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2. Clinical and Business Solutions for Managing Rising Resident Acuity Tim Fox, PT, DPT, GCS, CCI Doctor of Physical Therapy Board Certified Geriatric Clinical Specialist Founder & CEO 2

3. Tim Fox, PT, DPT, GCS, CCI Doctor of Physical Therapy Board Certified Geriatric Clinical Specialist APTA Credentialed Clinical Instructor Founder & CEO – Fox Rehabilitation 3 Faculty Disclosure

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5. Objectives Participant will be able to identify residents who are at risk of rising acuity Establish why resident acuity is rising and its adverse relationship to functional performance Develop an understanding of some current operational risks and risk reduction strategies Learn how the HCRA regulatory changes are currently affecting residents’ access to rehabilitation and future consequences 5

6. Objectives Review what rehabilitation evidence suggests your residents should be receiving Learn solutions on how to maximize and transform your Physical Therapist into your community’s Rehabilitation Consultant Review current proactive programming solutions to manage and reduce risk of increasing acuity 6

7. HIGHER ACUITY = INCREASED RISK & COST OR OPPORTUNITY? 7

8. High Acuity We are living longer with more chronic conditions Older adults have delayed entry for economic reasons and have become accustomed to utilizing family, technology, medicine and community support 8 Yedinak G. Top 10 Trends in Senior Housing for 2012. Senior Housing News: http://seniorhousingnews.com/2012/01/09/top-10-trends-in-senior-housing-for-2012/: January 2012

9. High Acuity – Solutions A.Raise costs B.Change policies C.Consult other providers D.All of the above 9

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11. 11 Our Future Resident Population

12. Chronic Conditions 50% of Medicare beneficiaries have been treated for at least 5 chronic conditions which accounted for over 75% of Medicare spending 80% of older adults have at least one chronic condition and 50% have 2 or more 12 Guccione AA, Wong RA, Avers D., Geriatric Physical Therapy. 3 rd ed. St. Louis, MO: Elsevier Mosby: 2012:22.

13. Top Chronic Conditions That Result in Activity Limitations Degenerative Joint Disease Hypertension Coronary Artery Disease Cancer *advancing age increases prevalence of activity limitations 13 Cerebrovascular Accident Diabetes Mellitus Hearing & Visual Impairments Fracture Guccione AA, Wong RA, Avers D., Geriatric Physical Therapy. 3 rd ed. St. Louis, MO: Elsevier Mosby: 2012:22.

14. Thanks to Modern Medicine …….our patients are living longer with more chronic conditions….. that were once the cause of our mortality…… ….but who is PROACTIVELY addressing the functional decline associated with such? 14

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16. Age biases lower expectations for high levels of function… Lack of awareness of age based functional norms… 16

17. Normal Aging Slippery Slope of Aging 17 Where we should be Current practice is here

18. Optimal Aging Life satisfaction in multiple domains (physical, social & psychological) – despite presence of disabling medical conditions 18 Guccione AA, Wong RA, Avers D., Geriatric Physical Therapy. 3 rd ed. St. Louis, MO: Elsevier Mosby: 2012:22.

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20. Sedentary Lifestyle aka: lack of physical activity (PA) Only 22% of older adults engage in regular PA Increase rate of age related functional decline Reduces ability to build physiological reserve needed to recover following illness or injury 20

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24. Physical Activity Guidelines Adults (aged 18 to 64) Adults should do 2 hours and 30 minutes a week of moderate- intensity, OR 1 hour and 15 minutes (75 minutes) a week of vigorous- intensity aerobic physical activity. Additional health benefits are provided by increasing to 5 hours (300 minutes) a week of moderate-intensity aerobic physical activity, or 2 hours and 30 minutes a week of vigorous-intensity physical activity, or an equivalent combination of both. Adults should also do muscle-strengthening activities that involve all major muscle groups performed on 2 or more days per week. 24

