APTA HHS Quarterly Report, Vol 54, No. 4

The Quarterly Report

FALL 2019

Vol. 55 | No. 3

In this VITAL SIGNS 2019: UPDATE AND REVIEW
Issue:
Preparing for PDGM Quality Expectations
1 Vital Signs 2019:
Update And Review By Donald Shaw, PT, PhD, D.Min.
Preparing for PDGM Quality
Expectations Introduction in The Quarterly Report titled “What’s so
As most readers are aware, the Patient Driven vital about vital signs?”3 Most discussion
2 Did You Hear Groupings Model (PDGM) is scheduled to related to either normative values or specific
Read All About It! begin on January 1, 2020. While the intent is measurement techniques. More recently,
to improve alignment between reimbursement I was asked to revisit this topic given the
6 Arterial Blood Pressure and patient needs, adequate preparation for higher clinical bar anticipated by the PDGM.
Response to Repeated this change will be critical for Home Health Thus, the present article will cover common
Cuff Reinflation without Agencies (HHA). The system will rely heavily technique/documentation pitfalls and
Interposed Rests in an on OASIS data, diagnosis coding, and data changes in normative values. Because of
Elderly Population grouped into payment categories. Therapy Bednarek’s4 excellent oxygen therapy article
service thresholds will disappear and a budget- that appeared in The Quarterly Report—
9 Value Based Purchasing: neutral model will be implemented.1 More Winter 2019, I will narrow my comments to
An Interdisciplinary importantly, “home health physical therapy include pulse and blood pressure only.
Cardiopulmonary Pathway service will no longer be a part of the case mix
in Home Health calculation that determines reimbursement.”2 Common Pulse Technique and
This begs the question: “Will our home health Documentation Pitfalls
17 PT Voice: agencies decide to retain our services at
Stepping Up to the Mic current levels, or will we possibly be viewed • Heart Rate vs. Pulse Rate—These
as a financial liability?”2 Clearly there will be words do not have the same
19 Spotlight Interview a: “….dramatic shift from volume to value; meaning and should not be used
with Philip Goldsmith physical therapists must strive to practice at interchangeably. Heart rate is the
the ‘top of license.’”2 number of ventricular beats as counted
20 OASIS D Guide to from records of the electrocardiogram
Accuracy: Background or blood pressure curves.3 Pulse rate
M to GG, Do They Crosswalk? Ten years ago, this author was asked to relates to peripheral arterial wave
address Home Health Section Listserv propagation as a function of the
25 Government Affairs questions and comments pertaining to vital heart’s contraction. It is easy to keep
Happenings: signs. The responses appeared as an article these straight if one remembers it
Section Responses to CMS is the “electrical” event (myocardial

Continued on 3

Published by the Home Health Section - APTA Did You Hear?
a component of the American Physical Therapy Association
Read All About It!
Editor
Dawn Widmer-Greaves, PT, DPT Listen Now: Section President Dee Kornetti

Managing Editor/Design Interviewed On ‘PT Pintcast” 
Don Knox
Home Health Section President Dee Kornetti is
Publications Committee
Julie Colaw, PT; Zachary Hampshire, PTA; Julie Hardy, featured on “PT Pintcast,” a PT podcast featuring
PT, MS; Mary Marchetti, PT, PhD; Olaide Sangoseni, PT,
DPT, MSc , PhD; Aban Singh, PT leading figures in physical therapy hosted—over a Dee Kornetti
beer—by Jimmy McKay, PT, DPT. 
Section Officers:
President......................................Diana Kornetti, PT, MA Scan the QR code here to listen to the
Vice President............................... Chris Chimenti, MSPT
Secretary........................................... Matt Janes, PT, DPT interview right now, or subscribe to the Pintcast
Treasurer............................. Philip Goldsmith, PT, DScPT
Executive Director..............................................Don Knox on Apple Podcasts, Android, Google Podcasts

The Home Health Section Quarterly Report is the or RSS.
official publication of the Home Health Section of
the American Physical Therapy Association. It is Dee talks with Jimmy about the section’s status
published four times per calendar year (Winter, Spring,
Summer, Fall). Statements of fact and opinion are the as the “go-to resource” for professional information on the
responsibility of the authors alone and do not imply an
opinion on the part of the officers or the members of the provision of physical therapy by PTs and PTAs in the home
Home Health Section.
health setting. “We’re specific to that post-acute setting, not
Article & Content Contributions
Guidelines for contributions are available from the the traditional bricks and mortar or inpatient type of facility.
Home Health Section website. If you have materials you
would like considered for publication, please email them We have unique situations that are all our own.”
via attachment to the Home Health Section Executive
Director: [email protected]. Regulatory issues, including PDGM, are a highlight of

Advertising the conversation!
Advertising rates and details are available from the
Section website, www.homehealthsection.org, or by 2019 Home Care & Hospice Conference and Expo of the
contacting the Section office at 866.230.2980.
National Association for Home Care & Hospice
Electronic subscriptions to the Home Health Section
Quarterly Report are available at a rate of $100/year. In October, members of the APTA Home Health Section
Order through the Section's online store.
attended the 2019 Home Care & Hospice Conference and
Copyright ©2019 by Home Health Section - APTA
Expo of the National Association for Home Care & Hospice in
Postmaster: Send address changes to Home Health
Section APTA , PO Box 3406 , Englewood, CO 80155. Seattle, Washington.

www.homehealthsection.org The conference carried
PO Box 3406 • Englewood, CO 80155 • 866.230.2980
the theme “Foresight: Care for
Page 2
the Future.” It came during an

acutely important time for home

health providers, from CMS’

new Patient-Driven Grouping

Model (including changes

to Requests for Anticipated

Payments); expansion of the

Review Choice Demonstration PTs at NAHC 2019—front row
program to Texas, Florida from left: Dawn Greaves, Dee
and North Carolina; federally Kornetti, Charlotte Norton; back
mandated Electronic Visit row from left: Jason Falvey, Cindy
Krafft, Clay Watson

Verification and more.

APTA HHS Member Spotlight: Todd Davenport
Todd Davenport, PT, DPT, MPH, OCS, Professor &
Program Director at the University of the Pacific,
was selected as a recipient of the Clarence W.
Hultgren California Physical Therapy Association
Service Award for his varied work over the years,
including serving as the Founding Chair of the Todd Davenport
California Research Council.

Dr. Davenport received an Outstanding Research
Publication Award as a lead author on the manuscript
entitled, “Chronotropic Intolerance: An Overlooked
Determinant of Symptoms and Activity Limitation in

Continued on 27

APTA Home Health Section

Continued from pg 1

depolarization) that precedes the “mechanical” action (89, 78, 82, 90, 83). Later in this same day the patient
(movement of blood through the vessel). Although heart slips into atrial fibrillation and a pulse oximeter resting
rates and pulse rates are generally the same, this is value of 113 beats·min-1 is observed—based on a five
not always the case. This is especially true for patients consecutive beat sample (136, 98, 123, 130, 76). Note the
having a history of cardiac dysrhythmias. Bottom line: wide range in pulse values now being considered. Indeed,
Never record a heart rate as a pulse rate (or vice versa). which number in the dysrhythmic array is closest to
• Pulse Measurement Duration—There appears to be a the actual resting rate? A device capable of identifying
great deal of variation in the length of time pulses are a median (middle) pulse would provide a count of 123
taken. When physical therapists are asked, “How long beats·min-1* In addition, one must face the same old
do you take a pulse?” answers frequently vary from 10 problem of sampling for less than a minute. Pulse rates
seconds to one minute. Ironically, therapists record a based on measurement intervals of less than this are still
pulse as beats·min-1 yet infrequently it is taken for an just estimates and pulse oximeter readings are generally
entire minute. In such instances, the physical therapist visible in seconds. This distinction could become a
might use an abbreviated count such as 15 seconds litigation issue if a therapist records a pulse count as
multiplied by 4. When using this approach, one assumes beats·min-1 when the pulse was really estimated from
the frequency of beats (and type of ECG waveforms an abbreviated count. Bottom line: Always determine
generated) in the last 45 seconds are the same as those the pulse count by actual 1-minute palpation whenever
seen in the initial 15 seconds. In truth, the physical possible. *(Note: The median value is located exactly in
therapist is documenting an estimated pulse based on a the center of a distribution).
value extrapolated from a shortened count…so this may
not be accurate. This tactic is especially risky when used Table 1. Factors influencing pulse oximeter readings
for patients with cardiac dysrhythmias. An exception to
this would be for patients who fatigue prematurely while Nail polish and nail coverings
exercising. In such cases, a pulse estimated on the basis Venous congestion
of a 10 or 15 second count would be required to avoid Irregular heart rhythms
overexertion. Bottom line: Always take a 1-minute pulse Hyperemia
unless there is a compelling reason to do otherwise. Motion artifact
• Peak Exercise Pulse vs. Exercise Recovery Pulse—As Pressure on the sensor
with heart rate and pulse rate, the words “peak exercise Electrical interference
pulse” and “exercise recovery pulse” should not be used Dyshemoglobinemias
interchangeably. The peak exercise pulse is counted Bright overhead lights
while an individual is still engaged in the exercise effort.
Taking one’s pulse just prior to turning the treadmill Pulse Oximeters in Perspective—Before wide-spread panic
off would be such an example. Recovery pulse on the is elicited regarding the use of this device, things need
other hand is counted just after exercise stops. This to be placed into perspective. Despite the limitations
approach is employed in step test protocols where mentioned above, pulse oximeters are excellent monitoring
post-stepping pulse recovery time is used as a measure of adjuncts. Attesting to this fact is their obvious presence
cardiorespiratory fitness. By far the most common error in most clinical venues. Their utility in measuring oxygen
occurs when physical therapists document an end of saturation is well-proven. Yet the nagging question
exercise pulse as a peak exercise pulse. Further, exercise remains: “is it appropriate, or even legal, to represent
intensity calculated from a recovery pulse is wrong abridged pulse counts multiplied by a constant as
conceptually and will underestimate actual endurance beats·min-1?” One way around this conundrum might be to
capability since pulses generally drop rapidly with rest. document as follows: “pulses are estimates only based on
Bottom line: Pulses should be documented as recovery the presence of a dysrhythmia” or “pulses were obtained
anytime the exercise challenge is withdrawn and the using a pulse oximeter and are therefore estimates only.”
pulse is taken. Remember, just because no one makes a “big deal” about
• Pulse Oximeter vs. Manual Pulse—A love-hate a shorter count doesn’t mean ignoring it will make it go
relationship often exists with the pulse oximeter. On one away. Bottom line: HHAs should discuss this issue with
hand, these devices are convenient, and they generally staff and the medical director to decide upon a uniform
render a pulse more quickly than palpation. On the other documentation approach.
hand, pulse counts are sometimes viewed as spurious and
unreliable (Table 1 presents a variety of possible reasons Common Blood Pressure Technique and
for this perception). However, few realize these devices Documentation Pitfalls
most often use a sampling average (statistical mean) of Most issues affecting blood pressure technique and/or
several beats to calculate the pulse. This poses a huge documentation lend themselves to presentation in table
problem when pulse values are obtained in patients with form. A table will introduce each segment to be followed by
dysrhythmias. By way of illustration, a patient in normal a summary comment.
sinus rhythm generates a resting pulse oximeter value of
84 beats·min-1—based on a five consecutive beat sample

The Quarterly Report | Fall 2019 Page 3

Table 2. Revised 2017 ACC/AHA Blood Pressure Categories

Source: www.heart.org/en/
health-topics/high-blood-
pressure/understanding-
blood-pressure-readings

Comment: There are three changes of specific importance in the revised categories. First, note a normal blood pressure
is no longer seen as 120/80 mm Hg. The new normal requires systolic blood pressures to be < 120 mm Hg with diastolic
pressures to < 80 mm Hg. Second, Stage 1 Hypertension onset is no longer defined as 140/90 mmHg. Both systolic (≥ 130 mm
Hg) and diastolic (≥ 80 mm Hg) pressures are now lower. Third, systolic pressures >180 mm Hg and/or diastolic pressures
>120 mm Hg now constitute a hypertensive crisis and necessitate immediate physician contact. Take a few minutes and
memorize all category limits. Bottom line: Knowing these new values is critical for proper physical therapy screening,
treatment, and documentation.

