Geriatric Physical Therapy 3rd edition

542 CHAPTER 28  The Senior Athlete Natural selection related to adverse anthropometric different from their younger counterparts. This philo- dimensions that influence biomechanical efficiency (such sophical approach is vital for those who work with se- nior athletes and attempt to return them to their chosen as height, physique, percentage body fat, and leg align- levels of function. Senior athletes use training and com- petition for maintenance of fitness, “enjoyment of the ment) and economy of movement tend to eliminate competition,”52 and to achieve their age-related peak performance.17 The best outcomes and most satisfied athletes from running throughout a lifetime. More athletes will occur when physical therapists honor the senior athlete’s motivation and drive to compete. specifically, taller, heavier individuals with anatomic SPORT-SPECIFIC REHABILITATION variations such as varus or valgus angulation of the APPROACHES FOR COMMON SENIOR SPORTS lower extremities are less likely to be able to sustain a As previously described in this chapter, senior athletes lifetime of running.3,8,15,47 are often injured in the course of training and perform- ing their chosen endeavors. Where there are injuries Running places repetitive, dramatic stresses on joints there is a need for rehabilitation! Rehabilitation of the senior athlete follows the same basic guidelines as reha- and supporting structures of the lower extremity. How- bilitation of a younger athlete; in fact, interventions used for younger athletes are almost always appropriate for ever, available evidence indicates that moderate running use with older athletes, including manual therapy, thera- peutic exercise, select modalities, functional retraining, in individuals without anatomic variances poses no and sport-specific training. Although specific treatments for every injury encountered by the senior athlete fall increased risk for development or acceleration of beyond the scope of this chapter, this section will high- light basic ideas and differences the rehabilitation OA.15,16,36,43,47,69-71 Forces transmitted through the lower provider may encounter. extremity during the midstance phase of running gait Aerobic fitness is one important consideration of total fitness in all senior athletes. Walking is possibly the sin- may equal 250% to 300% of total body weight,47 and gle most popular form of physical activity for the older individual.35 Accessible in all geographic areas, walking thus the frequency of OA may be increased in joints provides one of the highest compliance rates, greatest benefits, and lowest risk of injury in older persons. previously injured or which have anatomic flaws.8 Walking for general aerobic fitness should be a potential suggestion for exercise prescription for the older adult Despite the debate over the traditional concept that vig- who is beginning or returning to exercise. It is recom- mended that 10,000 steps be achieved each day to orous exercise causes OA, currently no research data achieve health benefits.68 Several activities have been described as popular for seniors, including walking, support the concern that athletic participation makes swimming, cycling, rowing, dancing, and less commonly running.8,35,52 In their assessment of older athletes, OA more likely.72 In fact, strengthening exercise for the Matheson et al8 described a decreased frequency of run- ning coupled with an increase in participation in racquet core, pelvis, hips, and thighs is widely recognized as a sports, walking, and other low-intensity sports with age. Also, running in the older age group showed the greatest treatment for OA.35,73,74 differences in gender ratios of participants, with males outnumbering females.8 Several sports with high partici- In an 8-year longitudinal study of more than 900 pation by senior athletes (running, swimming, golf, and tennis) will be specifically addressed. subjects, Fries et al concluded that older persons who Running engage in vigorous running and other aerobic activities For those healthy, anatomically stable adults, running have lower mortality and slower development of disabil- serves as an excellent choice for aerobic exercise, fitness, and training. Some individuals run for exercise and fit- ity than members of the general population. The authors ness, whereas others compete throughout a lifetime. also concluded that these positive benefits probably related to increased aerobic activity, increased strength, and better fitness of organ systems rather than post- poned development of OA.14 Researchers have also concluded that vigorous running activity over many years is not associated with increased musculoskeletal problems in older age and that age-related musculoskel- etal disability appeared to develop at a lower rate in runners.14,15 Much like the previously described body systems, running paedrfeocrlimneaninceV· doe2cmlianxes. with age primarily be- cause of Performance in a 10-km run modestly decreases in elite runners older than age 35 years, with progressively greater declines occurring after the age of 50 to 60 years.21 Gender differences are somewhat more pronounced after the age of 45 to 49 years, with women showing greater declines in pV· eor2fmoramxanincef.emTahliess,moarymbaey due to greater decline in be an apparent difference due to selection bias represented by smaller numbers of female runners in older age groups.32 Runners of all ages must use proper footwear. The shoe, a powerful tool for controlling human movement and affecting the function of the lower quarter, can also prevent or contribute to injury.14 Relative decreases in strength and flexibility that occur throughout a lifetime may contribute to decreased shock absorption by the

CHAPTER 28  The Senior Athlete 543 foot in closed kinetic chain activities. When shock ab- secondary to glenohumeral instability,76 whereas in older sorption of the foot diminishes, as is the case in many swimmers, the same pathologies are more likely due to senior athletes, it is essential to have a well-designed hypomobility and stiffness of the glenohumeral joint or shoe to compensate. Consequently, shoes remain the thoracic spine or insufficient steering provided by dy- single most important piece of equipment for the runner namic stabilizing musculature of the scapulothoracic or walker.47 joint. Swimming and Aquatic Exercise Glenohumeral pain and impingement/tendinitis symp- toms often plague swimmers, secondary to the greater Swimming and aquatic exercise are popular modes of force per stroke placed on the shoulder complex in exercise for many aging athletes. Traditionally, the “old” sprinters and secondary to fatigue in distance swimmers. swimmer is someone older than age 25 years, and as Because sprint swimming is used less frequently for train- previously mentioned, masters swimming competitions ing in most senior swimmers, injury often presents when are available for those older than age 19 years.5 The training volume increases. As volume increases, fatigue is advent of organized aquatic exercise programs contrib- likely to take its toll, and technique often suffers. Com- utes to increasing numbers of participants in water- mon technique errors include decreased body roll and based exercise. The discussion in this chapter focuses improper arm position during the recovery phase of the on the swimmer or aquatic exerciser older than age “freestyle” (both forward and backward) stroke. Both of 50 years. these training errors frequently contribute to shoulder complex dysfunction. The freestyle stroke requires ade- Aquatic-based exercise programs offer an excellent quate glenohumeral flexion/extension motion, concur- medium in which to exercise, especially in the presence rent with adequate spinal rotation and extension. of osteoarthritis. Seniors who are returning to exercise after not exercising for a time may be attracted to the The freestyle stroke, most commonly used for dis- water-based exercise classes common in fitness clubs. tance and recreational training, is broken down into four These classes offer an excellent method for the achieve- phases of movement (Figure 28-23): (1) hand entry into ment and maintenance of general fitness. The buoyancy the water and early pull-through, (2) late pull-through, of the water allows for aerobic training with decreased (3) early recovery, and (4) late recovery. The latissimus weight bearing and overuse to the joints of the lower dorsi and the pectoralis major muscles serve to propel extremities and spine. Nevertheless, injuries occur in this the body over the arm, the pectoralis working primarily type of exercise. Exercising in a pool with a subtle transi- during early pull-through and the latissimus working tion from shallow to deeper levels may produce a func- during late pull-through. The primary muscles used dur- tional leg length discrepancy in the senior athlete. The ing recovery are the middle deltoid, supraspinatus, and leg closer to the deeper end of the pool functions at a infraspinatus. The arm abducts and externally rotates as slight disadvantage, and the ankle must plantarflex to a the swimmer draws it out of the water. The serratus greater degree than the leg closer to the shallow end, anterior is also very active during the recovery phase. thereby increasing the plantarflexion stresses. Prevention The scapula must go from full protraction at hand entry and treatment of this injury requires proper warm-up to full retraction at the transition between late pull- and cool-down, with emphasis on stretching of the through and early recovery phase. The subscapularis and gastrocnemius and soleus. Use of specialized aquatic serratus anterior remain active throughout all phases of footwear and exercising on a level pool surface are the freestyle stroke, and prevention of anterior shoulder recommended. impingement is directly related to proper scapular mobility and dynamic positioning.77 When an athlete uses lap swimming for exercise or ongoing training for swimming or triathlon competi- Body roll during the freestyle stroke is described as tions, it is likely that sometime in their career they have transverse plane movement of the body in relation to experienced shoulder pain or dysfunction. Many young the horizon. Normal body roll during the freestyle and older swimmers alike experience conditions of over- stroke is between 70 and 100 degrees.77 Body roll use of the shoulder complex. Sixty percent of elite swim- allows for easier recovery of the arm as it draws out mers and probably a greater percentage of subelite of the water as well as offering improved mechanical swimmers experience the condition referred to as “swim- advantage to the opposite shoulder during pull- mer’s shoulder.”30,75 Swimmer’s shoulder, a nonspecific through in the water. The less the body roll, the diagnosis, refers to several pathologies including but not greater the abduction required of the glenohumeral limited to pain in the anterior aspect of the shoulder, joint during recovery. Diminished body roll due to likely because of inflammation of the subacromial bursa, fatigue during training or insufficient glenohumeral the tendons of the rotator cuff, and the long head of the range of motion may affect the swimmer by placing biceps.30,75 Rarely is bursitis a primary condition; rather, greater stresses on the shoulder complex. In short, the it is frequently related to tendinitis.75 In younger swim- better the maintenance of shoulder complex range of mers, rotator cuff tendinitis and impingement is often motion and flexibility, the less the body roll is needed. Therefore, stretching of the glenohumeral joint and

544 CHAPTER 28  The Senior Athlete 4 Late recovery Early recovery 1 3 Late Early pull-through pull-through 2 FIGURE 28-23  P​ hases of the swimming stroke. (From Pink M, Perry J, Browne A, et al: The normal shoulder during freestyle swimming. Am J Sports Med 19:569-576, 1991.) scapulothoracic articulations are important in training facedown position, avoiding the cervical rotation neces- as well as injury prevention. Of critical importance sary for breathing. are the muscles that tend to become tight due to pos- tural shortening, the latissimus dorsi and internal Rehabilitation of the senior swimmer’s shoulder com- rotators.30,75 plex must go beyond the traditional shoulder girdle stretching, strengthening, and use of modalities for pain The major movement of shoulder adduction and control and reduction of the inflammatory response. internal rotation provides powerful propulsion during Rehabilitation must focus on the biomechanical faults the pull-through phase. These two movements, if occur- and improper training techniques commonly used by the ring in excess, place the anterior shoulder in a closed senior swimmer. Range-of-motion and stretching exer- down position, thus making the subacromial space cises specific to any tight muscle group of diminished smaller, causing the potential for increased impingement. motion is important. Strengthening of the appropriate Coaching the technique modification of “high elbow muscles should be performed in the position that mimics position” can minimize this impingement force. As the the swimming stroke. For example, strengthening of the arm draws down from an overhead position during supraspinatus should be performed in a position that recovery, the proximal arm adducts in a plane nearly replicates the recovery phase, as compared to a standing, parallel to an imaginary line connecting both shoulders, arm at the side position. Strength and endurance exer- allowing for maximal force generation without excessive cises should focus on dynamic positioning of the scapula impingement on the anterior shoulder. The high elbow and thoracic spine for the different stroke phases. Cervi- position is also important during the mid–recovery cal, thoracic, and lumbar trunk rotation coordinates phase because it limits excessive abduction at the gleno- with arm and leg movements necessary for proper body humeral joint, thereby shortening the lever arm and roll. Stabilization and power generation from the pelvic decreasing torque at the joint.30,77 and trunk regions is also important, requiring adequate spinal positioning and control. Senior swimmers often The side predominantly used for breathing is most position themselves in the position of anterior pelvic tilt, often affected with rotator cuff dysfunction. The de- thus increasing thoracic kyphosis and closing down the crease in spinal and glenohumeral range of motion and anterior shoulder during all stroke phases. The physical flexibility noted in the aging swimmer are frequent con- therapist must be astute at instructing the athlete in how tributing factors. As the senior athlete loses rotational to position the pelvis in neutral, stabilize it there by flexibility of the cervical, thoracic, and lumbar spines, using small local musculature, and activate the global they actually have to increase the reliance on body roll muscles to achieve propulsion and body roll. The thera- to maintain the ability to breathe, thereby stressing the pist must be ready to evaluate the stroke technique of the shoulder on the side toward which the breath is taken. senior swimmer with regard to elbow position during In the senior swimmer with cervical osteoarthritis, range- recovery, arm position during other phases of the stroke, of-motion limitations, or pain, the use of a mask and as well as breathing technique. snorkel may allow the athlete to continue swimming and decrease the stresses on the neck and shoulder. The use Some common training errors include the improper of the snorkel allows the swimmer to maintain a neutral, use of fins, hand paddles, and kick boards. Many senior

CHAPTER 28  The Senior Athlete 545 swimmers bring training techniques and equipment from In male amateur golfers, the lower back is the most their younger years that may be too much stress for the commonly injured area, followed by the lateral elbow, aging body.38 The use of fins may be encouraged, as hand and wrist, shoulder, and knee. Women most com- they allow the senior swimmer to improve their upper monly injure the lateral elbow, followed by the back, extremity technique due to the increased swimming shoulder, hand and wrist, and knee.37 These injuries are speed offered by the fins. Fins are also helpful in building generally of the repetitive kind. Repetitive practice, strength in the lower extremities due to the longer lever related to volume, ranks as the most common cause of arm and increased resistance they provide. The use of injury in the amateur golfer, followed by poor swing fins by the senior athlete is contraindicated in the pres- mechanics. Both professional and amateur golfers ence of remarkable weakness or knee pain. The long believe that their injuries (as mentioned earlier in lever arm may cause increased transmission of forces to frequency) were caused by stresses occurring near the the knee, overpowering weak musculature or exacerbate impact phase of the golf swing as compared to micro- an already painful condition by overloading a biome- traumatic causes.78 chanically stressed joint (osteoarthritis or meniscal injury). The use of upper extremity training devices such Understanding the dynamics of potential injury helps as hand paddles or webbed gloves should be discouraged locate areas of preventive maintenance. The golf swing, because of the increased resistance they offer while pull- probably the most researched sporting technique in the ing the arm/hand through the water. This may contribute literature and equipment manufacturing industry, is de- to the development of impingement. Finally, if a senior scribed in five stages: (1) setup, (2) backswing, (3) transi- athlete is using a kickboard for a lower extremity work- tion, (4) downswing, and (5) follow-through. All phases of out, or to rest the upper extremities, it should be placed the golf swing impact the production of a successful, under the chest or near the face in order to avoid the accurate shot strategically placed to set up the next shot to outstretched upper extremity position, which occurs the hole. when the board is placed above the head. Positioning the kickboard above the head with outstretched arms and Although swing styles vary (Jim Furyk vs. Ernie Els), palms flat on the board places the shoulders in a fully and swing philosophies and teaching methods differ flexed and internally rotated position, thereby increasing (Natural Golf vs. Stack-N-Tilt), ball flight is based on the pressure on the anterior shoulder. several physical variables: club face angle, club path, club angle of attack, solidness of ball impact, and club Golf head speed. No two golfers on the PGA tour have the same swing style, yet they are all successful. Different The rapid growth of the game of golf, especially in the golfers have different swing capabilities based on their over-50 age group, attests to the need for knowledge in physical structure and physical capabilities. Therefore, treating the older golfer. The senior golfer has the time instead of focusing on swing style, it is more important and often the disposable income necessary to play golf to determine the efficiency of the particular swing. This and enjoys golf as a form of recreation and exercise; is especially important for the senior golfer. The question thus, he or she will be a principal player in using the golf is not how similar a swing is to a professional on video courses and purchasing equipment (Figure 28-24).78 analysis; rather the question should be “How efficient is the swing compared to a known standard (derived from FIGURE 28-24  ​Senior golfer, top of backswing. analysis of the best golfers in the world)?” Data collected from three-dimensional motion analysis systems have determined how golfers generate speed and transfer this speed or energy throughout their bodies, using a certain sequence in order to transmit this speed to the club head. This is called the “kinematic sequence.” The amazing thing is that all great ball strikers have the same kine- matic sequence or the same signature motion by which they generate speed and transfer that speed throughout their body. During the downswing in golf all body seg- ments must accelerate and decelerate in the correct sequence with precise and specific timing so that the club arrives at impact accurately and with maximal speed. The correct sequence of motion for the major segments is pelvis, trunk, arms, and finally club. This motion must occur sequentially, with each peak speed being faster but later than the previous one. This sequence reflects an efficient transfer of energy across each joint and facili- tates an increase in energy from the proximal segment to the distal one. The muscles of each joint produce this

546 CHAPTER 28  The Senior Athlete total knee replacement did not hinder playing golf.24 Most seniors resume full golf at 3 to 4 months after sur- increase in energy. On the other hand, if the timing of gery, but medical professionals advise them to start energy transfer is wrong, energy can be dissipated in- slowly with chipping and short shots and progress to stead of added and as a result, speed will be lost. Also if hitting the longer shots. Some recommendations, listed one body part has to compensate because another is not in Box 28-5, provide guidelines for individuals with total doing its job, then injury may result. hip or knee replacements who wish to return to golf. These recommendations are for right-handed golfers; There are three things that have been shown to create therefore, the terms “right/left” need to be reversed efficiency or kinematic sequence breakdowns: (1) im- for the left-handed golfers.78 proper swing mechanics, (2) physical limitations, and (3) improperly fit equipment. Determination of the se- Club head speed primarily creates distance when hit- nior golfer’s physical capabilities and limitations is there- ting the golf ball. The senior golfer, like the younger fore critical in establishing a swing that is efficient and golfer, ranks distance as important, and both age prevents injury. The SFMA, mentioned earlier in this groups constantly look for ways to gain length in the chapter, is an integral part of the physical therapist’s drive. Declines in performance in various facets of golf exam to determine these physical limitations. It is also are described with advancing age, although the rate per important to work closely with a respected golf profes- year depends on the skill. For example, greens in regu- sional for correction of swing mechanics and equipment. lation (0.36%/year) and driving distance (0.23%/year) had the greatest rate of decline, whereas scoring aver- Critical zones of stress during the golf swing exist in age (0.14%/year) and putts per round (0.11%/year) the trunk and impact the extremities during the different decline more slowly. This makes sense as muscular phases of the swing (Figure 28-25). The critical zones of power declines more rapidly with age than other motor restriction of mobility include the cervical region, upper properties.79 quarter, trunk (especially the thoracic spine and ribs), and the proximal lower quarter. These zones undergo Improved club technology, refined golf swing me- shear, lateral bending, compression, and torsional forces chanics, and physical conditioning, including strengthen- and must have the ability to change directions quickly ing and flexibility interventions, all contribute to increas- and smoothly. Golfers who use proper warm-up and ing club head speed at impact of hitting the golf ball. The maintain fitness during their golf participation are less physical therapist plays an important role in helping likely to have injury to these critical zones. Those who the senior athlete gain mobility in the critical zones do not are more likely to sustain an overuse injury, espe- cially as their connective tissues become stiffer with age. BOX 28-5 Recommendations for Return to Golf after Total Joint Replacement Although many senior golfers undergo a total hip or knee replacement, return to golf is often a primary goal. • Avoid playing in wet weather to decrease chance of slips/falls. A survey of orthopedic surgeons in the Hip Society and • The golfer may be able to play better without golf spikes, which Knee Society revealed that no respondent to the survey in the Hip Society felt that a total hip replacement puts less stress on the replaced hip/knee. prevented patients from playing golf. Of those respond- • The golfer must learn to play “more on the toes” to avoid ing to the survey in the Knee Society, 93% felt that a torsional loading on the replaced joint. FIGURE 28-25  S​ enior golfer, beginning downswing phase of • During backswing: the left heel should be elevated.* • During downswing: the right heel should come up off the swing. ground.* • The patient with a total hip replacement should learn to play with a greater hip turn, i.e., rotate the trunk more. To create more full body turn, have the golfer narrow their stance or to create more internal rotation of the hip, fan the feet outward. • Right-handed golfers with a right total knee replacement may benefit from “stepping through” the swing with the right leg. This assists in weight-shifting to unload the replaced joint. • Right-handed golfers with a left total knee replacement may benefit from an “open stance” to decrease stress and torque on the replaced joint. • Consider using a pull cart or caddy to decrease the stress on the replaced joint during carrying. Walking is encouraged. *Right handed golfer. (Data from Stover CN, McCarroll JR, Mallon WJ, editors: Feeling up to par: medicine from tee to green. Philadelphia, 1994, F.A. Davis Company.)