25. Physical Activity Guidelines Older Adults (aged 65 and older) Older adults should follow the adult guidelines. If this is not possible due to limiting chronic conditions, older adults should be as physically active as their abilities allow. They should avoid inactivity. Older adults should do exercises that maintain or improve balance if they are at risk of falling. For all individuals, some activity is better than none. Physical activity is safe for almost everyone, and the health benefits of physical activity far outweigh the risks. People without diagnosed chronic conditions (such as diabetes, heart disease, or osteoarthritis) and who do not have symptoms (e.g., chest pain or pressure, dizziness, or joint pain) do not need to consult with a health care provider about physical activity. 25

26. Scientific Evidence Strong Evidence Lower risk of: –Early death –Heart disease –Stroke –Type 2 diabetes –High blood pressure –Adverse blood lipid profile –Metabolic syndrome –Colon and breast cancers Prevention of weight gain 26

27. Medical and Rehabilitation 27 WHO Disablement Model

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29. Health Care Reform Act (HCRA) “while health care reform will continue to put a downward pressure on reimbursement, we believe that with bundling or site neutral payments, the long term winners will be those providers that can move beyond the current “silo” structure and operate across the continuum of post acute care, particularly in local markets” – Rehab Care Group, Wall Street Research, Dec. 2010 29

30. 30 HIGHER ACUITY = INCREASED RISK & COST OR OPPORTUNITY?

31. High Acuity We are living longer with more chronic conditions Older adults have delayed entry for economic reasons and have become accustomed to utilizing family, technology, medicine and community support 31 Yedinak G. Top 10 Trends in Senior Housing for 2012. Senior Housing News: http://seniorhousingnews.com/2012/01/09/top-10-trends-in-senior-housing-for-2012/: January 2012

32. High Acuity – Solutions A.Raise costs B.Change policies C.Consult other providers D.All of the above 32

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34. The Affordable Care Act - 2011 Fight Fraud, Strengthen Medicare Create rigorous screening process Temporarily stop enrollment Temporarily stop payments $350 million “increase feet on the street” Increase data sharing initiatives Increase MAC & ZPICS audits 34

35. Medicare Necessity Medical Necessity – as defined by professional best practice guidelines Medical Necessity – as defined by third party payer guidelines Skilled Intervention – a shrinking definition 35

36. Medicare Necessity – PT Based on results of PT exam When provided for the purpose of preventing, minimizing or eliminating impairments, activity limitations, or participation restrictions Delivered throughout episode of care, requires knowledge and clinical judgment, takes into account benefit vs. harm Not provided exclusively for convenience of patient Provided using evidence of effectiveness and best standards of practice Is considered medically necessary if type, amount and duration suggested in the POC increase the likelihood of meeting stated goals to improve function, minimize loss of function and / or decrease risk of injury or disease APTA Board of Directors - 2011 36

37. Medical Necessity – Medicare The Medicare definition of medical necessity under the Social Security Act states: “No Medicare payment shall be made for items or services that are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.” 37

38. Health Care Reform… 2011 OIG REPORT ON QUESTIONABLE BILLING FOR MEDICARE OUTPATIENT PROVIDERS OIG identified 6 billing characteristics that may ID fraud: 1.Over and inappropriate use of KX modifier National KX utilization: outpatient 15%, 85 years+ 22.5% 2.Premature assignment of KX modifier 3.Multiple providers per year 4.Therapy episode billed each quarter over year 5.Multiple providers exceeding CAP (PT, OT, SLP) 6.> 8 hrs of therapy per day 38

