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September 2016 CardioLAN Webinar
Maintenance
Therapy
Home Health Patient
with Heart Failure
Guest Experts:
Dee Kornetti, PT, MA
Cindy Krafft, PT MS
This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality
Improvement Organization supporting the Home Health Quality Improvement National Campaign, under
contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department
of Health and Human Services. The views presented do not necessarily reflect CMS policy.
Publication number 11SOW-WV-HH-MMD-091516
HHQI Announcements
HHCDR Updates
Continuing Education Credits
 Nursing: 2.25 hrs of Continuing Education
– Approved by the Alabama State Nurses
Association, an accredited approver by
the American Nurses Credentialing
Center’s Commission on Accreditation
 Physical Therapy: 1.0 Continuing
Competency Units (CCUs)
– Approved by The Federation of State Boards of
Physical Therapy
https://pt.fsbpt.net/aPTitude/content/public/FSBPTCertification

Maintenance Therapy for the
Home Health Patient with Heart Failure
Diana (Dee) Kornetti, PT, MA
Cindy Krafft, PT, MS
Webinar Objectives
 Upon completion of this course, participants will be able to:
 Define what “skilled, reasonable and necessary” means for
coverage, and when appropriate for discharge, of
maintenance therapy services under the Medicare Part A
Home Health benefit
 Describe at least two (2) heart failure (HF) characteristics
that would support decision to pursue a maintenance
therapy course of care for the HH patient with HF
 Identify at least three (3) key documentation elements to
support the medical necessity of a maintenance course of
therapy care fore the HH patient with HF
Housekeeping:
Answering Your Questions
 Please use the Q&A box to
type in any questions you
have about goal writing for
the home health therapist.
 We will gather questions
during the presentation
and provide Q&A time at
the end.
The Medicare Part A Home Health
Benefit

A review of key therapy concepts
Three Conditions for Coverage of Therapy Services:
The Home Health Benefit
Skills of a qualified
therapist are
needed to restore
function
Restorative
Patient’s condition
requires a qualified
therapist to design
or establish a
maintenance
program
Maintenance
Skills of a qualified
therapist are
required to perform
maintenance
therapy
Maintenance
Jimmo v. Sebelius: Background
 January 24, 2013 – US District Court for the
District of Vermont settlement agreement
reached:
 GOAL: ensure that claims are correctly
adjudicated in accordance with existing
Medicare policy, so that Medicare beneficiaries
receive the full coverage to which they are
entitled
 Specific steps that CMS must undertake (to be
completed by January 23, 2014)
 Issue clarifications to existing program guidance
 New educational material on subject
Jimmo v. Sebelius: Transmittal 179
 Medicare Benefit Policy Manual Updates to
Clarify Skilled Nursing Facility (SNF), Inpatient
Rehabilitation Facility (IRF), Home Health (HH),
and Outpatient (OPT_ Coverage Pursuant to
Jimmo vs. Sebelius
 Transmittal Date: 12/13/13
 http://www.cms.gov/Regulations-and-
Guidance/Guidance/Transmittals/Downloads/R
179bp.pdf
Jimmo v. Sebelius: Transmittal 179
 Summary: Medicare Program manual revisions
to clarify that coverage of skilled nursing and
skilled therapy services “…does not turn on the
presence or absence of a beneficiary’s potential
for improvement, but rather on the beneficiary’s
need for skilled care.”
 To improve current condition
 To prevent or slow further
deterioration of condition
Condition #2: Maintenance
What do the regulations say?
Patient is
responding
to therapy
and can
meet the
goals in a
predictable
period of
time
The
maintenance
program
must be
established
by a qualified
therapist
(and not an
assistant)
The unique clinical
condition of a patient
may require the
specialized skills,
knowledge, and
judgment of a
qualified therapist to
design or establish a
safe and effective
maintenance program
required in connection
with the patient’s
specific illness or
injury
Must include the
program design,
instruction of the
beneficiary, family, or
home health aides, and
the necessary periodic
reevaluations of the
beneficiary and the
program to the degree
that the specialized
knowledge and judgment
of a PT, SLP, or OT is
required
Ref: PPS-2011 Final Rule. Rehabilitative v/ Maintenance Therapy; §409.44(c)(2)(H)(4)
Condition #3: Maintenance
What do the regulations say?
Skills of a qualified therapist are needed to perform maintenance therapy
Where the clinical condition of the
patient is such that the complexity
of the therapy services required to
maintain function involve the use
of complex and sophisticated
therapy procedures to be delivered
by the therapist himself/herself
(and not an assistant), or
The clinical condition of the patient is
such that the complexity of the therapy
services required to maintain function
must be delivered by the therapist
himself/herself (and not an assistant) in
order to ensure the patient’s safety and
to provide an effective maintenance
program, then those reasonable and
necessary services shall be covered.
Ref: PPS-2011 Final Rule. Rehabilitative v/ Maintenance Therapy; §409.44(c)(2)(H)(4)
Anatomy of a Maintenance Program
Periodic
reevaluation
Safe &
effective
Skills
knowledge
judgment
Complexity
requiring
qualified
therapist
Program
design
related to
disease
Prevention
of decline
Defining Key Therapy Concepts
 Skilled Therapy Services (ref: HH Benefit Policy Manual, Chapter 7,
40.2 – Skilled Therapy Services)
Skill
Belongs to the clinician
• proficiency, facility, or dexterity that is acquired or
developed through training or experience; an art, trade, or
technique
Progress
• advancement, development, growth, steady improvement
Progress does not equate to skilled therapy.
What does Demonstrate “Skill?”
 Complexity such that safety and/or efficacy of the
intervention can only by achieved under the
supervision of a skilled clinician.
 Development, implementation, management and
evaluation of a care plan
 Goals, interventions, frequency & duration . . .
 Management and periodic reevaluation (of plan as
well as patient)
This applies to both restorative and
maintenance programs for therapy
More on Skilled Therapy. . .
Q: Where is the “skill” if there is no expected “progress” by the patient?