CHAPTER 28  The Senior Athlete 547 mentioned previously and educating the athlete in FIGURE 28-26  S​ enior tennis player, serving. strengthening and dynamic stability exercises specific to the golf swing. and other sports. They do not settle for anything less and do not expect the physical therapist to treat them differ- Like other athletes, golfers must select equipment ently than younger athletic counterparts. carefully with knowledge that proper-fitting golf clubs contribute to safe and successful golfing. The under- For the senior tennis athlete, the potential for chronic standing of golf equipment and fitting of this equipment injuries increases with age, playing time, and with use is usually beyond the scope of knowledge and expertise of ill-fitted equipment.82 The four areas most often of most physical therapists. Therefore, respected golf involved are the knee, elbow, shoulder, and back. The professionals in your geographic area can work with degeneration of the meniscus or articular cartilage sur- you to provide expert equipment modifications for any faces causes degenerative changes in the knee, creating senior golfer. increased forces at the knee. Chronic lateral epicondyli- tis, known as “tennis elbow,” commonly plagues the Tennis senior athlete and may result from the loss of strength and flexibility in the arm, accentuated by a poorly fit The United States Tennis Association (USTA) defines the tennis racquet (Figure 28-27). Rotator cuff tendinitis senior tennis player as someone aged 45 and older. The may also result from strength loss seen with aging. How- senior divisions encompass ages 45 to 85. The last age ever, we believe that the lack of spinal and upper quarter category of 80- to 85-year-olds, established in the early mobility, evident with the overhead volley and serve, put 1980s, came as a response to the growing numbers of the senior athlete’s shoulder more at risk than loss competitive players at these ages.80 Although both male of strength. Back pain, also a common injury for the and female age divisions exist, more males than females senior tennis athlete, can lead to significant limitations in currently compete in the senior age categories. Most playing level.81 senior players who play at a competitive level attribute their well-being to the playing of tennis itself. Senior A thorough examination of senior athletes perform- athletes who play two or more times a week seem to fare ing tennis strokes will lead the physical therapist directly better than those who play intermittently.81 to the critical areas of dysfunction due to lack of range of motion, loss of strength, poor technique, or poorly fit Tennis involves physical demands of quickness, agil- equipment. Looking at the big picture and having that ity, muscular strength and power, flexibility, eye–hand picture in mind as you prepare the athlete for return coordination, and reaction time (Figure 28-26). All of after a significant hiatus from the game, such as after these factors decrease with age. How do senior athletes surgery, is necessary to get the athlete back to preinjury continue to play at a competitive level? Although senior competition level. tennis players cannot play at the same level as when they were younger, they can maintain a high level of perfor- The authors of this chapter also believe the pelvis, mance well into their seventies, although rarely do they lower extremity, trunk balance concept, as previously play singles tennis. If you “don’t use it, you lose it” may discussed, plays a predominant role in the success of be exemplified in tennis more than other sports such as a tennis player. The core serves as an important link running or swimming. Examples include the demands for foot speed to move the body around the court and quickness and precision of upper extremity movement to contact the ball in all strokes. These demands require trunk, upper and lower extremity muscular strength, power, and endurance. Lifelong tennis participation can cause both macro- and microtraumatic injuries to several regions of the body,82 with a higher incidence of injury occurring in the overuse or microtrauma category. Some of the common macrotraumatic injuries include medial meniscus tear in the knee, tear of the medial head of the gastrocnemius, rupture of the Achilles tendon, and rotator cuff injury. Controversy still exists over the decision whether to attempt surgical intervention for some of these acute tears in 80-year-old athletes, depending largely on their decision regarding return to competitive athletics. Many competitive senior athletes elect for surgical repair and work hard during rehabilitation, over the course of several months, in order to return to competitive tennis

548 CHAPTER 28  The Senior Athlete FIGURE 28-27  ​Senior tennis player, note stretch/reach position, FIGURE 28-28  T​ raining the senior tennis player in stroke-specific and use of elbow brace for overuse of the forearm. position. between the lower and upper extremities, both regions rotator cuff. The decrease in glenohumeral external rota- important for different facets of the movements involved tion and abduction present with aging causes the senior in tennis. For example, if the tennis athlete fails the tennis player to use more elbow and wrist movement to SFMA deep squat test because of trunk or core instabil- hit the ball with power. This alteration in stroke mechan- ity (the trunk is not maintained in an upright, stable ics places the senior tennis athlete at risk for overuse position), this area must be targeted with stability inter- injury to the distal upper extremity. ventions. Most players perform tennis strokes in the semiflexed position or go from an extended trunk posi- The ground strokes of tennis require a significant tion to trunk flexion rapidly and with significant rota- amount of trunk rotation, and the arms and legs must be tional force. The pelvic girdle and anterior and posterior able to cross midline with ease while maintaining bal- trunk muscles provide significant stabilization and power ance over the base of support (Figure 28-29). When for tennis strokes. If aging or disuse has decreased the performing the backhand, if trunk rotation is limited or efficiency or synchrony of these muscles, the extremities the lower extremities do not cross midline, the shoulder must do more of the task and thus be at risk for over- girdle must horizontally adduct excessively to reach the strain. Once senior athletes develop baseline trunk ball. This alteration may cause shoulder impingement, strength, they must strengthen the trunk muscles in rotator cuff tears, or other upper quarter and cervical stroke-specific positions and in quick movement patterns injuries. Again players have shortening of collagen tis- to develop the power needed for strong, accurate shots. sues and concurrent declines in neuromotor control of The large muscles in the lower extremity such as the balance. Flexibility and balance losses need intervention quadriceps, hamstrings, hip adductors, and gastrocne- before the athlete can expect to be able to play tennis mius provide additional power that is transmitted to the without recurring chronic injuries. trunk and proximal musculature during stroke execu- tion. Rehabilitation should therefore address strength Strategies exist that help to keep the senior tennis and power of these muscles in addition to the stabilizers athlete competitive and injury free. Many senior tennis of the core (Figure 28-28). athletes play doubles instead of singles tennis to compen- sate for their loss in quickness and agility (Figure 28-30). Once strength and power of key muscles are ad- They also play on clay courts when possible as this cre- dressed, mobility and flexibility become key principles. ates a softer surface. The tennis racquet must be adjusted Mobility and flexibility of the body segments must be specifically to fit the senior athlete. Most senior tennis used in combination to get to the ball and hit an accurate players still like to play the power game rather than the shot, which are essential skills of tennis. Performing the finesse game and feel the bigger the racquet head, overhead volley and serve requires a significant amount the longer the racquet body length, and the tighter the of trunk extension. If that trunk mobility is not present, strings, the better. However, the decreased strength and the shoulder must abduct and externally rotate more to flexibility that comes with age, make it difficult to handle compensate, thus putting increased stress on the aging the powerful racquets used by young professionals and may be increasing the risk of injury. Therapists, there-

CHAPTER 28  The Senior Athlete 549 FIGURE 28-29  ​Senior tennis player performing a ground stroke as it creates a longer lever arm to transmit forces to the entire upper extremity. Increased forces to the upper (forehand). quarter place the athlete at risk for overuse injury. fore, must address the issue of racquet dimensions with Racquets weigh between 8.8 to 13 ounces and should senior athletes. A tennis professional can assist with have an equal weight distribution between the handle proper fit, according to the athlete’s physiological status and head of the racquet. Many seniors also use large- and type of game. head tennis racquets. Larger racquet heads have approximately 135 square inches of contact space and Length of racquet body, size of racquet head, tension have a larger “sweet spot” with which to contact the of strings, grip size (which often changes as a person ball. Larger racquet heads require adequate strength to ages because of the arthritic hand), racquet weight and control not only the racquet but also the force of the ball distribution from handle to head, and the texture of the hitting the racquet. A larger racquet head does not strings must all be considered. Tennis racquet length var- always enhance the power and accuracy of the player. ies between 27 inches, most often used by junior tennis players, and 29 inches, the newer “long body.” Older String tension is another feature of a properly fit rac- tennis players often purchase a longer racquet to com- quet. Correct string tension ranges from 45 to 70 pounds pensate for losses in quickness and agility. The selection of pressure. Average tension is 60 pounds. The higher of a longer racquet is not without consequence, however, the string tension, the more force is absorbed by the soft tissues of the upper extremity. Encourage the senior FIGURE 28-30  ​Doubles tennis play in senior athletes reduces the player to use a tension that his body can handle and rely more on finesse to outscore the opponent. Texture and need for running and court coverage. gauge of racquet string vary. The finesse game requires the ball to be in contact with the racquet head longer, so a larger string gauge and more textured string enhances spin and speed of the ball. Lastly, grip size, determined by measuring the dis- tance between the first palmar crease and the distal end of the third digit of the hand, varies. Grip size ranges from 4 to 4¼ inches, and correct sizing is essential for protecting the hand. It is important to reevaluate grip size as a player ages because of arthritic changes that can occur in the hand. These changes may cause alterations in gripping ability and also in grip size. There are special grip adapters for the arthritic hand. A properly fitting tennis racquet will enhance the player’s ability to make those difficult shots and continue playing at a competi- tive level, no matter what the age. CASE STUDIES Case 1 Mr. E. is a 74-year-old retired lawyer who presented postoperatively after having his rotator cuff repaired 1 week ago. He is right hand dominant, and in his retire- ment enjoys singles tennis on a three- to four-time-per- week basis. He noted a gradual onset of right shoulder pain and weakness during all overhead and outstretched upper extremity (UE) activities over the previous year, and reports that his tennis game had “gone down the tubes” because he was unable to serve or perform over- head shots secondary to pain. Additionally, his forehand and backhand had become painful (6/10 on a 0-10 Vi- sual Analogue Scale, 10 being the worst score). He also reported difficulty sleeping secondary to pain (5-6/10). Preoperatively, his physician had performed standard radiographs that demonstrated a type III acromion with spurring throughout the acromioclavicular (AC) joint,

550 CHAPTER 28  The Senior Athlete this was accomplished using accessory mobilizations (grades 1 and 2 for pain reduction) and PROM. and an MRI that demonstrated a medium-sized (3-cm), When soft tissue healing and resolution of chemical full-thickness rotator cuff tear. pain was appropriate, the SFMA was used for move- ment pattern assessment. The patient failed the total Surgery included a mini-open double row rotator cuff body extension, the overhead deep squat, and the repair of the supra- and infraspinatus using three bone shoulder screening tests. The central themes to be anchors and an acromioplasty. Cuff quality at the time of noted as to why these gross movement screens were the repair was described as “fair to good,” with a good failed are encompassed by insufficient scapular stabil- repair achieved. He had been performing Codman’s pen- ity and diminished rotator cuff stability/ dulum exercises and cervical/elbow/forearm/wrist/hand glenohumeral joint mobility. Scapular mobility was active range of motion (AROM) three times daily, while also carefully assessed and addressed, including tim- wearing a sling the rest of his day. Patient’s goals at initial ing of movement, PNF diagonals, and eventually evaluation were to decrease his postoperative pain (8/10), stability and mobility exercises consistent with the return to ADLs using his right (R) hand, and return to demands of tennis. When AROM was allowed, gen- competitive tennis. His physician has stated that he may tle, gradual demands were placed on the rotator cuff not perform AROM for 8 weeks postoperation, no over- in steering, stabilizing, and rotating functions. This head activities for 6 months, and no tennis for 12 months. was accomplished by gradually adding rhythmic Upon initial examination the patient had passive range of stabilization in open and closed chain exercises motion (PROM) of 88-degrees flexion, 65-degrees abduc- for stability, open chain rotational strengthening tion, 10-degrees external rotation (in adducted position), against gravity and then light weights and Theraband and 45-degrees internal rotation. All PROMs were limited (Blackburn exercises), and eventually more complex by pain, and no AROM was allowed. Posture was consis- motor tasks unique to tennis. It is essential that all tent with sling usage: neck in slight R lateral flexion, tasks be performed with correct scapulohumeral bio- R shoulder slightly elevated, and in the position of adduc- mechanics to encourage proper scapulothoracic and tion and internal rotation. R upper extremity arm swing rotator cuff synergy. The patient was only allowed to during gait restricted secondary to sling use. Patient dem- progress to more difficult exercises with progressive onstrated mild forward head, increased thoracic kyphosis, resistance if scapulohumeral rhythm was correct. and decreased lumbar lordosis, generally. Significant 4 . Return to tennis. Preparation for return to tennis was spasm noted in the pectoralis major and minor, and acces- initiated at 14 months postoperatively, with physician sory movements of the glenohumeral joint are restricted approval. The patient was eventually able to pass all and painful in the inferior and anterior directions. Strength SFMA screening tests, and it was deemed appropriate was not tested acutely postoperatively, but strength defi- to begin SST with regard to tennis-specific activities. cits were demonstrated in all scapular muscles and hu- To address this functional goal, it is important to meral internal rotators (31/5), external rotators (3/5), look at the base of strength the patient possesses. and deltoid (21/5) when they were able to be tested at 8 Criteria for Mr. E to move to this phase were: equal weeks postoperation. Prognosis for return to ADLs and AROM to left, MMT of 41/5 or greater in all UE sport over a 6-month time frame was considered good musculature, isokinetic internal–external rotator secondary to quality of tissue and quality of repair torques greater than 90%, and total work greater achieved. than 80% of the uninvolved arm. (Note that it may Problems/Treatment take several tests over the months to achieve these isokinetic scores.) Return to sport activities included 1. Loss of postural symmetry, abnormal UE movement dynamic trunk/core strengthening using resisted with gait. Initially this was addressed with active pos- stroke movements, elastic resistance, and dynamic tural correction via instruction and cervical and lumbar stabilization in tennis-based tasks; sport- appropriate upper quarter AROM. He was also specific movements with pulleys, tubing, the Intertial taught diaphragmatic breathing to improve thoracic trainer, and the Bodyblade (forehands, backhands, and cervical positioning and also to assist with pain overhead/serving); and LE footwork, balance, and management. When removed from the sling, arm drills for lateral movements and cross-over stepping swing during gait was addressed. Further postural necessary for tennis. When allowed to return, we sug- assessment in conjunction with return to sport phases gested that Mr. E. begin with ground stroke practice, of rehabilitation was necessary. and avoid serving and game situations. He gradually returned to full tennis activities with the progression 2. Pain throughout the upper quarter. Initially cryo- from doubles (minimal sets), no servesÆdoubles, in- therapy was used for both glenohumeral joint pain creased sets with servesÆdoubles, whole gameÆsingles, (postoperative, chemical pain) and also for spasm of diminished playÆsingles, regular play. Because this trunk musculature. In this case, as is typical, postop- rehabilitation progression takes many months, it erative pain was manageable within a few weeks postsurgery. 3 . Diminished PROM and AROM, and decreased strength of the upper quarter musculature. Initially

CHAPTER 28  The Senior Athlete 551 should be noted that this patient was only seen once followed by postural corrections to support optimal or twice a month in the final stages. functional alignment. Mobilizations with movement were used to mobilize the spine in rotational movements Case 2 similar to the golf swing. Mr. S. was instructed in soft tissue and spinal positional self-mobilizations using towel Mr. S is a 65-year-old male and avid golfer who pre- rolls, foam rollers and wedges. His home program also sented with complaints of chronic low back pain with- consisted of passive and dynamic stretching for the low out a specific mechanism of injury. Chief complaints back, anterior chest wall, and lower extremities. Patient consisted of generalized stiffness of the thoracic and was instructed to perform self-mobilizations once daily, lumbar spines after prolonged sitting, standing, or walk- and flexibility once daily in addition to before and after ing. He denied radicular symptoms and was able to sleep his aerobic exercise or round of golf. As previously men- undisturbed by pain. He reported some difficulty getting tioned, mobility problems must be managed prior to to sleep as a result of back stiffness especially after golf- adding interventions for stability. Mobility deficits in the ing. He golfs both recreationally and in a seniors, com- hip and thoracic spine were providing abnormal stresses petitive league, an average of three times per week. on the lumbar spine. He walks the 18-hole course pulling his clubs. He also reported having purchased a new large-headed driver Mr. S also needed to address his trunk strength and and attempting to “retool” his swing to increase his dis- dynamic core control in addition to initiating an overall tance from the tee. The patient’s primary goal was to be fitness program. Core exercises were targeted to address able to golf a minimum of three times per week without the core stabilizers (transversus abdominis, multifidi), spinal pain. the proximal hip musculature (gluteus minimus, gluteus medius, hip external rotators), and posterior scapular Mr. S was unable to complete the SFMA tests of muscles. Strengthening was initiated in straight planar forward bending, multisegmental extension, multiseg- movements, with progression to complex diagonal and mental rotation (bilaterally), single limb stance (bilater- rotational movements necessary for golf. Chops and lifts ally), the deep squat test, and the cervical rotation test and total body rolling motions were used to “balance” (bilaterally). Based on these gross patterns of movement out the rotational stability and dynamic motor perfor- dysfunction, specific clinical testing revealed that Mr. S mance of the trunk. Emphasis was placed on engaging exhibited pes planus feet bilaterally, an exaggerated the core muscles throughout reproduction of the golf anterior pelvic tilt, exaggerated thoracic kyphosis, pro- swing, as well as maintaining a neutral pelvic posture. tracted scapulae (bilaterally), and mild forward head Using the dynamic stability of the core was beneficial in with hyperextension of the upper cervical region. He is increasing club head speed, without excessive spinal minimally overweight in the abdominal region. Dra- pressure. An aerobic fitness program was formulated for matic soft tissue tightness is noted in the lumbar spinal Mr. S, which consisted of proper warm-up and cool- extensors, thoracolumbar fascia, bilateral iliotibial down phases combined with exercising in his target bands, anterior chest wall (pectoralis major and minor), heart rate zone. Initial target heart rate was calculated and cervical suboccipital muscles. No specific trigger using 60% of his maximal heart rate using the Karvonen points or tenderness was noted. Gross trunk motion formula. The target heart rate zone was increased to diminished by 50% in all planes with complaint of soft 70% to 75% in the fifth week of exercise. Aerobic exer- tissue tightness and pulling. Cervical rotation limited to cise (in his case bicycling or walking) was performed a 50 degrees bilaterally. Hip rotations (both IR and ER) minimum of three times per week. limited 50% bilaterally. Segmental assessment revealed remarkable decreases in anterior/posterior and rota- Body mechanics instructions for lifting and carrying tional joint play from C6-T4, as well as decreased upper the golf bag, picking up golf balls, and other ADLs were cervical (OA and AA) rotation to the left. Remarkably provided. Dynamic core activation during motions of decreased flexibility was noted in the gastroc/soleus the golf swing against resistance along with developmen- complex, rectus femoris, iliotibial band, psoas, pirifor- tal postures and closed chain neuromuscular training mis, pectoralis minor, and scalenes, bilaterally. He was (core, hip rotators) served to ready Mr. S for return to unable to actively recruit his transversus abdominis, and playing golf. tested very poorly for upper and lower abdominals (2/5). UE and LE strength was generally 41/5 to 5/5, with Finally, Mr. S was referred to a local golf professional exception of lower trapezius, middle trapezius, hip where analysis of Mr. S’s golf swing was conducted be- external rotators, and hip abductors (31/5). cause he had reported trying to “tune up” his swing in Problems/Treatment.  ​The above-noted soft tissue tight- order to gain more distance on his drives. During this ness and joint restrictions all place great compression and analysis, his functional range-of-motion restrictions torsional forces on the spinal segments during ADLs, helped confirm the importance of the manual stretching which are magnified during golf. Initial treatment con- and mobility interventions. He was instructed to return sisted of joint mobilizations to address the restrictions, to a less demanding golf swing with more upright pos- ture on follow-through to decrease the stresses on his thoracic and lumbar spinal segments. Excessive trunk

552 CHAPTER 28  The Senior Athlete FIGURE 28-31  B​ alance in an 87-year-old yoga practitioner/leader, lateral bending was also observed, and this should be demonstrated in “tree pose.” avoided by keeping the shoulder over the hips through- out the swing. While setting up to strike the ball, he Older athletes who are injured present a unique set of was cued to use the 30-degree rule: knees flexed to circumstances to the rehabilitation professional. These 30 degrees, with 30-degree forward flexion at the hips, seniors may regard themselves as athletes, and high and 30-degree external rotation of the lower extremities levels of participation are an important part of their (to compensate for lack of hip internal rotation, which lives. Physical therapists need to respect this value while helps decrease stress on the lumbar spine), which facili- suggesting ways to adapt to the sport. Addressing the tates pelvic and trunk muscular activation to provide concerns and rehabilitation of the aging athlete requires dynamic stability to the body during the golf swing. In knowledge, patience, diplomacy, and a healthy respect addition, Mr. S was coached regarding a club change and for the patients’ desires to return to activity. thorough warm-up procedure for return to golf, which were critical in his success. Communication between the REFERENCES golf professional and the physical therapist helped to facilitate positive outcomes for this patient. The patient To enhance this text and add value for the reader, all was eventually able to pass all SFMA screening tests, references are included on the companion Evolve site except the multisegmental rotation test secondary to OA that accompanies this text book. The reader can view the at the hips and, therefore, after communication with the reference source and access it online whenever possible. golf pro, it was determined that Mr. S should continue to There are a total of 82 cited references and other general modify his technique to work around the limitations references for this chapter. present at his hips. CONCLUSIONS How do they do it? When studying seniors who run into their eighth decades, perform yoga, climb mountains, hit tennis and golf balls, and play team sports into their sixth and seventh decades, health professionals of much younger ages are in awe (Figure 28-31). The fact that many individuals older than age 60 years participate in noncompetitive, physically demanding activities bears repeating. Frequently, these individuals remain unno- ticed unless they become injured and seek rehabilitation. When the question “What do we know about athletic injuries in the older population?” is asked, the answer is “Not much.” Much of the literature is anecdotal. Few epidemiologic studies have been conducted on this group of elite older adults; however, descriptions of the perfor- mances of the senior athlete are important and have value in understanding the physical and physiological changes that occur with successful aging.