39. $3,700 CAP Est. 2012 Great Wall of Risk AFFORDABLE CARE ACT Est. 2011 CAP Est. 1998 MANUAL EXCEPTIONS PROCESS, D/C’D CONDITIONS + COMPLEXITIES = AUTOMATIC CAP Est. 2006 Wall of Risk +KX 39 REHAB GOALS EPISODE #1 Jan 1 TREATMENTS: DOLLARS SPENT: Unknown Risk K S I R EPISODES #3+ $1,950 19 0 36 18 $3,700 Episode #1 cont’d OR Episode #2 (New POC – i.e., May 1) EPISODE #1 EPISODE #2 Not Met Progress Met D/C to SMB Scrutiny Audit, Risk & Denials 1 18 $0 $1,850 Not Met Progress Met D/C to SMB * HCRA & Resident Acuity… “Tell Me About That” Assumptions: 1) Strong evidence based clinical documentation supporting medical necessity 2) PT & SLP combined*, OT separate Manual Exceptions

40. $3,700 CAP Est. 2012 Great Wall of Risk AFFORDABLE CARE ACT Est. 2011 CAP Est. 1998 MANUAL EXCEPTIONS PROCESS, D/C’D CONDITIONS + COMPLEXITIES = AUTOMATIC CAP Est. 2006 Wall of Risk +KX 40 REHAB GOALS EPISODE #1 Jan 1 TREATMENTS: DOLLARS SPENT: Unknown Risk K S I R EPISODES #3+ $1,950 19 0 36 18 $3,700 Episode #1 cont’d OR Episode #2 (New POC – i.e., May 1) EPISODE #1 EPISODE #2 Not Met Progress Met D/C to SMB Scrutiny Audit, Risk & Denials 1 18 $0 $1,850 Not Met Progress Met D/C to SMB * HCRA & Resident Acuity… “Tell Me About That” Assumptions: 1) Strong evidence based clinical documentation supporting medical necessity 2) PT & SLP combined*, OT separate Manual Exceptions

41. Health Care Reform… PRIVATE PAY – HEALTH CARE Optimal Function & Meaningful Life Return to pre episodic level MEDICARE – ILLNESS DRIVEN Bare bones minimum, functional within confined environment FUNCTIONFUNCTION 41

42. What Does it Mean? Payor Drives Care – Providers may be less likely to assume the risk of going beyond CAP limits due to high levels of audit and non payment Quality of care will suffer as residents may not receive what they have been accustomed to receiving Resident acuity may increase 42

43. Disablement and Quality of Life *Adapted from Levine and Croog 1984 Services in the Nagi Disablement Model 43

44. Services in the WHO Disablement Model Medical and Rehabilitation 44

45. Positive Reform First Coast Service Options (Florida) Medicare Policy (LCD) for Major Joint Replacement (Hip and Knee) The policy calls for conservative treatment of usually 3 months including supervised physical therapy. Physical Therapist should be mindful of Medical Necessity for treatment and justifying continued care over a 3 month period. When the procedure is indicated for advanced joint disease, the following should be documented in the medical record: “Unsuccessful conservative therapy (non-surgical medical management). The Documentation should demonstrate a history of a reasonable attempt (usually 3 months or more) at conservative therapy as appropriate for the patient in their current episode of care. For example, documented trial of NSAIDs or contraindication to such therapy and/or documented supervised physical therapy. Documentation should support that ADLs are diminished due to pain and/or disability despite non-surgical medical management.” 45

46. American Geriatrics Society / British Geriatrics Society Clinical Practice Guidelines 2010 Older Persons Living in the Community The multifactorial fall risk assessment should be followed by direct interventions tailored to the identified risk factors, coupled with an appropriate exercise program. [A] A strategy to reduce the risk of falls should include multifactorial assessment of known fall risk factors and management of the risk factors identified. [A] The components most commonly included in efficacious interventions were: Adaptation or modification of home environment [A] Withdrawal or minimization of psychoactive medications [B] Withdrawal or minimization of other medications [C] Management of postural hypotension [C] Management of foot problems and footwear [C] Exercise, particularly balance, strength, and gait training [A] All older adults who are at risk of falling should be offered an exercise program incorporating balance, gait, and strength training. Flexibility and endurance training should also be offered, but not as sole components of the program. [A] Multifactorial/multicomponent intervention should include an education component complementing and addressing issues specific to the intervention being provided, tailored to individual cognitive function and language. [C] Mitigating Risk with Best Practice 46