Table 3. Factors that can affect blood pressure readings

Factor Impact

Blood pressure cuff is too small 10 to 40 mmHg pressure increase

Body temperature values not provided

Full bladder 10 to 15 mmHg pressure increase

Blood pressure cuff used over clothing 10 to 50 mmHg pressure increase Source: www.suntechmed.
Talking 10 to 15 mmHg pressure increase com/blog/entry/4-bp-
Not resting (3-5 minutes prior) 10 to 20 mmHg pressure increase measurement/49-10-factors-
Emotional state values not provided that-can-affect-blood-pressure-
readings

Smoking (no tobacco 30 minutes prior) values not provided

Extremities unsupported 2 to 8 mmHg pressure increase

Comment: Clearly blood pressure readings can be affected by any of the factors mentioned above. However, one must not
view the impact numbers as absolute ranges; too many variables must be considered. Rather the utility of this table lies in
providing the direction of change—not the magnitude of change. With all a therapist must remember, it is easy to overlook
the obvious. A few focused questions (e.g., “have you recently smoked?”) coupled with a quick perusal of the immediate
environment (e.g., is patient wearing a heavy sweater) will help ensure readings are accurate. Bottom line: Conditions
affecting blood pressure readings are frequently subtle—don’t rush the process.

Page 4 APTA Home Health Section

Table 4. Additional blood pressure measurement considerations

Factor Impact Source: Frese EM, Fick A, Sadowsky HS.
Blood pressure cuff is too small 10 to 40 mmHg pressure increase Blood pressure measurement guidelines for
Body temperature values not provided physical therapists. Cardiopulm Phys Ther J.
Full bladder 10 to 15 mmHg pressure increase 2011;22(2):3.
Blood pressure cuff used over clothing 10 to 50 mmHg pressure increase
Talking 10 to 15 mmHg pressure increase
Not resting (3-5 minutes prior) 10 to 20 mmHg pressure increase
Emotional state values not provided
Smoking (no tobacco 30 minutes prior) values not provided
Extremities unsupported 2 to 8 mmHg pressure increase

Comment: Table 4 was selected for presentation because these measurement considerations are often far from our minds. Yet
the impact they have is no less significant than those provided in Table 3. For example, is your sphygmomanometer calibrated
on a regular basis? Are you guilty of having a digit bias or are you easily distracted? Singly, violation of any item can carry
profound implications. However, imagine the impact of multiple item violations on the same patient! This compounding effect
can increase the likelihood of making a wrong treatment decision thus endangering the patient’s welfare. As a side note, any
blood pressure difference between arms of 10 mm Hg or less is considered normal and is not a cause for concern.5 Bottom
line: Correct any equipment or procedural concerns before you affix the cuff.

Table 5. Home blood pressure monitors

The American Heart Association recommends an automatic, cuff-style, bicep (upper-arm) monitor

Wrist and finger monitors are not recommended because they yield less reliable readings

Choose a monitor that has been validated—check with the manufacturer if unsure

Make sure the cuff fits—measure upper arm circumference and choose a monitor that comes with the correct cuff size

Check unit calibration by comparing it to another unit or by direct auscultation

Adapted from: Monitoring your blood pressure at home. www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings/monitoring-your-
blood-pressure-at-home.

Comment: It is beyond the scope of this article to provide anything more than a cursory overview of home blood pressure
monitors. On the plus side these units can provide valuable adjunctive data when medical personnel are not present. Further,
serial blood pressures taken at home may provide early warning for CHF decompensation, pending stroke, and needed changes
in medication. On the down side are such issues as device quality, lack of calibration and location and placement of cuff.
Additionally, most commercial units provide a pulse display as well. As previously discussed, automated pulse determination
is less than reliable in patients with cardiac dysrhythmias. Bottom line: Always compare your auscultated blood pressure
values to those rendered by these devices.

Table 6. Seven ways to embarrass yourself when taking a blood pressure Adapted from: Shaw DK. Patients
Forget to put stethoscope prongs in your ears with cardiovascular disease:
Put stethoscope prongs in your ears upside down Effective management in physical
Forget to twist stethoscope head to correct position (i.e., bell vs. diaphragm) and occupational therapy.
Cover arm antecubital area with cuff Continuing education program,
Forget to close inflation bulb valve before squeezing Portland, Oregon, 2013.
Pump cuff up to high or not high enough
Release cuff pressure too slowly or too quickly

Comment: It is fair to assume most physical therapists have embarrassed themselves on more than one occasion when
taking a blood pressure. What’s more, no healthcare professional is immune. The saving grace is these errors most
often fall into our camp; we can generally adjust quickly to resolve the issue…and must. Bottom line: Are any of these
embarrassments yours?

The Quarterly Report | Fall 2019 Page 5

Conclusion About the Author
In the introduction, it was noted the PDGM will require home Donald K. Shaw, PT, PhD, D.Min, recently retired
health physical therapists to perform increasingly at “the top as a full professor in the Physical Therapy Program
of their game.” While this carries an ominous sound, it really at Franklin Pierce University. In addition to his role
means continue to learn what you can and improve what you in academia at multiple universities over his career,
do. Hopefully this vital signs article helped move you forward he served as Director of Cardiac Rehabilitation at
toward both of these ends. Saint Thomas Hospital in Nashville, Tennessee. Dr.

By way of a final note, it is strongly recommended Shaw has a Bachelor and Master of Science degree in Physical
home health physical therapists consider becoming Education; a doctorate in Exercise Physiology; a Bachelor of
Advance Competency in Home Health credentialed. This Science in Physical Therapy; and a D.Min. degree in Christian
is a highly visible accolade and great testimony to your Apologetics. He is a Fellow of the American Association of
professional commitment. Cardiovascular and Pulmonary Rehabilitation.

References
1. Gaboury MA. Are you prepared? The Patient Driven Groupings Model (PDGM) is coming soon. healthcareprovidersolutions.com/pdgm-preparation. Accessed

September 4, 2019.
2. Childers C, Chimenti C. What the Patient Driven Groupings Model (PDGM) means to the individual clinician. The Quarterly Report. 2019;44(2):3.
3. Shaw D. What’s so vital about vital signs? The Quarterly Report. 2009;44(4):1-5.
4. Bednarek M. Oxygen therapy in the home health setting. The Quarterly Report, 2019;54(1):1
5. Monitoring your blood pressure at home. www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure- readings/monitoring-your-

blood-pressure-at-home. Accessed October 1, 2019.

Arterial Blood Pressure Response to
Repeated Cuff Re-inflation without
Interposed Rests in an Elderly Population

Edward Pagan, SPT; Austin Ryf, SPT; Miriam Zveitel, SPT;
Donald Shaw, PT, PhD, D.Min.

Preface produced a concomitant increase in the prevalence of many
It remains unclear how much time should be interposed diseases in the elderly.1 With such a wide-ranging population
between trials when serial blood pressures are taken. Some over age 65, many are classified as having multimorbidities.2
investigators argue 30 seconds or more are required to clear (Note: Comorbidity means more than one illness or disease
arm venous pooling, while others feel immediate re-inflation occurring in one person at the same time and multimorbidity
is appropriate. In actual clinical environments, back-to-back means more than two illnesses or diseases occurring in the
blood pressure readings are rarely needed. However, home same person at the same time.)3 Multimorbidity varies greatly
health therapists may find themselves auscultating in noisy by age with Violan4 commenting 13% of individuals 18 years
or cramped settings where blood pressures are hard to hear and older are categorized as having multimorbidities with
and where several repeated trials are necessary. Elderly, frail, this number increasing to 95% in individuals over age 65.
and obese individuals often present challenges in this regard Cardiovascular disease is a primary culprit with hypertension
as well. contributing to more than 50% of multimorbidity total.
Revised American College of Cardiology and American Heart
With the Patient Driven Groupings Model (PDGM) just Association guidelines indicate Stage 1 hypertension is likely
around the corner, it seems appropriate to share this original present when systolic (SBP) and diastolic (DBP) pressures
research on cuff re-inflation. This is particularly true given of 120-139/80-89 mm Hg are observed.5 Further, it is well
the vital signs focus of this Quarterly Report issue. documented hypertension is a major risk factor for coronary
heart disease, stroke, and renal failure.6,7 This noted, the
Introduction Centers for Disease Control and Prevention estimates 75
The United States’ healthcare system is facing a rapidly million American adults (one in three) have high blood
growing and aging population with more than 40 million pressure.6 Further, it is estimated 22% of those affected
people now over age 65. By 2050, it is expected there will be by this condition are unaware they are hypertensive. This
over 89 million people in America above the age of 65.1 Life accounts for approximately one in five Americans.
expectancy overall has increased due, in part, to medical
innovations which have profoundly affected this segment of With the prevalence of hypertension in the United
the population. However, this increase in life expectancy has States growing, it is estimated the cost to the nation is 48.6

Page 6 APTA Home Health Section

billion dollars per year which includes health care services, measurements and keeping one’s feet flat on the floor.
medication, and missed days from work. In 2014, high blood A second investigator initiated five rapid inflations
pressure was the cause of death for 410,000 Americans.7 The
topic of accurate arterial blood pressure (ABP) measurement of the cuff without interposed rest periods, while a third
is eliciting increased attention in healthcare, especially with investigator recorded SBP, DBP, and pulse measurements.
regard to physical therapy.8 With growing multimorbidity The Connex® display was not visible to subjects while
prevalence, the need for vital signs assessment, especially measurements were taken. Following the completion of the
ABP, is of genuine importance. Vital signs provide a baseline 5 repeated inflations, the second investigator removed the
when assessing cardiovascular status and help in the clinical blood pressure cuff and subjects were offered a water and
decision-making process. Inaccurate measurements can hinder nutrition bar for their participation. All data were analyzed
this process rendering a negative impact on patient outcomes. using SPSS Version 24 software.