Were impairments in body structure
& function found on evaluation?

Was an individualized maintenance
program developed?

Has the pt/CG been
educated/trained?

Is complexity such that only able to
be completed by trained clinician?

Is the program working?
A: The contributions of the clinician.
More on Skilled Therapy. . .
Patient “responsiveness” does not mean it required a therapist
 The documentation should include:
 Program development &
implementation
 Specific components and
rationale for inclusion
 Who was trained/educated
 Assessment of patient & program
efficacy
 Stabilization of condition(s)
 Halt/slowing of deterioration
or decline
Defining Key Therapy Concepts
 Reasonable and Necessary Therapy Services (ref: HH Benefit
Policy Manual, Chapter 7, 40.2 – Skilled Therapy Services)
Reasonable
• governed by or being in accordance with reason or sound
thinking; not excessive or extreme
Necessary
• Absolutely essential; needed to achieve a certain result
or effect; requisite
Therapy services must be in accordance with sound
judgment and be essential, requisite for the patient.
More on Reasonable & Necessary Therapy
Just because an intervention was completed does not mean it was
either reasonable or necessary

Why did therapist need to be
present for this visit?

What condition(s) was/were
addressed that are focus of
service provided?

What alterations in the patient’s
daily functioning occurred?

What stabilization/reduction of
deterioration would not occur
without this purposefully
injected intervention?
Medicare Benefit Policy Manual – Chapter 7
 20.3 - Use of Utilization Screens and "Rules of
Thumb" (Rev. 1, 10-01-03)
A3-3116.3, HHA-203.3
 Medicare recognizes that determinations of
whether home health services are reasonable and
necessary must be based on an assessment of each
beneficiary's individual care needs. Therefore,
denial of services based on numerical utilization
screens, diagnostic screens, diagnosis or specific
treatment norms is not appropriate.
What CMS has to say . . .
 “We believe that rehabilitation professionals, by virtue of
their education and experience, are typically able to
determine when a functional impairment could
reasonably be expected to improve spontaneously as the
patient gradually resumes normal activities.”
 “We expect rehabilitation professionals to be able to
recognize when their skills are appropriate to promote
recovery.”
What CMS has to say . . .
 Regarding therapy coverage based on patient diagnosis(es):
 “A prescriptive definition of these sorts of conditions,
such as a listing of specific disease states that provide
subtext for these descriptions is impractical, as each
patient’s recovery from illness is based on unique
characteristics.”
 No assumptions can be made about the skilled need,
reasonable and necessary status of a patient because
they present with diagnoses that typically receive
therapy
 i.e., stroke, orthopedic conditions or surgeries,
progressive neuromuscular diseases (Parkinson’s)
The Medicare Part A Home Health
Benefit
Heart Failure & Exercise – A Brief Review