47. 47 Muscle Weakness

48. Muscle weakness, termed sarcopenia, and dynapenia, is a normal age- related phenomenon, occurring at a rate of 1% to 5% annually from the age of 30. The rate of strength decline is dependent on age and physical activity. Those who are physically inactive lose muscle mass and strength more quickly than active individuals who participate in strength training.* After the age of 60, power decreases even more rapidly at a rate of 3% to 5% annually, affecting the ability to move and react quickly.** Thus, if a 60 year old maintains a sedentary lifestyle, at 70 years of age they will be up to 50% weaker than at 60. *Bortz WM. A conceptual framework of frailty: a review. J Gerontol. Med Sci. 2002;57A:M283–M288. **Metter EJ, Conwit R, Tobin J, Fozard JL., Age-associated loss of power and strength in the upper extremities in women and men. J Gerontol A Biol Sci Med Sci 1997;52:B267-76 48 Muscle Weakness

49. Mitigating Risk with Best Practice For older community residents, effective fall prevention has the potential to reduce serious fall-related injuries, emergency department visits, hospitalizations, nursing home placements, and functional decline. Evidence from randomized controlled trials and other types of studies supporting the beneficial effects of fall prevention programs has done little to change the lack of attention to fall risk in clinical practice. A recent study confirmed that effective fall risk assessments and strategies to prevent falls can significantly reduce serious injuries (hip and other fractures, head injuries, joint dislocations) as well as use of fall-related medical services. 49 Tinetti ME, Baker DI, King M, et al. Effect of dissemination of evidence in reducing injuries from falls. New England Journal of Medicine 2008 Jul 17;359(3):22-61.

50. Choking Carries Significant Risk for Residents and Facilities Ways to reduce risk of choking and aspiration: Proper and periodic assessment for swallowing deficits Therapy follow through with modified diets Consistent delivery of diet Adequate dining room supervision and trained staff Appropriate emergency equipment 50 Mitigating Risk with Best Practice Feldkamp JK. Choking Carries Significant Risk for Residents and Facilities. Caring for the Ages; http://www.caringfortheages.com/views/legal-issues/blog/choking-carries-significant-risk-for- residents-and-facilities/ea2655fc913a7e78840cb08d1ea9eba1.html; March 2012.

51. CDC Consensus Guidelines Essential to include all aspects of fitness in exercise prescription, especially for older adults (aerobic / endurance training, strength training, balance training, postural training and flexibility exercises) No one single type of activity will produce all the benefits of a well rounded physical activity program 51

52. ACSM / AHA 2007 Guidelines Physical Activity and Public Health: Updated Recommendations for Adults Physical Activity and Public Health in Older Adults Older adults: includes aerobic, strength, balance, and flexibility training, reducing sedentary behavior, developing an activity plan for achieving recommended physical activity that integrates preventative and therapeutic recommendations 52

53. Dosage 53

54. Keeping the Intensity “Clinicians who provide and bill therapeutic exercise to Medicare and who do not provide those programs at an appropriate (high) intensity, thus an inadequate intensity (<60% of a 1RM), are committing malpractice and fraud…the evidence has been available since the1990’s.” – Dale Avers, PT, DPT, PhD – SUNY Upstate 54

55. Functional Reach Test PURPOSE: To assess balance and postural control in community dwelling individuals WHEN TO USE: To detect balance impairments To set objective balance goals EQUIPMENT: 2 pieces of blank paper-taped together INSTRUCTIONS: Measure forward reaching three times and then take the average RESEARCH: FR = 0 8x more likely to have 2 falls in next 6 months FR ≤ 6 4x more likely to have 2 falls in next 6 months FR>6 but<10: 2x more likely to have 2 falls in next 6 months 55 Duncan, PW, et al., Functional reach: A new clinical measure of balance. J Gerontol. 1990; 45:M192.

