Today, we’re going to talk about effective documentation that justifies rehab services through the use of a disablement model.
This course will look at why we need to provide well documented justification for our services, then we’ll look at the definition of a disablement model. We will examine two different models and how each model defines disability thru patient characteristics, and finally, you will practice on your own writing a killer justification statement.
So, I know you are asking the question, why? Why do I need to be so concerned about the quality of my documentation? Over the years here’s some of the comments I’ve heard: My documentation is fine. I know what I’m doing is necessary. I have too much to do to worry about that. Unfortunately those comments are placing not only those clinicians at risk but the providers that employ them and the patients they are treating. Never more than now has comprehensive documentation that justifies the need for rehab services been so important. Medicare began using the Fraud Prevention System in 2010 that utilized specific clinical algorithms that identify suspicious billing patterns in REAL TIME. Those medical records are then pulled for a clinical review. If your documentation does not justify the level of intervention you are providing then those services will not be reimbursed, placing your patient, your employer, and YOU at risk.
The disablement model is a conceptual framework by which our patients underlying disease process, injury, or birth defect affects their ability to function within their environment and perform their role in society.
The Nagi model, developed in the 1960’s, identified 4 interrelated, yet distinct processes that link disease to disability. Considered unidimensional, sociocultural factors were added later that take into account a patients social support network, physical environment, behaviors, attitudes, and lifestyle.
Here we see the Nagi model in action. Active pathology or disease process occurs at a cellular level. In this case, a shoulder labral injury. This injury results in the physiologic impairment of decreased strength, that limits function, that is the patients inability to throw at maximal effort, thus creating this patients disability- the inability to be a starting pitcher.
So, in this case a justification statement for rehab services would be: The patient presents with a shoulder labral injury (the active pathology), resulting in decreased strength (physiologic impairment), causing an inability to throw at maximal effort (functional limitation), preventing him/her from starting the pitching rotation (disability).
The World Health Organization offered the ICF or International Classification of Functioning, Disability and Health in 2001. It is an in depth view of patient disability through a multi dimensional model of disability that expands on Nagi’s model by further defining the impact of personal and environmental factors.
Let’s now look at the same labral injury but through the ICF mode. The shoulder injury is the health condition. The body functions and structures affected are the labral tear and decreased strength, this results in a maximal activity limitation and prevents the patients starting in the pitching rotation. The environmental factor of having an athletic trainer is a positive factor in this patients recovery, however, the personal factor of prior injuries may be a negative factor
So, in this case a justification statement for rehab services would be: 20 y.o. patient with a history of should injury (personal factors) presents with a shoulder labral injury (the health condition), resulting in decreased strength (body function & structure), causing an inability to throw at maximal effort (activity limitation), preventing him/her from starting the pitching rotation (participation limitation). An athletic trainer is readily available to assist with rehab transition and prevention of further injury (environmental factors).
A nice neat justification package.
Let’s look at some patient examples that you are more likely to encounter in the SNF setting. A patient is admitted with a ORIF s/p a proximal humeral fracture. So, her health condition is a proximal fracture with ORIF, the body structure and function affected are: decreased ROM, decreased strength, edema, pain, and a surgical incision. The activity limitations she is experiencing are: the inability to wash, dress, get OOB, and feed herself. The environmental factors that affect her recovery are: living alone without family or friends available to assist and no history of prior services. The personal factors contributing to her rehab course is the fact that she is an active 91 y.o. alert and oriented female who wants to go home and previously was driving and shopping independently. This new health condition then results in her participation limitations which are: inability to go home alone, feed her cat, and drive to the store.
So, lets put this information into a justification statement for rehab intervention. (Read statement). This is a clear statement of what this patient must accomplish in rehab to go home and justifies our services. However, this then needs to be reflected in our problem statements, goals, and use of outcome measure.
Your problem statements are the patients activity limitation, your long term goals address the participation limitations, and the short term goals are the path to get you from start to finish.
The Boston University AM-PAC is a valid and reliable measure of a patients status. It is currently in use across the country and since 2004 is one of the measures that CMS recommends we use to measure level of disability and progress. It is a six question assessment in the areas of ADL’s, Basic mobility with and without stairs, and applied cognition. This outcome measure also is directly correlated to the Med B g codes- which takes the guess work of the g-codes.
Now we’re going to take a look at a chronic condition and how to relate these patient characteristics to a justification statement. We have a 77 year old male who was just admitted from the acute after a COPD exacerbation. He has significant organ level impairment which results in significant activity limitations that prevent him from ambulating to the bathroom. This is complicated by apparent depression and that fact that he lives in a 3rd floor walk up with no elevator.
An example of a justification statement is: READ Statement.
The problems come directly from the activity limitations, the Long term goals come directly from the participation limitations and the short term goals are the path in which the patient follows to return home.
The Basic Mobility AM-PAC has two versions, one that includes stairs and one that does not. This is the version with stairs since this patient must climb three flights to get home.
On to Dementia and a dysphagia problem. Here we have a typical patient in or near the end stage of dementia experiencing a weight loss. READ SLIDE
Read Justification statement
Currently the AM-PAC does not have a dysphagia inpatient short form. So we will be using the NOMs levels to assess current status, progress, and correct g code.