The effect of five rapidly repeated cuff inflations on Results
ABP without interposed rest was previously researched in The authors recruited 24 subjects to participate in this study,
college students.9 From this research, it was concluded all all were screened and deemed appropriate to participate. Five
SBP and DBP readings were lower than the first measurement measurements were performed on each of the 24 subjects for
performed.9 The range for both was quite small and the a total of 120 total measurements rendered for data analysis.
authors noted there appeared to be no consistent mechanism Twenty of 24 subjects self-reported they were taking at least
at play to alter ABP. However, the pressure fluctuation one antihypertensive drug and five of 24 subjects had arm
question has not been addressed as it relates to the elderly. circumferences greater than 44 cm requiring the large size
Specifically, is the cuff re-inflation response similar in this blood pressure cuff. The baseline mean SBP was 135 mmHg
group when compared to younger subjects? The present study and the mean DBP was 75 mmHg.
measured five rapid blood pressure cuff inflations obtained
without interposed rests to determine if this sequential Mean changes for SBP and DBP over the five trials
procedure altered ABP in the elderly. were: T1 - 134.9±14.9, 75.2±6.5; T2 - 132.1±14.9, 73.6±6.5;
T3 - 131.1±16.2, 72.9±6.3; T4 - 129.8±15.6, 73±6.6; and
Methods T5 - 129.2±16.8, 72.3±9. Pairwise comparisons revealed
Design significant differences between SBP T1 vs. T4 and T1 vs. T5;
There were 24 subjects (12 females, 70.9 ± 10.2; 12 males, (p≤0.02) and between DBP trials T1 vs. T2, T1 vs. T4, and T1
68.2 ± 9.6) from the Sun City retirement community in Sun vs. T5 (p≤0.03). Pulse rates appeared to vary independently
City, Arizona participated in the project. This was a quasi- of changes in ABP with the comparison of ABPs based on
experimental study using this convenience sample. The medication and sex being non-significant (p ≥0.05).
project was approved by the Institutional Review Board of
Franklin Pierce University. All subjects signed an informed Discussion
consent prior to participation. Previous research utilizing students and the same protocol
revealed SBP and DBP readings (T1 vs. T2, T3, T4, and T5)
Device were lower with each consecutive cuff re-inflation.7 These
A Welch Allyn Connex® 6000 Series automated blood results are consistent with those previously observed. This
pressure unit was used for all measurements. The device includes significant changes in both SBP and DBP when
was factory calibrated to ensure measurement accuracy. compared to T1. Only SBP T1 vs. T2, T1 vs. T3, and DBP T1
vs. T3 were not significantly different. It is noteworthy the
Once the monitor was switched on, display settings were ranges between SBP T1 vs. T5 and DBP T1 vs. T5 were quite
selected and one test inflation was performed on a single small. However, despite this fact, it does appear a consistent
investigator. Machine display included SBP and DBP (mm Hg) mechanism is present in altering ABP when it is obtained
and pulse (beats·min-1). Two blood pressure cuff sizes were sequentially without interposed rests. Specifically, ABP
utilized - adult regular (27-34 cm) and adult large (35-44 cm). tends to drop progressively as a function of repeated cuff
Cuff size was determined by circumference measurement of re-inflation. The authors hypothesize that the altered ABP
the right upper arm of each subject. might be a function of reduced venous return. Although the
mechanism is unclear, consecutive cuff re-inflation in the
Data Collection absence of adequate recovery time appears to disrupt local
Data were obtained at a centrally located local church in hemodynamics.

the multi-purpose room. Upon facility arrival, subjects were This finding is somewhat disturbing given the consistent
shown an informative video describing the study and a list of and accurate measurement of ABP carries very real health
present medications was obtained. Once informed consent implications. The American Heart Association states when
was received, subjects were escorted to a quiet area where they one is performing consecutive ABP measurements, 1-minute
rested for five minutes. Following this period of quiescence, of rest should elapse between cuff re-inflations.10 Thus,
a second investigator obtained right arm circumference and until further studied, it is not recommended clinicians
applied the appropriately sized cuff to the subject’s right arm immediately re-inflate blood pressure cuffs when serial
following standard protocol.8 Each subject was informed as measurements are indicated. Future investigation of ABP
to standard blood pressure measurement procedures which measurement should take into account comorbidities that
included remaining silent for the duration of blood pressure impact venous pooling, especially those having vascular

The Quarterly Report | Fall 2019 Page 7

disorders. Clearly, consecutive cuff re-inflations without About the Authors
interposed rest significantly affects ABP readings in the Edward Pagan, SPT, Austin Ryf, SPT, and Miriam Zveitel, SPT
elderly population. are third-year DPT students at Franklin Pierce University.
Donald Shaw, PT, PhD, D.Min., previously served as a Professor
Conclusion of Physical Therapy at Franklin Pierce.
Based on the current findings, it is not recommended
clinicians immediately re-inflate blood pressure cuffs when Edward Pagan Austin Ryf Miriam Zveitel Donald Shaw
serial ABP measurements of the elderly are indicated. There
is a confounding mechanism influencing ABP readings when
adequate deflation time is not provided. Future research is
indicated to ascertain the actual mechanism(s) related to this
ABP alteration as it relates to an elderly population.

References
1. Jacobsen LA, Kent M, Lee M, Mather M. America’s aging population. Population Bulletin. 2011;66(1):1-18.
2. Streit S, Gussekloo J, Burman RA, et al. Burden of cardiovascular disease across 29 countries and GPs’ decision to treat hypertension in oldest-old. Scand J Prim

Health Care. 2018;36(1):89-98.
3. Comorbidity - Comorbidity and multimorbidity. What do they mean? www.bgs.org.uk/resources/morbidity-comorbidity-and-multimorbidity-what-do-they-mean.

Accessed October 1, 2019.
4. Violán C, Bejarano-Rivera N, Foguet-Boreu Q, et al. The burden of cardiovascular morbidity in a European Mediterranean population with multimorbidity: a cross-

sectional study. BMC Fam Pract. 2016;17:1-12. doi:10.1186/s12875-016-0546-.
5. Understanding blood pressure readings. www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-readings. Accessed September

20, 2019.
6. High Blood Pressure (Hypertension) information. Centers for Disease Control and Prevention. www.cdc.gov/bloodpressure/ Accessed February 6, 2019.
7. High Blood Pressure Fact Sheet|Data & Statistics|DHDSP|CDC. (n.d.). www.cdc.gov/dhdsp/data_statistics/fact_sheets/fs_bloodpressure.htm. Accessed

February 6, 2019.
8. Frese EM, Fick A, Sadowsky HS. Blood pressure measurement guidelines for physical therapists. Cardiopulm Phys Ther J. 2011;22(2):5-12.
9. Johnson S, Hefferon T, Shaw D. Arterial blood pressure response to repeated cuff re-inflations without interposed rest. Cardiopulm Phys Ther J. 2017; 28(1):31.
10. Monitoring Your Blood Pressure at Home. American Heart Association. www.heart.org/en/health-topics/high-blood-pressure/understanding-blood-pressure-

readings/monitoring-your-blood-pressure-at-home. Accessed April 18, 2019.

Value Based Purchasing: An
Interdisciplinary Cardiopulmonary
Pathway in Home Health

By Denise Tillery Wagner, PT, DPT, GCS; Patricia Grimes, MSN, RN;
Stacee Minyard, OTR; William Weakland, PT, DPT

Introduction • JH Connect (In Home Call Button)
Johns Hopkins HH Services (JHHHS) is currently operating • HH Aide (HHA), if appropriate
under the Centers for Medicare and Medicaid Services
(CMS) pilot model for care delivery: Home Health Value Our bundle allows us to monitor the patients’ health status
Based Purchasing (HHVBP).1,2 Under HHVBP, we have everyday even when they are not scheduled to receive a visit
considered how we can most effectively and efficiently from a clinician. Our interdisciplinary team members use
deliver quality care that is meaningful to our patients. patient engagement techniques to educate patients and their
In response, we have created an interdisciplinary care care providers on early symptom recognition. This approach
bundle for patients with Heart Failure (HF) and/or Chronic supports early intervention by any member of the patient’s
Obstructive Pulmonary Disease (COPD). Utilization interdisciplinary team, often before the patient experiences
of these two care bundles has contributed to reduced symptoms or status worsens. Our broad interdisciplinary
hospitalizations and readmissions. approach includes not only the treating Home Health (HH)
clinicians listed above, but also the patient, patient caregivers,
Our bundle includes: our office staff, HH coordinators, case managers, disease
• Remote Patient Monitoring (RPM) management specialists (via RPM), our hospitalization
• Skilled Nursing (SN) reduction committee, social workers, quality improvement
• Physical Therapy (PT) team, diaphoresis clinics, and physicians.
• Occupational Therapy (OT)

Page 8 APTA Home Health Section

• Strengthen collaborative
interdisciplinary
documentation and
communication within
our clinician teams

• Promote and support
shared decision making

• Deliver highly reliable
evidence based, person
centered care.1,2,3

Figure 1: An example of JHHHS VBP dashboard results Home Health Clinical
Printed with permission of Melissa Millard, MPH). Pathways: Heart Failure (HF)
and Chronic Obstructive
Value Based Home Health Care Pulmonary Disease (COPD)
The United States spends more per capita on health care Changing practice patterns
than any other nation in the world. Poor health outcomes requires a collaborative,
prompted visionary healthcare industry and government evidenced based, and
leaders to pursue performance improvement throughout persuasive approach. Our
all sectors of the U.S. health care industry including HH PI team includes field
Services.3 The time-honored fee-for-service reimbursement clinicians from all disciplines,
model provided pay for service regardless of outcome. This quality safety specialist,
system was costly, has not demonstrated quality or value, documentation specialist, and
and ultimately is not fiscally sustainable. leadership representatives.
When presenting our plan to the field clinicians, we
In 2016, CMS rolled out the HHVBP pilot in nine states, emphasize that the pathways provide guidelines/frameworks
including Maryland, the home state of JHHHS. Medicare designed to meet the needs of the typical JHHHS patient
certified HH Agencies in these nine states are undergoing with HF or COPD. Clinicians are encouraged to use evidenced
enormous changes in the delivery, evaluation and based best practice when assessing, evaluating and
reimbursement of HH service. The HHVBP program pilot is intervening with their patients. The goal of our pathways is
a dynamic and evolving initiative which replaces the fiscally to transition patients toward successful self-management.
unsustainable 60-day fee-service reimbursement model with These guidelines are evidence based practices designed to
a quality performance reimbursement model. Payment is support field clinicians in managing their patients with
linked to performance and outcomes which may be expressed HF/COPD, and give them tools to do their jobs, improve
as value. Figure 1 shows the measures being tracked in the COPD/HF patient outcomes, and decrease our 60-Day
HHVBP pilot states. The pilot may be rolled out in additional Hospitalization Rate.
states prior to the completion of the five-year pilot phase
thus impacting more HH service providers.1,2,3 The Bundle: RN, RPM, PT/OT, Home Call Button
Our HF care bundle was introduced in fiscal year 2017. Since
Our Interdisciplinary Cardiopulmonary Pathway aligns introducing the bundle our 30-day readmission rate for heart
with CMS National Quality Strategy: Improving the Quality failure patients has decreased by 6%. This bundle contains at
of Health Care and has improved our HHVBP outcomes.1,2,3 least 3 services providing multiple visits and could be intrusive
The goals of this JHHHS Performance Improvement (PI) to the patient. Setting the stage for acceptance is crucial to an
initiative are: ultimately successful transition to patient self-management
without hospital readmission. We coach our clinicians with
• Improve outcomes for patients with COPD and/or HF talking points to use during the Start of Care (SOC) to promote
• Reduce hospital readmission rates in the HHS COPD patient acceptance of the entire bundle. Here is an example:
“We have a HF (or COPD) Care Bundle that has successfully
and HF population prevented our patients with HF (or COPD) from going back
to the hospital. We will provide you with Nursing, RPM, PT,
and/or OT, and an In-Home Call Button. These tools allow us
to monitor your health status everyday even when you aren’t
receiving a visit from your nurse or therapist. With this extra
support we will be able to intervene more quickly to keep you
out of the hospital if your symptoms or status worsens, often
before you start to feel bad.”