56. 30 Second Chair Sit to Stand PURPOSE: To assess functional lower extremity strength WHEN TO USE: Adaptation for frail elderly EQUIPMENT: Chair and stop watch INSTRUCTIONS: With arms folded across the chest, count the number of full stands that can be completed in 30 seconds. Age RangeMean # of completed sit to stand 60-69 years14.0 70-79 years12.9 80-89 years11.9 56 RESEARCH:

57. Timed Up and Go (TUG) PURPOSE: Used to evaluate basic functional mobility WHEN TO USE: Results correlate with gait speed, balance, functional level the ability to go out, and can follow change over time EQUIPMENT: Tape measure, chair, stop watch INSTRUCTIONS: Measure a 3 meter distance from the client’s seated position. Using a stopwatch, start timing on the word “GO,” and stop timing when the subject is seated again correctly in the chair with their back resting on the back of the chair. Repeat twice and take the average of the two trials. 57

58. RESEARCH: Relationship to basic mobility: –A score <20: all were (I) with basic toilet and chair transfers –A score >30: decreased (I) Relationship to falls: –14 sec - will identify 87% of fallers and those not fallers Women between ages 65-85 years should perform TUG <12 sec 58 Timed Up and Go (TUG) Bischoff HA, Stahelin HB, et al., Identifying a cut-off point for normal mobility: A comparison study of the timed "up and go" test in community-dwelling and institutionalized elderly women. Age and Ageing. 2003;32:315-320.

59. Manual TaskCognitive Task Carry water Pour water Pull things out of a bag Turn pages of a magazine Dial a phone Write a note Blow your nose Button a shirt Thread a belt Remember fact / word Read from a magazine Object recognition Remember phone number Hold a conversation, keep eye contact Count backwards Think of things you need to do this month TUG and dual-tasking TUG Scores - With dual-task: discriminate between fallers and non-fallers those with >5-6 sec difference with addition of task are at greater risk for falls 59 Timed Up and Go (TUG)

60. Gait Speed & Disability 60

61. How Can It Be Measured? 61

62. Problem – Review Population growing & living longer with more chronic conditions Cost to provide care increases as acuity increases Cannot rely on traditional sources to finance “functional well being” “the long term winners will be those providers that can move beyond the current “silo” structure and operate across the continuum of post acute care, particularly in local markets” – Rehab Care Group, Wall Street Research, Dec. 2010 REMEMBER: 62

63. High Acuity – Solutions A.Raise costs B.Change policies C.Consult other providers D.All of the above 63

64. Solutions D.All of the above 64

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66. Solutions Drive rehabilitation component of Assisted Living with the same clinical intensity as nursing Incorporate Physical Therapy as Rehabilitation Consultant into Assisted Living model 66

67. Pioneers in IT Mark Zuckerberg Net Worth: $17.5B Title: Founder, Facebook Age: 27 Forbes Lists: #9 Powerful People #14 Forbes 400 #52 Forbes Billionaires #22 in United States Bill Gates Net Worth: $59B Title: Co-Chair, Bill & Melinda Gates Foundation Age: 56 Forbes Lists: #5 Powerful People #1 Forbes 400 #2 Forbes Billionaires #1 in United States Larry Page & Sergey Brin Net Worth: $16.7B (each) Titles: Co-Founders, Google Ages: 38 Forbes Lists: #30 Powerful People #15 Forbes 400 #24 Forbes Billionaires #14 in United States 67

68. Pioneers in Medicine Heart-Lung: Dr. John Heysham Gibbon Penicillin: Sir Alexander Fleming 68

69. Were They Ready in 1981? Paul Klaassen CEO, Sunrise Senior Living (1981-2008) “I didn’t think I’d start a national movement that would change long term care in the U.S.” 69

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71. Data Validating Solutions Studies of work site health promotional efforts have demonstrated significant benefits from programs aimed at chronic care management and from lifestyle changes to reduce risk and generate meaningful health savings Studies of programs such as Silver Sneakers have found that participation in the program leads to significant reductions in hospitalizations and reductions in health care costs Presently available research, along with the results presented in this report, indicate the potentially great benefit of programs that specifically target Medicare individuals with chronic diseases such as CAD, DM & COPD 71 Rula EY, Pope JE, et al., Population Health Management. 2011, 14(S1):S-39.

