being " waiver " they can be part of the County (or State) Board of Mental Retardation/Developmental Disabilities), 4) Find out if there are any Parent Support Groups for the mother to get in touch with, 5) contact CP Society for any leads/funding, and 6) contact the Easter Seal's Society (i.e where I live the students/adults can use the pool for a few bucks to perform supervised home/maintainence rehab programs -- but only after HEP instruct has been provided for say 6 visits. I do not consider myself to be insensitive to the mother's plight, nor more importantly, insensitive to the child's needs, but the mother must assume some responsibility for care: dare I say child/adult protective services if she is withholding essential PROM (provided she is physically capable)?. As holistic? altruistic? as I would like to think hospitals are with regard to providing pro bono visits (which could be an option parlayed into any of the above recommendations), the mother does have to realize there are certain laws of the land regarding progress vs maintenance. Trust me on this...there are some services available out there, but it just takes some aggravated investigating. Hope this is of some help. Babich, MS, MS-PT, CSCS Ohio State University Medical Center: Home Care Services, and lin County Board of MR/DD Visit our EStore at www.RehabBusiness.com Rehab Pro - The software solution to controlling your rehab business! Call to arrange a demo -. Rehab Management Solutions can can improve your bottom line - ! Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 27, 2000 Report Share Posted September 27, 2000 I'd like to add my concensus to your recent recommendations regarding the utilization of a competent case manager. This individual should in my opinion receive the benefits she's entitled to before her benefits are drastically pared down at the age of 21. I feel she should be evaluated at an inpatient rehab center with a pediatrics dept. if possible for a coordinated transdisciplinary rehab program which would preferably be lead by medical management by a physiatrist & /or pediatric neurologist to medically address the spasticity effectively as possible, SLP and OT to address basic communication of needs and compensatory equipment needs for blindness, appropriate seating, positioning, progressive splinting, etc.. Perhaps PT could try some tone inhibiting exercises to be included in a home program, and use soft tissue/myofascial release techniques in addition to ROM, NDT, PNF or whatever may suit her neurorehab needs. I fully suppory the premise of our ethical responsibilities to serve our communities' needs, which includes the appropriate referral of complex cases with medical, rehab, and social / family issues to providers which are best suited to provide the resources necessary to stand a chance at impacting this individual's situation and quality of life. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted September 28, 2000 Report Share Posted September 28, 2000 When some one no longer qualifies for skilled service, but requires a maintenance program, we offer training for a home program, OR access to our equipment/pool for a therapist designed (and time limited) "transitional program" OR a "routine" program , that is maintenance in nature, designed by the therapist, but carried out by the trained rehab aide.(skilled therapy discharges). For this third type of program, we charge privately- 2 rates based on level of assist necessary, and charge by the unit. The amount is small compared to skilled service, the ROM is done competently, and perhaps over time mom could be engaged in the process. Some times a community organization may donate $ to a family to pay for these types of services....It has worked for us ...also enables the therapist to catch any declines, new problems quickly--through the eyes of the rehab aide... Caren morell OTR/L Dir rehab Broad Reach Health I have been asked to post this for another member who wishes to remain anonymous. Clinical Dilemma Please do not respond directly to me but rather to the list with your comments. The problem is this: We are a small acute care hospital that provides inpatient and outpatient services primarily to adult/geriatric population. We have received a referral for PT "strengthening and therex 2x/week" for an 18 you female with a diagnosis of birth CP/CMV. This patient is well know to our facility as we have provided PT services for her each summer while school is out. She is currently w/c bound, blind, ? hearing, dependent in all ADLs and is contracted x 4 extremities. The mother has been taught ROM repeatedly and is resistant to performing home ROM stating that "it's your job". Mom has now decided that she will no longer be sending her daughter to school as she is 18 and she expects to have PT services at our facility. The patient has Medicaid coverage. Knowing that PT will not provide any improvement in her function or ability to interact with her environment and that it would strictly be for maintenance ROM which Medicaid will not cover I feel that we do not have to provide these services. The referring MD is unsupportive, although he understands our point of view he feels that "if the mother wants it" we should provide the services. If anyone on the list serv has had a similar experience or can offer suggestions on how to deal with this situation it would be greatly appreciated. Visit our EStore at www.RehabBusiness.com Rehab Pro - The software solution to controlling your rehab business! Call to arrange a demo -. Rehab Management Solutions can can improve your bottom line - (877) 552-2996 Quote Link to comment Share on other sites More sharing options...
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