Therapy Can Help Those With COPD

Chronic Obstructive Pulmonary Disease or COPD is an umbrella term used to describle progressive lung diseases such as emphysema, chronic bronchitis, and non-reversible asthma. People with COPD suffer with continued and increasing breathlessness. The symptoms of COPD are sometimes difficult to notice because they can be mistaken for the common cold or normal aging. COPD affects an estimated 30 million people in the United States and over half of them are unaware of their condition. Taking note of your symptoms and asking your doctor to screen you can help you avoid losing major function in your lungs.

Symptoms of COPD:

  • Increased Breathlessness
  • Frequent Coughing
  • Wheezing
  • Chest Tightness
  • Increased Mucus
  • Dizziness Upon Waking
  • Swollen Ankles
  • Frequent Respiratory Infections
  • Difficulty Sleeping
  • Fatigue or Inability to Exercise

COPD leads to the decline of pulmonary function and can lower your quality of life. Genetics and exposure to work/environmental pollutants can cause COPD, but the primary cause is smoking. Smoking and second-hand smoke account for 90% of COPD cases. Quitting smoking is extremely important to slow the progression of COPD. Slowing the progression of the disease can also be done through changing the air quality in your home and work environment.

Exercise and rehabilitation are great weapons in the war on COPD. Too often, patients with COPD avoid exercise because of their shortness of breath. Without exercise and improving endurance, the shortness of breath will only worsen. Physical therapists can help COPD patients exercise in a safe and secure environment. Physical and occupational therapy can improve your ability to exercise, your strength and endurance, and help you conserve energy doing daily tasks. Therapists can also help reduce difficulty in breathing by providing helpful breathing exercises. Talk to your doctor today about the benefits of both physical and occupational therapy to slow the progression of COPD!

 

Sources: COPD Foundation
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Byron Health Center to Host Trunk-O-Treat Event

Start Your Trick-or-Treating Fun a Bit Early

Byron Health Center will host a Trunk-O-Treat Event in the Friendship Corner courtyard and parking lot, on Thursday, October 26th from 5:00–7:00 p.m.  Byron Health Center is located at the corner of Carroll and Lima Roads, 12101 Lima Rd in Fort Wayne, IN.

What can be better than cars and candy bars?  Byron Health Center staff and family along with special guests, the Fort Wayne Corvette Club and the Eel River Elementary school PTA, are expected to bring trick-or-treaters out a bit early to enjoy some pre-Halloween Trunk-O-Treat fun among parked cars with decorated trunks and plenty of candy.  Members of the community are also invited to join in on the family-friendly Trunk-O-Treat presented by HTS Healthcare Therapy Services event.  Byron Health Center residents will also come out and help pass out the candy.  There will be a fire roaring in the fire pit.  You can also warm up in the Eakin Family Room with some hot chocolate and catch a spooky movie on the big screen TV.  The Wyss Farm Enterprises straw bale maze will also provide fun and frolic for area children.  This will be a fun-filled fall evening for all!  The event will be held rain or shine and is FREE of charge.

Several local mascots, including the Fort Wayne Derby Girl’s Mean Jean, the Fort Wayne TinCaps’ Johnny TinCap, Crazy Pinz’s Stryker the Parrot, the Fort Wayne Mad Ant, Indiana Tech’s Maximus & the Indiana Tech Cheerleaders, the Three Rivers Festival’s Admiral Andy, IPFW’s Don the Mastodon and the Fort Wayne Fire Department’s Spotz and are expected to attend the event along with the Huntertown Fire Department.  Several area car clubs have also been invited to attend the event.  Candy for the Trunk-O-Treat presented by HTS is being generously provided in part by several Byron Health Center friends and partners, including Goodwill and MKM architecture + design, as well as members of the Byron Health Center staff.  As always … donations of Halloween candy are appreciated.  Current sponsors include HTS, Indiana Tech and ProStrip Professional Metal Refinishing.

Byron Health Center provides compassionate long-term care for adults with complex needs including physical, mental, emotional and neurological services.  Each resident is recognized as an individual who seeks and deserves to reach his or her optimal potential.  Byron Health Center and Miller’s Place continue a tradition of over 160 years of serving the long-term health care needs of Indiana residents.  Byron Health Center is licensed to provide intermediate and skilled nursing care while Miller’s Place provides assisted living services to individuals who are more independent and are able to live in a residential setting.