72. Fox Better Living Strength, Mobility, and Balance Exercise Program CRITICAL PROGRAM COMPONENTS: Assisted Living now has full time Physical Therapist / Rehabilitation Consultant overseeing care in collaboration with Nursing Strength, Mobility, and Balance Assessments performed on all residents Custom Strength, Mobility, and Balance Improvement Plans of Care for each resident Execution: Strength, Mobility, and Balance Exercise Program Assisted Living Community passes cost on to the resident Improve community revenues while adding profound clinical value Assisted Living Community does not assume costs or risks of operating rehabilitation component but gains all the benefits 72

73. Were They Ready in 1981? Paul Klaassen CEO, Sunrise Senior Living (1981-2008) “I didn’t think I’d start a national movement that would change long term care in the U.S.” 73

74. Strength, Mobility and Balance Assessments Performed on All Residents Upon move in / return from hospital Quarterly Observed functional decline After a fall / incident 74

75. Strength, Mobility and Balance Assessments Performed on All Residents The Tests Timed Up and Go Functional Reach 30 Second Sit to Stand History of Falls Gait Speed 75

76. Custom Strength, Mobility, and Balance Improvement Plans of Care As a result of the Strength, Mobility, and Balance Assessment, the health care team may recommend: Referral to OT, PT, SLP Referral to physician Referral to Better Living Strength, Mobility, and Balance Exercise Program Assessment of environmental hazards Medication review Change in toileting schedule Caregiver education Durable medical equipment 76

77. The Strength, Mobility, and Balance Exercise Program A customized and progressive exercise program designed to improve participants muscle strength, mobility, and balance The exercise program is led by a trained Exercise Physiologist The exercise program is held two times per week for twelve weeks Each exercise session ranges 60 to 90 minutes 77

78. 12-Week FBL Exercise Class N=288, (Male=28, Female=260 with mean age 84.4 years) 24 Assisted Living Communities POST12-Week Functional Outcome Measures –30 Second Sit to Stand increase from 7.2 to 9.8 reps 32% Improvement (MDC: 2 reps) Age Normative Values = 12 reps –Timed Up and Go decrease from 18.9 to 15.9 (s) 18% Improvement (MDC: 2.5(s)) Age Normative Values = 11(s) –Functional Reach increase from 8.1 to 9.4 in Improvement of 1.3 in, just under MDC (MDC: 1.5 in) Age Normative Values = 8.8 in Strength, Mobility & Balance Data 78

79. Rehab as a Partner Closing the Back Door, While Opening the Front Fall Reduction –2011 average monthly falls = 23 –Q1 2012 average monthly falls = 18.3 –22% reduction in falls Community Rehabilitation Exercise and Activity Program –69 unique visitors to Assisted Living Community over 12 months Discharged by Fox OT, PT, SLP – 51 Outreach by Fox/ALF marketing to community resources – 15 Direct physician referral – 3 79

80. Summary Health Care Reform will cause us to change and adapt Strong companies: Keep & don’t dilute core business Examine & build on mission Consult with experts See way over the horizon Get in front of trends Costs of care will be passed down to the consumer Implementation of innovative, evidence based programming aimed at reducing expenses, increasing revenues and most importantly improving quality of life, will be welcomed solutions to open minded providers 80

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82. The End Tim Fox, PT, DPT, GCS, CCI Doctor of Physical Therapy Board Certified Geriatric Clinical Specialist Founder & CEO tim.fox@foxrehab.org 82