29C H A P T E R Older Adults with Developmental Disabilities Toby M. Long, PT, PhD, FAPTA, Kathleen Toscano, MHS, PT, PCS INTRODUCTION Wellness of Persons with Disabilities,6 focus on promot- ing a healthy lifestyle, healthy aging, and preventing The population of individuals older than age 65 years is further impairment, disability, and disease. Closing the close to 13%.1 Included in this group are individuals Gap is a national campaign designed to help improve the with a developmental disability who up to a few years health of people with intellectual disability. The goals ago would not be expected to live to the age of 65 years, of the Surgeon General’s initiative, Call to Action on much less beyond that.2 Physical therapists are integral Disability, are to: members of the team that serves individuals with devel- opmental disabilities and will be expected to contribute • Increase understanding nationwide that people with to their care as they get older. A developmental disability disabilities can lead long, healthy, and productive is defined as a condition that occurs before age 22 years, lives. continues indefinitely, is a substantial obstacle to the ability to function, and results in a functional limitation • Increase knowledge among health care profession- in three or more of the following: self-care, receptive or als and provide them with tools to screen, diagnose, expressive language, learning, mobility, self-direction (or and treat the whole person with a disability with motivation), capacity for independent living, or eco- dignity. nomic self-sufficiency.3 This definition includes individu- als with intellectual disabilities, cerebral palsy, Down • Increase awareness among people with disabilities of syndrome, autism, and a host of other conditions that the steps they can take to develop and maintain a encompass a wide range of physical and mental changes healthy lifestyle. that alter the functional abilities throughout the life span. The purpose of this chapter is to discuss the role • Increase accessible health care and support services of the physical therapist in providing intervention ser- to promote independence for people with disabilities. vices to an older adult with a developmental disability. Covered specifically are the legislative mandates and Globally, the World Health Organization’s (WHO) philosophical underpinnings of providing services to this program Healthy Aging—Adults with Intellectual Dis- population, the unique aspects of aging in selected abilities7 and four other WHO documents8-11 outline the disability categories, the services rendered by the physi- key issues facing aging adults with developmental dis- cal therapist, and the facilities where services may be abilities globally and offer specific recommendations to provided. support healthy aging, including an emphasis on reha- bilitation. The U.S. Healthy People 20104 initiative targets the top American health care concerns. The two main goals Consistent with these prevention- and wellness- of the U.S. Healthy People 2010 initiative are to increase focused initiatives, there has been a paradigm shift in how the quality and numbers of years of healthy living and disability is viewed. The medical model, an impairment- eliminate health disparities. People with disabilities are based model that regards disability as a biological abnor- represented in the objectives used to track progress for mality requiring treatment, is being replaced with a social these goals. Two other national initiatives, Closing model. The social model conceptualizes disability as a the Gap: A National Blueprint to Improve the Health condition that occurs primarily within the context of psy- of Persons with Mental Retardation5 and the Surgeon chological, social, and environmental constraints that General’s Call to Action to Improve the Health and may interfere with functioning.12 This change in percep- tion supports community-based programming that takes into consideration the needs, wants, and preferences of the individual. Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc. 553

554 CHAPTER 29  Older Adults with Developmental Disabilities Four major events occurred during the 1970s with disabilities agree to treatment in the community. enabling the growth of community-based services and Thus, legislation is in place which ensures that indi- supports: viduals with developmental disabilities are becoming members of the community at increasing rates. • Passage of the Intermediate Care Facilities/Mental Retardation Program of Title XIX (Medicaid) of the DEMOGRAPHICS Social Security Act (1971)13; It is estimated that there are between 3.2 and 4.5 million • Landmark ruling on the right to treatment in the individuals with sensory, mental, physical, or other devel- Wyatt v. Stickney case (1971)14; opmental disabilities that impair their ability to effectively care for themselves.2 Of these, 641,000 are older than age • Passage of Section 504 of the Rehabilitation Act 60 years, and this number is projected to double by (1973)15; 2030.2 According to Cooper et al,23 individuals with developmental disabilities represent about 1% of the • Passage of the Education for All Handicapped population. Of these, 12% are older than age 65 years. As Children’s Act (now called IDEA) (1975).16 the number of individuals with developmental disabilities has grown, so has life expectancy. Life expectancy has Building on these initiatives, several major legisla- increased by approximately 250% since the 1930s from tive efforts were passed mandating that older persons 19 years of age to 70 years.24 Unless the individual has a with developmental disabilities be afforded services to significant disability such as Down syndrome, cerebral meet their unique needs (Box 29-1). In addition, the palsy, multiple disabilities, or a severe level of cognitive Americans with Disabilities Act of 199019 ensures ac- impairment, the life expectancy and age-related medical cess to and participation in senior citizen centers, day conditions of older adults with developmental disabilities care sites, and social service centers for individuals are similar to that of the general population. with developmental disabilities. Most recently, the Su- preme Court22 ruled that the states are required to In the population of older adults with developmental provide community-based services for those with intel- disabilities, women tend to outlive men by about 3 to lectual disabilities if appropriate and if the individuals 1.24 Surviving cohorts of women who have an intellec- tual disability are more often mildly or moderately im- BOX 29-1 Legislation Affecting Services to paired, whereas men tend to be severely impaired. The Older Adults with Developmental ratio of older men to women with cerebral palsy, how- Disabilities ever, tends to be higher than that found in the general population of individuals with developmental disabili- Older American Act Amendments (OAA) 198717 ties. Also, there exists an interaction between gender, • Mandated that older persons with developmental disabilities be age, degree of retardation, and longevity.24 Women with milder disabilities, such as mild intellectual disability, served under the Act’s provisions tend to live longer. Women with developmental disabili- • Mandated that the Administration on Aging (AOA) collaborate ties present with unique considerations, placing them at greater risk for developing health-related problems than with the developmental disability service system to design and women without developmental disabilities. They receive implement appropriate services significantly less preventive care than other women and • OAA programs were opened to older adults with developmental lead very sedentary lives, which often results in greater disabilities risk for cardiovascular diseases. For example, participa- • Developmental Disabilities Bill of Rights and Assistance Act tion in breast cancer screening is much less likely if (1987)18 the woman is older and has a disability or functional • Extended the provisions of the Developmental Disabilities limitations.25 Services and Facilities Construction Act of 1970 • Identified service delivery models to accommodate growth in Whereas the majority of the general geriatric popula- population and need for trained professionals tion live alone or with a spouse, the majority of older • Promoted community-based residential services adults with a developmental disability live in varied types of community residences.26 Community-based res- Americans with Disabilities Act (ADA) (1990)19 idential facilities are designed as home-like living envi- • Provisions include access to and participation in senior citizen ronments that combine supervision and care with sup- port of a family or group setting. There are four basic centers, day care sites, and social service centers for individuals types of community-based residential facilities: with developmental disabilities 1. Intermediate care facilities (ICFs): These provide the The Domestic Volunteer Service Act (1975)20 most intensive group home setting for individuals • Authorized senior companions to assist adults with develop- with health problems, multiple disabilities, or very mental disabilities • Omnibus Budget Reconciliation Act (1981)21 • Before admission to a nursing home, a screening must be performed for every person with a developmental disability • Annual review of every person with a developmental disability who resides in a nursing facility • Persons with developmental disabilities who are found to be inappropriately placed in a nursing home must be discharged

CHAPTER 29  Older Adults with Developmental Disabilities 555 limited daily living skills. No more than eight indi- take advantage of these programs were more functional viduals reside together in this type of setting. and independent than their counterparts in institutions 2 . Community residencies (CRs): These are group home and on some parameters than those living with their settings for individuals with moderate abilities to care parents.28 Thus, the movement toward deinstitutional- for themselves. Individuals whose primary disability ization took hold, and by 1991 a nationwide movement is moderate mental retardation or autism often reside took place to close all state-supported residential in these facilities. Up to 12 adults may live together facilities and develop community-integrated living and in a CR. vocational and leisure programming. As noted previ- 3 . Supportive residencies: These are for individuals with ously, legislation has been passed that supports the a significant level of independence. These facilities are community-based model of care and provides systems to often apartments and usually consist of two to three increase the likelihood that adults and older persons “roommates.” Monitoring by a supervisor is done with a developmental disability will become integral weekly or as needed. members of the community. Thus individuals with devel- 4 . Family care homes: These are for individuals of all opmental disabilities now live and receive the services degrees of disability. An individual resides with a and supports they need in their local communities. They family who has been trained and licensed to care for are no longer relegated to institutional settings away individuals with a developmental disability. from family, friends, and their community. Clients are now able to access a variety of appropriate service pro- In addition to these community-based residencies, viders, such as physical therapists, through direct access older individuals with a developmental disability may or upon physician referral. reside in skilled nursing facilities, nursing homes, or pri- vate residential facilities for persons with developmental AGE-RELATED HEALTH CARE disabilities. ISSUES SPECIFIC TO ADULTS WITH DEVELOPMENTAL DISABILITIES THE DEVELOPMENTAL DISABILITIES SERVICE SYSTEM Obesity and Cardiovascular Disease Federal legislation passed since the 1970s supports the Obesity affects individuals with all types of developmen- community-based model of care and provides systems to tal disabilities. Research, however, has focused on indi- increase the likelihood that adults and older persons viduals with an intellectual disability who have been with a developmental disability will become integral found to have a higher incidence of obesity than adults members of the community. The system of services for without an intellectual disability. Yamaki29 estimated the general population of older Americans, funded pri- that the obesity rate for adults with intellectual disabili- marily through federal monies, is defined as an age- ties was significantly higher than that of the general based service system, that is, the age of the individual population at each of the four 4-year observation peri- determines eligibility for service. The services are de- ods of the National Health Interview Survey. For in- signed focusing on the needs of the group of older citi- stance, in the time period between 1997 and 2000, zens. In contrast, the service system for older adults with 36.4% of adults with intellectual disabilities were con- a developmental disability is considered to be needs- sidered obese as compared to 20.6% of adults without based and provides individualized, specialized services. intellectual disabilities.29 More recently, Rimmer and Provisions for age-specialized models of service exist Wang30 found that the rate of obesity in people with in- within this system, which is primarily state funded. The tellectual disabilities was twice as high compared to that current focus of service provision is to bridge these two of the general population. Seventy percent of adults with service delivery systems to encourage collaboration and Down syndrome and 60.6% of adults with intellectual joint planning between the systems to ensure that an disabilities were found to be obese. What is especially individual’s needs are best met in the most efficient alarming is that extreme obesity was 4 times greater community-based manner as possible. This contempo- in adult individuals with Down syndrome (19%) and rary model of service provision has evolved from the 2.5 times greater for adults with other forms of intellec- “normalization” movement of the 1960s.27 This move- tual disabilities (12.1%) as compared to the general ment was grounded in the belief that individuals would population. In addition to various health conditions develop optimally if they were integrated into society such as hypertension, diabetes, heart disease, stroke, and and afforded the same experiences as those without stress, obesity also results in significant societal and per- disabilities. sonal limitations such as employment and leisure activi- ties.31 As seen in the general population, obesity in older The community-based model of care operationalized adults with intellectual disabilities results in higher the normalization philosophy. By the mid-1970s states medical costs for obesity-related chronic health condi- began to develop community-based residential and treat- tions.32,33 Furthermore, it requires a greater effort on the ment programs. Individuals who had the opportunity to

556 CHAPTER 29  Older Adults with Developmental Disabilities part of caregivers to assist obese individuals with intel- general population. It is recommended that individuals lectual disabilities, thus placing caregivers at greater risk with Down syndrome receive psychological testing an- for health problems such as low back pain.31 Lack of nually starting at age 30 years to determine and monitor physical activity, poor diets, and environmental factors loss of skills. Because of the known cognitive impair- have been linked to obesity in persons with intellectual ments of individuals with Down syndrome, declines in disabilities.31 ADL skills may be a better indicator of Alzheimer’s dis- ease than memory and cognitive loss.36 A checklist has Cardiovascular disease (CVD) has also been found to been developed that can be used reliably to identify early affect those with developmental disabilities. As in the signs of Alzheimer dementia in adults with Down syn- general population, CVD is the leading cause of death in drome.39 Other tools, such as the Adaptive Behavior those with an intellectual disability, except for those Scale,40 the Client Development Evaluation Report,41 with Down syndrome.34 Factors that would indicate a and the Vineland Adaptive Behavior Scales, Second higher CVD incidence in this population include longer Edition,42 also have been used to identify functional de- life expectancy, physical inactivity, and higher dietary fat cline in individuals with Down syndrome. These tools intake.34 have been found to be valid with this population. Depression.  ​There is indication that some individuals The three most common types of developmental dis- with Down syndrome are erroneously diagnosed as abilities seen by physical therapists are intellectual dis- having Alzheimer’s disease when, in fact, they are de- abilities, cerebral palsy, and Down syndrome. Until pressed.38 Because depression is a treatable condition and recently, little research had been conducted documenting Alzheimer’s disease is only manageable at this time, dis- the changes seen in individuals with these disabilities as tinguishing between the two is important for caregiving they age. It was not until the mid-1980s that the medical purposes. The prevalence of depression in individuals community felt the need to conduct such research with Down syndrome is between 6% and 12%.38 In ad- because up until that time, few individuals with disabili- dition to Alzheimer’s symptoms associated with other ties lived beyond middle age. Longevity for individuals conditions such as hypothyroidism and hearing loss mask with Down syndrome and those with cerebral palsy is the identification of depression in individuals with Down increasing. With increasing longevity, there has been a syndrome. Although severely depressed individuals also concomitant interest in the aging process for these indi- show a loss of adaptive skills, the pattern of loss tends to viduals. be up and down rather than a continuous decline as seen in dementia. Also, individuals with depression respond Down Syndrome positively to intervention and will regain skills that were once thought to have been lost. In addition to changes Age-related changes in the behavior of individuals with noted in adaptive skills, it is important to document Down syndrome have been documented.35-37 The age of changes in affective behaviors, such as sadness; crying; onset of the decline and underlying reasons for this pre- increases in self-injurious, assaultive, or aggressive behav- mature decline have yet to be determined. However, iors; and somatic complaints.38,43 A framework that there is a growing body of literature that discusses two distinguishes among depression without dementia, de- possibilities for this decline: Alzheimer’s disease36,37 and pression with dementia, and dementia without depres- depression.38 sion is needed to guide rehabilitative interventions.38 Alzheimer’s Disease.  A​ lthough the exact incidence of Alzheimer’s disease in individuals with Down syndrome Cerebral Palsy is unknown, an estimated 40% to 45% of these indi- viduals between 50 and 70 years of age will develop Little information exists on how the aging process af- Alzheimer’s disease. This incidence is three to five times fects persons with cerebral palsy, and there is no reason greater than in the general population.36 Furthermore, to suspect that cerebral palsy alters the genetically driven the age of onset is much earlier in those with Down syn- process of aging. Life expectancy for individuals with drome (age 35 to 45 years) than seen in the general cerebral palsy has not been studied extensively. Of the population.36 Current research suggests a causative link studies conducted in the 1990s, data indicate that indi- between the excess material in chromosome 21 and apo- viduals with cerebral palsy who lack mobility, are se- lipoprotein production and deposition—the neuropatho- verely or profoundly intellectually disabled, and cannot logic finding seen in individuals with Alzheimer’s who feed themselves have a decreased life expectancy.43 How- are not developmentally disabled.36 ever, the chronic physical impairments and conditions associated with cerebral palsy may affect the onset or Early symptoms of Alzheimer’s disease in older adults severity of age-related changes. with Down syndrome are similar to those in the general population: loss of memory and logical thinking, dimin- Older adults with cerebral palsy are at high risk for ished abilities to perform activities of daily living (ADLs), secondary conditions that cause a loss of function and changes in gait and coordination, and loss of bowel and deterioration of their quality of life. Complications related bladder control. Individuals with Down syndrome also develop seizure activity, a symptom not common in the

CHAPTER 29  Older Adults with Developmental Disabilities 557 to musculoskeletal changes including increasing scoliosis, therapists who specialize in the area of pain management contractures, hip subluxation or dislocation, pathological will want to reach out to ensure they receive appropriate fractures, and pain contribute to a loss of independent service. living skills as individuals with cerebral palsy age. Lower extremity contractures are prevalent in individuals with Fatigue is another problem that is often reported by cerebral palsy who do not walk (up to 91%) and can be adults with cerebral palsy and is associated with dimin- problematic for transfers, positioning, hygiene, and skin ishing functional independence.48 Adults with cerebral protection.44 In addition, scoliosis appears to show a sig- palsy report a higher rate of physical, but not mental, nificant progression over time, which can lead to difficulty fatigue than the general population, and the number re- sitting and positioning, and has further effects on mobil- porting fatigue increases with age. The greatest predic- ity, comfort, pelvic positioning, independence, skin integ- tors that were associated with fatigue were low life sat- rity, and respiration.45 isfaction, bodily pain, limitations in emotional and physical role function, and deterioration of functional Pain, related to musculoskeletal dysfunction, overuse skills.48 Fatigue was not strongly associated with type of syndromes, and degenerative arthritis, is often reported cerebral palsy; however, it was most prevalent in those in adults with cerebral palsy44 Sixty-seven percent of reporting a moderate degree of motor impairment. women within one community complained of pain These results reveal that physical fatigue is an issue in greater than 3 months’ duration, 62% had daily pain, adults with cerebral palsy, it increases with age, and it and 53% reported their pain to be moderate to severe in has an impact on preserving functional skills and life intensity.46 The most common areas of musculoskeletal satisfaction. pain are the hips, knees, ankles, and lumbar and cervical spine.46 In 2004, Jahnsen et al47 found that 33% of Pain, fatigue, and musculoskeletal changes can ulti- adults (aged 18 to 72 years, mean is 34 years) with cere- mately lead to loss of function and independence. Very bral palsy report chronic pain; this compares to 15% in little information is available on diminishing indepen- the general population. They also found that pain was dence in this population as they age. Work done in associated with low life satisfaction, deteriorating func- Sweden in 200052 indicates that 43% of the 221 adults tion, and chronic fatigue.48 Even though pain is reduced with cerebral palsy who responded to a survey (61% with intervention, most adults with cerebral palsy expe- return rate) had either decreased their walking ability or riencing pain do not seek help from health care providers stopped walking by the age of 35. During the same time about their discomfort.49 In addition, it may be difficult period, Buttos et al53 also found a significant decrease in for caregivers to fully appreciate and interpret nonverbal walking ability in their sample of adults with cerebral pain behavior from persons with severe cognitive and palsy. Most lost their ability to walk between 20 and 40 communication impairments.49 Thus, it is important to years of age.53 monitor individuals for behavioral changes that can be linked to pain, especially in older adults. In addition to the resultant problems directly related to the musculoskeletal impairments of cerebral palsy, The Pain Assessment Instrument for Cerebral Palsy women with cerebral palsy are more likely to be diag- (PAICP)50 was developed to assist practitioners in mea- nosed with late-stage breast cancer than the general suring the extent of pain experienced by nonverbal cli- population.25 Women with cerebral palsy underuse ents with severe cerebral palsy and a cognitive age of at mammography, often leading to delayed diagnosis of least 4 years. The PAICP demonstrates adequate test– breast cancer and less favorable outcomes.25 Barriers to retest reproducibility and construct validity for use in obtaining this service include lack of information about measuring pain in this population.50 The instrument the benefits,54 transportation challenges, inability to be consists of six drawings of typically nonpainful daily positioned appropriately55 in the mammography ma- situations and six drawings of activities that are typically chine, communication challenges,56 and negative atti- painful. Respondents are asked to rate each activity as tudes from staff.57 Appropriate services and knowledge- painful, not painful, or possibly painful. Use of this in- able service providers must be available to provide strument may give physical therapists and caregivers a intervention that meets both the unique challenges pre- better understanding of those activities that provoke sented by the population as well as the age-related health pain in these individuals. care challenges. Physical therapists are in an ideal posi- tion to consult with mammography technicians and in- A consequence of chronic, unmanaged pain is a strument manufacturers in making mammography more higher level of psychological distress.51 Individuals who accessible for adult women with cerebral palsy. experience chronic pain are often forced to change their lifestyle (i.e., reduce work hours, begin to use a wheel- Intellectual Disabilities chair or other assistive device, or look for additional home services).52 Chronic pain is a significant and poten- Intellectual disability is characterized by significant tially life-altering problem for adults with cerebral palsy, limitations in both intellectual functioning and adap- negatively affecting work and daily life as well as func- tive behavior (conceptual, social, and practical skills).3 tional skills and quality of life. This is a population that According to Krahn et al,58 the health status of