Our clinicians also received education on the following points:
• Every patient with HF/COPD must be evaluated for RPM

The Quarterly Report | Fall 2019 Page 9

RN in person or phone/RPM
check, PT, OT, or HHA visits)
weekly in weeks 1-3 with
the goal of only 1 discipline
visiting daily. Later in the
episode, there may be 4-5
touchpoints weekly in weeks
4-8 including once every other
week for some disciplines.
Careful coordination and
communication amongst
clinicians are required to
allow all clinicians to provide
the needed care without
overwhelming the patient.
Throughout the episode of
care, RPMs are monitored
daily by “disease management
specialist” nurses who contact
the patient’s physicians
when indicated and closely
coordinate care with the
physician.

Figure 2: CHF zone tool Discharge Planning
In HH we see patients with
(we have both landline and cell phone connected options) HF/COPD in three different
• The value of increased “touch points” using in-home call disposition groups. Those patients who are in the end stages
of the disease process may transition to hospice, some
buttons/RPM others may remain homebound, and some may transition to
• The value of phone assessments outpatient cardiac rehabilitation. Recent studies have shown
• If RPM is not accepted, strongly consider HHA to assist that people who complete a cardiac rehabilitation program
can increase their life expectancy by up to five years but
with personal care only 10% of eligible patients with heart failure are referred
• Strongly encourage every patient with HF/COPD to to cardiac rehabilitation.10,11 It is important to advise our
patients with HF/COPD of their outpatient rehabilitation
accept PT evaluation as evidence shows these patients options and facilitate their transition. Medicare has been
benefit greatly from exercise 4,5,6,7 covering outpatient cardiac rehabilitation for patients
• Instruct the patient in the role of therapy to safely with a hospitalization for exacerbation of heart failure
increase activity and exercise with reduced ejection fraction since 2014 but many health
care providers are not aware of this change. We include
In the first week of care, we strive to do all of the following: some written materials on the benefits of exercise in our
front-load visits & address risks for re-hospitalization; ensure diagnosis specific teaching booklets for each patient and
a physician follow up visit has been scheduled and secure our therapists review this information with them during
a cardiologist for patients who do not have one; ensure visits. We help these patients to identify the closest provider
the patient or their caregiver demonstrate accuracy with for outpatient cardiac or pulmonary rehab and their
medication dosing/setup; utilize teach back method to ensure transportation options to attend in order to address this
the patient understands and is using the Zone Tool (Figure common barrier to participation.
2); teach the patient or caregiver the importance of taking
daily weights and charting them on the in-home record; Figure 3: EMR noting patients’ status by team member
identify if they have their own scale and if not begin planning
for obtaining one; assess for PT; order and initiate RPM.8,9

In addition to these items, we consider adding a HHA
(especially when RPM is not installed). If a patient is
following two or more diets and or has high nutritional risk, a
dietician is added. Other rehab disciplines and social work are
included as indicated.

During the episode of care, which may span 6-8 weeks
as long as the patient remains homebound, the whole team
starts every visit with the same question… “What zone are
you in today?” There will be 6-7 touchpoints (including

Page 10 APTA Home Health Section

Figure 4: Case communication note examples conferences, a manager
enters a summary case
Figure 5: Patient Completed In-Home Record conference note in the EMR.

Interdisciplinary Communication Tools Another communication
Easy to use communication tools facilitate timely tool used in the home is
communication resulting in more effective and efficient care of our “In-Home Call Button”.
patients with COPD and HF.12 We use several communication Through a partnership with
tools with the patient, caregiver, and interdisciplinary a medical alert supplier,
team. Our electronic medical record (EMR) provides shared our patients receive a free
interventions which are utilized by multiple HH disciplines trial of a medical alert
including zone tools (Figure 3) and case communication device for up to 60 days.
notes (Figure 4). All team members can easily see the patients We encourage the patients
reported status on the zone tool from visits provided by other to use the button just like
disciplines. Case communication notes are part of the official the hospital call button.
medical record and can be directed to specified team members. From 9/30/14- 8/31/17, our
Our EMR is shared throughout the hospital system. This allows In-Home Call Button service
our HH clinicians can to see notes and results of physician, interacted with at least
clinic, or other specialty inpatient or outpatient consultations or 3679 patients and resulted
tests. Likewise, other health system clinicians can see our HH in at least 186 potential
notes and receive our case communication notes. readmissions avoided. Calls
ranged from needing help
We also have communication tools utilized in the home with making appointments
by patients and their caregivers as well as HH clinicians. to social reassurance calls
These tools promote communication and confirm the to responding to a small
patient and caregiver’s comprehension and implementation number of emergencies.
of critical chronic disease management skills and processes. Since the In-Home Call
These tools include the In-Home Record Tool (Figure 5), Button is a two-way cellular
Home Medication Management Sheet, and BORG rate of device, our partner can
perceived exertion. assist to provide medication reminders and wellness check in
calls as well as communicate with patients who do not have
In addition to our written communication tools, we reliable phone service.
hold virtual interdisciplinary case conferences for our
patients with HF and COPD. Each team member calls in to a Patient Engagement and Motivational Interviewing
conference line for a 15 to 30 minute virtual team conference Our JHHHS admission orientation during the SOC sets the
where disease management challenges, hospital readmission tone for our clinicians to utilize patient engagement (PE)
risks, and discharge planning are discussed. After virtual and motivational interviewing (MI) strategies to promote
optimal outcomes. Optimal outcomes in chronic disease
management require patient engagement. Chronic disease
management frequently requires significant lifestyle
changes. Patient Engagement as defined by the Agency for
Healthcare Research and Quality is: “A set of behaviors by
patients, family members, and health professionals and a set

Figure 6:
Patient Engagement
(used by permission:
Pat Grimes, MSN, RN)

The Quarterly Report | Fall 2019 Page 11

of organizational policies and procedures that foster both the and COPD research and disseminate articles to the staff.
inclusion of patients and family members as active members So how do you get started to improve your agencies
of the healthcare team and collaborative partnerships with
providers and provider organizations”.13 These techniques HH and COPD care? Consider sponsoring HF and COPD
are grounded in psychoanalytically based patient centered continuing education courses. Select a champion who
medicine principles and are intended to facilitate frequent, commits to attending HF and COPD courses and subscribing
meaningful person-healthcare provider conversations/ to research databases. Utilize the research to create
interactions surrounding health and wellness. an evidenced based pathway (bundle) for your typical
population and select tools for the success of your pathway.
Patient engagement hinges on provider engagement & Promote clinician use of motivational interviewing and
training. At JHHHS we provide ongoing monthly training to patient engagement and give your team PE and MI tools.
our clinicians in PE and MI. Our clinicians learn that PE & MI Consider how strategies for successful collaboration and
are not just current buzz words. PE & MI are evidenced based documentation can be built into your EMR. The result could
best practices to support the patient’s transition to effective be improving your re-hospitalization rates, your VBP, and
self-management and improved health outcomes through your Home Health Consumer Assessment of Healthcare
shared decision making. PE and MI are pathways to empower Providers & Systems (HHCAHPS) scores. Most importantly
consumers of healthcare. These are methods for helping though, HH Agencies can impact the health and outcomes
patients to explore their uncertainty, overcome ambivalence, of this patient community and increase the population of
change behavior, and improve their health.2,7,13,14,15,16 The people with cardiopulmonary diseases who are successfully
building blocks of PE and MI are based on Patient Centered managing their health and thriving at home.
Care. Figure 6 shows a schematic of Patient Engagement we
utilize in our training. About the Authors:
Denise Tillery Wagner, PT, DPT, GCS is a physical therapy
Patient Centered Care supervisor at Johns Hopkins Home Health
In order to provide effective patient centered care, JHHHS Services. [email protected]
and the Johns Hopkins system provide robust IT systems, and
training cultivating emotionally intelligent and culturally Patricia Grimes, MSN, RN is a home
competent clinicians. We participate in and support health nurse case manager and preceptor
partnerships between healthcare organizations, patients, at Johns Hopkins Home Health Services.
providers, community support networks, government [email protected]
organizations, and health IT. We also provide organizational
support for shared decision making and shared responsibility Stacee Minyard, OTR is an occupational
wherein providers and patients work together to make therapist II and preceptor at Johns Hopkins Home Health
decisions about tests, treatments and care plans based on best Services. [email protected]
practice clinical evidence that balances risks and expected
outcomes with patient preferences and patient values. Our William Weakland, PT, DPT is a physical therapist at Johns
EMR supports robust information sharing within our hospital, Hopkins Home Health Services. [email protected]
outpatient, and home care divisions which allows providers
and patients to access and securely share a patient’s vital Authors’ Acknowledgements: Melissa Millard, MPH; Suzanne
medical information electronically from many locations. This Havrilla, PT, DPT, GCS; Donna Beck, MSPT
improves the speed, quality, safety, coordination, and cost of
patient care. Lastly, JHHHS promotes emotional intelligence
and cultural competence through regular in-services,
supervisor support, and coaching to our clinicians.2,7,13,14,15,16
Figures 7–11 are examples of evidence based patient and staff
education tools utilized in our program to support our focus
on patient centered care.

Heart Failure Care Bundle Sustainability
An Interdisciplinary Cardiopulmonary Pathway in HH
requires an intentional plan for sustainability. Annual
education for existing staff, orientation for new staff,
mentoring from experienced staff, monthly conferences
with supervisors, grouped interventions built into the EMR
which remind staff of all available treatments, and utilization
review which will note if a clinician is not following the
pathway are all methods used at JHHHS to sustain our
pathway. Additionally, we have recruited Heart Failure and
COPD “Champions”. A Champion is someone who has a
passion for this population. Champions stay current in HF

Page 12 APTA Home Health Section

Figure 7: ACE (used by permission: Pat Grimes, MSN, RN) Accept where the patient is in their disease
management without judgment.

Show compassion for how difficult lifestyle
changes are.

Evoke how patient feels about these
lifestyle changes.

How confident (ready) are you that you can do this exercise program?
What would it take for you to move from unsure to somewhat ready?

Figure 8: Confidence (or readiness) Ruler (used by permission: Pat Grimes, MSN, RN)

Open-ended question: What Page 13
would it be like for you if you
did your exercise program 3
days a week?

Affirmation: Congratulations for doing
your exercise program 2 days this week!

Reflective Listening: It sounds like you are
angry about…

Summary Reflections: Here is what I heard … tell
me if I missed something.

