Phase 3 of the implementation schedule for the Mega Rule go into effect in November of this year. Phase 2 and 3 require facilities to demonstrate staff competencies and skill sets based on resident population, as well as providing training to remediate identified knowledge gaps.   Part of these Requirements include Trauma Informed Care (TIC).  This in an introductory discussion about how these changes will impact care delivery in the future.

Historically speaking, populations that have been served by staff experienced with treating traumatic issues include youth and children.  Lifelong impact of trauma during developmental periods has been well documented.  Secondly, trauma care treatment has been focused on our military, PTSD is a prominent diagnosis that focuses on impact trauma will have in daily life. 

Recent discussions within the Geriatric Care Provider Organizations have included impact of trauma in elderly and benefits of receiving care that focuses on behavioral health and/or post traumatic stress disorders.  With the increase in awareness of the benefits coupled with drive to ensure person centered care is being delivered comes the need to increase the educational exposure for staff caring for the aging populations.

 A potentially traumatic event is one that will affect your daily life.  Take for example how a devastating weather event, destructive tornado, hurricane, or flood may have had significant impact on someone’s life and their current reaction to severe weather.  Per Leading Age “A majority of us- somewhere between 55% and 90% by some measures- have experienced at least one traumatic event.”   Examples of traumatic experiences could include experiencing or witnessing domestic and sexual violence, car, train, plan crashes, combat, becoming a refugee, homelessness, medical trauma, violent crime, discrimination, and numerous other potentially harmful life events.

The mere thoughts of 90% of our population having exposure to a traumatic event is staggering.  Knowing that situations occur in everyday life that may trigger those memories and affect patient responses is imperative to assist with care.  As caregivers, how we react when those memories are triggered may make all the difference in the world to the patient’s ability to actively participate in care.

Many times, in older adults when those memories are triggered it may result in responses by the elder that could be easily misdiagnosed.  Behaviors such as irritability, argumentative and confusion, could lead to medication prescriptions that are not necessarily appropriate.  Treating behavior instead of underlying cause.  It is increasingly important that employees in LTC environment are aware of trauma informed care principles to keep those at risk safe.

Start off by defining trauma and look at the components of trauma.

Trauma:  Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has lasting adverse effects on the individual’s functioning and mental, physical, social, emotional, or spiritual well-being.

 

The Three E’s of Trauma: The Three E’s of Trauma are event(s), experience of event(s) and effect.

EVENTS — can include actual or extreme threat of harm, or severe, life-threatening neglect for a child. Events can occur once or repeatedly over time.

EXPERIENCE — how the individual experiences an event helps determine if it is a traumatic event. Does recall of the event disrupt normal behavior?  Does recall of the event trigger feelings of humiliation, shame, guilt? Is there a Cultural component that is affected? Has there been social or psychological support in the past?

EFFECT — adverse effects can occur immediately or after a delay and can have a range of duration. Individuals may not recognize the connection between traumatic events and their effects.

Adverse effects include:

• Inability to cope with normal stresses of daily living
• Inability to trust and benefit from relationships
• Cognitive difficulties — memory, attention, thinking, self-regulation, controlling the expression of emotions
• Hypervigilance / hyperarousal, numbing, avoidance

The first step towards being able to provide adequate trauma-informed care is a basic understanding.  We’ve provided you with facts regarding trauma and how patients may present if actively dealing with traumatic situations.  Let’s next look at how to effectively deal with patients experiencing trauma associated symptoms.

TRAUMA-INFORMED: What does this mean?

With basic understanding of trauma, next we’ll focus on recognition that past trauma may never have been dealt with and that triggering behaviors may be misinterpreted many ways.  Providing a fully integrated Trauma-Informed program will assist in preventing re-traumatization to individual.

The trauma informed approach can be broken down into four components.  All employees must be able to have a working knowledge of the following components.

The Four R’s.