558 CHAPTER 29  Older Adults with Developmental Disabilities many individuals with intellectual disabilities is individuals with developmental disabilities, especially ce- adversely affected by a range of disparities, which if rebral palsy, will have a history of surgical intervention. addressed, can improve health outcomes. Persons with As multiple surgical procedures may lead to scarring and intellectual disabilities have relatively high rates of deformity, it is essential to document the time frame of epilepsy, behavioral/mental health problems, fractures, when the surgery occurred and how it has affected the skin conditions, respiratory disorders, and poor oral person over time. Medications for treatment of conditions health. Older adults with severe to profound levels of directly related to the developmental disability and those intellectual disability are at increased risk to die from related to additional conditions should be thoroughly intestinal obstruction, cardiovascular diseases, pneu- documented. Long-term use of anticonvulsive medica- monia, trauma, and other physical disabilities.59 There tions may lead to physical findings such as ataxia and are also reported cases of unrecognized problems with tardive dyskinesia60 or behavioral changes. Most individ- vision and hearing and an unnecessary increase in the uals with a developmental disability will have had many use of medications for psychiatric concerns. years of various therapeutic interventions, and summariz- ing those interventions and their effects will prove invalu- EXAMINATION AND EVALUATION able for treatment planning. Documenting the use and effects of additional interventions, such as occupational A key role of the physical therapist working with indi- therapy, special instruction, and therapeutic recreation viduals with developmental disabilities is to comprehen- that the client participates in, will assist in designing sively examine the patient/client because a comprehensive comprehensive programming that is collaborative—not examination forms the basis for clinical decision making. redundant—with other disciplines. The components of a comprehensive examination are described in the following text and listed in Box 29-2. Behavioral Response History Individuals with a developmental disability, especially those with severe or profound intellectual disability, au- Documenting pertinent history of the patient/client’s tism, or emotional disturbance, may demonstrate behav- health and behavioral changes can help the therapist ioral characteristics that can interfere with functional make decisions on the appropriateness of specific thera- use of motor skills. Documentation of the person’s re- peutic strategies. In addition to the patient/client’s devel- sponse to interactions and performance demands during opmental disability, confounding problems such as the examination will assist with designing appropriate congestive heart disease, hypertension, or diabetes also treatment plans. Documenting behavior also will help may be present. These comorbidities could influence rec- differentiate between behavioral characteristics that are ommendations or treatment strategies. It is likely that consistent with the individual’s developmental diagnosis and with those that are consistent with aging or other BOX 29-2 Components of a Comprehensive disabilities or medical conditions, such as depression. Physical Therapy Examination Documentation of antecedents to a behavioral outburst for an Individual with or change in behavior will assist the team in designing Developmental Disability appropriate interaction plans and behavioral support strategies. Also, the therapist should document the History method used by the individual, for example, verbal, Medical gestures, or sign language, to communicate needs. Surgical Therapeutic Neuromusculoskeletal Status Intervention Medications Traditional tests of neuromusculoskeletal status, such as Cognition manual muscle tests and goniometry, may not provide Behavioral Response the information needed to make functionally oriented Neuromuscular Status habilitation plans. The physical therapist should judge Flexibility through observation the patient/client’s degree of flexi- Strength bility, strength, and balance within activities that are Muscle tone functional for the individual. It is likely that the patient/ Posture client may have long-term limitations in range of motion Endurance and decreased strength that he or she has learned to Functional Skills compensate for and do not contribute to his or her func- Balance tional limitations. In addition, the therapist must be Gait aware of the individual’s interests and activity level to Activities of daily living determine whether an impairment results in functional Use of assistive technology

CHAPTER 29  Older Adults with Developmental Disabilities 559 limitation. For example, a person with an intellectual subsequently. One of these tools, the Functional Out- disability who swims on a regular basis may consider a come Assessment Grid (FOAG),61 also incorporates the decrease in shoulder range of motion a significant limita- assessment of neuromuscular components in the perfor- tion over a person who does not swim. This same ap- mance of specific functional activities. proach should be taken when examining endurance and muscle strength. Assessment of strength and endurance Motor Function and Functional Activities should be performed within the context of functional activities that are meaningful to the individual, are Motor function skills are those that underlie activities age-appropriate, and are consistent with the patient/ that the individual does or would like to do on a regular client’s desired outcomes. Table 29-1 outlines a variety basis and are meaningful to both the patient/client and of tools that are used to evaluate functional status of an caregivers. These skills are evident in examining mobil- individual with a disability and are discussed in depth ity within the home and community and ADLs. Gait TA B L E 2 9 - 1 Tools Commonly Used to Evaluate Functional Status and Assist with Program Planning in Individuals with a Severe Level of Disability Tool Purpose Components Functional Outcome To determine performance factors that Performance areas: Assessment Grid (FOAG)61 limit or support the accomplishment 1 . Posture and alignment against gravity of specific functional tasks 2 . Movement patterns Functional Skill Scale of the 3. Movement of body in space Pediatric Evaluation of To determine functional capabilities and 4 . Secondary physical disabilities Disability Inventory (PEDI)66 performance, monitor progress, and Administration: Direct observation of attempts to accomplish evaluate therapeutic or rehabilitative Scales of Independent Behavior program outcome task. (SIB)–Revised67 Components of each performance area are rated as to how To measure functional independence and Supports Intensity Scale (SIS)66 adaptive functioning across settings intensely they influence the accomplishment of a functional task Norm referenced and standardized for Functional Skill Scale subtests: older adults 1 . Self-care: eating, grooming, dressing, bathing, toileting 2. Mobility: transfers, indoors and outdoors mobility To measure the practical supports 3 . Social function: communication, social interaction, needed by adults with intellectual household and community tasks disabilities in functional living areas Administration: Caregiver report, structured interview, or by ranking activities according to through observation. frequency, amount, and type of Environmental modification and amount of caregiver support required assistance is also systematically recorded. Adaptive behavior clusters: 1 . Motor skills 2 . Personal living skills 3. Social interaction & communication skills 4. Community living skills Problem behaviors: Support score predicts level of support required based on the impact of maladaptive behaviors on adaptive functioning. Functional limitations in adaptive behavior can be identified. Administration: Structured interview or checklist procedure. Identifies supports needed in: 1 . Medical 2 . Behavioral 3. Life activity Home living Community living Lifelong learning Employment Health and safety Social Administration: Comprehensive interview of patient/client and those who know him or her well.

560 CHAPTER 29  Older Adults with Developmental Disabilities patterns and balance are components of motor function Supports Intensity Scale.  ​The Supports Intensity Scale that influence mobility. (SIS) is unique in that rather than measuring ability or inability the SIS measures the support needed by an adult Historically, older adults with developmental disabili- with a developmental disability in 57 life activities and ties were administered developmental motor assessments 28 behavioral and medical areas.68 The assessment is that determined the developmental age level of their skill completed through an interview with the patient/client performance. It is inappropriate to test an adult with and those who know him or her well. The SIS measures measures used to determine developmental skill level in support needs in the areas of home living, community children. It is, however, important to document skills that living, lifelong learning, employment, health and safety, have been linked to functional activities and ADL (basic social activities, and protection and advocacy. The scale and instrumental), mobility, and recreation. In addition ranks each activity according to frequency, amount, and to the functional assessment tools widely used across a type of support. Finally, a Supports Intensity Level is broad scope of health status (Katz Index of Independence determined based on the Total Support Needs Index, in Activities of Daily Living,64 Functional Independence which is a standard score generated from scores on all Measure,65 Older American Resources and Services,66 the the items tested by the scale. The SIS is an excellent pro- Philadelphia Geriatric Center Multilevel Assessment In- gram planning tool, especially for those individuals who strument67), older adults with developmental disabilities are known to have significant impairments and activity can be assessed more specifically using dimensions con- limitations. According to the manual, content validity, tained on the Pediatric Evaluation of Disability Inven- criterion-related validity, and construct validity were tory,62 the Scales of Independent Behavior–Revised,63 the calculated using a variety of methodologies. All scores Supports Intensity Scales,68 and the FOAG.61 were intercorrelated, and coefficients exceeded the mini- Pediatric Evaluation of Disability Inventory.  ​The mum level needed to demonstrate criterion-related reli- Pediatric Evaluation of Disability Inventory (PEDI)62 is a ability.68 Results indicate that the SIS is suitable for standardized, norm-referenced inventory that can be measuring unique characteristics of support needed by administered by caregiver report, structured interview an individual and not abilities as measured by adaptive with a caregiver, or through professional observation of behavior scales or achievement tests and that the scores a client’s behavior. The PEDI is divided into two scales. correlate with level of intelligence (the lower the intelli- The Functional Skill Scale has three subtests: self-care, gence quotient, the higher the level of support needed).68 mobility, and social function. Environmental modifica- Functional Outcome Assessment Grid.  T​ he FOAG61 tion and amount of caregiver assistance is systematically is based on the top-down model of assessing the influence recorded in the Modification Scale and Caregiver Assis- of impairments on patient/client-specified functional out- tance Scale. Although standardized on children from comes. Using the desired outcome as the starting point, ages 6 months to 7 years 6 months, the items on the the therapist determines barriers to the accomplishment PEDI can be administered to older individuals to de- of the task and strengths that will assist the patient/client scribe patterns of strengths and needs to assist with in accomplishing the task. Using this model, the purpose program planning. The Modification Scale and the Care- of the FOAG is to assist the team in implementing func- giver Assistance Scale also provide valuable information tional outcomes. The FOAG is individualized, based on for program planning and documenting benefits from team consensus of desired outcomes for the patient/cli- intervention aimed at decreasing the burden of care for ent. Although there are six functional outcome areas that an individual. can be assessed, each area can be assessed independently. Scales of Independent Behavior–Revised.  T​ he Scales The six areas—caring for self, communication, learning of Independent Behavior–Revised (SIB-R) measures and problem solving, mobility, play, and leisure—are as- functional independence and adaptive functioning in the sociated with four disability categories: physical, sensory, school, home, and employment and community set- special health care needs, and other. The patient/client is tings.63 It has been specifically designed to be used with observed attempting the desired outcome, and the thera- children, adults, and the older adult population. The pist rates component skills, such as muscle tone, strength, SIB-R is a norm-referenced test63 that has been standard- and flexibility, on a 5-point scale from no problem to ized on individuals aged 3 months to 90 years and older. significant problem that affects or prevents skill perfor- The full scale is divided into 14 subscales, which are mance. Program plans are then designed that bypass ob- organized into four clusters: motor skills, social interac- stacles, promote strengths, and/or improve deficits. This tion and communication, personal living skills, and com- tool is an informal program-planning strategy, providing munity living skills. Of particular interest to the geriatric therapists with a systematic approach to link impair- population are items related to domestic skills, such as ments and functional limitations to client-desired out- homemaking and community orientation. The design of comes. the SIB-R also allows comparison of an individual’s Gait, Fall Risk, and Locomotion.  I​n addition to using functional independence with cognitive status. A Screen- specific assessment tools, documenting the gait pattern ing Form and a Problem Behavior Scale are also part of of the patient/client is important. Individuals with the SIB-R package.

CHAPTER 29  Older Adults with Developmental Disabilities 561 developmental disabilities, especially those with cere- may increase for adults with developmental disabilities as bral palsy, have well-documented gait deviations and they become older. As seen in older adults without devel- neuromuscular impairments. Gait assessment should opmental disabilities, the use of mobility devices will in- document those impairments but, more importantly, crease. This is especially true for the use of wheelchairs for determine the functional limitation imposed by the gait individuals with cerebral palsy. A thorough assessment of deviations. It is preferred that a gait assessment be per- the fit and appropriateness of a wheelchair or ambulatory formed in various natural settings and over a variety of device should be part of a comprehensive examination. terrains to determine the impact of the gait characteris- The assessment of the use of assistive technology should be tics on the ability of a person to maneuver functionally. performed within the environment that it is to be used. As noted in the older adult population without devel- Assessing the devices also will require assessment of the opmental disabilities, the patient/client may show a environment to determine whether it is conducive for the decrease in speed of ambulation and an increase in en- size, shape, and weight of the device. Before a person is ergy expenditure as he or she ages. Increased energy placed in a community residential facility, the physical expenditure may be more pronounced in individuals therapist may be asked, as part of the team, to assess the with postural deviations.69 environment to ensure appropriateness for an individual’s needs. Fall risk and balance also should be assessed. Again, traditional balance tools used with younger individuals The evaluation of an older adult with a developmental with developmental disabilities, such as the ability to disability must be comprehensive and meaningful to the walk a balance beam or stand on one foot, may not be person’s activity level and living situation and must be the most appropriate methods to determine balance in individualized to meet specific needs. The therapist must the context of function. Maintenance of balance within consider the patient/client’s impairments, functional limi- functional activities, such as individuals maneuvering tations, skill acquisition, environment, and desired func- in their own environments during routine activities, may tional outcomes in planning the evaluation strategies and be more helpful for program planning. procedures. Functionally based examinations are clini- cally useful. Many balance tools have been found reliable and valid in detecting risk for falls in the general older adult popu- PROGRAM PLANNING lation, but further research is needed to determine if these AND IMPLEMENTATION tests are valid in detecting fall risk in individuals with developmental disabilities.70-72 Bruckner and Herge73 Individuals with developmental disabilities living in a com- found that modifying the Timed Up and Go test74 is a munity need access to supportive care providers and reliable method of determining fall risk in ambulatory skilled health care clinicians who are knowledgeable older people with developmental disabilities. However, about the person, the condition of the individual, and there was no correlation found between fall history and the system of services and supports available to them. performance on the modified test. Using the Tinetti Accessing appropriate services is challenging because Performance-Oriented Mobility Assessment Tool,75 Ad- of an array of disparities seen in the health, rehabilita- ams et al76 found that the tool was a reliable way to as- tion, and social service arenas. Older adults with sess mobility in individuals with intellectual disabilities. developmental disabilities experience lower rates of The use of observation to assess mobility was found to be preventive care and health promotion than that of the the most useful aspect of the tool for those individuals general population. with intellectual disabilities or behavior problems. A greater awareness of such disparities has resulted in There are also cognitive and injury risk assessment numerous intervention programs and practices aimed at tools that could be helpful for falls risk assessment. promoting successful aging in those with developmental These tools do not directly assess balance and gait, but disabilities. Person-based practices promote the health because changes in cognition or mental status can be a of persons with developmental disabilities by educating risk factor for falls, use of tools that assess mental status and supporting the individual in such areas as nutrition, may be helpful.77 A change of scores in the Mini-Mental physical activity, preventive care, rest, and the manage- State Examination (MMSE)78 was shown to predict falls ment of stress. The Healthy Lifestyles Curriculum,82 the for the general population as well as individuals with a Exercise and Nutrition Health Education Curriculum cognitive impairment (odds ratio is 0.88 to 1.06).79 As for Adults with Developmental Disabilities,83 and seen in the general population of older adults, those with Women Be Healthy: A Curriculum for Women with developmental disabilities who are at risk for falling Mental Retardation and Other Developmental Disabili- have more than one factor contributing to that risk.73,80,81 ties,84 although not developed specifically for the older Assistive Technology.  M​ any individuals with develop- adult, are structured, center-based health promotion in- mental disabilities use assistive technology. Assistive tech- tervention programs that have been shown to effectively nology consists of simple adaptive equipment devices, such change health behaviors in adults with developmental as adaptive spoons, to very complex computer-driven disabilities. The M.E.E. Calendar,85 a less structured communication systems. The use of assistive technology

562 CHAPTER 29  Older Adults with Developmental Disabilities approach, provides a variety of activities that can be direct provider of service, a consultant to other team done with older adults to promote fitness and activity, members, or a monitor of programs carried out by direct maintain language skills, and facilitate problem solving. care providers. Although individuals have long-term dis- Provider-based practices call for the standard and abilities, the role of direct provider of physical therapy systematic inclusion of information on developmental may be intermittent. The level of intensity will be related disabilities within curricula for service providers.86,87 to the prioritized outcomes of the ISP or the need for Professional organizations, such as the American Physi- services after an acute illness or injury. More often, the cal Therapy Association88 are including a variety of therapist may be an indirect provider of service. As a programs to increase knowledge and skill among their monitor of services, the physical therapist establishes members. Policy-based practices have focused on creat- functional goals that are consistent with the outcomes ing a system of care to improve coordination among agen- prioritized on the ISP and trains other individuals (usu- cies providing services to those with developmental dis- ally direct care providers) in a specific program aimed at abilities. Service coordination, interdisciplinary care, and achieving goals. The physical therapist creates a data interagency collaboration are receiving a great deal of at- collection system for the person implementing the pro- tention. The Special Olympics Healthy Athlete89 program gram and monitors the client’s progress at an appropri- is one attempt to provide hearing, vision, and musculo­ ate frequency. Figures 29-1 and 29-2 are examples of skeletal screenings during the Special Olympics Games. In simple data collection systems designed for individuals the United States, there has been a desire to increase com- living in an intermediate-care facility. The data collection munication between interagency and interdisciplinary system must be very simple to increase the likelihood groups for addressing mental health needs in people with that it will be completed by the staff. Also, the staff intellectual disabilities.90 These practices recognize that carrying out the program implementation must be adults with developmental disabilities are aging and with trained and supervised. Monitoring of the program data increasing life expectancies there will be a need for a collection and intermittent retraining must be performed greater array of comprehensive, integrated services. on a regular basis with adaptations to the program as necessary. Habilitation vs. Rehabilitation The role of consultant requires the physical therapist Older adults with developmental disabilities generally to respond to specific requests of the patient/client, care- necessitate habilitation programs. Habilitation, as distin- givers, or program staff. Unlike monitoring services, the guished from rehabilitation, refers to services that assist physical therapist providing consultation is not directly an individual in gaining skills and abilities.91 Rehabilita- responsible for the outcomes of the individual client. tion attempts to restore skills that have been lost as a result of injury or medical condition.91 Habilitation is re- Goal: Tom will walk with his walker from the living room to his quired by law, under Medicaid regulations, and financed bedroom in 5 minutes. by Title 19 of the Social Security Act. Habilitation services for the older adult are generally provided by an interdis- Date 4/1 4/2 4/3 4/4 4/5 4/6 4/7 4/8 4/9 4/10 ciplinary team. The Individualized Service Plan (ISP) is the document that records the outcomes, goals, and pro- Record time 10 10 9 10 8 9 8 8 7 8 grammatic strategies decided by the team to be necessary in minutes for the client to attain or maintain an optimal level of in- dependence. Initial The interdisciplinary team is the team approach that FIGURE 29-1  E​ xample of a simple data collection system identify- is most commonly used with older persons with develop- mental disabilities.92 The team consists of various pro- ing a mobility goal and displaying the scores achieved over a 10-day fessionals, in addition to physical therapists—for exam- period by Tom Charles, a 77-year-old man with mild-moderate level ple, occupational therapists, physicians, speech-language of intellectual disability and decreased endurance due to acute pathologists, nurses, psychologists, nutritionists, special emphysema. education teachers, and social workers—who indepen- dently evaluate the individual and then meet together Goal: Chris will transfer from a chair into his walker independently. and share their findings with each other and the indi- vidual. Based on this information and the desired out- Date 4/1 4/2 4/3 4/4 4/5 4/6 4/7 4/8 4/9 4/10 comes of the patient/client and caregivers, the team for- mulates a comprehensive plan that will best meet the Assistance Y Y Y Y Y N N Y N N needs of that individual. needed to steady the The role of the physical therapist on the team is deter- chair (Y/N) mined by the needs of the client and the priority out- comes established on the ISP. The therapist may be a Assistance Y Y N Y Y N Y Y N N needed at arms to pull up to stand (Y/N) Initial FIGURE 29-2  ​Example of a simple data collection system identify- ing a mobility goal and displaying the scores achieved over a 10-day time period for Chris Allen, a 59-year-old with moderate spastic diplegia.