Overview of Heart Failure
 A chronic, progressive condition where the heart muscle is
unable to pump enough blood to meet the body’s needs for
blood and oxygen
 To attempt to accommodate:
 Enlargement of heart chambers leads to retention of
fluid lungs congest with fluid heart beats irregularly
 Contractile cells of heart become larger to attempt to pump
more strongly
 Increased heart rate to increase output
 continues with compensatory strategies that result in overall
worsening of condition
Overview of Heart Failure
 Heart failure (HF) can involve left side, right side or both sides of
heart
 Most common = left side initially
 Left-sided HF types:
 Systolic – L ventricle loses ability to contract normally
 Lacks force to push blood into circulation
 May be documented as HFpEF
 Diastolic – L ventricle loses ability to relax normally (muscle
becomes stiff)
 Can’t properly fill during resting period (between beats) due
to cardiac muscle becomes stiff
 May be documented as HFrEF
Overview of Heart Failure
 Right-sided HF types:
 Usually occurs as a result of left-sided failure
 Increased fluid pressure results from left-sided failure and
ultimately damages right side of heart
 Right-sided loss of pump power results in blood backing up
into veins (swelling or congestion in legs, ankles, abdomen)
 Congestive HF:
 Blood flow out of heart slows
 Blood returning to the heart through veins backs up
 Requires timely medical attention
Overview of Heart Failure
A. Right-sided heart failure
Back-ups in the area that collects “used” blood
B. Left-sided heart failure
Failure to properly pump out blood to the body
C. Congestive heart failure
Fluid collects around the heart
The Role of Exercise in Heart Failure
 Aerobic exercise produces significant improvements in
functional capacity
 Exercise produces little or no improvement in cardiac
performance
 Physiological changes that occur appear to be due to
peripheral, rather than central adaptations






Improvement aerobic metabolism Improved autonomic regulation
Improved peripheral perfusion
Decreased local inflammation
Improved ventilatory control
Improved quality of life
Decreased hospital readmission and mortality
More on Aerobic Metabolism
 Improvement in VO2peak
 Results from improvement in oxygen extraction peripherally
or increase in cardiac output/oxygen delivery
 Increase in exercise time
 Increase in anaerobic threshold
Defining Terminology
 Progressive Resistance Training

Exercise that requires muscles to generate
force to move or resist weight, with the
intensity increasing as physical capacity
improves (e.g., strength training)
 Aerobic Capacity/Endurance Training

Exercise that involves repetitive motions, uses
large muscle groups, increases heart rate for
an extended period, and raises core body
temperature (e.g., walking, dancing, swimming)
The Medicare Part A Home Health
Benefit

