Recipe for Success
Monday October 26, 2009
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> Muir SW, Berg K, Chesworth B, Speechley M. Use of the Berg Balance Scale for predicting multiple falls in community-dwelling elderly people: a prospective study. Physical Therapy. 2008;88(4):449-59.
> Silsupadol P, Shumway-Cook A, et. al. Effects of single-task versus dual-task training on balance performance in older adults: a double-blind, randomized controlled trial. Arch Phys Med Rehabil. 2009;90(3):381-7.
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“I know [P4P] is down the pike a while, but I think outcomes measures are going to be a large tool that they’re going to use to decide how effective PT is and how often it should be used,” says Shelene Thomas, PT, DPT, a physical therapist with the Visiting Nurses Association in Denver, and affiliate faculty member of Regis University.
Thomas has observed the importance of outcomes measures with other payers as well. She remembers one older gentleman she was treating whom she thought had been prematurely discharged from the hospital to his home. In her clinical judgment, he needed to go to rehab. “He was a max assist to transfer; he could not ambulate. I had all these good objective measurements in the PT world, but until they got that FIM (Functional Independence Measure score), they weren’t going to change their decision,” Thomas says.
She would have preferred to have chosen an outcomes measurement more appropriate for her patient than the HMO-required FIM, but acknowledges that the formal outcomes tool spoke volumes to the insurer. “These outcomes measures are coming whether we like it or not,” Thomas says. “I could see Medicare and other agencies dictating which ones we have to use, such as the FIM. I would much rather be the one who chooses. I went to school a long time. I’d rather pick which one I think works best for my patient.”
Measuring Up
But choosing the right outcomes measurement tool can be a daunting task.
“I think from a therapist’s perspective, there are so many tests out there ... that it overwhelms them,” says J.J. Mowder-Tinney, PT, PhD, NCS, director of clinical education for the Nazareth College Physical Therapy Program in Rochester, N.Y.
Mowder-Tinney presented on the use of balance measures by homecare PTs at the 2009 APTA Combined Sections Meeting. She also developed, implemented, and evaluated a continuing education module as part of her doctoral dissertation to help home health therapists use standardized balance measures in their practice. “Although some of the balance measures were being used, they were definitely not being consistently implemented,” she says.
In her research, Mowder-Tinney found that home health PTs who used outcomes measures based their test choices on several factors. “They want something easy, that they can do quickly, but that they can do in a small amount of space to be able to document change,” she says.
Interestingly, in polling the three largest homecare agencies in Rochester, she found that PTs with master’s degrees were more likely to use clinical outcomes measurements than those with bachelor’s degrees.
The most popular measures used by the home health PTs were the Single Leg Balance Test (67.5%), the Tinetti Balance Test (62.5%), the Timed Up and Go (55%), and the Berg Balance Scale (45%).
Based on her review of the literature, Mowder-Tinney identified an additional four outcomes tools that were useful for home health therapists. They included the modified Clinical Test for Sensory Integration and Balance (a balance measure with eyes opened and closed on different surfaces), the Dynamic Gait Index (a more challenging gait measurement for higher level patients), and two surveys, the Dizziness Handicap Inventory and the Activities, Balance, Confidence Measure, to measure impairments on the participation restriction level.
Regardless of the outcomes measuring tool chosen, Mowder-Tinney emphasizes that the literature suggests PTs should use at least two measurements to get a clear picture of their patients’ abilities and to document progress.
Recipe for Success
The objective documentation of progress is not only important for reaching patient goals, but also can go a long way toward securing timely reimbursement.
Using formal outcomes measurements “adds a great deal of validity to your request for reimbursement, especially if you can establish a baseline that a patient is at significant risk for falls and has diminished mobility based on that standardized measure,” says Chris Chimenti, MSPT, director of therapeutic services for Home Care of Rochester and chair of the research committee for the APTA’s Home Health Section.
“A Timed Up and Go score is commonly cut in half from pre-test to post-test during the course of the homecare episode, so that’s a clear delineation of progress in our patients,” Chimenti says. “On the Berg Balance Scale, if you can improve eight to 10 points, you can justify a significant reduction in the patients’ risk for falls.”
Chimenti concludes, “I think if you can show functional progress through standardized measures, you’re much more likely to stand up against any kind of reimbursement scrutiny.”
Anne Federwisch is a medical writer for Gannett Healthcare Group.
To comment, e-mail pteditor@gannetthg.com.