Figure 9: OARS (used by permission: Pat Grimes, MSN, RN)

The Quarterly Report | Fall 2019

Figure 10: Important TO vs. important FOR (used by permission: Pat Grimes, MSN, RN)

Figure 11: ICF Applied17, Self-Efficacy18, and use of Modeling & Role Modeling19 (used by permission: William
Weakland, PT, DPT)

Page 14 APTA Home Health Section

References
1. Centers for Medicare & Medicaid Services. HH quality reporting measures. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/

HomeHealthQualityInits/index.html. Accessed October 23, 2018.
2. Centers for Medicare & Medicaid Services. HH quality initiative. www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-

Programs/Value-Based-Programs.html. Accessed October 23, 2018.
3. Agency for Healthcare Research and Quality: Advancing excellence in healthcare. www.ahrq.gov/patient-safety/resources/advances/index.html. Accessed

October 1, 2018.
4. Antonicelli R, Spazzafumo L, et al. Exercise: a “new drug” for elderly patients with chronic heart failure. Aging. 2016;8:860-869.
5. Bauldoff GS. When breathing is a burden: how to help patients with COPD. Am Nurse Today. 2009;4(9):17-22.
6. Belardinelli R, Georgiou D, Cianci G, Purcaro A. 10-year exercise training in chronic heart failure: a randomized controlled trial. JACC. 2012;60(16):1521-1528.
7. Corbridge S, Wilken L, Kapella MC, Gronkiewicz C. An evidence-based approach to COPD: Part 1. Am J Nurs. 2012;112(3):46-59.
8. Fritz, D McKenzie, P. Avoiding emergency department visits for COPD, pneumonia and heart failure. HHc Nurse. 2014;32(10):578-586.
9. Gheorghiade M, Vaduganathan M, Fonarow GC, et al. Re-hospitalization for heart failure. J Am Coll Cardiol. 2013;61:391–403.
10. Martin BJ, Arena R, Haykowski M, et al Cardiovascular fitness and mortality after contemporary cardiac rehabilitation. Mayo Clin Proc. 2013;88:455–463.
11. Taylor RS, Sagar, VA, et al. Exercise-based rehabilitation for heart failure. Cochrane Database SystRev 2014. (4). doi: 10.1002/14651858.CD003331.pub4.
12. Hirsch K. National Council for Behavioral Health. National Conference presentation. The Golden Thread: Weaving Together Treatment and Collaborative

Documentation. 2017. www.integration.samhsa.gov/mai-coc-grantees-online-community/Breakout4_Collaborative_Documentation.pdf. Accessed October 2018
13. Pelletier LR, Stichler JF. Ensuring patient and family engagement. J Nurs Care Qual. 2014;29(2):110-114.
14. Allen C. 2014. The spirit of motivational interviewing. www.youtube.com/watch?v=_KQr9TFJvBk. Accessed October 1, 2018.
15. The IHI triple aim. Institute for Healthcare Improvement website. www.ihi.org/Engage/Initiatives/TripleAim/Pages/default.aspx. Accessed October 23, 2018
16. Schechter N. Patient engagement training. April 2017.
17. World Health Organization. Towards a Common Language for Functioning, Disability, and Health: ICF (PDF), Geneva: WHO. 2002. www.who.int/classifications/icf/

icfbeginnersguide.pdf. Accessed, September. 19, 2018.
18. Bandura A. Self-efficacy: the exercise of control. New York: W.H. Freeman; 1997.
19. Erickson, H, Tomlin E, Swain, M. Modeling and Role-Modeling: A theory and paradigm for nursing. Cedar Park TX; EST Company Prentice Hall: 2005.
Other Resources:
20. Bradley EH, Curry L, Horwitz LI, et al. Contemporary evidence about hospital strategies for reducing 30-day readmissions: a national study. JACC.

2012;60(7):607-614.
21. Burt L, Corbridge S. COPD Exacerbations. Evidence-based guidelines for identification, assessment, and management...second in a two-part series. Am J Nurs.

2013;113(2):34-45.
22. Deyo P, Swartwout E, Drenkard K. Nurse manager competencies supporting patient engagement. J Nurs Adm. 2016;46(3S):S19-S26.
23. Hall M. Chronic obstructive pulmonary disease and asthma. HHc Nurse. 2012;30(10),607.
24. HH Quality Improvement website. hhqi.wordpress.com/tag/home-health-quality-improvement/. Accessed October 24, 2018.
25. Krames Patient Education Material. Living well with COPD. 2017.
26. Patient engagement vs. patient experience. NEJM Catalyst website. catalyst.nejm.org/patient-engagement-vs-patient-experience/. Published October 16, 2018.

Accessed October 23, 2018.
27. Sobell, LC, & Sobell, MB Group therapy with substance use disorders: A motivational cognitive behavioral approach. New York, NY: Guilford Press; 2011
28. Blueprint for diagnosis, management and prevention of chronic obstructive pulmonary disease. Elevating Home website. vnaablueprint.org/copd/copd-critical-

interventions.html. Accessed October, 23, 2018.
29. Zhang C, Weihong W, Jiping L, et al. Development and validation of a COPD self-management scale. Respir Care.2013;58(11), 1931-1936.

The Quarterly Report | Fall 2019 Page 15

Reach

a higher peak

Registration and Housing are Open!

EARLY BIRD RATES / BEST SAVINGS END
Wednesday, November 13

ADVANCE RATES END
Wednesday, December 18

FULL CONFERENCE RATES
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APTA.org/CSM

APTA Home Health Section

PT Voice: Stepping Up To The Mic

By Megan Valenzano, PT, DPT, GCS

In 2018 I proposed a session for the American Physical Involvement with the APTA and the Home Health Section
Therapy Association’s (APTA’s) Combined Sections Meeting will introduce you to other people who are finding or have
(CSM) in 2019. The premise was simple: four industry leaders, found their voice. Many are willing to extend a hand and help
each with different backgrounds would provide their insights someone else do the same.
on simple advocacy strategies. After the panel discussion, the
session became interactive e1 and attendees were encouraged Why You Shouldn’t Be Afraid
to present a professional project or advocacy topic they Advocacy starts with building a relationship.3 While most
felt strongly about to the panelists and be paired with a of us think of letter writing campaigns, social media bursts
professional mentor, a la NBC’s “The Voice.” When combined or the more “short-term” strategies to change policy, for
with 4 spinning chairs and a great group of people at CSM, advocacy to really be effective it starts with talking to a
what resulted was a forum where people who had previously person even when you don’t need something from them.
been quiet were handed a microphone. Advocacy on any level This may mean building a relationship with a congressman,
is really that simple, not being afraid to step up to the mic. an editor, a clinical director, or an administrator. The
comparison can be made to a situation we’re all familiar with
How Do I Find A Microphone? from high school. When the big test comes, who are we more
Everyone’s comfort level with advocacy is different, and likely to share our notes with: the person who has been half
there are ways to speak up for every physical therapist (PT). asleep three rows away, or our best friend who helped us ask
For many, it will be championing care, equipment needs, or “that person” to prom? For most of us, it’s the best friend.
ongoing services for patients within their Agency. This is
vital work we do every day. Advocacy is the same. For advocacy strategies to be
most effective, the person has to want to hear your message.
For those who want more, there are comment Building this relationship follows the same steps as making
opportunities made available to us by the Centers for a new friend. Find things you can agree on. Find ways you
Medicare and Medicaid Services (CMS). Each year, CMS has can help the person. Whether it’s a legislator who has a
to tell us what they want to do the next year for payment, question about healthcare or a news editor who needs an
this is the proposed rule. Each year we have the opportunity article on pain, there are ways we can all help other people
to comment on it. The nice thing is that Medicare wants to and simultaneously demonstrate the value of our thoughts
hear from us. They want to hear how their proposed changes prior to the actual, “Ask.” The key is to find something that
will impact your care for the beneficiaries they are trying you have in common and build from there. The upside of this
to protect. APTA and Home Health Section leadership work approach is it quickly turns that person who may have been
hard to ensure their comments help protect the practice of intimidating to talk to into a friend or colleague.
PTs in the Home. That being said, when practicing PTs join
the comment process, the message gets louder. This doesn’t What Is An “Ask” And How Do I Craft A Message
guarantee change, but it does make it more possible. This is the critical second part of advocacy. Once a
relationship has been built (or even if one hasn’t been
There are always other regulatory avenues. Meeting cemented yet), anyone advocating can’t forget about the
with members of Congress, speaking with local legislators, change they are seeking. This is the “Ask.” That thing that
or meeting directly with their staff are also good avenues to you want to see changed that you need that other persons
speak about the profession. Talking to a local radio station, help with. Whether it’s a new clinical program at your
writing a letter to a newspaper, blogging, and contributing to Agency, a piece of equipment your patient can’t access, or
a magazine are all ways to get broader messages about PT out new content on a website, you are asking someone to see the
to the public. Utilizing the media can amplify your voice, as value of what you are asking for.
it provides the ability to reach outside of the profession and
engage patients and their family members. That can sound like an ominous process, but it can be
broken down into 3 simple steps:
If you’re really not sure where to start, find a mentor.2

The Quarterly Report | Fall 2019 Page 17

1. Understand the issue at hand rehospitalizations. New ways they can keep people at home.
2. Determine the impact of your “Ask” We have a role to play in this change, if we are willing to talk
3. Find a way to make it personal about and demonstrate our value.

This simple formula is the key to being an effective How Do I Get Started?
advocate. We are all asked to see the value of so many things The opportunities to speak on behalf of your profession
during the course of one day. If there isn’t any evidence to and your patients will abound. While some comment
support why we should take an interest in something, it is opportunities have passed, others will come up. A letter to
easily brushed off as “unimportant.” Similar to any new the editor may turn into a monthly column on “Aging at
intervention in PT, if someone doesn’t know or understand home.” A guest lecture on treating in the home could turn
the data or evidence behind it, they are less likely to use it. into a full course. A clinical idea with a mentor could turn
Once someone says, “Hey, this issue, which impacts 40% into a change in practice across a multi-state agency. To have
of your patients, can be improved 50% with X. Let me tell a voice, you only have to step up to the microphone.
you how it will work with your patient Sally,” it becomes
something you want to hear about. Megan Valenzano, PT, DPT, GCS, received her doctorate
in physical therapy (DPT) from Drexel University in 2007. She
This needs to be done carefully. Perhaps there is an became a Board Certified Specialist in Geriatrics in 2011 and a
expectation that you don’t understand where you practice. Certified Exercise Expert for the Aging Adult in 2012. She took
You may have to start your advocacy by reading through a over as Director of Regulatory Affairs for FOX Rehabilitation in
few policies to actually determine the real cause.4 Through the fall of 2013, and subsequently added the role of Director of
that investigation you might find there are unintended Documentation Review in January of 2018. She has presented on
consequences of your “Ask” that would make your idea a applying the clinical components of maintenance care at both
less viable option. That’s okay! Whether you revise your the district and state level for APTANJ, has served as Co-Chair
“Ask” or accept that the current situation is the best option of the NJ Geriatric Special Interest Group and a delegate for NJ
you’ve done something. Through that investigation, you’ve from 2016-2017. In 2017, Dr. Valenzano presented on, “More
likely asked questions and built relationships you didn’t have than Exercise: Psychosocial Implications for the Older Adult”
before. The next time you ask a question, you are more likely at APTA’s NEXT Conference in Boston. During 2017 served as
to be seen as someone who is trying to find solutions. That is adjunct faculty in Drexel University’s DPT program, presenting
someone people want to listen to. their Lifespan course focused on care of the older adult, and
continues to guest lecture on Medicare. She has also presented
Why Are We Talking About Value? posters at national conferences for both the APTA and the
Having a voice is about demonstrating the value of your American Medical Director’s Association (AMDA). Her poster
message. Often, this means demonstrating the value of PT. titled, “Impact of the Interdisciplinary Team and Individualized
In considering the overall changes coming to healthcare, Therapy Sessions in Managing Behaviors: A Case Study,” was
we as a profession have gotten used to our value being awarded “Best Poster in a Case Report/Case Series” at AMDA’s
determined largely by the dollars we bill in CPT codes, the LTC Medicine Conference in March of 2012. In March of 2015
visits we perform, or the minutes of therapy we provide. Dr. Valenzano was named as one of the “Best in Healthcare
When you actually look at equations that calculate value,5 it Advocacy” by South Jersey Biz for her work on a social media
is important to note where the dollars actually sit: campaign to raise awareness of the Medicare Outpatient
Therapy Cap that year.
Outcomes Patient Experience
References
VALUE 1. Peluso M, Seavey B, Gonsalves G, Friedland G. An inter-professional