Maintenance Therapy & Patients With HF
Common Presentation of HF in HH Pts
 Subjective Complaints:
Fatigues (easily) with
activities
Short of breath with
exertion/sustained activity
Dependence on
others/loss of
independence
Inability to carry out
normal
roles/responsibilities
Prioritizes most important
daily activities
Altered quality of life (QoL)
Anxiety, fear, depression
Impaired functional
mobility
Impaired strength/aerobic
capacity
Impaired ADLs
Fall risk
Limited community
mobility
Difficulty with transfers,
gait, balance
Limits or discontinues
normal ADLs/IADLs
 Objective Findings:
A Roadmap to Maintenance Therapy
SN on SOC
Therapist on IE
Assess
pathology/pathophysiology
of CV system
Quantify impairments in
body structure/ function
Link to functional limitations
/ participation restriction
Assess functioning within
constraints of disease
process (severity)
Determine risk for
deterioration/decline
Develop plan of care to
remediate risk(s)
Attention to Functional Deficits in HF
 Chronic disease is either managed well or poorly; it is not
“cured.”
 Focus on the patient’s functional abilities/limitations within the
constraints of the disease process.
 What can’t the patient do, and should be able to do?
 What is the patient doing that, in light of the severity of their
disease process, they should not be doing?
 Focus skilled, evidence-based interventions on optimizing
patient’s independence within the environment in which they
currently (must) function
Considerations for Maintenance Therapy
Disease Severity/Acuity
Patient Accountability/Motivation/Support
Appropriately Prescribed & Dosed Exercise
New York Heart Association (NYHA)
Class
Patient Symptoms
Class I (Mild)
No limitation of physical activity. Ordinary physical activity
does not cause undue fatigue, palpitation, or dyspnea
(shortness of breath).
Class II (Mild)
Slight limitation of physical activity. Comfortable at rest,
but ordinary physical activity results in fatigue, palpitation,
or dyspnea.
Class III
(Moderate)
Marked limitation of physical activity. Comfortable at rest,
but less than ordinary activity causes fatigue, palpitation,
or dyspnea.
Class IV
(Severe)
Unable to carry out any physical activity without
discomfort. Symptoms of cardiac insufficiency at rest. If
any physical activity is undertaken, discomfort is increased.
Making a Decision
Therapy
Assessment
Restorative
Therapy
Return to
PLOF?
At Optimal
Level?
Need
Intervention?
Need
Intervention?
No Therapy
Maintenance
Therapy
No Therapy
Knowledge Application Exercise
 CHF NHYA Stage IV with
multiple rehospitalizations;
PMHx: RA, HTN, pacer, CABG
x3; BLE fem-pop bypasses
 Acute exacerbation of chronic
diastolic heart failure with
ACH for diuresis
Coverage Criteria 1:
Restorative Therapy
Coverage Criteria 2:
Maintenance Program
development and
management
 Combined systolic and
diastolic HF NYHA Class II;
symptoms with completion of
independent ADLs/light
IADLs; resides alone
Coverage Criteria 3:
Maintenance Therapy
Program performance
Jimmo v. Sebelius: Transmittal 179
 Enhanced guidance on DOCUMENTATION
 Does not require the presence of any particular phraseology
or verbal formulation as a prerequisite for coverage
 Provided to assist providers in their efforts to identify and
include the kind of clinical information that can most
effectively serve to support a finding of skilled care
 DOES identify certain vague phrases as being insufficiently
explanatory to establish coverage
 “patient tolerated treatment well”
 “continue with POC”
 “patient remains stable”
Documenting Interventions
Source: American College of Sports Medicine (ACSM)
 ACSM Exercise Prescription Principles
Category
Cardiovascular
Muscle
Strengthening
Frequency
Intensity
40/50-85% of HRR or
3-5 days/week
VO2R
2 or 3
days/week
3- to 20RM range;
typically 8-20RM
Time
Type
20-60 minutes
Large muscle
mass,
continuous,
rhythmic
One set each of
8-10 exercises
(< 1 hour)
Major muscle
groups, full ROM,
controlled speed
15-30sec for
each of 2-4 reps
Static
*8RM ~ 84% 1RM
*12RM ~ 76% 1RM
Flexibility
2 or 3
days/week;
ideally 5-7
To point of tightness
Rate of Perceived Exertion & Work Load
Ordinal Scale1
Percent Effort
6
20%
7
30%
8
40%
1
9
50%
2
10
55%
11
60%
12
65%
13
70%
14
75%
5
15
80%
6
16
85%
7
17
90%
8
18
95%
9
19
100%
10
20
Exhaustion
Modified Scale
3
4
Perceived Work Load
Very, very light
Talk Test
At rest
Gentle walking or “strolling”
Very light
Fairly light
Steady pace, not breathless
Moderately hard
Brisk walking, able to carry on a
conversation
Hard
Very brisk walking, must take a breath
between 4-5 words
Very hard
Unable to talk and keep pace
Very, very hard
Source: Avers D, Bown, M. White Paper: Strength Training for the Older Adult, Journal of Geriatric PT Vol. 32;4:09, 148-152
Documenting Goals:
A Template
 Five (5) necessary elements that all goals should include:
 Who the goal pertains to
 What objective measure is used
 Where is score interpretation/
expected change to occur
 Why? Functional relevance
 When is it to occur: time frame
 “These guidelines are not exhaustive and should be
considered a starting point for goal setting.”
 Source: Goal Writing Guidelines for Home Health
Therapists, www.homehealthsection.org
Goals for Maintenance Programs in HF
 Example 1:
 Patient will independently utilize energy conservation strategies
during and upon completion of personal hygiene and bathing as
evidenced by Borg RPE scores < 12/20 x 6 weeks.
 Example 2:
 Patient will demonstrate aerobic capacity to support IADL
completion as evidenced by 2-Minute Step Test > 80% of
age/gender norms x 8 weeks.
 Example 3:
 CGs will independently don/doff resting splints nightly for
contracture prevention as evidenced by bilateral ankle DF PROM >
O degrees (neutral) x 3 weeks.
Documenting Utilization:
Parameters To Be Considered
 Maintenance: Outcome = optimize function;
reduce risk of deterioration or decline; reduce
(re-) hospitalization
 Lower intensity (frequency)*
 All visits require the skill of a qualified therapist to
provide training, instruction, re-evaluation and
program modification
 Variable duration
 Dependent on training/instruction needed
 Probable longer duration to monitor
stabilization/plateau of the beneficiary
Sample: Therapy Utilization