CHAPTER 29  Older Adults with Developmental Disabilities 563 The physical therapist is responsible for providing to the adults with developmental disabilities (Box 29-3). The consultee information that is helpful to assist the patient/ National Institute on Disability and Rehabilitation Re- client in meeting the outcomes. Case consultation search also funds a Rehabilitation Research and Training focuses on the needs of an individual patient/client. Center on Aging with a Developmental Disability at the The physical therapist, for example, may provide sugges- University of Illinois at Chicago. tions to a caregiver about how to involve a patient/client with cerebral palsy in leisure activities. Colleague con- CASE STUDIES sultation targets the needs of other service providers. Discussing with direct caregivers proper body mechan- Case 1 ics to prevent back injury when transferring a patient/ client would be an example of colleague consultation. Zachary is a 67-year-old man with mild-moderate intel- The purpose of system consultation is to effect system lectual disability and cerebral palsy of the spastic diple- change, with the focus being on the service delivery sys- gic type, Gross Motor Function Classification System93 tem rather than a specific client. In-service training, level 3-4. He is able to communicate verbally. He lives in program development, or evaluation are examples of an intermediate-care facility and attends a day treatment system consultation. program. As a child, he walked with crutches and long leg braces. He had hamstring lengthenings and heelcord Regardless of the role the physical therapist takes in lengthenings at age 10 years and again when he was implementing the therapeutic program, an appropriate 14 years old. As he got older, he continued to walk with documentation system must be established. Documenta- crutches but without the braces. By the time Zachary tion is important and should meet the needs of those reached age 60 years, his gait had slowed considerably involved in the program, third-party payers, and the service system (developmental disabilities or aging). If BOX 29-3 University Centers for Excellence the therapist is acting as a direct service provider, prog- in Developmental Disabilities with ress and the response to intervention should be docu- Specific Programs for Older Persons mented at each visit. The plan for future intervention with Developmental Disabilities also should be included. If service is being provided on an indirect basis, a system for documentation must • Center for Child and Human Development, Georgetown be created for those implementing the program. Figures University, Box 571485, Washington DC 20057-1485, 202-687- 29-1 and 29-2 provide examples of simple documenta- 2071. http://gucchd.georgetown.edu tion systems. As indicated previously, this documenta- tion should provide an objective measurement of the • Eunice Shriver Center, 200 Trapelo Road, Waltham, MA 02115, individual’s progress, and the system must be clear and (617) 734-7509. http://www.umassmed.edu/shriver concise so that it is not burdensome to caregivers. Ther- apists also must follow the regulations of the Medicaid • Institute for Study of Developmental Disabilities, Indiana and Medicare systems (see Chapter 30). Unfortunately, University, 2853 E. 10th St., Bloomington, IN 47408-2601, 812- this may require duplication of documentation in vari- 855-6508. http://www.iidc.indiana.edu ous formats to meet the requirements of the various regulatory systems. • Institute for Human Development, University of Missouri-Kansas City, 22200 Holmes St., Third Floor, Kansas City, MO 64108, 816- Resources 235-1770. http://www.ihd.umkc.edu Because the challenge of providing services to this popu- • Mailman Center for Child Development, University of Miami, lation is an emerging area of service delivery, it may be School of Medicine, P.O. Box 016820, D-820, Miami, FL 33101, helpful to consult current journals in geriatrics and devel- 305-547-6635. http://www.ihd.umkc.edu opmental disabilities. Periodicals such as Intellectual and Developmental Disabilities, American Journal on Intel- • North Dakota Center for Developmental Disabilities, Minot State lectual and Developmental Disabilities, and Journal of University, 500 University Ave. W, Minot, ND 58071, 701-857- the Association for Persons with Severe Handicaps may 3580. http://www.ndcpd.org/ be helpful. Topics in Geriatric Rehabilitation has recently published a special issue, Aging with a Developmental • Partners for Inclusive Communities, University of Arkansas Disability. Also, the Administration on Developmental for Medical Sciences, 2001 Pershing Circle, Ste 300, North Disabilities has funded selected University Centers for Little Rock, AR 73114, 501-682-9900, http://www.uams.edu/ Excellence in Developmental Disabilities to develop partners training and service programs specifically for older per- sons with developmental disabilities. These programs • Rehabilitation Research Training Center on Aging with Intellec- offer multimedia information and are available to train tual and Developmental Disabilities (RRTCADD, Department of service providers in providing appropriate care to older Disability and Human Development (DHD); College of Applied Health Sciences, University of Illinois at Chicago (UIC) 1640 West Roosevelt Road, M/C 626, Chicago, IL 60608-6904, Phone: 312-413-1520. http://www.rrtcadd.org/About_Us/Home.html • Strong Center for Developmental Disabilities, University of Roches- ter Medical Center, 601 Elmwood Ave., Rochester, NY 14642, 716-275-2986. http://www.urmc.rochester.edu/pediatrics/divisions/ developmental_disabilities/index.cfm

564 CHAPTER 29  Older Adults with Developmental Disabilities and he was encouraged to use a wheelchair by the staff interest in swimming, the physical therapist in collabora- at his day treatment program. A manual wheelchair was tion with the recreational therapist designed a swimming purchased for Zachary when he was 62 years old. By 67, program that would (1) promote cardiovascular fitness Zachary had gained 17 pounds and his wheelchair and weight loss and (2) improve lower extremity needed to be replaced. The range of motion in Zachary’s strength. Both of these goals would assist him in reach- legs had become more limited, making even stand-pivot ing his stand-pivot goal as well. Activities included transfers difficult. swimming laps and practicing standing and walking in the water. The recreation therapist monitored the pro- Planning and implementing a program appropriate gram monthly with an agreement to contact the physical for Zachary involved a comprehensive examination therapist with any questions or concerns. as previously described. Through an interview with Zachary and his caregivers, it was found that Zachary In collaboration with the team that included Zach- was somewhat depressed regarding his inability to ary, his caregivers, the social worker, and physician, walk. He also was found to have an interest in improv- a new, appropriate wheelchair was prescribed and ing his ability to manage transfers to and from the toi- obtained for Zachary. The therapist assessed the wheel- let independently. The caregivers stated that Zachary chair on a quarterly basis for safety, fit, and function. enjoyed swimming and was independent in the shallow The therapist taught the staff appropriate wheelchair water at the pool. care and maintenance. The information gained from the person-centered Zachary and his caregivers were pleased with the pro- planning interview94,95 (Box 29-4) was enhanced by the gram because it took into consideration everyone’s needs structured interview of the SIS and the SIB-R. These data and Zachary’s desired outcome. Zachary was pleased be- coupled with the information gained from the neuro- cause he was able to practice “walking” in the water, muscular assessment allowed the therapist to create ap- which he enjoyed. He was motivated to practice the propriate goals and a realistic plan that was driven by stand-pivot transfer because he wanted to regain the abil- the outcomes identified through the person-centered ity to transfer independently. This intervention program planning process according to the desires of Zachary and proved to be quite successful. At the end of 3 months, his caregivers. The team decided that one outcome Zachary had lost weight; was able to complete a standing- would be a return to independence in the bathroom. pivot transfer with only stand-by assistance; and his new wheelchair was modern and streamlined, allowing him to In order to regain independence in the bathroom, in- maneuver in his home more efficiently. The success of this dependence in stand-pivot transfers was one goal. To program was due to the collaboration among all team achieve that goal, the therapist instructed Zachary’s members including Zachary and the fact that it was based caregivers on performing transfers with the client and on Zachary’s desired outcomes. The physical therapist, in encouraging greater assistance from Zachary. The plan collaboration with her team members, successfully moni- involved having Zachary practice this transfer each time tored his program and consulted with daily caregivers and he needed to use the bathroom. To create a program that Zachary. was more likely to help Zachary reach his goals, the staff at the day treatment program also received training Case 2 and agreed to follow the plan as designed. The therapist monitored progress weekly for 1 month and then Lisa is 71 years old and has a diagnosis of mild intellec- monthly for another 2 months to ensure progression tual disability. She lives in a supervised apartment with toward the goal. In addition, building on Zachary’s two other older women and attends an integrated adult day care program at a local nursing home. Lisa ambu- BO X 2 9 - 4 Key Elements of a Person-Centered lates independently on all surfaces including stairs. She is Planning Interview independent in ADLs. She is able to take a bus to a des- tination, after she has been shown three to four times. • Respect the individual as a key informant Lisa has always enjoyed riding a stationary bike, but her • Address questions to the client directly knees and hips have begun to bother her. She has been • Maintain a conversational tone throughout the interview diagnosed as having osteoarthritis, and her physician • Clarify information with follow-up questions to the client first suggested that she find an alternate activity to replace the stationary bike riding. and then to other team members as needed • Begin the conversation by eliciting information on the dreams The community in which Lisa lives funds her residen- tial program as well as her day program through the and aspirations of the client state Medicaid program. Medicaid programs for adults • Identify natural supports prior to determining professional with developmental disabilities in her state (as in many) require that a physical therapist be a member of the services team and available to consult with the client, any care- • Focus on desired outcomes and capacities, not deficits or givers, or administrative staff as appropriate. Being a impairments • Maintain a reflective, creative, positive environment where all members of the team contribute equally to problem solving

CHAPTER 29  Older Adults with Developmental Disabilities 565 direct-access state, the physical therapist received a re- disabilities have begun to be recognized by service pro- ferral from Lisa’s home supervisor to consult with the viders and policy makers as a large heterogeneous group team regarding Lisa and the suggestion that she find an who require specialized services integrated into the ser- alternative to stationary bike riding. Upon interviewing vice system of the general population of older adults. Lisa and the supervisors, it was discovered that Lisa once enjoyed swimming, but since she had moved to This chapter reviewed the legal mandates and social this apartment 7 years ago, there had been no opportu- policy impetus guiding service to this group. The role of nity for this activity. Following a chart review, a systems the physical therapist in examining individuals and as- review, and a screening for strength, balance, and ambu- sisting team members with designing appropriate, holis- lation ability, the physical therapist determined that Lisa tic habilitation plans was presented. Although little in- was not in need of his direct services but he felt that she formation is available on specific aspects of the aging could benefit from a non–weight-bearing exercise pro- process in adults with developmental disabilities, aspects gram to avoid knee pain. The physical therapist collabo- of aging in persons with Down syndrome and cerebral rated with the apartment supervisor, recreational thera- palsy were discussed. pist, and social worker to involve Lisa in a regular swimming program at the local indoor pool at the com- Physical therapists are in a unique position to as- munity fitness center. The social worker found a com- sume leadership roles in the care of older adults with panion to accompany Lisa on the bus to the pool. The developmental disabilities and develop integrated recreation therapist arranged with the staff at the pool programs of habilitation. In addition, a critical role for to have Lisa participate in a water aerobics class. The physical therapists will be to design and foster leisure adult day care staff were made aware that Lisa would skill programming for these persons that will promote be coming in late on Wednesdays and Fridays—the days and maintain functional skills. Physical therapists also she would participate in the aerobics program. The are in a position to effect system change, specifically physical therapist was available to consult with the recognizing the importance of leisure skill program- home care providers, recreation therapist, and pool ming and creating reimbursement strategies that will staff, if necessary. take leisure skill programming into consideration. Lisa and the staff were pleased with the progress. Lisa REFERENCES experienced a problem often seen in the aging popula- tion, but her developmental disability made it difficult for To enhance this text and add value for the reader, all her to access appropriate care and activities. The thera- references are included on the companion Evolve site pist in consultation with other members of the interdisci- that accompanies this text book. The reader can view the plinary team found an activity that Lisa enjoyed and reference source and access it online whenever possible. created an effective program for her. Through a collab- There are a total of 95 cited references and other general orative effort, a program was implemented that met the references for this chapter. patient/client’s needs. SUMMARY Information regarding aging individuals with develop- mental disabilities has recently begun to receive attention in the literature.94,95 Older persons with developmental

VIP A R T Societal Issues 566

30C H A P T E R Reimbursement and Payment Policy Jean Oulund Peteet, PT, MPH, PhD, Rhea Cohn, PT, DPT INTRODUCTION payers for their insurance products and supporting pay- ment policies. Employees are dependent on the health It is virtually impossible to understand reimbursement insurance options that are offered by their employer; for physical therapy services provided to older adults however, participation is voluntary and requires em- without understanding federal programs and payment ployee cost sharing to some degree or other. Analogous policies. These programs and policies must also be con- features are found in Medicare programs and insurance sidered within the context of the American health care products. Large group employers usually offer more system and its complex blend of public and private than one health insurance option to their employees. financing. Although the United States offers techno- Small group employers usually offer only one health logically advanced health care, it has been the only insurance option. Large group employers can often ne- developed nation that did not provide universal health gotiate better premium rates because their risk pool is insurance,1 leaving some 47 million Americans without larger. Small group employers and individuals purchas- access to care.2 In 2006, 74% of Americans thought ing their own insurance have access to smaller risk pools, that the health system had serious failings or was in thereby decreasing their ability to negotiate more afford- crisis.3 Universal health insurance programs rely on able premiums. Also, one very sick employee in a small social insurance and expect that a large number of business will have serious consequences for future pre- people will each contribute small amounts of money to mium rates for the other employees. Therefore, health fund the program. The reluctance of the United States insurance premiums are generally more expensive for to embrace universal coverage is the result of funda- small business owners. mentally different political philosophies and attitudes concerning the role of government and the private sec- In contrast to the private sector, Medicare has stan- tor in formulating health care policies and underwrit- dard benefits and premiums for all individuals who ing health care policies.4,5 Thus, presidents and legisla- qualify. As more people older than age 65 years remain tors had attempted more than five times in the past employed, a greater number of older adults will likely 50 years to pass legislation for universal access to have primary health insurance coverage through their health care and previously only partially achieved it for employer and Medicare will become their secondary older adults through the Medicare law enacted in 1965 payer. In summary, the interplay between the public and and for a portion of low-income people through Med- private sector regarding health care dynamically influ- icaid legislation enacted along with the Medicare law.6 ences similarities and differences in beneficiary qualifica- tions, policy options, coverage, and premiums as well as Employment-based private insurance remains the pri- reimbursement for services. mary source of insurance coverage used by some 51% of the population in the United States.2 This fact describes Although the Medicare program is available for peo- the current context of health care policy formulation for ple age 65 years and older, access to all desirable health individuals of any age and the backdrop to all health care services is still a problem for older adults because care reform proposals affecting older adults. For exam- the Medicare program lacks coverage for many aspects ple, many ideas about how to control rising costs flow of preventive care, has limits for hospital and skilled bidirectionally between the governmental and private nursing facility (SNF) care, and lacks coverage for long- sectors. Federally funded benefits and payment schedules term care provided at home or in nursing homes. Medi- are scrutinized and often utilized by the private sector care enrollees may choose to obtain supplemental or Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc. 567

568 CHAPTER 30  Reimbursement and Payment Policy secondary coverage that will help offset their financial for hospital care (Medicare A) and voluntary insurance obligations for services provided under the Medicare for physician services (Medicare Part B). Medicaid, a program or for services that are not covered. federal and state funding program providing public as- sistance for low-income people was established at the Comprehensive health reform legislation, the Patient same time. These two programs facilitated access to Protection and Affordable Care Act (PL 111-148), was health care for individuals age 65 years and older as well signed into law by President Obama in March 2010 and as many younger people with disabilities by providing addressed many of the limitations described previously. insurance to help pay for their health care expenses.6 The law impacts both federally funded programs as well as the private insurance market. This complex law in- These programs are two among other programs that cludes provisions to expand insurance coverage to meet provide health insurance to Americans. The mix of pri- the requirement that all Americans have health insur- vate and public financed health care coverage makes the ance, to control health care costs, and to improve quality health care system in the United States complex and of care. Implementation of this law will be phased in costly. In 2008, the United States spent more than 16% through the year 2014; however, the effects will be felt of its gross domestic product (GDP) on health care— for many years.5a more than any other industrialized nation in the world.7 In contrast, Canada spent only 10%.8 Factors contribut- This chapter will help readers understand the health ing to lower costs in Canada were (1) administrative insurance programs for older adults and the complexi- costs 300% lower than in the United States, (2) lower ties of reimbursement methods and reforms to control costs per patient day in hospitals, and (3) lower physi- costs and improve quality. Application of this knowledge cian fees and pharmaceutical prices.9 The United States will enable readers to effectively advocate for patients, is spending an increasing percentage of its GDP on for older adults as a population, and for policy changes health care, and cost escalation is compelling the federal that benefit society as a whole. Health care is a rapidly government to reconsider how to fund and regulate changing industry, and readers are encouraged to refer these public programs. to the Centers for Medicare & Medicaid Services (CMS) and the American Physical Therapy Association (APTA) Funding for Health Care Coverage websites to read up-to-date information on legislation, regulatory interpretation, and opportunities for profes- The health care system in the United States can be seg- sional legislative advocacy. mented by funding source as well as the categories of services covered by the funding (Figure 30-1). Although ACCESS TO HEALTH CARE government funding (i.e., Medicare or Medicaid) is the primary payment vehicle for older adults of all income The Title 18 Amendment of the Social Security Act in levels, those adults who continue to work full-time past 1965 was landmark legislation that established Medi- age 65 years usually have employment-based or private care, a federal health insurance program for older adults Personal health care expenditures, 2005 Expenditures $1.7 trillion Out-of-pocket Private health Other Hospital State and local insurance Prescription drugs government Federal government Nursing home Physician Source of funds Other Type of expenditures private funds FIGURE 30-1  ​Sources of funds for health care expenditures and types of expenditures.  (Sources: Centers for Disease Control and Prevention, National Center for Health Statistics, Health, United States, 2007, Figure 6. Data from the Centers for Medicare & Medicaid Services.)