Cost ‘advocacy and activism in global health’ module for the training of physician-
advocates. Glob Health Promot. 2013;20(2):70-73.
This is basic algebra that requires a numerator and a 2. O’Connell E., Stoneham M., Saunders J. Planning for the next generation
denominator. That being said, it is striking that cost is at of public health advocates: evaluation of an online advocacy mentoring
the bottom, underneath clinical indicators like outcomes program. Health Promot J Austr. 2016;4:43-37.
and patient experience. Our ability as PTs to impact both of 3. Fitch B. The Complete Citizen-Advocate’s Toolkit. Oral presentation at: APTA
these areas are ways we can craft a message that is relatable. Federal Advocacy Forum; March 2016: Washington, DC.
A message that speaks to the impact a change will have not 4. Sheldon M. Policy-making theory as an analytical framework in policy
just on our patient, but a number of patients. Not just on our analysis: implications for research design and professional advocacy. Phys
agency, but a number of agencies. Ther. 2016;96:101-110.
5. Solving the Healthcare Value Equation. HIMSS Innovation Center website.
The key here is that we have to be ready to define our www.healthcareitnews.com/sponsored-content/solving-healthcare-value-
own value.6 With the waves of change coming to healthcare, equation-0. Updated June 2016. Accessed September 2, 2019.
we are in an exciting time. It is easiest to effect change when 6. Stover A. Client-centered advocacy: every occupational therapy
change is already happening. With the implementation practitioner’s responsibility to understand medical necessity. Am J Occup
of PDGM, Agencies are going to continue to look for new Ther. 2016;70(5):1-6.
ways they can improve their outcomes. New ways they can
improve patient satisfaction. New ways they can prevent

Page 18 APTA Home Health Section

INTERVIEW An Interview with the Section Treasurer:
Philip Goldsmith, PT, DScPT, COS-C

Interviewed by Zach Hampshire, PTA

Question: What motivated you to enter the profession of Physical Therapy?

Answer: Initially, I entered the profession as many therapists may do, thinking that they will
be working with athletes mostly. My area of interest changed as I began graduate school and learned about the
vastly different populations of patients that I could work with.

Question: What brought you to Home Health?

Answer: After finishing school, I worked in outpatient orthopedics for five months. I found that this wasn’t the
setting that I really wanted to work in and saw that a local home health company was hiring. The rest is history.

Question: What is your current job/role/work in Home Health?

Answer: Believe it or not, for the past four years, I’ve not been in home health but have worked at a skilled
nursing facility. I needed a break and was getting burned out at the agency I was at, and this allowed me to
change gears. In about a month, though, this is about to change. I recently accepted a role as a staff PT for a
home health company in central Pennsylvania.

Question: What are your roles and responsibilities within the section, what is your favorite
part of your role within the section?

Answer: I’m the treasurer for the section. My responsibility lies in the financial stewardship and planning.
To assist me, I have a wonderful finance committee. My favorite part of my job is networking with varying
professionals. Through my participation with committees and attending meetings/conferences, I have been to
meet many new people, which I enjoy.

Question: What does the section most need from the membership?

Answer: The Uncle Sam poster comes to mind, “We need you!” Be an active member and participate. The
section is what you make of it, and the more active our participants, the louder our voice. With increased member
participation, we can bring greater value and diversity to the organization. No matter where you are in your
career, we have a place for you in the section.

Question: What changes have you encountered in your profession and how has that
impacted you as a Home care therapist?

Answer: Oh, my goodness, where to start. When I first started, everything was done on paper and then
transitioned to the electronic health record (EHR). The EHR has streamlined documentation and improved it for
the better. Then second, we are a vastly greater clinically informed through evidence than when I first started. In
school and shortly after graduation, the research that we had was very limited and not very clinically relevant.
Now the amount of research that has been done is such an improvement, and that allows for greater clinical
treatment for our patients.

Question: What would you say to a new therapist who may be contemplating joining a
committee or entering the home health environment? 

Answer: To a new therapist considering joining a committee, I say absolutely, do not hesitate, jump in with
both feet. The networking, the opportunity to serve your profession and be a part of shaping your profession is
invaluable. There is so much you can gain by being an active part of the organization and so little to be lost.
Then as for any therapist thinking about entering home health, don’t be afraid and be confident about the skills
that you have developed knowing that you will utilize every one of them. Be sure to view the patients as a whole
and don’t have tunnel vision. The patient’s entire background/situation feeds back into your treatment plan.

The Quarterly Report | Fall 2019 Page 19

OASIS D Guide to Accuracy:
M to GG, Do They Crosswalk?

By Bryce Williams, PT, COS-C

Introduction full compliance with the IMPACT Act.3 These sections are
Since 1999, the OASIS has been an integral part of data a portion of the Minimum Data Set (MDS), which is the
collection and quality measurement for in-home health data collection tool used in Skilled Nursing Facilities. As
care. During the course of the two decades since its mentioned previously, the J section collects data related
implementation, there have been several iterations of the to the number and severity of falls while the GG section
OASIS (OASIS D being the most recent, as of 01/01/2019). collects data related to the patient’s ability to perform ADLs
Throughout the many revisions, however, the goals have and functional mobility. The GG section also includes the
remained the same: to enhance the quality of home health collection of data related to the patient’s prior assistive
care, as well as to improve how that quality is measured.1,2 device use as well as prior level (i.e. before current illness,
injury, or exacerbation) of function in 4 areas: ADLs, indoor
OASIS-D Revision ambulation, negotiation of stairs, and cognition. This prior
As of January 1st of 2019, the most recent revision, OASIS level of function item essentially replaces M1900 (Prior
D was implemented across all home health agencies. Functioning ADL/IADL) from OASIS C-2.1 The remainder of
The implementation of OASIS D came with the addition, the added GG items, however, mirror the corresponding M
modification, and removal of several OASIS items from the items that remain in OASIS D.
previous version, OASIS C-2. Perhaps the most significant
addition to OASIS-D, however, was the full addition But do section M and GG crosswalk?
of Section J and Section GG. Section J, called Health The M ADLs/IADLs and GG sections collect data related to
Conditions, collects data related to the number and severity the following ADL and mobility tasks:
of falls sustained by the patient during the quality episode.
Section GG, called Functional Abilities and Goals, collects • Grooming
data related to the patient’s ability to perform ADLs and • Upper Body Dressing
mobility tasks. • Lower Body Dressing
• Bathing
Why OASIS D Revision? • Toileting Hygiene
This latest OASIS revision is a part of the ongoing • Toilet Transfers
implementation of the Improving Medicare Post-Acute • Bed/Chair Transfers
Care Transformation Act of 2014 (IMPACT Act), whose goal • Ambulation/Locomotion
is to standardize assessment information across all Post- • Feeding/Eating
Acute Care (PAC) settings. These settings include Inpatient
Rehabilitation Facilities, Skilled Nursing Facilities, Home Each of these sections, however, collect the data for each
Health Agencies, and Long-Term Care Hospitals. These of these tasks by somewhat different means. Understanding
standardized patient assessment data elements (also known these differences is key to accurate scoring of the items.
as SPADEs) are designed to promote improved coordination
of care, communication, and discharge planning as the Conventions for Section M-ADLs/IADLs
patient transitions through the continuum of care after For the M-ADLs/IADLs section, the purpose of these items
hospitalization.3 is to denote the patient’s ability to safely complete a task,
not the patient’s adherence or willingness to complete the
Sections J & GG task.4 It is the clinician’s responsibility to utilize a holistic
The addition of Sections J & GG to OASIS is a step toward perspective when scoring these items. This is inclusive

Page 20 APTA Home Health Section

Figure 1: GG Coding System1,4 clinician range from 01 to
06. Unlike the M-ADLs/
of, but not limited to physical impairments, emotional/ IADLs section; however,
cognitive/behavioral impairments, sensory impairments, and the coding convention
environmental barriers.4 There is no standardized scoring is such that the lower
for the M1800s. You will find that the items are scored number codes represent
from as low as 0 to as high as a score of 6, depending on the an increasing need for
item. Though the scoring numbers are not standardized, assistance, and higher
the general scoring convention for these items is consistent number scores represent
throughout each of the M items: greater independence (see
Figure 1).
• Lower number scores represent increasing independence
• Higher number scores represent an increasing need At SOC and ROC,
each item has a code for
for assistance current performance
as well as a code for
Additionally, several items in the M ADLs/IADLs section discharge goal. Discharge
must account for both the patient’s ability to safely complete goals can be established
the task and to safely access the location where the task based on clinical
occurs. This is of paramount importance for scoring accuracy, judgment, the patient’s
as the responses related to mobility can have a significant prior level of function,
impact on responses to some of the items related to the discussions with the
performance of ADLs. patient and the patient’s
family, prognosis for the
Conventions for Section GG-Functional Abilities & Goals patient’s condition(s),
In contrast to Section M ADLs/IADLs, the GG section etc.1,4 Each item should
features standardization with scoring and presents scoring be scored based on the
options for the instances when the task was not attempted. patient’s usual ability
The scoring numbers for tasks that were assessed by the during the comprehensive
assessment timeframe (i.e.
days 0-5). Usual ability
refers to the patient’s
level of ability 50% of the
time within a given timeframe.4 While there are codes for
reasons why a task was not attempted, the clinician should
consider that assessment of the task can be completed via
patient report, as well as information from other clinicians,
care staff, and/or family members if assessment via direct
observation cannot be completed.
The patient’s ability to access the location where the task
occurs is not taken into consideration when coding GG items.
It should also be noted that the patient’s need for the use
of an assistive device to complete the task is not considered
when scoring in the GG section.
Now that some of the conventions for the M ADLs/IADLs
and GG Functional Abilities and Goals sections have been
reviewed, we will now examine how they are applied to the
ADL and mobility tasks for which they collect data.

Grooming
M1800 is the item for grooming. This item is inclusive of
the patient’s ability to wash his/her hands and face, comb/
brush hair, shave, put on and take off makeup, teeth/
denture care, and caring for fingernails. This item excludes
bathing, washing hair, and tasks related to toileting
hygiene. GG0130B, Oral Hygiene, is the comparable GG
item for grooming. It differs from M1800 because it is only
1 component that is covered within M1800. For M1800, the
patient’s ability to safely access the location of the task(s)
must be considered. No such consideration must be made

The Quarterly Report | Fall 2019 Page 21

when scoring GG0130B. Given that and FIGURE 2: Scoring for M1800, M1810, & M18201
the fact that GG0130B is but a single
component of M1800, scoring a patient Figure 3: Scoring for M1830 & M18401
as needing assistance on M1800 does excludes consideration for accessing the location of the
not necessitate GG0130B being coded as task, excludes transferring in and out of the tub/shower, and
requiring assistance. excludes washing the back.
Toilet Transfers
Dressing-Upper Body M1840 is the item that assesses the ability to get to and from
M1810 is the item for assessing the patient’s the toilet or bedside commode safely and transfer on and
current ability to dress the upper body. off of the toilet/commode. GG0170F is the comparable GG
This includes managing undergarments, item which assesses the ability to get on and off of a toilet or
pullovers, front-opening shirts and blouses, commode. While they similarly assess transfers to and from a
managing zippers, buttons, and snaps. toilet or commode, the GG item excludes assessing the ability
GG0130F is the comparable GG item for to get to and from the toilet or commode. The M scoring
upper body dressing. It codes the ability scales for bathing and toilet transfers are noted in Figure 3.
to dress and undress above the waist; Toileting Hygiene
including fasteners (if applicable).1,4 M1845 is the M item that represents the patient’s ability

M1810 and GG0130F are similar items
concerning what is assessed. The only
difference between the two is that the
patient’s ability to access the location
of the task of upper body dressing must
be considered for M1810 but is not a
consideration for GG0130F.