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5 Ways Physical Therapy Can Help!

Physical therapists work to preserve, enhance, or restore movement and physical function. Physical therapy may be necessary for those recovering after an illness, injury, surgery or chronic condition. It can help reduce pain and speed up the recovery process by improving mobility, strength and balance.

Here are some ways physical therapy may help you:

Improve Mobility and Reduce Pain. If you’re having trouble standing, walking or moving — physical therapy can help. Therapists customize care plans that can restore muscle and joint function, reducing pain and improving mobility.

Manage Diabetes and Vascular Conditions. If you have diabetes, physical therapy can help you control your blood sugar through exercise. Diabetes may also cause a person to lose sensation in their feet and legs. Physical therapists can help you to regain sensation and prevent further problems.

Improve Balance and Prevent Falls. If you have fallen or are at high risk for falls, therapists will provide exercises that will help you improve coordination and problems stemming from the vestibular system.

Manage Age-related Issues. Osteoporosis and arthritis are common ailments for seniors. Physical therapists can help you recover from joint pain, joint replacements, and manage these conditions.

Manage Heart and Lung Conditions. After suffering a heart attack or having surgery you may need physical therapy to regain strength and daily function. If you suffer from a pulmonary condition, physical therapy can help improve breathing and clear fluid from the lungs.

Physical therapists work hard to help patients retain and regain their quality of life. Speak with your doctor to find out how a therapy treatment plan could benefit you!

October is National Physical Therapy Month!

National Physical Therapy Month is designed to recognize the impact that physical therapists and physical therapist assistants make in restoring and improving motion in people’s lives. Healthcare Therapy Services is proud to be a leading provider of therapy services throughout the Midwest. More info here.

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Is Your Therapy Provider Losing You Money?

Therapy Part B MPPR

 

Background of MPPR

Effective January 3, 2011, as part of the Affordable Care Act, CMS implemented the MPPR (Multiple Procedure Payment Reduction).  This is a reduction on fees paid to providers for Part B services, with the reduction of the “Practice Expense” (PE) portion of the Medicare Physician Fee Schedule.  This affects physicians and non-physician practitioners that bill Medicare Part B via code or unit. For long term care providers, this relates to your Part B therapy services, and even sometimes many private B-type insurances.

Initially, CMS reduced the PE portion by 20%, but then increased it to a 50% reduction of the PE, as of April 1, 2013.  These reductions apply when more than one code is performed/billed on the same day, regardless of discipline.  For example, if your physical therapist bills 4 codes, your occupational therapist bills 3 codes, and your speech therapist bills 2 codes, all on the same day, then the FIRST CODE BILLED is paid at 100%. MPPR is then applied to the rest of the codes, thus reducing the reimbursement for each of the remaining codes for that day.

 

Why Is This Important?  We Already Know About This!

I think by now, most all long-term care providers that also provide part B services to their inpatients, and/or provide outpatient therapy, are well aware of these reductions.  However, here is where it can get surprising….this on average is a 6-7% reduction in your overall reimbursement for those services.  Thus, if you typically bill (excluding your contractual allowances and co-insurance) $20,000 per month in therapy Part B services (inpatient and/or outpatient), then this lessens the reimbursement between $1200 to $1400 per month or more.  That may not sound like a lot of money, but keep reading…

 

My Therapy Company Charges Me Based On The Medicare Fee Schedule, So It’s Their Problem, Right?

Um, not necessarily.  Your contract may state that they are charging you 70% of the fee schedule, but more and more I am seeing therapy contracts that DO NOT ADDRESS THE MPPR.  If they don’t, that means you as the provider are EATING THAT COST.  NOOOOOO!

Suddenly, if you look at a provider that says they are charging you 70%, but do not take out the MPPR, then you are billing $20,000, they are taking $14,000, but you are only getting back $4,600, not $6,000.  That’s a pretty big deal since that money typically flows directly to your monthly bottom line.  That means that the therapy provider is actually charging you 77% of the fee schedule, not the 70% you THINK you are getting charged.

Think of what you could do in a year with just an additional $1,200 to $1,400 per month?  That $16,800 of pure net revenue could go a long way in any building, as there is no additional costs associated with that revenue going straight to your bottom line.

