How Close Are You Pat Comoss RN BS MAACVPR No Disclosures or Conflicts Academic Confession I do NOT have the perfect ITP 2018 ITP Expectations My Objective To outline key ITP expectations from Medicare AACVPR ID: 933966
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Slide1
2018 ITP Expectations: How Close Are You?
Pat Comoss RN, BS, MAACVPR
Slide2No Disclosures or Conflicts
Academic
Confession: I do NOT have the perfect ITP!
2018
ITP Expectations
Slide3Slide4My Objective: To outline key ITP expectations from Medicare, AACVPR
Your
Objective: Compare your current ITP to the content & format of
presented models
2018
ITP Expectations
Slide5Slide6WHYMedicare: 2010 rules/requirements =
Conditions of Coverage
Federal Register; Nov. 25, 2006 Cardiac Rehab = Section 410.49 Pulmonary = Section 410.47
2018
ITP Expectations
Slide7Slide8Medicare: ITP Definition
Slide9Medicare: Physician Review
Slide10Medicare: Medical Director
CR Involvement
Slide11Medicare: Medical Director
PR
Involvement
Slide12Office of Inspector General (OIG) The Medicare Police =
FBI inspectors
Medicare: Site Inspection
Slide13Consequence
PAY BACK
$$$$$$$
Medicare: Site Inspection
Slide14WHY 2. AACVPR Program Certification 2016
&
2017About 1/3 of 600+ cert/recert submissions Got “Remedial Status”
Due to ITP issues!
?
2018
submissions ?
2018
ITP Expectations
Slide15Content Not complete = some component of care missingNot individualized = too canned, too many check boxes
Not enough data or description to show progress
Not legible AACVPR ITP Issues
Slide16Slide17Slide18Timing Per Medicare rules:
Strict
last 2 years Not signed by MD within 30 days Stricter 2017 forwardNot signed on the same day as assessment by staff
(if a billed visit)
At least before
patient’s 1
st
rehab session in gym
(next visit after assessment)
AACVPR ITP Issues
Slide19A document that meets both Medicare requirements & AACVPR expectations forContent = WHAT
Services
planned/providedTiming = WHEN Show timely review/approval CHALLENGE!
Slide20IF external expectations require…THEN let’s do a good job to:
Make it functional for staff to use
Create a guide for rehab care for each patient 2018 ITP Expectations
Slide21ITP Design
Paper or EMR
Slide22WHAT = Content Design to show
components of care
: Exercise/activity Nutrition Other core components/risk factorsPsychosocial Oxygen Assessment for PR
Optional for CR = Signs/symptoms
2018
ITP Expectations
Slide23WHAT = Format Design to show
sequence & flow
: So reader/reviewer can follow “patient’s story” from rehab start to finish Document each step in process of rehab care ASSESSMENT
PLANNING/IMPLEMENTATION
REASSESSMENT
DISCHARGE EVALUATION
2018
ITP Expectations
Slide24ITP: Content & Format
Slide25ITP: Content & Format
Slide26WHAT = Format Design to show Physician/Medical Director review & signature
Initially = “the ITP must be established…”
(after assessment, before first exercise session)Every 30 days = “reviewed & signed” At discharge = final review
2018
ITP Expectations
Slide27Slide28WHAT = Format Design to show patient outcomes
Pre & post data can be:
Embedded with ITP content Reported on a separate ITP page 2018 ITP Expectations
Slide29Slide30NOTE: Neither Medicare nor AACVPRm
andate the design/format of ITPs
Focus is on content & flow of care ITP: Content & Format
Slide31HOW Invent your own
OR
Modify from telemetry vendor sample OR Adopt/adjust today’s example
ITP: Content & Format
Slide324 Page ITP: see paper handout Page 1 = MD review & signature pagePages 2 & 3 = Staff tracking of rehab flow & documentation of care content provided
Page 4 = Patient outcome data
Today’s Design Example
Slide33ITP Documentation
Helpful Do’s & Don’ts
Slide34Assessment DON’T use ITP as complete assessment tool
Assessment is a separate process
with multiple parts:
2018
ITP Expectations
Subjective
Objective
Medical History Review
Patient
Interview Questions
Psychosocial Status
Cardiopulmonary Exam
Medication Reconciliation
Functional Evaluation
Slide35Assessment DO use Assessment section/column to summarize problems/issues discovered on assessment to be followed in rehab
Note key issues that need to be addressed
Findings that could HELP or HINDER rehab performance or progress2018 ITP Expectations
Slide36Psychosocial
DO NOT
Leave initial assessment blank! Write an assessment conclusion whether positive or negative…
2018
ITP Expectations
Slide37Medicare Expectation: “Psychosocial assessment means a written evaluation of an individual's mental & emotional functioning as it relates to the individual’s rehabilitation or respiratory condition.”