Realization:  All employees realize that trauma can affect individuals, families, organizations, and communities. Individual behaviors may be coping strategies used to survive adversity and overwhelming circumstances both past and present.

Recognition:  All employees can recognize the signs of trauma and have access to trauma screening and assessment tools.

Responding:  With increased awareness of specific resident experiences, all employees can provide care using trauma informed approaches.

Resisting:  Understanding the impact of creating a potentially toxic environment by using devices such as restraints or seclusion with residents who have a trauma history.

Alison Mitchell, MA, MSW and Len Kay, Ph.D., DSW of the University of Maine Center on Aging have developed core principles outlining guidance for trauma-informed care.  We will review the three core principles in detail.

Principle 1: The impact of adversity is not a choice.  The old adage of “what doesn’t kill you makes you stronger” is not necessarily true.  Even one acute traumatic experience, sometimes called a single incident trauma, can change the brain in harmful ways.  In addition, your genetic makeup plays a part in how you deal with stressful situations.  The genetic makeup you inherit makes some of us more likely than others to experience difficult events as traumas that, in turn, produce health-damaging traumatic stress.

Principle 2: Understanding adversity helps us make sense out of behavior. Without understanding that prior adverse events may manifest as behaviors in the elderly population, the likelihood of going undetected and possibly treated incorrectly goes up.

Principle 3: Prior adversity is not destiny.  The ability of the human brain to continue to learn and grow lasts throughout life, this is known as neuroplasticity.  In a safe and supportive setting, elderly patients can learn new coping mechanisms and how to deal constructively with adversity.

Identify the Presence of Prior Trauma and Triggers

What then, is the best approach to teach staff?  How might we adjust our daily tasks to ensure that patients are thoroughly assessed and screened for prior trauma and staff respond appropriately?  It must start with an assessment that will ferret out history of trauma.  Lisa M Brown, PhD Director of Trauma Program at Palo Alto University suggests using questions such as:

“some patients have told me about difficult experiences they had during their lifetimes, such as being threatened or ___.  Has anything like that ever happened to you?”

Opening that vein of communication will help get a better understanding and begin to allow you to incorporate strategies in daily care.  Always validate the response: “That must have been very frightening”.  Make certain that you respond with a response that normalizes the event: “You are not alone.”  “Many people have had these experiences and may feel angry, embarrassed, fearful, etc.”

It’s inappropriate to probe the patient for details at this point.  You should not respond by questioning the patient “if that really happened” or if they are in some way responsible for the incident.  Helpful, trauma-informed care individuals will validate the incident back with the patient.

Only three questions, the briefest screen ever was introduced by Gabriella Grant of the CA Center of Excellence for Trauma-Informed Care.

• Do you feel safe speaking with me today? If not, what would help you feel safer?
• Do you feel safe being here/living here today? If not, how can we help you feel safer?
• Did you feel safe at home as a child? If not, how does that affect you today?

If you are unable to ascertain that there is a history of trauma the best approach is to assume there is.  Using specific therapeutic interactions, the answer may become clearer and direct care based on responses.  Gabriella Grant also recommends specific responses, such as recognizing bravery for coming forward with troublesome information, recognizing the disclosure was difficult, redirect the elder to the present if trauma occurred in early life.  You must also be aware of reporting responsibilities, if this is new information to your care team, ensure it is reported up through the supervisory system where mandated State reporting can occur if applicable.

Understanding what triggers memories of traumatic event is helpful to prevent re-traumatization. Triggering the memory is not always easily identifiable. It could be a scent, a sound, something seen, or felt.  The act of revisiting the incident could stimulate the patient to react in manner that feels as if the incident/insult is fresh.  The goal is helping the patient understand what stimulates and then preventing triggers.