Dressing-Lower Body
M1820 is the item for assessing the patient’s
current ability to dress the lower body.
This includes undergarments, slacks, socks
or nylons, and shoes (with or without a
dressing aid).1,4 The scoring for M1820
is identical to that of M1810-Upper body
dressing. Unlike upper body dressing,
however, there are two comparable GG
items (GG0130G & GG0130H) for lower
body dressing. GG0130G assesses the
patient’s ability to dress and undress below
the waist, including fasteners. GG0130H
assesses the ability to put on and take
off socks and shoes or other footwear
that is appropriate for safe mobility.1,4
The patient’s ability to safely access the
location of the task must be considered when scoring M1820,
while GG0130G and GG0130H require no such consideration.
However, since M1820 is inclusive of managing footwear,
a patient could potentially be scored as independent with
GG0130G while M1820 is scored as requiring assistance due
to the patient requiring assistance with footwear. Like all
other items, each one should be scored individually based on
the clinician’s clinical assessment.

Bathing
M1830 is the item that assesses the patient’s current ability
to wash his/her entire body safely (excluding washing face,
hands, and shampooing hair).1,4 It also includes the
patient’s ability to safely transfer in and out of the shower
or tub. GG0130E is comparable to GG item for bathing.
Like M1830, it includes ability to bathe self while excluding
shampooing hair.1,4 Unlike M1830, however, GG0130E

Page 22 APTA Home Health Section

Figure 4: Scoring for M1845 & M18501 is also complicated by the amount of
assistance required by the patient as well as
the potential need for an assistive device.
For example, if the patient requires an
assistive device in order to safely complete
the entirety of the transition from supine
to transfer to the nearest chair or sitting
surface, a minimum of response “1” is
appropriate. However, if the patient also
requires assistance from another person
(e.g. hand-on assistance or verbal cues/
supervision), response “1” is no longer
appropriate. Conversely, the corresponding
GG items for transferring are broken into
five individual components:

• GG0170A-ability to roll from the
supine position to left and right side
lying, then returning to supine.

• GG0170B-ability to transition from
sitting at the edge of the bed to the
supine position.

• GG0170C-ability to transition from
supine to sitting on the side of the
bed with feet flat on the floor, and
with no back support.

• GG0170D-ability to transition from
sitting (e.g., in a chair, wheelchair, or
edge of the bed) to standing.

• GG0170E-ability to transition to and
from a bed to a chair or wheelchair.

Figure 5: Scoring for M1860 & M18701 These 5 GG items are all individual
components that make up the totality of
to safely maintain perineal hygiene, adjust clothing and/ the components that are included in M1850.
or incontinence pads before and after using the toilet, The major difference between M1850 and
commode, bedpan, or urinal. If the patient has an ostomy, the five individual GG items is that the
M1845 is inclusive of cleaning around the stoma, but not patient’s use of an assistive device is not considered when
managing equipment.1,4 Similarly, GG0130C represents the scoring the GG items.
patient’s ability to adjust clothing before and after voiding
and/or a bowel movement, as well as maintaining perineal Ambulation/Locomotion
hygiene. Like M1845, GG0130C also excludes management of M1860 is the item that represents the patient’s ability to
ostomy equipment. M1845 and GG0130C have no exceptions walk safely, once in a standing position, or use a wheelchair,
between them; thus, they will likely be scored similarly in the once in a seated position, on a variety of levels (See Figure
comprehensive assessment. 5 for M1860 scoring). Like M1850, M1860 considers multiple
factors that can complicate how a clinician scores this item.
Bed/Chair Transfers Considerations include the patient’s ability to safely ambulate
M1850 is the M item that represents the patient’s ability without a device, with a one-handed device, with a two-
to safely move from bed to chair, or the ability to turn and handed device, on even surfaces, and uneven surfaces and
position him/herself in bed if the patient is bedfast. M1850 stairs. It also includes considerations for the patient’s ability
tends to be one of the challenging M items to answer, due to safely mobilize in a wheelchair if the patient is unable to
to the verbiage in the item. It not only includes the patient’s safely ambulate with assistance. Similar to the comparable
ability to transfer between the bed and the nearest chair, GG items for transfers, the GG items for ambulation are
but also the patient’s ability to transition from the supine broken in nine separate components that are encompassed
position to sitting position at the side of the bed. M1850 in M1860:

• GG0170I-ability to walk at least 10' in a room, corridor,
or similar space

• GG0170J-ability to walk 50' and make 2 turns.

The Quarterly Report | Fall 2019 Page 23

• GG0170K-ability to walk at least 150’ in a corridor are expected to be minor. In fact, the majority of time points
or similar would not see any additional items. Most of the changes with
OASIS-D1 will be several items transitioning from being
• GG0170L-ability to walk 10’ on uneven surfaces required to being optional (1 item at SOC/ROC, 3 items at
• GG0170M-ability to go up and down a curb and/or 1 step. Transfer/Discharge, and 19 items at Recertification/Follow-
• GG0170N-ability to go up and/or down 4 steps with or Up). In the context of this discussion about M and GG items,
the only notable addition is that of M1800 (Grooming) to the
without a rail Recertification/Follow-Up time point. This item will factor
• GG0170O-ability to go up and down 12 steps with or in determination of case-mix during the implementation of
Patient Driven Groupings Model (PDGM) in 2020.
without a rail
• GG0170R-ability to wheel at least 50 and make 2 turns With the addition of the full complement of GG items
• GG0170S-ability to wheel at least 150’ in a corridor or to OASIS-D, it has added a significant amount of additional
sources of data collection to the OASIS. Although the M-ADL/
similar space IADL items (M1800s) and the GG-Functional Abilities and
Goals items address data collection for the same functional
While the GG above items and M1860 are similar with tasks, there are notable differences between the two. The
regard to the fact that they address safety with ambulation purpose of this article was to present the similarities and
on even surfaces, uneven surfaces, and stairs, and wheelchair differences between the items from each section, with the
mobility (if applicable), it is clear that there are distinct intent of maximizing the accuracy of data collection. As of
differences between them. When scoring M1860, there is no this writing, the GG items are not a factor with regard to
gait and wheelchair distance requirement, and there is no payment and/or quality reporting for home health. However,
stair quantity requirement. In contrast, the GG items do not that may change soon. Given the gradual push toward full
consider assistive device use or type. Like all of the other M compliance with the IMPACT Act over the next several years,
and GG items, each item should be answered individually, it is of paramount importance to optimize accuracy when
and the responses should be consistent with the rest of the answering these items. It may soon be the difference between
clinical documentation about the specific patient. a home health agency’s ability to continue to serve their
community and closing its doors for good.
Feeding/Eating
M1870 addresses the patient’s ability to safely feed him/ About the Author
herself meals and snacks. The ability to prepare meals Bryce Williams, PT, CGS, COS-C, CEEAA, is a
is not considered in this item (See Figure 5 for Scoring). graduate of Florida A&M University with a BS in
Similarly, GG0130A addresses the patient’s ability to bring Physical Therapy who has practiced the last 10
use appropriate utensils to bring food and/or liquid to the years in the home health setting. He is currently
mouth and swallow food and/or liquid once the meal is placed pursuing his DPT at the University of Montana
in front of them. Like M1845 and GG0130C, the abilities and works as a Quality Review Specialist for
addressed by these two items do not have exceptions. Providence Saint Joseph’s Health supporting
Western Washington and Northern California.
The Future of OASIS
As of 01/01/2020 OASIS-D1, the first revision of OASIS-D
will take effect. Changes that are associated with OASIS-D1

References
1. Quality initiatives patient assessment instruments. Centers for Medicare & Medicaid Services website. www.cms.gov/Medicare/Quality-Initiatives-Patient-

Assessment-Instruments/HomeHealthQualityInits/Downloads/draft-OASIS-D-Guidance-Manual-7-2-2018.pdf. Accessed 19 Sep. 2019.
2. O’Connor M, Davitt, J. The outcome and assessment information set (OASIS): a review of validity and reliability. Home Health Care Serv Q. 2012;31(4):267-301.
3. IMPACT Act standardized patient assessment data elements. Centers for Medicare & Medicaid Services website. www.cms.gov/Medicare/Quality-Initiatives-

Patient-Assessment-Instruments/Post-Acute-Care-Quality-Initiatives/IMPACT-Act-of-2014/-IMPACT-Act-Standardized-Patient-Assessment-Data-Elements.html.
Accessed 19 Sep. 2019.
4. Krulish L. Instant OASIS Answers 2019 A CMS-based Ready Reference for Data Collectors. Redmond, WA, OASIS Answers, Inc. 2018