(Medicare Conditions of Coverage for Cardiac Rehabilitation;
Federal Register 410.47, Nov. 2009)
2018
ITP Expectations
Slide38Medicare expectation: “…includes an assessment of those aspects of an individual’s family and home situation that affects the individual’s rehabilitation treatment,
And psychosocial evaluation of the individual’s response to and rate of progress under the treatment plan.”
(Medicare Conditions of Coverage for Cardiac Rehabilitation; Federal Register 410.49, Nov. 2009)
2018
ITP Expectations
Slide39At this time, patient reports low levels of stress, is in upbeat mood, reports good family support, and is eager to start rehab & meet others in his exercise group.
2018
ITP Expectations
Slide40NOTE: timely completion of initial ITP may require blocking added time for assessment visit, e.g. 2 hours face-to-face with patient 30-60 minutes post assessment to start ITP
2018
ITP Expectations
Slide41PLAN = identify strategies you can offer to address problems/issues documented from assessment Intervention/Treatment
Education/Teaching
Patient Goals = 1 for each of the 5 categories of rehab care: Exercise Nutrition
Psychosocial
Other Core Components/Risk Factors
For PR: Oxygen Assessment/Management
2018
ITP Expectations
Slide42AACVPR CertificationGoals for each category of rehab care:
Program goal
Example: Nutrition pageBy end of rehab, to establish healthier eating patterns that contribute to overall health & improved body composition
2018
ITP Expectations
Slide43AACVPR CertificationGoals for each category of rehab care:
PATIENT GOALS
Give worksheet to get started Converse/convert to SMART goal statements
2018
ITP Expectations
Slide44Plan DO’s Project “Treatments” Advise
Arrange
Monitor Recommend Schedule Teaching1:1 or small group
Plan DON’Ts
Target to teach everything to everybody
Instead = prioritize both teaching & treatments on assessed Readiness to Change
2018
ITP Expectations
Slide45Plan DO’s Document DATES when each flagged treatment or teaching strategy is done
Plan DON’T’s
Date too many items as done on same day
Selected strategies are not carried out (“done”) on assessment date, they are just identified to be done
2018
ITP Expectations
Slide46Exercise Plan MUST include ExRx: Frequency = how often?
times/week in rehab, at homeIntensity = how hard? guidelines: THR, RPE Time/Duration = how long? m
inutes each session
Type/Mode = what find?
a
erobic devices, strength
2018
ITP Expectations
Slide47Initial MD Review/Sign
BEST= same day as staff Assessment
& Plan
LEAST= before
patient returns for 1
st
gym visit
In
PR
,
initial MD
face-to-face with
patient between above
2018
ITP Expectations
Slide48Reassessment DON’Ts Just check-off:
Treatments or teaching was
completed = give datesGoals were met = explain in words or sentences
2018
ITP Expectations
Slide49Reassessment DO’s Describe status in words = improved/in progress , pending/ongoing, resolved/met Write/type explanation of how that status was determined:
Subjective =what did patient tell you?
Objective = what did you observe or measure? 2018 ITP Expectations
Slide50Psychosocial example: Assessment: severe depression, PHQ9 = 16
Plan: encourage verbalization, recommend support group, collaborate with PCP re: meds
Reassessment: 30-day update ongoing improving resolved S. Reported sleeping better & more alert
O. More interactive with others, PHQ9 = 12
2018
ITP Expectations
Slide51WHEN is 30 days? NOT same date each month Must be on/before 30 calendar days
Consider every 4 weeks rotation
2018
ITP Expectations
Slide52Discharge DON’Ts Repeat what had already been documented
Re-write every problem already resolved
Write a lengthy discharge report Discharge DO’s
Focus on problems/ issues NOT yet resolved
Document hand-off instructions to patient & to physician
Use a form letter with fill-in
i
nfo for d/c report & attach outcome sheet
2018
ITP Expectations
Slide53Discharge Interview: Consider carving-out 20-30 minutes from an exercise session during the last week of rehab to:
Review ITP
Report outcomes Solicit feedback 2018 ITP Expectations
Slide54How YOU respond to the challenge of a
new/revised
ITP determines if change succeeds or fails
ITP Summary
Slide55For Program: Compliance Certification Payment
For Staff
Job security Professional satisfaction
Patient gratitude
ITP
Summary: Signs of Success
Slide56FOR PATIENTS: Timely individualized treatment Realistic goal attainment
Enhanced competence/confidence in self-management of chronic
heart or lung disease ITP Summary: Signs of Success
Slide57The BEST reason to review/revise your program’s ITP in 2018 is to:
Comply with Medicare rules
Pass AACVPR program certification Report patient progress to your Medical Director Document the content & flow of each patient's rehab care
2018
ITP Expectations
Slide58THANK YOU!! Wishing you every success
with your
ITP!