De-escalation techniques should be focused on ensuring the patient is safe from injury.  Staff need to understand that often the patient’s response to the memory will bring back memories of the time and place and may require assistance to bring the patient back (psychologically and emotionally) to the here and now.  As with all patient care, this requires individual plan of treatment and approach.  As, what may work with one individual may not with another.  For continuity, it is best to keep a written plan to address de-escalation techniques and share with the treatment team.

Organizations should be ensuring that your team has an understanding how exposure to prior trauma can affect patients later in life.  Putting these concepts into practice will help position your organization to successfully address patients who may be affected by trauma.  Provision of trauma-informed care starts with understanding and effectively assessing for it’s presence.  Organizations that invest in leadership who will champion this initiative will successfully be able to address the patient’s needs. 

 

 

Source:

Leading Age Maryland; Foundations of Trauma-Informed Care: An Introductory Primer

The shoulder is a complex body part that consists of 3 bones, 3 joints, bursa, cartilage, numerous ligaments, tendons, and muscles. In the United States in 2015 there were over 100,000 workplace injuries involving the shoulder. Over 66% of those injuries were a sprain, strain, or tear. Some common injuries include rotator cuff tear, tendonitis, dislocation, and impingement. These are called Musculoskeletal Disorders (MSDs), injuries that are commonly caused by repetitive work, forceful exertions (such as lifting, pushing, or pulling something heavy), working in an awkward position, using tools that vibrate, and contact stress like working with a part of your body against a hard or sharp object.

What Are the Signs of MSDs?
1. Decreased range of motion
2. Deformity
3. Decreased grip strength
4. Loss of muscle function

What are the Symptoms of MSDs?

• Pain
• Tingling
• Cramping
• Numbness
• Burning
• Stiffness

How Do You Prevent MSD Shoulder Injuries?

• Stretch and warm up before beginning your work day.
• Minimize any reaching, lifting, pulling, or pushing below your knuckles and above your shoulders, or “Strike Zone”.
• Avoid working in an uncomfortable or awkward position, such as holding a phone to your ear with your shoulder.
• DO NOT make sudden movements, such as twisting or jerking, while moving an object.
• Ensure you take your break and rest. Your body needs downtime to recover and repair itself.
• If possible, break up or stagger tasks that use the same body part to prevent overuse.
• Complete a hazard assessment to identify where there is potential for someone to develop a shoulder injury.

Ask Yourself
1. Is there a better way to do this process?
2. Are there tools or equipment to help you move an object or assist in your job? Are they in good working order? Are
they readily available?
3. Can the work area physically be changed or improved to reduce hazardous behavior like overhead reaching or lifting?
4. Has this task brought about previous shoulder injuries? If so, where were they? What can we change to prevent these
injuries in the future?

 

Sources: medlineplus.gov, orthoinfo.aaos.org, www.osha.gov, www.bls.gov

Lisa Chadwick
Director of Safety and Risk Management

Beginning October 1, 2019 providers will need to begin coding a new set of Health Insurance Prospective Payment System (HIPPS) codes in Section Z0100A of the MDS as well as on the Part A claim. This coding of HIPPS codes will identify the resident’s SNF PDPM classification for payment.

Like RUG-IV HIPPS codes, PDPM will also use five characters in the HIPPS code.  Below is a breakdown of what each character represents:

1. The first character represents the resident’s PT and OT payment group.
2. The second character represents the resident’s SLP payment.
3. The third character represents the resident’s nursing payment group.
4. The fourth character represents the NTA payment group.
5. The fifth character represents the resident’s assessment used to classify the resident.

Keep in mind that PT and OT use the same component classification process so they will have the same payment group. For this reason, they will share one character of the HIPPS code.  Another thing to keep in mind is that even though PT and OT use the same classification process, their case-mix is calculated separately. CMS provides this example: a resident who classifies into the TC case-mix group for PT will also classify into the TC case-mix group for OT. But the TC will pay differently for PT than OT due to the base rate difference and Case-Mix Indexes.