 

Here’s Your Homework…

If you use contract therapy, reread and double check your contract.  If it’s not stated in the contract, look at your invoice and see if the MPPR reduction has been applied, or ask your therapy company directly.  When we talk with other LTC providers, we are seeing this with both local therapy providers in additional to national providers.  Getting a handle on this is increasingly important as we see SNF utilization going down nationally and outpatient utilization trending up by our surgeons and acute care partners.  In today’s ever-changing reimbursement, we all know that every penny matters.  And in this case, we aren’t just talking chump change!

GUEST BLOG:

Kerry Wright, OTR/L
Executive Director of Business Development and Southern Operations
Healthcare Therapy Services, Inc.
kerry@htstherapy.com

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Getting You Back to the Life You Love

with Physical, Occupational and Speech Therapy!

 

Physical, Occupational and Speech Therapists work together to help individuals overcome obstacles and regain or maintain independence and health.

Physical Therapy is the examination and treatment of musculoskeletal and neuromuscular problems that affect peoples’ abilities to move and function in their daily lives.  Physical therapy may be necessary for those recovering after an illness, injury, surgery or chronic condition. It can help speed up the recovery process by improving mobility, strength, and balance.

Occupational Therapy is the holistic intervention in many areas of occupation including: bathing, dressing, grooming; instrumental activities of living, such as: home and financial management, rest and sleep, education, work, play, leisure and social participation.  Occupational therapy interventions include helping with learning to compensate and/or regain skills to lead a full and productive life.

Speech Therapy is for those who have difficulty communicating, swallowing, or eating. Speech therapy can aid patients in recovering from a stroke, brain injury, or those who have difficulty communicating due to dementia. It can also help patients learn safe swallowing techniques to reduce choking risks.

Most people will require at least one rehabilitation service at some point in their lives, making it important to know the role and benefits of therapy. After therapy, many patients find a renewed sense of confidence and may even discover that daily tasks are easier and safer to complete. If you or a loved one could benefit from physical, occupational, or speech therapy, speak to your doctor today about treatment options.

Celebrate National Rehabilitation Awareness: September 18- 24

Every year, the National Rehabilitation Awareness Foundation designates a week in September to educate people about the benefits and impact of rehabilitation. Healthcare Therapy Services is proud to be your trusted authority in post-acute rehabilitation.

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CMS Requirements of Participation

Are You Ready for the Phase 2 November 28th Deadline?

If you are a skilled provider, you are actively thinking about November 28th.  It is most likely keeping you up at night. For those that are not in the loop, November 28th is the due date for Phase 2 completion of CMS’ new requirements for participation. If this is not something you’re taking seriously or actively working on well before November, you may want to keep reading.

RoP Summary

On October 4, 2016, CMS published in the Federal Register the final rule on the Requirements of Participation (RoP) that long-term care facilities must meet to participate in the Medicare and Medicaid programs. This rule represents the most comprehensive update to the RoP since the 1990’s. CMS explained that the changes to the requirements are needed keep pace with the changes in the industry and assist in the goal of improving the provision of health care and patient safety.

A major theme of the new requirements is person-centered care, with an emphasis of residents and their representatives being informed, involved, and having control. You will see examples of this person-centered emphasis in the care planning and discharge planning requirements. The facility assessment is integrated throughout multiple sections of the RoP. The purpose of the facility assessment is to ensure that facilities have sufficient number of staff who are competent to meet the needs of the population the facility serves and that facilities have appropriate resources to meet the needs of their population on a day-to-day basis and in emergency situations.

The RoP is effective in three phases:

  • Phase 1: CMS contends that these requirements are relatively straightforward to implement, and require minor changes to survey process. They were effective November 28, 2016.
  • Phase 2: Includes the requirements that CMS felt providers need more time to develop and will include a new survey process to assess compliance. These requirements are effective November 28, 2017.
  • Phase 3: These are the requirements that need more time to implement and may require personnel hiring and training and implementation of systems approaches to quality. Facilities must comply with these requirements by November 28, 2019.

The RoP is expansive and cannot be easily summarized. We expect that CMS will issue interpretive guidance to assist providers in complying with the new requirements.

Although CMS contends the Phase 1 Requirements are relatively straightforward to implement and require only minor changes to the survey process, providers need to review their policies and procedures and make revisions to ensure compliance.

