Critical countdown
Monday February 13, 2012
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Recent Medicaid cuts already have limited the number of physical therapy visits in states including Arizona, New York, North Carolina, South Carolina and Washington, capping the visits at eight to 20, depending on the state. Many other states also are contemplating cuts in an attempt to manage budget shortfalls. These cuts are leaving PTs scrambling to identify ways to help patients who have suffered complicated traumatic brain injuries make the most of their limited visits.
"The Arizona Health Care Cost Containment System has cut many of our patients' PT visits from 55 to 15 visits," said Kay Wing, PT, DPT, NCS, GCS, founder and owner of SWAN Rehab in Phoenix. "The cuts are a setback for many of our patients who suffer from TBI or stroke."
TBI patients present a unique challenge to PTs because no two patients are alike. "Patients with TBI can present very differently, with some only having certain parts of the body affected, versus others with generalized deficits," said Michael Casey Maynard, MSPT, of the University of California-Davis Medical Center in Sacramento, Calif. "In addition to the physical deficits, some patients with brain injuries have expressive, emotional and psychological issues that need to be respected and addressed."
Carmen Elliott, MS, director of payment initiatives for the American Physical Therapy Association said the organization recently adopted a physical therapy model benefit plan design, developed to inform decisions made by insurers, employers, individual insurance plan subscribers and public policy-makers regarding covered physical therapy services in insurance benefit plans.
"It is also a tool for physical therapists to advocate for additional medically necessary physical therapy services for their patients," Elliott said. "For TBI patients, additional PT visits can improve the quality of life and allow the patient to participate in activities of daily living as well as reduce or eliminate impairments and activity limitations." (For information, visit apta.org/Payment/PrivateInsurance/ and scroll down to Insurance Plan Design.)
When advocacy fails, however, one option is for patients to continue therapy in a group setting. At SWAN Rehab, ongoing classes are offered twice a week under the direction of two non-PT exercise specialists. Membership costs $224 per month.
"We keep the cost of these classes down, but it's still an expense that patients have to pay out of pocket," Wing said. That "can prove to be a hardship."
PTs also can provide patients with an at-home exercise regimen that can be continued long after insurance coverage runs out.
"There's no cookie-cutter approach when it comes to designing a PT program for a TBI patient," said Sara Baker, SLP, director of medical programs of the Rehabilitation Institute of Kansas City (Mo.). "If a patient is looking at a limited number of PT visits, it's important to look at what their priorities are, and how you as a PT can help them to navigate the challenges of daily life without reinjuring themselves."
TBI rehab on fast track
When a TBI patient's visits are limited, PTs are forced to draw up a basic plan of attack for his or her rehab intervention. This plan should include the following elements:
Assessment of the patient's equipment needs: "It's important to determine what each patient needs in terms of medical supplies for their home," Wing said. "An assessment can show whether they need a wheelchair, adaptive devices, bracing or AFOs, a standing frame, a grab bar in the bathroom, or a showerhead extender to improve their quality of life at home."
Determination of individual activities of daily living skills: "If a patient only has a limited number of physical therapy visits, we look at what skills they need to master in order to navigate through their daily life," Baker said. "Sometimes this means giving them exercises they can work on at home, and then checking on their progress after a few weeks before moving on to the next level."
Focus on balance and controlled walking: If a patient is presenting mobility problems, it's important to emphasize exercises that can help him or her safely navigate the home environment. "I use the parallel bars often for standing balance and strengthening exercises, pre-gait training, as well as gait," Maynard said. "We are also fortunate enough to have a LiteGait system that allows us to gait train without the patient or therapist having to worry about the patient falling. "
Focus on increased range of motion: "We typically start working with TBI patients as soon as they are medically stable," said Nicole Lovell, a PT in the TBI center at Hennepin County Medical Center in Minneapolis. "We begin with range of motion, positioning and strengthening exercises," she said, adding that it's important for PTs to teach TBI patients how to keep all of their joints flexible to avoid contractures.
Identification of community resources: "To help patients maintain their function, we often refer them to the Disability Empowerment Center in Phoenix that offers a gym at a reasonable price," Wing said. "Many local YMCAs also offer aqua therapy programs for a nominal cost that can benefit TBI patients."
Recommendations for home exercise equipment: "Many TBI patients can have problems using a treadmill, but can use a recumbent bike to safely exercise," Wing said. "Cuff weights and Thera-Bands are also useful when giving written instructions for an at-home exercise program."
Recommendations for bodyweight exercises: "Bodyweight exercises can help patients work out and stay within a tight budget," Baker said. "And exercise balls can help to improve a patient's balance, movement and range of motion by utilizing and targeting different muscle groups."
Interaction with the patient's family members: "Assess the family's ability to follow through with an at-home exercise program," Wing said. "Practice return demonstration with the person who will be helping the patient, and repeat the exercises several times to ensure they are doing it correctly." Identify the exercises, such as balance work, that need to be done under the supervision of a family member, she said.