 

 

 

Example 1: PT/OT Payment Group: TN SLP Payment Group: SH Nursing Payment Group: CBC2 NTA Payment Group: NE Assessment Type: Initial Medicare Assessment HIPPS Code: NHNE1

Example 2: PT/OT Payment Group: TC SLP Payment Group: SD Nursing Payment Group: NC NTA Payment Group: PBC1 Assessment Type: Initial Medicare Assessment HIPPS Code: CDXC1

 

Keep an eye on CMS PDPM Webpage for updates.

 

Gina Tomcsik
Director of Compliance

PDPM!  I am sure you have heard about this new payment system by now, right? As you prepare and position yourself for this major change, we have to not only understand all of the moving parts, but more importantly, how all of those moving parts affect resident classification. MDS Section J will play a major role in determining resident classification and is no “J”oking matter!

 

Let’s take a look at the current RAI manual instructions for Section J, specifically section J2000, where the question is asking, “Did the resident have major surgery during the 100 days prior to admission?” Why is this important? The RAI manual explains that if the resident had a major surgery during the 100 days prior to the SNF admission, this surgery can affect the resident’s recovery.

 

How to assess? Ask the resident and his or her family or significant other about any surgical procedures in the 100 days prior to the SNF admission.  Review the resident’s medical record to determine whether the resident had major surgery. Review records received from facilities where the resident received care during the previous 100 days. The most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available are crucial for proof of the major surgery.  Receiving paperwork from the hospital is extremely important, especially surgical reports.  We need to work diligently to receive the supporting documentation from the hospital to ensure appropriate resident care is provided in the SNF as well as to appropriate classify the resident into an appropriate PDPM classification.

 

CMS defines a ‘major surgery’ that meets all of the following criteria in the MDS 3.0 RAI User’s Manual

1. The resident was an inpatient in an acute care hospital for at least one day in the 100 days prior to admission to the SNF, and
2. The surgery carried some degree of risk to the resident’s life or the potential for severe disability.

 

In the draft item set in section J2100, the MDS asks the question, “Did the resident have a major surgical procedure during the prior inpatient hospital stay that requires active care during the SNF stay?” If the Nurse Assessment Coordinator answers ‘Yes’ (J2100=1), the next step is to check all that apply in the following areas:

 

Major Joint Replacement.

J2300. Knee Replacement – partial or total.

J2310. Hip Replacement – partial or total.

J2320. Ankle Replacement – partial or total.

J2330. Shoulder Replacement – partial or total

 

Spinal Surgery.

J2400. Involving the spinal cord or major spinal nerves.

J2410. Involving fusion of spinal bones.

J2420. Involving Iamina, discs, or facets .

J2499. Other major spinal surgery.

J2599. Other major orthopedic surgery.

 

Other Orthopedic Surgery.

J2500. Repair fractures of the shoulder (including clavicle and scapula) or arm (but not hand).

J2510. Repair fractures of the pelvis, hip, leg, knee, or ankle (not foot).

J2520. Repair but not replace joints.

J2530. Repair other bones (such as hand, foot, jaw).

 

Neurological Surgery.

J2600. Involving the brain, surrounding tissue or blood vessels (excludes skull and skin but includes cranial nerves).

J2610. Involving the peripheral or autonomic nervous system – open or percutaneous.

J2620. Insertion or removal of spinal or brain neurostimulators, electrodes, catheters, or CSF drainage devices J2699. Other major neurological surgery.

 

Cardiopulmonary Surgery.

J2700. Involving the heart or major blood vessels – open or percutaneous procedures.

J2710. Involving the respiratory system, including lungs, bronchi, trachea, larynx, or vocal cords – open or endoscopic.

J2799. Other major cardiopulmonary surgery .

 

Genitourinary Surgery.

J2800. Involving male or female organs (such as prostate, testes, ovaries, uterus, vagina, external genitalia).