Phase 1 included many obligations regarding admissions, transfer and discharges, care planning, the use of side rails, as well as many updates to resident rights, abuse procedures and definitions, grievance process requirements, and various other changes. It is imperative that facilities evaluate their current policies and procedures, facility postings, and admission process to ensure compliance with the Phase 1 requirements.

To prepare for the Phase 2 implementation date, which is mere months away, facilities should establish a Phase 2 work plan to accomplish the many tasks required for compliance. This will include:

  • Completing a facility assessment to ensure the facility has the appropriate resources and competent staff to meet the needs of its population.
  • Developing the written QAPI plan to present to surveys on the next annual survey.
  • Implementing an antibiotic stewardship program.
  • And many other changes in current processes which includes a 48-hour initial care plan.


Creating a sound QAPI program is one of the largest components of this task list. If you haven’t already, look for Lean Six Sigma and QCP (QAPI Certified Professional) certifications that may be offered through various state and national associations. CMS doesn’t specify which method is preferred, but encourages formalized process improvement training in order to implement at successful and integrated QAPI program.

In conclusion, the new requirements have very broad implications on facility operations and administration and facilities will need to allocate additional resources to ensure compliance.  We suggest developing a RoP Implementation Team that is focused on driving a RoP implementation work plan targeted at accomplishing required actions for each phase of implementation. Many of the changes will require updates to policies and procedures, new or revised training, comprehensive systems review, formal notices to residents, and impact daily care processes.


HTS is assisting our clients through this RoP process by partnering with Proactive Medical Review who offers a partnership plan for assisting clients through each phase of implementation. This plan includes a facility-specific needs assessment and detailed implementation guidance, as well as:

  • Off-site policy and procedure review in each implementation area with redline suggestions for meeting the updated requirements. Policy templates will be provided as needed based on the policy/procedure gap analysis.
  • Implementation site visit and training options.
  • Access to our implementation checklists, timelines, and updated resident notices which meet RoP requirements, as well as training tools and resources.

It’s an “all hands on deck” world to meet the RoP Phase 2 deadline. We encourage you to act now by seeking proper education and forming your committees and to not wait until September to make this happen. November 28th will be here before you know it.

Guest Blog

Article co-written by:

Cassie Murray, OTR/L, QCP
Exec Director of Clinical Operations, Healthcare Therapy Services, Inc.
cmurray@htstherapy.com | 800-486-4449 ext 210

 

Shelly Mafia, MSN, MBA, NHA, QCP
Director of Regulatory Services, Proactive Medical Review
smaffia@proactivemedicalreview.com  |  812-471-7777

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Therapy’s Role in Managing Parkinson’s Disease

As many as one million people in the US are living with Parkinson’s disease (PD). Parkinson’s is a chronic and progressive movement disorder, meaning the symptoms continue and worsen over time. The average onset for all people with Parkinson’s is age 60 and although there is no cure for the disease, there are treatment options to help manage the symptoms.

Early Warning Signs
It’s important to recognize the early warning signs of PD. An early diagnosis may help slow the onset of the disease. Some of these symptoms are normal signs of aging. If you have more than one symptom or a symptom persists, talk with your doctor.

  • Tremor or Shaking
  • Dizziness or Fainting
  • Trouble Moving or Walking
  • Loss of Smell
  • Trouble Sleeping
  • Constipation
  • Soft or Low Voice
  • Change in Handwriting

 

How Can Therapy Help?
Taking advantage of the expertise of a team of professionals can be very beneficial for somebody living with Parkinson’s. In addition to a specialized neurologist, physical, occupational and speech therapy can effectively manage the symptoms and side effects of PD to maximize quality of life.

Physical Therapy
A Physical Therapist (PT) is trained to work with individuals to regain and maintain mobility. A PT can develop customized exercise programs to address balance problems, lack of coordination, fatigue, pain, gait, immobility, and weakness.

Occupational Therapy
Occupational Therapists (OT) can help modify your environment and daily activities in order to accommodate your changing needs. Occupational therapy focuses on helping you maintain your independence.

Speech Therapy
A Speech-language Pathologist (SLP) can help improve Parkinson’s disease speech problems and provide coping strategies for those who have trouble swallowing.

 

If you or a loved one has been diagnosed with Parkinson’s disease, talk with your doctor about the benefits of physical, occupational and speech therapy.