CHAPTER 30  Reimbursement and Payment Policy 569 insurance that will have specific coverage and limita- TABLE 30-1 Examples of Provider Payment tions. For these people, Medicare may be a secondary Methods for All Insurance Types payer.6 Figure 30-1 illustrates that hospital and physi- cian services account for more than half of the health Type Definition Provider care expenditures in the United States, making these Fee for Risk services important for examining the potential for im- An amount assigned to a specific Lowest proved efficiency and cost savings. service procedure or service Per diem Highest Historically, health care services were paid based on An amount associated with all the number and type of services provided in both the Episode of services provided in each public and private sectors. Therefore, as the number of illness day of care services provided increased, so did the potential for rev- enue growth for those providing care. This method pro- Capitation An amount for all procedures and moted an escalation in health care expenditures across services associated with an all settings, regardless of who might be responsible for episode of hospitalization reimbursement of the services. In 1983, well ahead of cost control in the private sector, the federal government A fixed payment given to providers changed this paradigm and established prospective pay- at specified intervals for all ment systems for hospitals, and in 1997 extended these care provided to patients in a systems to SNFs and home care services. Under prospec- managed care plan tive payment, Medicare reimburses acute care hospitals based on the patient’s specific diagnosis grouping, known aggregated method is capitation, where providers re- as diagnosis-related groups (DRGs) rather than paying ceive a fixed payment based on the number of enrollees for each individual service provided in the hospital. in a defined geographic area for a patient’s care during SNFs are paid a per diem rate based on a classification a month or year, regardless of the type or number of gleaned from an evaluation tool known as the Minimum services provided. Capitation is less common than it Data Set. Home health agencies use yet another tool, was 10 years ago and has primarily been used for pri- Outcome and Assessment Information Set, that assists mary care physicians. Payers can control costs by se- with the classification of payment.6 lecting a payment method, such as fee schedules or contracted payment rates with preferred providers.5 Although each of these prospective payment systems Because hospitals and providers were historically paid are configured differently, they all provide a common on a fee-for-service basis contributing to escalated incentive—provide care in a cost-effective manner be- costs, there was a rise in managed care plans in the cause the payment for the admission will essentially be private market in the 1990s.5 These plans utilized pay- the same, regardless of the number or type of services ment mechanisms that favored more aggregated pay- provided. Prospective payment has not yet been devel- ment methodologies. The evolution of payment meth- oped for outpatient services. It should be noted, how- odologies continues as payers search for the most ever, that current outpatient payment methodologies effective way to control costs and ensure the provision are broadly perceived as unsustainable and the federal of appropriate services. government continues to explore alternatives. Medi- care and Medicaid, not unlike private insurers, want to A number of broader strategies are also used to con- become more active purchasers of health care and, at trol costs. Regulations and competition are two com- the same time, influence how their beneficiaries access monly used strategies to limit the amount of money that services. providers receive. The traditional fee-for-service Medi- care program is an example of a program that uses regu- Cost Control Methods across All Settings latory strategies and an adjustable fee schedule conver- sion factor to control costs. The Balanced Budget Act of Health care insurers, purchasers of health care cover- 1997 is the most dramatic example of legislation that age, and providers alike are concerned about costs and reduced reimbursement for services.10 The reduction in several methods have been, and are being, used to con- payments along with stricter and comprehensive regula- trol health care costs.5 First, payments to providers are tions are intended to control utilization of services and controlled by different reimbursement methodologies. expense to the program. Fee for service, per diem, episode of illness, and capita- tion are the primary methods. Table 30-1 provides a Competitive strategies focus on making purchasers definition of these methods and illustrates that each (employers and employees) more price-sensitive. Em- method carries a different level of risk for providers. ployers negotiate with insurers to maintain or lower Fee for service is the least aggregated method of premium rates, revise employee deductibles and payment whereby a provider or hospital is paid a fee copayments, and determine a reasonable benefit pack- for each procedure or service provided. The most age for their employees. A few large group employers have begun to design their employee health insurance benefit to promote use of prevention services that will

570 CHAPTER 30  Reimbursement and Payment Policy ultimately save costs associated with inappropriate BOX 30-1 Common Cost Control Mechanisms use of hospitalizations, imaging, and emergency de- partment visits.11 Employees and individuals purchas- 1. Choice of payment methodology for providers ing their own insurance coverage usually select a plan 2. Utilization management based on price; however, educated consumers may 3 . Benefit restrictions also consider the details of the benefit package. 4 . Increased patient cost-sharing 5 . Limitations on covered services There are economists who oppose the traditional in- 6. Financial caps on services surers’ response to competitive market forces, that is, raising rates or diminishing the benefit package. It can be facility-based services.13 One concern with this mecha- argued that a more beneficial long-term approach would nism is that cost sharing creates inequity for lower be to encourage utilization of services that will provide income patients as they pay a higher percentage of their higher quality outcomes at lower costs. Another payer total income toward health care. strategy to decrease financial exposure is to select enroll- ees based on the likelihood of enrollees having or devel- Employers, providers, patients, and payers all assume oping a particular health condition, hoping to assume as some level of risk. Varying payment methodologies shift little risk as possible for future expenditures. risk among these groups and influence consumer behav- iors related to accessing services and choosing providers. Insurers can also control their expenses by reducing Each of these cost controls is in some way “painful” to the payments to providers and hospitals. A response by one or more of these entities and understanding the im- providers to such reductions can be increased utilization pact a cost control has on any entity, whether patient, of services or procedures, or contracting with insurers provider or payer, is important to understanding that who offer better reimbursement for the delivery of the entity’s response to the control.5 No matter who is service. Medicare and other third-party payers carefully affected or in what ways, physical therapists must al- monitor utilization of services by all providers. If an ways bear in mind that payment methodologies and cost unexpected and unwarranted increase in utilization is control strategies will always either support or restrict detected, the usual response is yet another type of pay- access to care. Moreover, it is highly unlikely that any ment control mechanism. Private payers usually monitor particular combination is “all good” or “all bad.” On use of services either concurrently (while the services are the contrary, the best system will optimize the “pros” for being provided) or retrospectively (after the care is com- all entities and simultaneously minimize the “cons” of plete). This review of services, known as “utilization various mechanisms for each entity as well. Box 30-1 management,” is a third type of cost control mechanism details common cost control mechanisms. highly utilized by managed care plans.4,5 HEALTH INSURANCE PROGRAMS: Most payers have defined benefits for coverage of MEDICARE physical therapy services. This fourth method of con- trolling costs helps the payers predetermine their liabil- The Department of Health and Human Services, part of ity for physical therapy services. A benefit for physical the executive branch of the federal government, admin- therapy could be defined by a specified number of visits isters the Medicare program and funds it through contri- per year (e.g., 20 visits per year) or a specific number of butions from employees who have paid into the Social visits per condition. Medicare has intermittently had a Security system. This entitlement program has no pre- financial cap on services provided under a physical mium for Part A (hospital services) but does have a therapy plan of care.12 Medicare and many other payers premium ($96.40 to $110.50/month in 2010) for the specify that physical therapy must be for restorative voluntary component, Part B (medical services and du- care rather than maintenance care. Although many pro- rable medical equipment). People can also purchase viders, including physical therapists, realize the poten- supplemental private insurance known as Medigap to tial benefits from prevention services, this is usually not help pay for Part A and B uncovered services. Box 30-2 a covered benefit. All of these controls help the payers provides examples of services provided under Medicare know the extent of their financial liability for physical A and B. Box 30-3 details coverage of Parts A, B, C, and therapy services, thereby reducing their risk and, ulti- D of the Medicare program. Both Medicare A and B mately, their costs. require the patient to make out-of-pocket payments for deductibles and coinsurance costs. The deductible and Patient cost-sharing is yet another type of cost control copayments only apply to covered services. If a particu- mechanism and is very typical throughout the industry. lar service is not covered, the patient must be notified in When instituted, patients may pay a portion of the pre- advance and would have to assume full financial respon- mium and also assume responsibility for the deductible sibility for that service.13 and copayments. Medicare uses this method as does the private sector. Medicare beneficiaries typically have a copayment of 20% for some services, an annual deduct- ible, and/or a per diem fee associated with hospital or

CHAPTER 30  Reimbursement and Payment Policy 571 B O X 3 0 - 2 Medicare Part A and Part B: BOX 30-3 Medicare Choices Examples of Covered Services Original Medicare Part A and Part B Medicare Part A (Hospital Insurance) • Run by federal government • Hospital stay • Provides Part A (Hospital Insurance)—no premium for adults • Skilled nursing facility stay • Inpatient rehabilitation facility who are eligible for Social Security or Railroad Retirement • Home health care Benefits • Hospice care • Provides Part B (Medical Insurance)—requires a monthly premium Medicare Part B (Medical Insurance) • Beneficiary pays deductibles and coinsurance Helps to cover: • Beneficiary can add drug coverage (Part D) and purchase • Doctor’s services, outpatient care a Medigap policy from a private insurer to cover some • Outpatient mental health therapy services out-of-pocket expenses • Occupational, physical, and speech–language pathology services • Outpatient diagnostic tests Medicare Advantage Plans–Part C (similar to Health Maintenance Organizations and Preferred Provider Examples of Medicare Part B Covered Preventive Organizations) Services • Run by Medicare-approved private companies • Abdominal aortic aneurysm screening • Provide Parts A, B, and D • Bone density measurement every 2 years • A Medigap policy is not needed • Cardiovascular screening every 5 years • Costs vary by plan • Colorectal cancer screenings • Diabetes screenings for people with high-risk factors Other • Flu shots • Medicare Cost Plans, Demonstration and Pilot programs, • Glaucoma tests • Mammograms Programs of All-Inclusive Care for the Elderly (PACE) • One-time “Welcome to Medicare” physical exam • Pap tests Medicare Part D Drug Coverage • Prostate cancer screenings • Run by Medicare-approved insurance companies • Smoking cessation counseling • Beneficiary pays a monthly premium • Beneficiary can change plans once per year Examples of Part A and Part B Non-Covered Services • Acupuncture standardize a retiree’s coverage, regardless of residence, • Chiropractic services within the framework of a Medicare Part C model.14 • Custodial care • Deductibles, coinsurance or copayments Medicare Part D, implemented in 2006, provides op- • Dental care and dentures tional prescription drug coverage to all Medicare enroll- • Eye exams ees. Plans vary in cost and in drugs that are covered. To • Foot care obtain Medicare drug coverage, patients must join a • Hearing aids and exams plan run by an insurance company that is in their state.6 Medicare Part D provides coverage of medications up to Medicare Part C offers an alternative to the tradi- a certain dollar amount ($2840 in 2011); there is no tional Medicare fee-for-service coverage, which allows a additional coverage until they have reached the ceiling of beneficiary to choose to join a Medicare-approved the “donut hole” ($4550 in 2011)13 (Table 30-2). Thera- health plan that is operated by a private insurance pists need to be sensitive to the possibility that their payer. Costs vary by plans and the plans provide cover- patients may be without drug coverage for a portion of age for Parts A, B, and D (Prescription Drug Coverage). the year and this could seriously affect the levels of par- These plans are more comprehensive than traditional ticipation in therapy as well as the outcome of care. Medicare coverage, and patients do not need a Medigap policy if they choose this plan.13 This type of coverage Medicare Coverage in Different Settings is attractive to beneficiaries because they will have lower out-of-pocket costs; however, they are limited to a re- The Medicare program offers varying coverage in differ- stricted provider network. A newer alternative is the ent practice settings for services and durable medical Medicare Part C fee-for-service health plan. These plans equipment (DME). Benefits in the acute care hospital, are most often offered to retirees of large companies inpatient rehabilitation, SNFs, outpatient settings, home that need to devise ways to cover lives dispersed across health, hospice, the community, and DME coverage can many areas of the country. This permits the employer to be accessed through Chapter 15 of the Medicare Benefit Policy Manual.16 It is important for providers to access this manual and its updates on a regular basis to mini- mize the risk for claims denials.

572 CHAPTER 30  Reimbursement and Payment Policy TA B L E 3 0 - 2 Example of Medicare Drug Costs Ms. Smith joins the ABC Prescription Drug Plan. Her coverage begins on January 1, 2010. She doesn’t get “extra help” and uses her Medicare drug plan membership card when she buys prescriptions. Yearly Deductible Copayment or Coinsurance Coverage Gap Catastrophic Coverage Ms. Smith pays the first Ms. Smith pays a copayment, and Once Ms. Smith and her plan have Once Ms. Smith has spent $4550 $310 of her drug her plan pays its share for each spent $2840 for covered drugs, out of pocket for the year, her costs before her plan covered drug until what they she is in the coverage gap. She coverage gap ends. Now she starts to pay its pay (plus the deductible) will have to pay all of her drug only pays a small copayment for share. reaches $2840. costs beyond the $2700, until each drug until the end of the she reaches $4550. Some drugs year. will be discounted through 2020 when she will have full coverage in the gap. Source: Medicare and You 2010.13 Acute Care Hospital.  ​Medicare Part A covers acute care created an incentive for hospitals that provide specific- inpatient hospital stays for 90 days of care per episode of quality data to the U.S. Department of Health and Hu- illness with 60 lifetime reserve days. The “episode” begins man Services to receive the full rate increase.17 when a person is admitted, and ends when the person has Inpatient Rehabilitation.  ​Inpatient rehabilitation fa- been out of the hospital or SNF for 60 consecutive days. cilities (IRFs) provide intensive services such as physical, Box 30-4 provides an example of the out-of-pocket costs occupational, or speech therapy for patients after sur- a person would pay in 2011 for a hospitalization.13 gery, an injury, or illness. To qualify for Medicare cover- age, patients must be able to benefit from and tolerate Medicare groups patients with similar clinical prob- 3 hours of therapy for 5 of 7 days each week or partici- lems into DRGs and reimburses hospitals based on the pate in 15 hours of therapy in 7 days. When patients are DRG and the Inpatient Prospective Payment Rate (IPPS) transferred from an acute care hospital to an IRF, they per discharge that includes a complex method of account- have no additional deductible. However, they will have ing for the patient’s condition, treatment, and the market a deductible to meet if admitted from the community. conditions of the hospital’s location. The hospital receives Acute hospital days and IRF days all count toward the the same payment whether the patient stays in the hospi- Medicare Part A inpatient hospital limits.18 tal 3 days or 3 weeks (although outlier payments are added for excessively complex patients). In 2009, Medi- Reimbursement to IRFs has been under a prospective care implemented a transition to a system that is known payment system (PPS) since 2002. IRFs receive a prede- as Medicare severity (MS) DRGs that increase the number termined per-discharge rate based on the patient’s diag- of DRGs and recognizes comorbidities and major compli- nosis, cognitive status, functional status, market area cations. Rates are annually updated and Medicare has wages, and a system of case-mix categories that reflects the expected resources needed to provide care. The rate BO X 3 0 - 4 Example of Out-of-Pocket Costs covers all capital and operating costs associated with for Medicare Services13 providing intensive rehabilitation. Medicare increases payment rates for rural areas (because of fewer cases in Sonia is 68 years old and has Medicare parts A and B. She experi- those areas, longer length of stays, and higher costs per ences a cerebral vascular accident with multiple medical complica- case), makes adjustments for teaching institutions, and tions. She spends 65 days in the hospital, followed by 25 days in a for patient stays that are outliers providing a lower rate skilled nursing facility (SNF), and then receives home health services for short stays and a higher rate for high-cost stays.18 (nursing, physical therapy, occupational therapy, speech–language pathology) for 21 days. Her out-of-pocket costs in 2011 for these An important rule applied to IRF admissions is the settings would be: 60% rule (formerly known as the 75% rule) whereby in order for an IRF to receive payment, 60% of their ad- Hospital deductible $283 3 5 days 5 $1132.00 missions must have one or more of 13 qualifying medi- Hospital daily cost $141.50 3 5 days cal conditions. Box 30-5 lists those conditions as of 5 $1415.00 2009.18 The 60% rule intends to promote proper place- after 60 days ment of postacute care patients into the most cost- SNF daily cost after 5 $707.50 effective setting. If a patient covered by Medicare can- 5 0.00 not tolerate 3 hours of therapy each day or if the 20 days $3254.50 patient’s condition does not warrant comprehensive Home health care rehabilitation combined with 24-hour skilled nursing TOTAL and medical supervision, Medicare will not cover the See Table 30-2 for out-of-pocket costs she would incur for drugs once she is home.

CHAPTER 30  Reimbursement and Payment Policy 573 BOX 30-5 Inpatient Rehabilitation Facility services are included in the prospective bundled payment Conditions That Qualify for Medicare made by Medicare to the SNF.13 Under the 60% Rule16 Outpatient Therapy Services.  ​Outpatient therapy ser- vices include physical therapy, occupational therapy, and Stroke speech-language pathology, and can be provided in dif- Spinal cord injury ferent settings. Figure 30-2 illustrates how therapy tends Congenital deformity to be distributed by setting. More than half of outpatient Amputation services are provided in nursing homes and private prac- Major multiple trauma tices under the Part B benefit. In order for Medicare to Hip fracture cover these services, they must be provided by qualified Brain injury provider (i.e., not an aide), be appropriate and effective Neurologic disorders (such as multiple sclerosis, Parkinson’s for a patient’s condition, and be reasonable in terms of frequency, intensity, and duration.19 Technically, a refer- disease ral to therapy from a physician is not required under the Burns Medicare program; however, a physician must sign the Three arthritis conditions for which appropriate, aggressive, and therapy plan of care within 30 days of the initial therapy treatment. Therefore, if state law permits, a therapist can sustained outpatient therapy has failed evaluate a patient covered by Medicare without a refer- Joint replacement for both knees or hips when the surgery immedi- ral, and subsequently ask the physician to sign the plan of care. The physician must recertify the plan of care ately precedes admission when body mass index is greater than every 90 days, but may request to recertify the plan of or equal to 50 or age is .85 years. care sooner. The patient must have impairments that have the potential to improve with therapy interven- admission to an IRF. Instead, that patient may be a tions. Medicare will not cover any treatment intended to more appropriate candidate for an SNF, which is con- maintain the same level of function or that is a general sidered a less intense level and lower cost level of care. exercise program. Medicare will, however, cover the in- struction of a home exercise program to the patient or Like acute care facilities, prospective payment pro- vides an incentive for IRFs to control costs, either by Distribution of outpatient therapy spending by setting managing the number and type of services being pro- vided or minimizing the length of stay. The outcome of OT private care could potentially be negatively affected if an IRF practice were to provide insufficient or inadequate care because CORF 2% of reducing the delivery of necessary services with the 3% goal of increasing profit from the prospective payment. Skilled Nursing Facilities.  ​Skilled nursing facilities may Physician Hospial provide 24-hour skilled care and/or custodial (also office outpatient known as maintenance) care, either for short-term skilled 7% nursing and/or rehabilitation or for long-term care. 20% Medicare and most private insurance will cover care ORF provided in an SNF for a limited time if the patient had 12% been hospitalized for 3 days, enters the SNF within 30 days of an acute care hospitalization discharge, and PT private Nursing requires skilled care from a registered nurse and reha- practice home bilitation therapies. The patient must be making func- 27% 29% tional gains to qualify. In an SNF stay covered by Medi- care Part A, the patient has no financial obligation for FIGURE 30-2  ​Medicare outpatient therapy services by setting. the first 20 days. Starting on day 21, the patient is re- sponsible for a daily copayment, and there is a 100-day CORF, comprehensive rehabilitation facility; ORF, outpatient reha- maximum stay.13,15 bilitation facility; OT, occupational therapist; PT, physical therapist. (From Medpac: Outpatient Therapy Services Payment System. In a SNF, Medicare covers physical therapy evaluation http://www.medpac.gov/documents/MedPAC_Payment_Basics_08_ and treatment programs, as long as the patient meets the OPT.pdf.) requirement of being able to make functional progress. Progress needs to be demonstrated in the documentation. Therapists may provide the treatment or supervise a physical therapist assistant to administer the treatment program. When the patient is no longer making func- tional gains that support the continued use of skilled providers, Medicare will cover the instruction of a main- tenance program to ancillary personnel. Again, docu- mentation needs to support this instruction. Therapy