J2810. Involving the kidneys, ureters, adrenal glands, or bladder – open or laparoscopic (includes creation or removal of nephrostomies or urostomies).

J2899. Other major genitourinary surgery.

 

Other Major Surgery.

J2900. Involving tendons, ligaments, or muscles.

J2910. Involving the gastrointestinal tract or abdominal contents from the esophagus to the anus, the biliary tree, gall bladder, liver, pancreas, or spleen – open or laparoscopic (including creation or removal of ostomies or percutaneous feeding tubes, or hernia repair).

J2920. Involving the endocrine organs (such as thyroid, parathyroid), neck, lymph nodes, or thymus – open.

J2930. Involving the breast.

J2940. Repair of deep ulcers, internal brachytherapy, bone marrow or stem cell harvest or transplant.

J5000. Other major surgery not listed above

 

Why is it important for classification to ensure proper coding of major surgery under PDPM? By coding appropriately, there may be a change in the component clinical category. Some ICD-10-CM codes can map to a different clinical category if the resident received a surgical procedure during the prior inpatient hospital stay that relates to the primary reason for the SNF Part A admission. In order for this change, the surgical procedure must be recorded in section J of the MDS (J2000).

 

Gina Tomcsik
Director of Compliance and Regulatory Strategy

 

Measles is making a comeback in 2019

 Since January of this year, 22 states have experienced a total of 704 cases of measles, an infectious disease that was supposed to be eradicated almost two decades ago. 

The most recent cases were found at two California university campuses, where nearly 300 students, staff and faculty are being quarantined due to being unvaccinated (or their inability to prove otherwise). Most people who get (and spread) measles are those who have not been vaccinated.

 

 

Since measles tends to break out in geographic pockets, the best way to track the measles outbreak is by state. States that have reported cases to the CDC are Arizona, California, Colorado, Connecticut, Florida, Georgia, Illinois, Indiana, Iowa, Kentucky, Maryland, Massachusetts, Michigan, Missouri, Nevada, New Hampshire, New Jersey, New York, Oregon, Texas, Tennessee, and Washington.

As a precaution, the CDC recommends that all persons working in health-care facilities show presumptive immunity to measles. Depending on immunization dates, this information may require time to obtain, so to be pro-active you should attempt to locate your immunization records and have them available should they be requested.

Presumptive evidence of immunity to measles for persons who work in health-care facilities includes any of the following:

• Written documentation of vaccination with 2 doses of live measles or MMR vaccine administered at least 28 days apart
• Laboratory evidence of immunity
• Laboratory confirmation of disease or
• Birth before 1957

It is always best to be proactive and have the information available before it is requested.

 

Lisa Chadwick
Director of Safety and Risk Management

 

 

 

Do you remember when your light bulb starting to shine … the moment your life’s direction was aligned with the field of occupational therapy? 

For many clinicians, their career choice was based on a specific event, individual or experience which opened their eyes to this exciting and emerging field of health care. Many people knew they wanted to work with people.  OT allowed the diversity to use activities as a key component of achieving goals. A field that encourages creativity and allows you to do what you love.

For others, exposure to the field was through the OT care provided to themselves or a loved one.  Many people link their interest to a challenging situation – a grandfather who suffered a stroke, a younger sibling with cerebral palsy, a friend injured in an accident. Seeing the holistic and functional approach providing by OT was the key to a career path.

Becoming an occupational therapist will not only change your life; it will make a positive impact on the lives of others.  According to the Bureau of Labor and Statistics, occupational therapy is one of the fastest growing careers and is almost recession proof.  The opportunity to enhance the quality of another person’s life is one of the best parts of our profession.

As you go through your work day, do you share your love of your profession? Do you tell your clients why you chose to become a rehabilitation professional?  Do you take home special memories of making a difference in the lives of those you treat?  Take a minute to remember why you are working within the field of occupational therapy. You are unique, special and important.

Beth Reigart
Clinical Operations Specialist