Source: Parkinson’s Disease Foundation

 

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Tips to Improve Skilled Nursing Documentation

In today’s climate of scrutiny and burden of justifying therapy services and skilled stays, it is becoming increasingly critical for nursing to take charge in documenting each patients’ skilled needs. Specifically, what should the nurses be documenting in the medical record? How specific is the training for your nursing staff?

Before you answer, remember that the rules of documentation have changed greatly in the past 3 years. Even now, something that is the norm could likely be scrutinized in future audits. Whether you’ve had ADRs and denials for payment, it’s not a matter of if…but when. Those of us that are laser focused on the regs and changing climate of our industry know why things have altered so greatly. However, I have found that keeping to the basics is the best way to explain documentation expectations that are critical for justifying a skilled stay. I have also had my own documentation scrutinized, reviewed my fair share of ADRs and audited countless charts for congruent nursing and therapy documentation. The ideas below are a culmination of questions, mistakes, training and conversations by nurses, administrators and corporations. Try using these proven strategies to improve your skilled nursing documentation to support therapy services, and ultimately support the skilled stay:

The Do’s and Don’ts:

 

 

Justifying a Skilled Stay:

Nurses must ask themselves the following questions (and document the answers) each and every day:

  • Why is this patient here?
  • What is preventing this patient from going home right now? Could this patient go home right now and be safe and independent? Why not?
  • What are you doing that would not or could not happen for this patient at home?
  • Have you noticed this patient improving in any aspect of mobility? Self-care? Communication?
    *Even minor improvements need to be noticed and documented.
  • Why is this patient receiving PT, OT or ST?
  • What would/could happen if this patient was not an inpatient receiving care?
  • What are all of the medical complexities that are impacting this patient’s recovery. Explain the multiple conditions that you are managing. What is making this patient’s recovery take this amount of time?

 

RUG Supportive Documentation: Do they know the Why?

  • Do your nurses know what a RUG level is? Try asking several nurses on your rehab unit if they know what a RUG level is…you may be surprised by how many do not know. Do your nurses understand the importance of ADL coding?  Nurses need to understand the basic reimbursement system for the stay in order to understand the importance of the documentation. Provide a basic PPS inservice to help your staff understand how the MDS, nursing notes and therapy notes combined determine the RUG level. The medical record must make sense—nursing notes and therapy notes must support the coding on the MDS.
  • Do your nurses understand that PLOF is critical for establishing all goals? What was the patient doing prior to the hospitalization? Was he/she completely independent with all self-care and mobility? What about higher level tasks—grocery shopping, driving, cooking, laundry?
  • What does the patient need to be able to safely do prior to returning home? What impairments are preventing the patient from doing these things?
  • Are your nurses documenting their skilled nursing interventions? What if therapy services are denied? Will your nursing documentation prove a skilled nursing level? Provide nursing education regarding specific skilled nursing interventions. Provide sample documentation that reflects skilled nursing interventions.

I hope that these tips and questions help to gauge the level of training and direction for our SNF nurses. Now more than ever, you deserve to be paid for the great care you provide.

HTS is committed to the success of our clients and partners. That is why we provide on-going support and education for our therapists, nurses, and the entire IDT. With the changing expectations for justified skilled stays, make sure you are partnered with a dynamic, progressive therapy provider who will support and enhance your position in our post-acute care market.

Guest Blog

Cassie Murray, OTR, QCP, IASSC CYB 
Cassie Murray is the Executive Director of Clinical Services for Healthcare Therapy Services. A 1994 graduate from Indiana University in Occupational Therapy, Cassie has over 22 years of experience in long term care, hospital, outpatient and home health. She provides support for HTS therapists and partnering communities through program development, training on regulatory requirements and ongoing quality assurance. She is active in state and national associations such as Leading Age, AHCA, NASL, AOTA. Her passion for rehabilitative services is inspired from personal experience with her father suffering a stroke while Cassie was in high school. This led to her successful career path in occupational therapy.

To contact the author: cmurray@htstherapy.com | 800-486-4449 ext 210 | www.htstherapy.com

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Protect Yourself from the Summer Heat

Summer is a great time to spend time with family and friends. The summer sun allows us to enjoy many outdoor activities. Barbecues, swimming, and trips to the beach make summer an exceptional time of year!