574 CHAPTER 30  Reimbursement and Payment Policy caregiver.19 Medicare covers some services when pro- have caused home health services to provide more spe- vided by a physical or occupational therapist assistant cialized services such as nutritional feeding via feeding only if a qualified therapist is supervising the assistant as tubes, intravenous antibiotic infusions, home renal dial- regulated by Medicare. If state law regarding supervision ysis antibiotic, morphine pumps, and chemotherapy. is more stringent than the Medicare regulations, Medi- This decrease in length of stay has concomitantly in- care will follow state laws. Medicare does not permit creased the level of complexity of the patient conditions physicians to directly supervise physical or occupational in the home health setting, requiring therapists in the therapy assistants when services are provided “incident home care setting to use knowledge and skills generally to” the physician’s services. States may allow physician associated with therapists in acute care settings.5 assistants, nurse practitioners, and clinical nurse special- Hospice Care.  ​Hospice care gives patients the choice to ists to provide therapy services. Medicare does not rec- maintain quality of life, remain alert and pain-free, and ognize aides, chiropractors, athletic trainers, and nurses to receive end-of-life care at home, in a hospital or nurs- as qualified providers of therapy services and these pro- ing facility. End-of-life care is costly; some 27% of viders cannot bill Medicare for such services.19 Medicare dollars are spent in patients’ last year of life.23 Hospice care is a lower-cost alternative. Public or pri- Congress has been involved since 1972 in setting vate hospice organizations provide supportive services forth laws that both enable physical therapists to pro- and pain relief to terminally ill patients who are ex- vide outpatient services and also restrict those services pected to live 6 months or less as determined by their through spending caps.21 Therapists are paid under physician. Care is provided in the patient’s home or in Medicare’s physician fee schedule (PFS). Public Law hospice care based in a hospital or nursing facility. 92-03 of 1972 allowed qualified physical therapists in Medicare Part A helps to pay for these services when the independent practice to provide services in a patient’s following conditions are met: (1) a doctor certifies that home or the therapist’s office, thereby increasing pa- a patient is terminally ill; (2) a patient chooses to receive tients’ access to care. However, since 1979, Medicare has care from a hospice instead of curative treatment for the imposed various reimbursement caps on Part B services terminal illness; and (3) care is provided by a Medicare- provided by physical therapists, occupational therapists, participating hospice program. Box 30-6 details the and speech–language pathologists.20 These caps do not services that hospices can provide. Physical, occupa- affect outpatient rehabilitation services provided in inpa- tional, and speech therapy are covered under Medicare, tient hospitals, inpatient skilled nursing facilities, and as are all other services, when treatment is for pain relief most home health settings that are covered under Medi- and symptom management.13 care Part A. Home Health Services.  H​ ome health services may in- Hospice services are growing and Medicare estimates clude medically necessary intermittent skilled nursing, that spending for hospice by 2018 will double, repre- physical therapy, occupational therapy, speech-language senting the largest growth rate of all Part A services.24 pathology, medical social work, home health aide ser- Medicare pays for these services through a daily rate vices, and DME for homebound patients. Medicare Part schedule that includes four base payment amounts based A covers these services and includes 100 days of service on the type of hospice care provided: routine care, con- after a hospitalization. The patient has no copayments tinuous home care, inpatient respite care, and general for these services. Since 2000, the CMS has utilized a inpatient care. Most care (95% of days paid for under prospective payment system for home health services hospice) is provided at the routine home care level. and pays home health agencies a preestablished rate Patients pay no copayment for these services and only for each 60-day episode of illness. Patients who require $5/day for inpatient respite care.25 five or more visits are categorized in 1 of 153 home Community Services, Prevention, and Wellness.  ​The health resource groups based on the measurement tool, United States health care system in 2006 spent less than the Outcome and Assessment Information Set (OASIS). 3% of the $2.1 trillion health care dollars on services to Clinical and functional status, expected resource use in the different groups, and geographic factors are consid- B O X 3 0 - 6 Medicare Hospice Benefits23 ered in developing the payment rates.22 Private practice physical therapists may see patients in the patient’s home Skilled nursing service under the Part B benefit and the reimbursement is based Drugs for pain control symptom management on the Physician Fee Schedule used for Part B services. Physical, occupational, and speech therapy The claim form must note that the service was provided Dietary, spiritual, family bereavement and other counseling services in the home. Home health aide and homemaker services Short-term inpatient respite care and symptom and pain Historically, home health agencies provided services that assisted people with their functional limitations in- management cluding activities of daily living and instrumental activi- Other services needed for palliation and management of the ties of daily living. However, the demands and incentives placed on hospitals that promote shorter length of stays terminal illness

CHAPTER 30  Reimbursement and Payment Policy 575 prevent illness,5 despite research showing that the risks Durable Medical Equipment.  ​Medicare covers equip- of the top causes of death in the United States, including ment a patient needs at home to treat his or her health cardiovascular heart disease, cancer, and cerebrovascular problem under its DME benefit through Part A benefits. disease, are in large part reducible26 if people adopt be- DME is also available under Part B benefits. DME is haviors such as eating a low-fat diet, not smoking, and equipment that is reusable, such as wheelchairs and increasing their physical activity. walkers.29 Thus, all patients have access to this benefit and Box 30-7 shows the conditions and categories of Historically, Medicare has been a health insurance coverage. The categories are additionally sorted into program focusing on treating health problems within some 2000 product groups and within these groups, the health care settings. Medicare covers some preventive payment rate is the same using a fee schedule that Medi- screenings and services as detailed in Box 30-2. How- care sets.29 Medicare has seen widespread abuse in the ever, these services have little if any impact on primary area of DME and closely monitors acquisition and pay- prevention of the major causes of death when initiated at ment for DME. In response to the abuse, the new Com- the time of Medicare enrollment, age 65 and older. Be- petitive Bidding Program is being implemented in an cause Medicare is primarily a program for older adults, attempt to rein in costs of the DME benefit and ensure it cannot address the need for risk reduction in health that beneficiaries are receiving appropriate equipment.29a plans or programs that cover children and young adults. REGULATIONS AND PRACTICE Recognizing that a large number of Medicare benefi- IMPLICATIONS ciaries have one or more chronic conditions that are costly and require the expertise of multiple specialists, Medicare Contracting Reform Medicare is testing a new model termed “medical home.” In a “medical home,” the high-need older adult will be The Medicare program is vast and administrative duties part of a physician-directed medical practice that coordi- are contracted to certain entities known as contractors. nates access to care, utilizes an electronic medical record, In the past, carriers and fiscal intermediaries (FIs) were and monitors use of pharmaceuticals and specialty ser- the entities that managed claims for Part A and Part B vices. Medical homes will be paid an additional amount services. The Medicare Prescription Drug, Improvement, per patient to cover their added value for managing the and Modernization Act (MMA) passed by Congress in patients’ multiple needs.27 The medical home initiative is 2003 required the CMS to replace the existing FI and meant to promote coordination of services for beneficia- carrier contracts for Part A and Part B services with ries who are using multiple providers and resources. The competitively procured contracts. The provisions con- intent is not only to provide cost savings for the program tained under section 911 of the MMA are collectively but also to coordinate and improve the care provided to referred to as Medicare Contracting Reform.30 The CMS the beneficiaries. was given 6 years, between 2005 and 2011, to complete the transition of Medicare Fee-for-Service claims pro- Another targeted program for high-need older cessing activities for Part A and Part B services from the adults is the Programs of All Inclusive Care for the FIs and carriers to 15 Medicare Administrative Contrac- Elderly (PACE). In this program, medical, social, and tors. These contractors will be a single point of contact long-term-care services as well as drug coverage are for providers and beneficiaries and also become a mod- provided through community-based care to seniors ern administrative information technology platform. who otherwise would need nursing home level of Also, each Medicare Administrative Contractor will in- care.6 Medicare and Medicaid fund PACE jointly and teract with one Program Safeguard Contractor regarding although the program has demonstrated cost savings investigations of fraud and abuse. through lower hospitalization rates, it only serves a very small portion of older adults who are high need.28 The Medicare program has two layers of coverage. As Medicare works to control costs, it will necessarily First, Medicare will cover specific services, procedures, continue to focus on helping older adults stay well and avoid use of unnecessary medical services. B O X 3 0 - 7 Durable Medical Equipment (DME) Covered Under Medicare27 Conditions of Coverage Categories of Covered Equipment • Withstand repeated use • Inexpensive or routinely purchased equipment • Primarily service a medical purpose • Items that require frequent and substantial • Generally not be useful to a person without servicing an illness or injury • Prosthetic and orthotic devices • Capped rental items • Oxygen and oxygen equipment

576 CHAPTER 30  Reimbursement and Payment Policy or technologies on a national basis as outlined in na- The calculation for payment of services under the Part tional coverage decisions (NCDs). The CMS publication B Physician Fee Schedule changes each year, and changes 100-03, National Coverage Determinations Manual, is are usually effective January 1 of each year. The payment the source document for the NCDs.31 changes because of revisions in the valuing of the Current Procedural Terminology (CPT) codes, the geographic Contractors must follow the guidance issued in practice cost index, or the conversion factor.35 The annu- NCDs. If an NCD does not specifically exclude or limit ally assigned conversion factor, a dollar amount that is an item or service, or if the item or service is not men- included in a formula with the value of the code and the tioned in an NCD, a Medicare contractor may choose to geographic practice cost index, changes the payment rate write a local coverage determination (LCD). An LCD year to year. So although the relative value of each billing contains “reasonable and necessary” information about code may not change, the actual payment for services will coverage.32 Each contractor has a website that includes change because of the updated conversion factor. its LCDs. The contractors are required to publish articles that provide guidance for providers regarding any perti- The Medicare Benefit Policy Manual (Publication nent coverage decisions. 100-02, Chapter 15, Sections 220-230) details the ben- efit available to beneficiaries related to Part B therapy The practical application of this information is critical services.36 The manual includes information regarding to understanding and obtaining payment under the conditions of coverage, reasonable and necessary ther- Medicare program and decreasing provider risk for de- apy services, use of qualified personnel, supervision, nial of payment. Providers should not assume that all documentation requirements, and the plan of care. Cor- services are covered under the program and if they are in rect implementation of this information is critical or the doubt, should access the NCDs and LCDs prior to devel- provider may be at risk of denial during claims process- oping a plan of care with the patient. If a service is not ing or payback after an audit. covered as defined by an NCD or LCD, then the pro- vider should discuss this with a patient in advance of For many years, Medicare has utilized an annual pay- providing the treatment and inquire if the patient would ment cap on Part B therapy services as a means to con- assume the financial responsibility if the service or item trol costs.37 The cap on physical therapy services is is provided. This conversation must be documented us- combined with services provided by speech–language ing the Advance Beneficiary Notification form and in- pathologists. The cap for occupational therapy services cluded in the medical record.33 If the patient does not stands alone. The cap in 1997 was raised to $1500 un- want an additional financial obligation above and be- der the Balanced Budget Act and continues to exist in yond his or her deductible and copay, then the provider 2010, at $1860 per beneficiary for physical therapy and needs to consider alternative treatment options and speech-language pathology, and a separate $1860 limit document the alternative plan in the medical record. If for occupational therapy.21 This method of controlling the service is not covered under the LCD as being “rea- costs has been politically controversial and has been ap- sonable and necessary,” the patient cannot be charged plied with and without an exceptions process. Therapy for the service or item, even if it is rendered. Knowledge providers affected by the cap, along with their profes- and implementation of information contained in NCDs sional organizations, have aggressively advocated for and LCDs will decrease the provider’s risk pertaining to removal of the cap. The APTA has been a steadfast voice fraud, abuse, and claims denials. on behalf of its members to have the caps removed, as have the American Occupational Therapy Association Medicare Cost Control Mechanisms and the American Speech Language Hearing Associa- tion. These associations stressed that the caps are an Under Medicare, payment to facilities and home health arbitrary restriction placed on therapy providers and agencies is made under a prospective payment methodol- negatively affected patients who either require multiple ogy. Currently, payment for Medicare’s Part B services is episodes of therapy within a calendar year or have a seri- made under a fee schedule called the “Physician Fee Sched- ous condition requiring extensive therapy (e.g., stroke). ule.”34 Medicare has multiple mechanisms to control costs Although an exceptions process, which excluded pa- for services covered under Part B. Despite the current con- tients with some diagnoses from the cap, was enacted in trols, the program is actively considering alternative pay- 2005 under the Deficit Reduction Act, it places addi- ment mechanisms that will not only control costs but also tional administrative burden during the claims submis- align provider incentives with the goals of the program. At sion process.20 Although these spending restrictions may the time of this writing, the most visible controls that are result in cost savings to the Medicare program, patients currently in place and the most important to understand and providers alike continue to challenge these laws.12 include the fee schedule conversion factor, the benefit defi- Medicare’s interest in an alternative payment methodol- nition, coverage guidelines as previously discussed, the ogy is partly a result of the recognition that the cap is therapy cap, the Correct Coding Initiative program, and arbitrary and negatively affects their beneficiaries who the Recovery Audit Contractor program. have complex and long-term rehabilitation needs.

CHAPTER 30  Reimbursement and Payment Policy 577 The National Correct Coding Initiative (NCCI) was the guidance reflects the minimum requirements for developed as a means to control improper and duplica- documentation and that any state laws that are stricter tive billing under the Medicare program for Part B ser- will supersede Medicare’s requirements. The documen- vices.38 NCCI is an extensive list of claims edits that are tation needs to defend the patient’s need for skilled applied when claims are processed. The contractors use services or medically reasonable and necessary care. the edits to reduce their liability for inappropriate The Benefit Manual states: claims. At the time of claims submission, there is the op- tion for some code pairs identified as duplicative services Services are medically necessary if the documentation indi- to be modified on the claim form. The use of a modifier will alert the contractor that the services were provided cates they meet the requirements for medical necessity in different time intervals and, consequently, should not be considered duplicative. Use of the modifier on the including that they are skilled, rehabilitative services, pro- claim form requires complete and thorough documenta- tion to support the claim. Anyone submitting claims to vided by clinicians (or qualified professionals when appro- the program should familiarize themselves with the NCCI edits prior to submitting claims or they will as- priate) with the approval of a physician/NPP, safe, and ef- sume an unnecessary level of risk for claims denials. fective (i.e., progress indicates that the care is effective in The Medicare program has a variety of mechanisms to investigate overpayments made by contractors. Not rehabilitation of function).41 only do the contractors themselves have an audit mecha- nism but they will also rely on the four new Recovery Not all payers have such detailed documentation guid- Audit Contractors (RACs).39 The RAC program is being ance. However, all therapists should familiarize themselves phased in and medical necessity reviews will begin in with the Medicare Benefit Manual language as some pri- earnest in 2010. The RACs have a financial incentive to vate payers have adopted Medicare’s guidance. If a pro- identify over- and underpayments made by the program. vider is able to comply with Medicare’s documentation Initially, the RACs will look at hospital and facility requirements, it will most likely meet the requirements of claims, but services provided under Part B as well as other payers. The Benefit Manual has detailed information providers of DME will also be audited. Any provider pertaining to evaluations and reevaluations, progress that submits claims to a Medicare contractor should notes, treatment notes, and discharge notes. It should also track the implementation of this program and be pre- be noted that each contractor’s LCDs may have guidance pared for an audit. The four RACs are required to offer pertaining to documentation. Providers should access educational sessions to providers in their region. It is those documents and carefully follow the instructions. highly recommended that any provider participating in the Medicare program be knowledgeable about this A payer expects that the documentation will reflect initiative. the need for skilled services and include information pertaining to the patient’s progress. So rather than just Documentation noting a specific impairment measurement, it is recom- mended that the provider translate that measurement The medical record serves many purposes, including into a functional finding that reflects the need for being a formal record of the patient’s status and the skilled services. For example, instead of noting only services that were provided to the patient. Even more that the patient has “Fair plus” strength of the quadri- critical and challenging for physical therapists is that ceps, it would be far more informative for a reviewer to the medical record must reflect the decision making of also see how that impairment affects the patient’s func- the provider and substantiate the need for skilled care, tion. Box 30-8 provides an example of documentation regardless of the site of the provision of care. Some that includes the translation of the impairment into third-party payers, including Medicare, have detailed activity limitation. documentation requirements, and the payment for ser- vices is often dependent on the information contained in The APTA has a Web-based tool for members called the medical record. The documentation must substanti- “Defensible Documentation.” This interactive tool pro- ate the services that are reported on claim forms. Other- vides therapists with a wealth of information pertaining wise, the services are at risk for nonpayment should the to documentation and its importance relative to reim- documentation be audited. bursement for services.42 For Part B services, Medicare’s detailed guidance for BOX 30-8 An Example of Documentation documentation is located in the Medicare Benefit That Includes the Translation Manual, Publication 100-02, Chapter 15, Sections of an Impairment into Activity 220-230.40 The Medicare Benefit Manual states that Limitation Language Strength Functional Deficit F1 right quadriceps Patient requires a standard cane on all surfaces; unable to climb stairs without a railing or minimal guarding of one person.

578 CHAPTER 30  Reimbursement and Payment Policy In summary, the Medicare program provides access to should not have a pattern of waiving fees or providing health care for all older adults. There are restrictions in discounts that could be construed as inducement. Pro- benefits, and cost-sharing with beneficiaries is required viders should have written policies and procedures for for some services. Although the historical focus of the these exceptions, and there should be no identifiable pat- program has been coverage for illness and injury, the tern of discounting or waiving fees. program is beginning to focus attention on prevention services as a means to both improve beneficiary health Submitting claims that misrepresent the services that and lower costs. The program has transitioned to pro- were provided is another form of fraud. Unbundling spective payment in hospitals, SNFs, and home health. CPT codes (billing separately for each component of an Services covered under Part B continue to be paid under all-inclusive procedure code), reporting more services a fee schedule. Medicare has signaled its intent to be- than what were actually provided, or misrepresenting come a “value-based” purchaser and resources are in- who provided the services are all examples of intentional creasingly being devoted to promote better use of the erroneous billing. Guidance for compliance activities is limited resources. Therapists and other providers need to available on the OIG website.44 and professional asso- closely monitor Medicare’s activities in this area. The ciations such as the APTA offer considerable informa- changing population demographics will continue to be a tion and education pertaining to fraud and abuse.45 driving force for Medicare to be fiscally prudent in its spending. The Physician Self-Referral Prohibition statute, some- times called the “Stark Law,” prohibits physicians from Fraud and Abuse referring to designated health services or entities in which the physician or a family member has a financial All third-party payers are concerned with overutilization interest, unless an exception is permitted. Physical ther- of services and cost controls. However, it is a priority of apy is considered a designated health service. However, payers, particularly Medicare and Medicaid, to identify exceptions have been identified. For example, if the ser- activities that improperly utilize limited public monies vice is being provided by someone who is supervised by needed for their beneficiaries’ health care. The Office of that physician, the exception is permissible under the “in Inspector General (OIG) is responsible to protect the office ancillary services” provision. This law applies only programs covered by the Department of Health and Hu- to physicians and intent does not have to be apparent. man Services such as Medicare and Medicaid. Through Civil penalties are applied for Stark law violations and a coordinated program of audits, investigations, and in- these are less onerous than the criminal penalties under spections and the publication of advisory opinions and the Anti-Kickback statute.43 compliance guidance, the OIG manages activities related to fraud and abuse. Providers in all settings should be aware of the legal ramifications of the provision and billing of services they The Anti-Kickback statute and the Physician Self- provide. They should not assume that the billing office Referral laws are very important for all providers to or billing service is appropriately reporting their services. understand. The rationale behind these two statutes is Rather, they should regularly ask to see bills that are that the government does not want to encourage incen- generated and compare them to internal fee slips and tives that would increase inappropriate utilization of documentation. The treating therapist whose name is on services and distort medical decision making. The Anti- the claim form is responsible for the bills that are gener- Kickback Statute of the Social Security Act makes it a ated and will have to defend any claims that are audited. criminal offense to knowingly and willfully “offer, pay, solicit, or receive any remuneration to induce or reward Value-Based Purchasing services covered by a Federal health care program.”43 Remuneration is anything of value including cash or in- There has been a significantly increased interest since the kind services. The criminal penalties are significant for late 1990s in value-based purchasing. Value-based pur- violation of the Anti-Kickback statute. Besides monetary chasing models attempt to link payment to quality and penalties, a provider can be prohibited from participat- efficiency of care as a means to control excessive health ing in the Medicare program and may be sent to prison. care costs and promote appropriate utilization of ser- Examples of violations include leasing space to a referral vices. This increased interest comes from the recognition source that is below market value, discounting or waiv- that traditional models of health care delivery, including ing patient copays or deductibles, and giving physicians managed care, have had limited impact on the rising elaborate gifts such as season tickets to sporting events. costs and utilization of services in the United States. De- Exceptions are in place, but providers need to be aware cision making by the patient as well as the employer, of these regulations. For example, if a provider fails to who is the usual purchaser of health care, must be influ- collect copays and deductibles after multiple attempts, enced in order to realize cost savings. Value-based pur- then an exception might be made. However, the provider chasing is based on the premise that allowing consumers access to information regarding quality of health care services as well as cost, coupled with financial incentives