Page 24 APTA Home Health Section

Government Affairs Happenings:
Section Responses to CMS

By Carol Zehnacker PT, DPT, CEEAA

The CY 2020 Home Health Proposed Rule was released place. Given the risks associated with the proposed
on July 11, 2019, and the Patient Driven Groupings Model behavioral assumption payment cuts, we urge CMS to
(PDGM) will take effect as of January 1, 2020. Under the reconsider its proposal and ensure that any assumption
proposed PDGM, as mandated by the Bipartisan Budget Act of is based in actual data and observed evidence. Thus, we
2018, the unit of payment would switch from 60-day episodes recommend that CMS revisit the behavioral assumptions
of care to 30-day periods and remove therapy visit thresholds to ensure that they do not threaten patients’ access to
as a determinant of payment. The PDGM would base the home health services.
432 case-mix adjustments solely on patient characteristics, • Rural Add-on Payments for 2020 through 2022: The
including diagnosis, functional level, comorbidities, and Home Health Section supports continuing the rural
admission source, to place patients into clinically meaningful add-on through 2022, as it will ensure that HHAs are
payment categories. adequately equipped to serve Medicare beneficiaries
in rural areas. HHAs in these regions already face
Section Comments to the Proposed Rule geographical and financial obstacles to providing
The section submitted comments to CMS during the sufficient care to this Medicare population. However, we
comment period. Highlights of those comments follow. The have concerns that discontinuing the add-on payment
final rule for CY 2020 HH PPS should be released on or about beyond 2022 will likely prevent these agencies from
November 1, 2019, and the GAC appreciates all of you who furnishing care to patients with the most critical clinical
had taken the time to submits comments to CMS. conditions. Therefore, Home Health Section urges CMS
to continue its work to develop policies that support
• CY 2020 Home Health PPS Rate Update: Home Health improved access to home care in rural areas.
Section supports CMS’ proposal to rebase the home • Split Percentage Payment Approach: Home Health
health market basket and update the payment rates Section opposes CMS’ proposal to reduce the
under the HH PPS by 1.3%, resulting in an estimated RAP split percentage payment to 20% for existing
$250 million increase in payments to HHAs in CY 2020. HHAs beginning in CY 2020 with elimination of
split percentage payments for all HHAs in 2021.
• Patient-Driven Groupings Model—Case Mix: The Home We recommend that CMS phase out the RAP split
Health Section appreciates CMS’ efforts to address percentage payment approach over a period of three
case-mix methodology refinements that represent a to four years. Alternatively, or in conjunction with
more patient-driven approach to payment. However, this longer transition period, CMS could consider
due to continued concerns that Medicare beneficiaries— phasing out the split-percentage payment approach
particularly those with substantial physical therapy, with bi-annual or quarterly reductions, allowing for a
occupational therapy, and/or speech-language pathology smooth transition until the split percentage payment
needs—may not receive the level, duration, amount, approach is completely phased out. Smaller agencies
or frequency of therapy services medically necessary, and those in rural areas have a significant need for cash
given the potential economic incentives inherent in flow support; therefore, instituting a longer transition
this revised case-mix methodology to provide less care period will help agencies continue to remain financially
for these beneficiaries, we encourage CMS to closely viable, particularly with implementation of the 30-day
monitor utilization of therapy services upon patient- unit of payment under the PDGM. With each transitional
driven groupings model (PDGM) implementation year, we urge CMS to monitor utilization patterns and
trends of home health admissions, discharges, and
• Patient-Driven Groupings Model (PDGM)—Behavioral the delivery of therapy services, particularly in rural
Assumptions: The Home Health Section has serious and underserved areas, and examine whether any
concerns with the proposed application of the behavioral policy changes may be necessary to ensure continued
assumptions as described in the proposed rule. The beneficiary access.
8.01% decrease in payments for HHAs is significant • Notice of Admission: To ensure that the claims processing
and would impose serious financial burdens on HHAs. system is alerted in a more timely manner that a
Beneficiaries with complex rehabilitative care needs beneficiary is under an HHA period to care to enforce the
and patients who reside in rural areas are more likely consolidated billing edits required by law, rather than
to be adversely impacted if HHAs are forced to close require HHAs to submit a Notice of Admission (NOA),
their doors or reduce their services due to the economic which is likely to be overly burdensome, we request that
impact of the behavioral assumptions. Moreover, CMS consider adopting a simple mechanism by which
patients who are unable to access home health HHAs can make a notation in the Common Working
services would be diverted to more costly post-acute
care settings, contrary to CMS’ goal to ensure care is
delivered to the patient at the right time in the right

The Quarterly Report | Fall 2019 Page 25

File (CWF) or Electronic Data Interchange (EDI) system related items from hospital patient surveys. Home Health
to indicate the beneficiary has been admitted under Section opposes CMS’ proposal to remove Question
a home health plan of care. Further, we disagree with 10 from all HHCAHPS Surveys (both mail surveys and
CMS’ proposal to impose a financial penalty on HHAs for telephone surveys) which says, “In the last 2 months of
failing to submit a timely NOA and instead recommend care, did you and a home health provider from this agency
that CMS consider making the “admission notification” talk about pain?” which is one of seven questions (they
a survey requirement in the future. If CMS does move are questions 3, 4, 5, 10, 12, 13 and 14) in the “Special
forward with the NOA process, we recommend that CMS Care Issues” composite measure, beginning July 1, 2020.
not require the completion of the OASIS or a signed plan HHCAHPS reflects patient experience, and pain remains
of care before accepting the NOA. an issue that is important to patients served in the
• Notice of Discharge: We respectfully request that CMS home health setting. Regardless of the use of opioids,
consider adopting a simple mechanism for HHAs to use it is important for a provider to have a discussion with
to timely notify the claims processing system that the the beneficiary regarding whether he or she has pain,
beneficiary has been discharged. For example, requiring to ensure that the beneficiary receives appropriate care.
HHAs to make a notation in the CWF or EDI system to Moreover, as previously stated, there is a need for greater
indicate the patient has been discharged or submit a provider education on nonpharmacological interventions
no-pay RAP. Such notification could be required to be that are available to patients with pain. For these reasons,
submitted within 5 days following beneficiary discharge we recommend that HHCAHPS Surveys continue to
to establish that the beneficiary is no longer under a include this question.
Medicare home health period of care. • Proposed Standardized Patient Assessment Data
• Proposed Regulatory Change to Allow Therapist Reporting Beginning with the CY 2022 HH QRP:
Assistants to Perform Maintenance Therapy: CMS CMS is continuing its efforts to increase the range of
plans to allow PTAs and OTAs to perform maintenance standardized patient assessment data (SPADE) reported
therapy services under a maintenance program by HHAs. The use of SPADE in home health was
established by a qualified therapist, as long as the instituted to bring HHAs up to speed with provisions
services fall within scopes of practice in state licensure of the 2014 IMPACT Act, a law that mandated more
laws. In addition to supervising the services provided by uniformity in reporting across post-acute care settings.
the therapist assistant, the qualified therapist still would The proposed rule would follow through with the
be responsible for the initial assessment; plan of care; requirements for reporting on cognitive function and
maintenance program development and modifications; mental status, comorbidities, and social determinants
and reassessment every 30 days. Home Health Section of health, among other categories. HHAs would be
supports CMS’ proposal to allow therapist assistants required to report these additional elements beginning
(rather than only therapists) to perform maintenance in 2022 for admissions and discharges that occur
therapy under the Medicare home health benefit. We between January 1, and June 30, 2021. The Home Health
agree this regulatory change would allow HHAs more Section supports CMS’ proposal to adopt the following
latitude in resource utilization. Furthermore, allowing seven data elements as SPADEs under the proposed
assistants to perform maintenance therapy would be Social Determinants of Health category: race, ethnicity,
consistent with other post-acute care settings, including preferred language, interpreter services, health literacy,
skilled nursing facilities. transportation, and social isolation. The HH Section
• Home Health Consumer Assessment of Healthcare also supports the expansions of patient assessment data
Providers and Systems (HHCAHPS) Survey: Partially elements within the categories of cognitive function
in response to concerns about the potential for over and mental status; special services, treatments, and
prescription of opioids, CMS is proposing to remove the interventions; medical condition and comorbidity data;
Improvement in Pain Interfering with Activity Measure and impairments.
(NQF #0177) from the Home Health Quality Reporting
Program (HH QRP) beginning in 2022. Under this Legislative Update
proposal, HHAs would no longer be required to submit Home Health Payment Innovation Act of 2019(H.R.2573/S.
OASIS Item M1242, “Frequency of Pain Interfering with 433): Requires Medicare to implement adjustments to home
Patient’s Activity or Movement” for quality reporting health reimbursement rates only after behavioral changes by
purposes beginning in 2021. Also, CMS proposes to home health agencies that affect Medicare spending actually
remove a patient survey question that asks whether occur. 76 House co-sponsors and 26 Senate co-sponsors.
the patient and provider talked about pain in the past
2 months. The question, currently in the “Special Care • Medicare Home Health Flexibility Act of 2019(H.R.3127/S.
Issues” composite measure, would be dropped beginning 1725): This bill establishes circumstances under which
July 1, 2020. Similar to the pain measure being proposed an occupational therapist may conduct an initial or
for deletion, the survey question is being eliminated comprehensive assessment for an individual who is eligible
due to concerns about the ways it might influence for home health services under Medicare. Specifically, an
unnecessary drug prescriptions. The changes are occupational therapist may conduct the assessment if the
consistent with an earlier CMS decision to eliminate pain- physician’s referral order does not include skilled nursing
care but does include (1) occupational therapy, and (2)

Page 26 APTA Home Health Section

physical therapy or speech language pathology. 6 House Help Wanted—Helping Us to Help You
co-sponsors, 2 Senate co-sponsors. The Home Health Section Government Affairs Committee
• Home Health Care Planning Improvement Act of 2019 continues to seek section members to volunteer as
(H.R.2150/S.296) This bill allows Medicare payment for government affairs liaisons. Liaisons will serve as a contact
home health services ordered by a nurse practitioner, a point to state chapters and area members with questions
clinical nurse specialist, a certified nurse-midwife, or regarding home health regulations and legislative initiatives.
a physician assistant. Currently, coverage is provided Submit a volunteer form through the Home Health Section
only for services ordered by a physician. 109 House website to express your interest in this role. Check the box
co-sponsors and 35 senate co-sponsors. for “Government Affairs Liaison” under “Specific Program
• Physical Therapist Workforce Act(S.970/H.R.2802): To Project.”
address the opioid crisis, this bill would allow physical
therapists to be eligible for student loan forgiveness if About the Author:
they practice in rural and underserved areas. 56 House Dr. Zehnacker is the owner of Physical
and 7 Senate co-sponsors. Therapy Consults. LLC and contracts with
• Allied Health Workforce Diversity Act (H.R.3637): Bayada Home Health. She is the Chair of
Provide funding for physical therapy scholarships for APTA Home Health’s Government Affairs
students from underrepresented populations. 16 House Committee and may be reached at
co-sponsors. Passed House E&C Committee, awaiting [email protected].
full vote by the House.

Continued from pg 2 Competency in Home Health program are provided with
a certificate, in, and may describe themselves as having
Myalgic Encephalomyelitis/Chronic Fatigue Syndrome?” obtained: “Certificate of Advanced Competency in
Dr. Davenport was also recognized for his research Home Health.”
contributions as a co-author on publications.
Below are the latest recipients of the ACHH Certificate:
Latest ‘Home Health Minute’ Podcast Features Public
• Erika Albertini—Hollywood, FL
Relations, Volunteering, New Section Website • Anthony Cali—Peoria, IL
• Alicia Demchak—Mars, PA
The newest edition of the Home Health • Kristen Groenhout—Caledonia, MI
• Michael Mercado—Roseville, CA
Minute podcast features Section Volunteer • Jennifer Paul—Chestertown, MD
• Erin Pazour—Cedar Rapids, IA
Leader and Board Member Sean Hagey • Xiaoxu Qu—BC, Canada
• Ann Reppermund—Allison Park, PA
discussing the public relations committee. • Jacki Ruskay—Elizabeth, PA
• Dwayne Shillingburg (PTA)—Oakland, MD
It also talks about volunteering for the • Carla Steinberg—Ellicott City, MD
• Sondra Stikeleather—Brownsburg, IN
section in general and why our volunteers • Jared Woods—Ukiah, CA
• Derek York (PTA)—Spotsylvania, VA
are so vital. • Amy Yurkovich—Elizabeth, PA

This podcast was recorded before our Members: Tell Us Your News!
APTA Home Health Section would love
new website launch, and the podcast talks to hear about exciting changes and
achievements in your professional and
about what you can expect. And speaking personal endeavors. Please fill out the form
here so your news can be highlighted in
of our new website, have you been to the Sean Hagey our bi-weekly e-mails, and possibly at our
events. Scan the QR code here.
new website at homehealthsection.org?

Check out the new resources that

are available!

If you’re going to the site for the first

time, you’ll need to create a new password

to access members-only features. Scan the

QR code here that discusses how to do that.

16 PTs and PTAs Receive ACHH Certification Between
Sept. 1 and Oct. 8
APTA Home Health Section’s Advanced Competency in
Home Health program synthesizes current evidence-based
practice and tailors it to the unique physical therapy setting
of home health. This program enables home health agencies,
outpatient practices that provide home care physical therapy,
and individual clinicians to enhance efficacy and efficiency of
treatment of their home health patients and clients.

This program is for licensed physical therapists and
physical therapist assistants.

Individuals who successfully complete the Advanced

The Quarterly Report | Fall 2019 Page 27

P.O. Box 3406
Englewood, CO 80155
www.homehealthsection.com