For aging adults, the summer months can also be hazardous to your health and heart. Problems like dehydration, sunburn, and exasperation of pre-existing conditions are common after too much exposure to the sun. For people with heart conditions, the heat can be a matter of life and death. It’s important to stay safe when the temperature rises!

 

Tips for Beating the Heat:

  • Stay Hydrated: Seniors are less likely to feel thirsty and dehydration can set in quickly. Be sure to drink the recommended 6 to 8 glasses of water a day.
  • Apply Sunscreen: Sunscreen takes time to work, so apply it prior to going outdoors. Reapply the sunscreen every two hours.
  • Dress for the Weather: Wear lightweight, breathable fabric such as cotton. Wide-brimmed hats can help protect from the sun.
  • Wear Protective Eyewear: Sunglasses can help reduce damage that could cause cataracts and age-related eye disease.
  • Stay Indoors During Peak Heat: The sun is most intense during the middle of the day (12pm to 3pm). Schedule your outdoor activities in the morning or evening when the weather is cooler.
  • Check Your Medications: Some medications can cause increased sensitivity to the sun. Look at the warning labels and talk to your doctor about concerns or questions you may have.

 

How Therapy Can Help
Heat is stressful on the cardiovascular system and can exasperate cardiopulmonary conditions making it more difficult to breathe. If you have heart and lung disease, you may benefit from Physical and Occupational therapy. Therapy can help individuals manage and minimize the debilitating effects of pulmonary and cardiac diseases by helping you control your symptoms and resume an active life within the limits of your condition. Talk to your doctor today about the benefits of therapy for your cardiopulmonary needs!

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5 Tips for Making Coding Complexity Simple

Are you making evaluation complexity coding too complex? Don’t make this more difficult than it is! Instead of trying to navigate all of the fancy terminology being used to educate us on how to correctly code complexity, let’s try looking at it plain and simple.

Here are some common problems that have already been discovered and tips for improvement (in plain language):

1. Clinical Decision Making
Clinical reasoning and decision making occurs throughout the evaluation as the clinician decides which questions to ask, what assessment tools and tests to use, identifying goals, deciding what modifications are necessary, etc. Keeping in mind all decisions being made through the course of the evaluation and documenting/justifying those decisions will provide support of the complexity chosen.

2. Patient History
Consider what you need to know about the patient’s medical history to make clinical decisions and develop a skilled POC. Be sure to clearly document all aspects of the patient’s history that you used to determine the plan and goals. Explain specifically how the patient’s medical history is impacting the current POC and your approaches to therapy intervention.

3. Occupational Profile
OT should document detailed description of the occupational profile. Use an Occupational Profile worksheet to assist. If you don’t already have a worksheet, create one for your OTs to help guide the narrative within the documentation. AOTA has provided an occupational profile template. Utilize the available tools from your associations and simply describe the areas within the evaluation.

4. Formal Tests
In order to accurately code the complexity of the evaluation, formal testing must be completed. Make frequently used tests readily available. With the new coding, it is necessary to go ahead and complete at least one formal test on day 1 with the initial evaluation and summarize the results within the POC. This is another component to accurately coding the complexity of the evaluation. Be sure to update the results of the selected tests at re-cert and DC as well.

5. All Criteria Required
Remember that you must code “down” if all criteria for the complexity level is not met. All criteria must be met (and documented) for each complexity level.

Keep in mind that the evaluation is still the same evaluation! Consider that by coding the complexity level, this is really just a way to ensure that we are documenting more thoroughly and justifying our services. I think that often we take for granted the skill and sophistication that we provide. Document your thinking process as you are creating the plan for your patients. No one else is able to do what you do!

Guest Blog

Cassie Murray, OTR, IASSYC CYB 
Cassie Murray is the Executive Director of Clinical Services for Healthcare Therapy Services. A 1994 graduate from Indiana University in Occupational Therapy, Cassie has over 22 years of experience in long term care, hospital, outpatient and home health. She provides support for HTS therapists and partnering communities through program development, training on regulatory requirements and ongoing quality assurance. She is active in state and national associations such as Leading Age, AHCA, NASL, AOTA. Her passion for rehabilitative services is inspired from personal experience with her father suffering a stroke while Cassie was in high school. This lead to her successful career path in occupational therapy.

To contact the author: cmurray@htstherapy.com | 800-486-4449 ext 210 | www.htstherapy.com

 

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