Maintenance program development and instruction
 1x for evaluation and program development
 1-3x for training/instruction of person(s) completing program

Follow up on instruction/training; determine program efficacy and
need for modification(s)
 1-3x for follow up on program completion and need for
modification
 Can be PRN visits

Reevaluation of patient and current program
 1x for reevaluation
 Estimated time period for reevaluation completion – every 30
days
Completion of the
Mandatory Reassessment
 1st: Dispel The Myth ...
 Are therapy re-evaluations at 30 days or visit 13 and 19
required for maintenance patients?
 A: They are required at all three stages, though therapy
maintenance case is unlikely to reach the 13th visit since
frequency would be limited. Keep in mind, though, that a
patient receiving PT maintenance also might be getting
occupational and speech therapy. If so, the 13/19th visit
could become a re-evaluation issue. In any case, the 30-day
assessment would be required if the maintenance program,
once established, extends beyond 30 days.
 training/instruction needed
 Probable longer duration to monitor stabilization/plateau
of the beneficiary
Completion of the
Mandatory Reassessment
 2nd: Defining “Compliance”
 Requires attention to two
equally important and
critical areas:
 Timing of the reassessment
visit
 Actual documentation that
comprises the visit
Completion of the
Mandatory Reassessment
 3rd: Clarify What Constitutes a FRA
Guidance: “At least once every 30 days, for each therapy
discipline for which services are provided, a qualified therapist
(instead of an assistant) must provide the ordered therapy
service, functionally reassess the patient, and compare the
resultant measurement to prior assessment measurements. The
therapist must document in the clinical record the measurement
results along with the therapist’s determination of the
effectiveness of therapy, or lack thereof.”
Source: CMS Manual System – Pub 100-02 Medicare Benefit Policy:
Transmittal 176 (Dec. 13, 2013). 40.2.1 – Section 1ii Reassessment at least
every 30 days (performed in conjunction with an ordered therapy service).
Resource Materials
www.exerciseismedicine.org

Revenue protection specialist for
therapy in the home health settings
Kornetti & Krafft Health Care Solutions, physical
therapists with over 70 years of clinical,
management and ownership experience, is a
consulting company with proven home health care
solutions in interdisciplinary, patient-centered care
management to fortify your agency’s fiscal security.
Dee Kornetti COO
[email protected]
Cindy Krafft CEO
[email protected]
Questions?
Exercise Prescription for the Home
Health Patient with Heart Failure
 March 2016 CardioLAN Webinar
– HHQI University
• Under Cardiovascular Health Course Catalog
• Free Nursing (2.25 hrs CE) and Physical Therapy (1.0 CCUs)
HHQI Heart Failure Resources
 Disease Management:
Heart Failure (Focused) BPIP
– Clinical evidence-based
practices for heart failure
– Heart failure medication
reference for clinicians
– Comprehension test
– Bulletin board example
HHQI Heart Failure Resources (cont.)
 Heart Failure (Focused) BPIP Patient Tools
– 6 Tips to Cut Sodium (also in Spanish)
– Heart Failure Stoplight Tool
– Heart Failure ZONE Tool
(also in Chinese, Spanish, Russian & Vietnamese)
– Managing My Heart Failure: I Know, I Can, I Will
– Heart Talk: Living with Heart Failure
(patient workbook from Qualidigm; also in
Spanish & Polish)
Continuing Education Steps
Follow these steps to get your CE certificate:
1. Register/log in to HHQI University. You will be automatically
redirected to this website when you exit this webinar.
Continuing Education Steps
2. Click on the Maintenance Therapy for the Home
Health Patient with Heart Failure course in the
Cardiovascular Health course catalog.
3. Click on Enroll under the
icon.
4. Click on My Account
to launch the course.
5. Click on the
icon next to the course in the
View column.
Continuing Education Steps
6. Click on the
to Lesson 1.
icon in the Action column next
• Complete Maintenance Therapy for the Home Health Patient
with Heart Failure evaluation
7. After completing the evaluation, you can print your
certificate from the My Account area in HHQI
University.
Thank You!
[email protected]
www.HomeHealthQuality.org
This material was prepared by Quality Insights, the Medicare Quality Innovation Network-Quality Improvement Organization supporting the Home Health Quality Improvement National
Campaign, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The views presented do not
necessarily reflect CMS policy. Publication number 11SOW-WV-HH-MMD-091516