Establishment of measurable goals: These goals will vary from one TBI patient to another, depending on the severity of the injury and any comorbidities. "For some patients, that means working on mat or bed-style exercises, focusing on functional exercises to improve strength and mobility for getting in and out of bed, transfers and standing," Maynard said. •
Linda Childers is a freelance writer.
"The Arizona Health Care Cost Containment System has cut many of our patients' PT visits from 55 to 15 visits," said Kay Wing, PT, DPT, NCS, GCS, founder and owner of SWAN Rehab in Phoenix. "The cuts are a setback for many of our patients who suffer from TBI or stroke."
TBI patients present a unique challenge to PTs because no two patients are alike. "Patients with TBI can present very differently, with some only having certain parts of the body affected, versus others with generalized deficits," said Michael Casey Maynard, MSPT, of the University of California-Davis Medical Center in Sacramento, Calif. "In addition to the physical deficits, some patients with brain injuries have expressive, emotional and psychological issues that need to be respected and addressed."
Carmen Elliott, MS, director of payment initiatives for the American Physical Therapy Association said the organization recently adopted a physical therapy model benefit plan design, developed to inform decisions made by insurers, employers, individual insurance plan subscribers and public policy-makers regarding covered physical therapy services in insurance benefit plans.
"It is also a tool for physical therapists to advocate for additional medically necessary physical therapy services for their patients," Elliott said. "For TBI patients, additional PT visits can improve the quality of life and allow the patient to participate in activities of daily living as well as reduce or eliminate impairments and activity limitations." (For information, visit apta.org/Payment/PrivateInsurance/ and scroll down to Insurance Plan Design.)
When advocacy fails, however, one option is for patients to continue therapy in a group setting. At SWAN Rehab, ongoing classes are offered twice a week under the direction of two non-PT exercise specialists. Membership costs $224 per month.
"We keep the cost of these classes down, but it's still an expense that patients have to pay out of pocket," Wing said. That "can prove to be a hardship."
PTs also can provide patients with an at-home exercise regimen that can be continued long after insurance coverage runs out.
"There's no cookie-cutter approach when it comes to designing a PT program for a TBI patient," said Sara Baker, SLP, director of medical programs of the Rehabilitation Institute of Kansas City (Mo.). "If a patient is looking at a limited number of PT visits, it's important to look at what their priorities are, and how you as a PT can help them to navigate the challenges of daily life without reinjuring themselves."
TBI rehab on fast track
When a TBI patient's visits are limited, PTs are forced to draw up a basic plan of attack for his or her rehab intervention. This plan should include the following elements:
Assessment of the patient's equipment needs: "It's important to determine what each patient needs in terms of medical supplies for their home," Wing said. "An assessment can show whether they need a wheelchair, adaptive devices, bracing or AFOs, a standing frame, a grab bar in the bathroom, or a showerhead extender to improve their quality of life at home."
Determination of individual activities of daily living skills: "If a patient only has a limited number of physical therapy visits, we look at what skills they need to master in order to navigate through their daily life," Baker said. "Sometimes this means giving them exercises they can work on at home, and then checking on their progress after a few weeks before moving on to the next level."
Focus on balance and controlled walking: If a patient is presenting mobility problems, it's important to emphasize exercises that can help him or her safely navigate the home environment. "I use the parallel bars often for standing balance and strengthening exercises, pre-gait training, as well as gait," Maynard said. "We are also fortunate enough to have a LiteGait system that allows us to gait train without the patient or therapist having to worry about the patient falling. "
Focus on increased range of motion: "We typically start working with TBI patients as soon as they are medically stable," said Nicole Lovell, a PT in the TBI center at Hennepin County Medical Center in Minneapolis. "We begin with range of motion, positioning and strengthening exercises," she said, adding that it's important for PTs to teach TBI patients how to keep all of their joints flexible to avoid contractures.
Identification of community resources: "To help patients maintain their function, we often refer them to the Disability Empowerment Center in Phoenix that offers a gym at a reasonable price," Wing said. "Many local YMCAs also offer aqua therapy programs for a nominal cost that can benefit TBI patients."
Recommendations for home exercise equipment: "Many TBI patients can have problems using a treadmill, but can use a recumbent bike to safely exercise," Wing said. "Cuff weights and Thera-Bands are also useful when giving written instructions for an at-home exercise program."
Recommendations for bodyweight exercises: "Bodyweight exercises can help patients work out and stay within a tight budget," Baker said. "And exercise balls can help to improve a patient's balance, movement and range of motion by utilizing and targeting different muscle groups."
Interaction with the patient's family members: "Assess the family's ability to follow through with an at-home exercise program," Wing said. "Practice return demonstration with the person who will be helping the patient, and repeat the exercises several times to ensure they are doing it correctly." Identify the exercises, such as balance work, that need to be done under the supervision of a family member, she said.
Establishment of measurable goals: These goals will vary from one TBI patient to another, depending on the severity of the injury and any comorbidities. "For some patients, that means working on mat or bed-style exercises, focusing on functional exercises to improve strength and mobility for getting in and out of bed, transfers and standing," Maynard said. •
Linda Childers is a freelance writer.
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Monday February 13, 2012