CHAPTER 30  Reimbursement and Payment Policy 579 to the best-performing providers, will have a meaningful health plans, physicians and nonphysician providers, impact on the utilization of services.46 and facilities. Key elements of value-based purchasing include the The CMS is also aware that it must try to influence availability of information to support the decision the utilization of services over an episode of care rather making of employers or individuals purchasing health than only considering resource use at the individual pro- insurance, a quality reporting and management sys- vider level. Historically, the CMS has drawn conclusions tem that promotes continuous improvement, incen- of utilization based on retrospective reviews of claims. It tives for providers and consumers that promote and monitors trends in utilization by provider groups and reward certain behaviors and practices, and educa- individual providers. It would be more meaningful, how- tional initiatives directed at consumers that reinforce ever, to analyze the full use of services for a specific the desired decision-making and health behaviors.46 condition when assessing resource use and outcomes of The Institute of Medicine’s study “Rewarding Pro- care. For example, evaluating utilization of all services vider Performance: Aligning Incentives in Medicare” over an episode for patients with low-back pain (e.g., notes that a system is needed that rewards both higher physician services, imaging services, medications, and value and better outcomes.47 The Institute of Medi- physical therapy) may be more meaningful than evaluat- cine recommended that Medicare should focus on the ing services provided by individual providers. The devel- three conditions that affect 32% of patients covered opment of this analysis capability is in progress and under the Medicare program and account for 61% of could have a major impact on the development of future the payments: chronic heart failure, coronary artery payment models and incentives for providers. disease, and diabetes. The CMS has shown its intention to develop value- Consumer education can take many forms, including based purchasing at all levels of care. In 2003, the CMS enrollment counselors, public service announcements, began its hospital value-based purchasing initiatives brochures, computer decision-making tools, as well as with the Premier Hospital Quality Incentive Demonstra- health plan and provider report cards. It is thought that tion project. Payments to the participating hospitals are an educated consumer will make wise and desirable contingent upon their performance on specific quality health care choices. Research has indicated, however, measurements. Measures being utilized by the broad that consumer decision making regarding choice of pro- spectrum of participating hospitals include process of vider is often based on location of the provider, word-of- care and patient outcomes measures.50 The demonstra- mouth recommendations, and out-of-pocket financial tion has been so successful that extended funding was obligation.47 made available to continue through 2009. The CMS is a leading driver of the promotion and As of October 1, 2008, the CMS limits payment to interest in value-based purchasing. In a 2007 testimony certain hospitals for ten categories of specific conditions to the House of Representatives Subcommittee on caused by medical error. Payments to those hospitals will Health, a CMS official noted that “it is a top priority at not be increased for the hospital-acquired complications. CMS to transform Medicare from a passive payer to an Categories on the list that are pertinent to physical active purchaser of high quality, efficient health care.”48 therapists include fall or trauma resulting in serious in- The goal is that Medicare intends to pursue an active jury and stage III and IV pressure ulcers.51 This is yet and thoughtful purchasing strategy that promotes effi- another example of value-based purchasing by the CMS. cient utilization of services and public reporting of com- parative data pertaining to facilities and providers that In 2005, the CMS announced its intention to fund a will be used by consumers to make decisions pertaining Nursing Home Value-Based Purchasing demonstration to accessing medical care. project. Quality performance in four domains would be assessed for nursing homes: staffing, appropriate hospi- To this end, the CMS has begun to develop value- talizations, Minimum Data Set outcomes, and survey based purchasing programs. For example, the Tax Relief deficiencies.52 The CMS currently offers information on and Health Care Act of 2006 provided the CMS instruc- nursing home quality to the public through the Nursing tions to institute the 2007 Physician Quality Reporting Home Quality Initiative that was started in 2002. “Nurs- Initiative that included a bonus payment for successful ing Home Compare” is easily accessible on the Internet reporting of specific measures pertaining to care delivery and provides information on Medicare and Medicaid by physicians and nonphysicians. Funding for this pro- certified nursing homes.53 This kind of public reporting is gram was expanded for 2009 and 2010.49 During the expected to ultimately be available at the individual pro- development of this initiative, the CMS has continued to vider level based on information obtained from the Physi- collaborate with various external stakeholder groups cian Quality Reporting Initiative program. such as the American Medical Association, the National Committee on Quality Assurance, National Quality Fo- The significance of value-based purchasing should rum, and the Ambulatory Care Quality Alliance to fa- not be underestimated. Physician and nonphysician pro- cilitate measure development that can be utilized by viders treating older adults will be affected by these programs, regardless of site of practice. It is expected

580 CHAPTER 30  Reimbursement and Payment Policy that quality measure reporting will continue, and public Dual Coverage reporting of facility and individual providers will be- come more pervasive and increasingly transparent to “Dual eligibles” are low-income older adults with dis- the consumer. Incentives had been built into inpatient abilities who qualify for Medicare Part A and need both facility payments to affect costs over an episode of care Medicare and Medicaid programs to help pay for their but now outcomes and medical errors are being moni- care. Dual eligibles typically have extensive health care tored and reported publicly. Similar incentives are being needs, and rely on both programs to help pay for care. developed for outpatient providers, and Medicare is Medicare provides primary health benefits such as physi- developing the analytic tools to analyze costs, quality cian and hospital care under Medicare Part A and Med- measurements, and outcomes over an episode. icaid pays for the Medicare B premium, cost-sharing, and critical benefits that Medicare does not cover, such In summary, the Medicare program provides vital as long-term-care services. Because Medicaid is a state- health care benefits for older adults. Continued reform administered program with varying levels of state and and change will be needed to meet the needs of this grow- federal financing depending on the state, states take on ing population, especially around issues of cost control, an additional financial burden for low-income older management, and efficiency and around the benefits cur- adults.57 rently excluded, such as some preventive services, and long-term-care coverage. Medicaid’s Value-Based Purchasing: Controlling Costs and Improving Quality MEDICAID Value-based purchasing initiatives are also an integral The federal government became involved with health care part of the Medicaid program.58,59 The Center for for individuals with low income through the 1965 con- Medicaid and State Operations (CMSO) has infused gressional enactment of Title 19 of the Social Security Act. incentives throughout the state-managed programs, in- Medicaid provides health insurance for low-income fami- cluding the State Children’s Health Insurance Program lies with children and people with disabilities, long-term (SCHIP).60 The value-based purchasing programs are care for older adults and people with disabilities, and critical to identify appropriate utilization of limited supplemental coverage for low-income Medicare benefi- program dollars. ciaries for services not covered by Medicare, such as out- patient prescription drugs, Medicare premiums, deduct- The CMSO, in its role as an organization that trans- ibles, and cost sharing. Each state sets its own guidelines fers information from the federal government to the as to who qualifies for assistance and determines funding states, recognizes that each state may approach its value- levels for its Medicaid recipients. The Medicaid program based purchasing decisions differently. Managed care functions as a safety net for older adults but in order to Medicaid model health plans have also been included in qualify, older adults must meet a “means test” demon- the program’s design for promotion of value-based pur- strating that their income is under a certain level as deter- chasing. Despite state differences, the basic elements of mined by federal and state governments.54 the plan include attention to (1) evidence-based care and quality measurement, (2) pay-for-performance, (3) Coverage for Nursing Home health information technology, (4) partnerships, (5) in- and Custodial Care formation and technical assistance, and (6) health care disparities.58 Medicaid covers more than two thirds of nursing home residents who require long-term care for chronic medical In 2007, the CMS announced its intent to develop a conditions. Because Medicare does not cover nursing National Medicaid Quality Framework.61 The CMS has home care for chronic conditions, many middle-income supported the ongoing “Medicaid and SCHIP Promising adults who enter a nursing home enter it as a private pay Practices” initiatives taking place in a number of states.62 patient and then “spend down” almost all of their assets For example, in Louisiana, a phone-based disease man- to eventually qualify for Medicaid.55 Although this long- agement program for asthma has effectively decreased term care is important, Medicaid coverage for this care unnecessary, expensive emergency room visits. Washing- is limited to services provided within an institutional set- ton State has developed strict criteria for bariatric sur- ting. Medicaid provides limited home services that would gery after recognizing that the surgeries were costly and enable older adults to live at home with help. Some mortality rates were high. Other states have designed states are testing new models of care that have increased programs dealing with dental issues, health literacy, obe- Medicaid funding for community- and home-based ser- sity, disease management, and care coordination. vices to minimize nursing homes costs.55,56 These models of more efficient use of funds and payment reforms are As Medicaid programs increasingly look at costs and steps toward improving care provided to lower-income outcomes over an episode of care, it will be important older adults. for rehabilitation professionals to advocate for recogni- tion that the services they provide are valuable in manag- ing high-cost chronic conditions such as cardiovascular

CHAPTER 30  Reimbursement and Payment Policy 581 diseases, pulmonary disease, and diabetes. Participation 24-hour custodial care, is a serious omission in health by rehabilitation professionals in programs that are de- care coverage. As an attempt to fill this void, private in- signed to address value-based purchasing initiatives will surers for many years have been promoting private poli- be critical. Ultimately, payment for services may depend cies to ensure for the need for long-term care. Only a on participation in the effective management of certain small percentage of older adults have purchased this conditions by a team of skilled professionals. costly insurance, with only 9% of long-term-care costs covered by such insurance.5 Reimbursement in Other Settings THE FUTURE: IMPROVING THE HEALTH At Home: Family and Community Services OF OLDER ADULTS Older adults who live at home may find activities of First, improving the health of older adults requires inte- daily living such as personal care or preparing meals dif- gration of financing across all settings and a whole- ficult to accomplish alone. Medicare, Medicaid, and system approach to improve access, quality, and cost.67 private insurance cover some of these needs through Medicare is conducting innovative demonstration proj- home health aides but typically only in the context of the ects to measure the effect of potential program changes. person’s medical home care needs as it relates to a medi- For example, one project is using nurse practitioners to cal problem. As a result, many older adults who need partner with primary care physicians to provide care for such long-term-care services pay for it themselves and/or homebound frail older adults to prevent unnecessary hos- receive it from friends and family.63 It is estimated that pitalizations. Second, more data are needed to better 28 million people provide informal care to older adults quantify and understand services that best improve the and in 1996, estimated to total 21.5 billion hours of help function of people who have limitations and require reha- per year, which approaches a value of $200 billion.64 bilitation services. Post–acute care providers (IRFs, SNFs, Average costs in the United States in 2008 for some long-term-care hospitals, and home health agencies) all home services were $29 per hour for a home health aide, have relatively new prospective payment systems and each $18 per hour for a homemaker service, and $59 per day have different classes of providers as well as separate pay- for care in an adult day health care center.65 Only the ment systems and outcome measurement tools. Compar- very wealthy can afford to pay out of pocket for such ing outcome data from one setting to the next is difficult services, and these costs support the need for health care and, although payment incentives exist, they are not nec- reform in long-term-care services. essarily based on research of what services most change patient function.68 Further research is needed to collect Nursing Home and Chronic Custodial Care functional outcome data to provide the evidence needed to advocate for financing rehabilitation services. Long-term care, although sometimes provided in a nurs- ing home, includes the services and supports needed Third, increasing preventive services would improve when the ability to care for oneself has been reduced by older adult’s health. Research is indicating the secondary chronic illness, disability, or aging. Long-term care is preventive efforts in this population that focus on life- provided in a number of different settings, including at style changes are worthwhile, and predictions are that home by family and friends, in the community through better prevention and investments in public health would services such as home health and adult day care, or in be more effective than investment in technologies.69 For institutional settings, such as nursing homes. Often, example, the projected 10-year impact on national spend- long-term-care users will need a combination of these ing (for all ages) by reducing obesity through taxes in- types of care over the course of their lifetimes. vested in prevention programs is estimated to be $283 billion. Instituting positive incentives for health behavior Custodial or maintenance care is not a covered service through federally funded wellness programs are esti- in nursing homes under Medicare or most private insur- mated to have the potential to save $19 billion.70 Health ances. However, low-income older adult who need ongo- is shown to be affected by genetics, social circumstances, ing 24-hour maintenance care can qualify for coverage environmental exposures, behavioral patterns, and health under Medicaid. Higher-income older adults must first care; behavioral patterns are estimated to contribute “spend down” their savings by paying privately in a nurs- 40% toward premature death.71 Focusing on preventive ing home before qualifying for Medicaid as a person with behavior changes could have a significant impact on risk low income. Medicaid is the safety net for coverage for reduction resulting in improved population health, and if nursing home custodial care and on an aggregate level these efforts also targeted children and young adults, the covers some 49% of long-term care in nursing homes.5 impact on spending could be significantly greater. The yearly cost estimate of a nursing home in 2009 A number of Web-based resources are available to was $219 per day for a semiprivate room or almost help the reader stay updated on current federal health $80,000 annually.66 Lack of long-term-care coverage, insurance regulations, research, and health reform for that is, nursing home care when older adults need older adults. Box 30-9 details these resources.

582 CHAPTER 30  Reimbursement and Payment Policy BOX 30-9 Useful Websites to Stay Updated adults as well as methods used for reimbursing providers on Current Federal Health Insurance and for controlling health care costs, is foundational for Regulations for Older Adults advocating for change. Legislators, insurers, health care providers, and consumers all need to have a voice in the Centers for Medicare & Medicaid Services discussion of how best to improve the health care system www.cms.hhs.gov in the United States. Chapter 31 that follows will discuss advocacy and health policy and provide the reader with Medicare Consumer Handbook tools and resources to effectively advocate as a health www.medicare.gov/Publications/Pubs/pdf/10050.pdf care professional. Centers for Medicare & Medicaid Services: Medicare benefit REFERENCES policy manual. www.cms.hhs.gov/Manuals/IOM/itemdetail. asp?itemID=CMS012673 To enhance this text and add value for the reader, all references are included on the companion Evolve site American Physical Therapy Association. Federal regulatory affairs that accompanies this text book. The reader can view the www.apta.org reference source and access it online whenever possible. There are a total of 71 cited references and other general Kaiser Family Foundation www.kff.org references for this chapter. National Institute on Aging http://www.nia.nih.gov/ SUMMARY Opportunities exist for health professionals to advocate changing the health care system for older adults. Under- standing health insurance programs provided to older

31C H A P T E R Health Policy and Advocacy in the United States: A Perspective for Geriatric Physical Therapy Justin Moore, PT, DPT INTRODUCTION definitions and provides a pragmatic approach to a broad and diverse discipline that is without a consensus The desired outcome of policy and the advocacy process definition. Health policy, as it is used in this chapter, is is to influence decisions aimed to improve the health of consistent with this public policy definition but also the individuals physical therapists serve. Health policy can be understood in a multidimensional way, with its and advocacy are interwoven together with the policy impacts extending beyond the formal system of laws decisions that determine how health care professionals promulgated by government entities. Health policies practice linked with the advocacy processes that influence can be as basic as handwashing procedures for a restau- these decisions. Physical therapists who provide services rant, which is a voluntary health policy based on scien- to older adults are subject to a number of policies that tific evidence and backed by public interest, or as com- range from determining the scope of practice through plex as payment based on the adherence to clinical state licensure laws to the payment for services delivered guidelines. through entitlement programs, such as Medicare and Medicaid. Many health care professionals actively en- Health policy is the decisions, usually developed by gage in the advocacy process to improve current policies government policy makers, for determining present and or to enact new policies to enable physical therapists to future objectives pertaining to the health care system.2 better serve this growing population of Americans. Health policy comprises the decisions policy makers make to establish laws and regulations with which For the purposes of this chapter, it is important to health care professionals must comply or outline the use understand the concepts of policy and advocacy. Policy of finite resources within the health care delivery system. refers to the decisions issued by government bodies with Advocacy is the process to change or influence these which health care professionals have to comply. The decisions. Advocacy supplies the process and framework process to arrive at these decisions is informed and influ- to enact, change, or advance health policy and therefore enced by the advocacy process. Another way to think of is dependent on the sociopolitical construction of the it is that policy is an outcome and describes a current community, state, or country in which one is trying to status; advocacy is the plan or desire to change this shape public policy. In many venues, the advocacy policy or status. process is itself governed by public policies that define how you can influence or impact policies. Regardless of PUBLIC POLICY, HEALTH POLICY, the venue, whether it is local, state, or federal, the right AND ADVOCACY to petition government and to exercise freedom of speech is well protected and is the foundation of advo- Public policy is whatever the government chooses to do cacy in the United States. This chapter will describe the or not to do and covers action, inaction, decision, and multidimensional aspects of health policy and the advo- nondecisions as it implies a very deliberate choice be- cacy process by which individuals attempt to shape tween alternatives.1 Public policy are the laws promul- health policy. Interwoven throughout the text will be gated by government entities that authorize specific rules examples specific to physical therapists and the health and regulations with which individuals must comply or policies that guide physical therapist practice, education, appropriate funds to implement specific actions. This and research. definition is an amalgamation of several contemporary Copyright © 2012, 2000, 1993 by Mosby, Inc., an affiliate of Elsevier Inc. 583

584 CHAPTER 31  Health Policy and Advocacy in the United States: A Perspective for Geriatric Physical Therapy COMPONENTS OF HEALTH POLICY When the regulatory process issues a policy that is not consistent with an individual or group’s objectives, they The National Library of Medicine describes the com- can petition the agency for policy change or seek legisla- ponents of health policy as legislation, regulation, tive change to alter the parameters within which this professional guidelines/standards/protocols, public regulation was authored. health policy, and health advocacy. For the purposes of this chapter, we will consider these components of Health policies issued by formally established govern- health policy, but discuss health advocacy as part of mental entities seek to impact the health of individuals the advocacy process at the conclusion of the chapter3 and communities. These policy bodies have to make de- (Figure 31-1). cisions across varied populations and with finite re- sources. Setting priorities and choosing among numer- The components of health policy provide a multidi- ous policy proposals are key functions of these policy mensional construct of health policy that applies across bodies with recognized jurisdictional authority. Among all venues. Each venue involves a recognized authority the concerns that health policies seek to address, remedi- that is empowered to make these decisions by adjudicat- ate, or impact across the broadest population possible ing among the varied opinions and priorities of the mul- are public safety, disparities and inequities, and alloca- tiple stakeholders who will be affected by these deci- tion of resources. sions. Although not covered in detail in this chapter, it is important to note that health policy can be promulgated Health policy development also draws from several or implemented by an organization, a place of work, a fields of study, including law, economics, sociology, and local school district or community, or by the more tradi- ethics, as well as health and medical research findings. tionally understood jurisdictions, such as cities, states, or Data and insights from these disciplines assist the determi- countries. For example, a school district might author a nation of resource allocation, a perennial pressure point policy that all children will participate in 30 minutes of on health policy. Health policy formulation also involves organized and supervised physical education, which in- making a case for the economics of a course of action, corporates elements of both health policy and public establishing the legality and ethics of the proposed action health advocacy. This chapter will focus on the formal if implemented, and identifying the most likely outcome recognized jurisdictions that can promulgate policies on the health status of the individuals affected by the ac- that determine how health care professionals can prac- tion. All three of these considerations are crucial to many tice. These formal jurisdictions are primarily state and decisions in health-related public policy (Figure 31-2). federal legislatures and the executive branch agencies that enforce the laws, regulations, and rules that the The individuals who serve in formal policy-making legislative body authors. roles in health care include elected officials, appointed government officials, and bureaucrats within govern- The components of health policy of legislation and ment entities. Because these policy makers (such as mem- regulation occur in a defined process and public forum. bers of Congress) are educated, influenced, and informed When the legislative process yields a determination on a by citizen advocates, community activists, lobbyists, particular health policy, this determination becomes law public policy analysts, academics, and business leaders, with statutory authority. Regulation is an administrative the development and implementation of health policy is process defined by the regulatory agency with the au- interconnected to the advocacy process. thority to issue policies within the parameters of the law. Examining each of these three critical considerations Legislation in depth during the formulation of specific health policy adds greatly to our understanding of public policy devel- opment in general. In the United States, health policy also must make the case for adoption within a closed economic market, where scarce or limited resources must be allocated across a diverse population. The Public Regulation Economics health policies Professional Legality and ethics Outcome on health standards of individual or population FIGURE 31-1  ​Components of health policy. FIGURE 31-2  C​ onsiderations for health policy decisions.

CHAPTER 31  Health Policy and Advocacy in the United States: A Perspective for Geriatric Physical Therapy 585 economics of health policy must speak to issues of cost- health, safety, and welfare. The classic Hippocratic Oath effectiveness and resource allocations while detailing the “I will do no harm or injustice to them” is the ethical specific features of the payment policies that will support foundation of the charge to health policies to advance the health policy. The intended outcome of policies to quality.5 The domain of quality is on a continuum that improve the health status of a population should be re- begins with doing no harm and transitions to advancing sponsive to issues of health disparities, accessibility and the health status of a population through evidence and availability of services, and provide incentives to encour- clinical judgment. If we can regard health policy as mak- age the adoption of specific practices that are linked to ing determinations and decisions to improve health, then improving health care. Health policies can also be used those decisions that have a defined impact are critical to to build and continuously improve the infrastructure health policy determinations. Quality measurement and and capacity of the health care system by promoting outcomes are currently still in their infancy but represent structural elements, such as the adoption of health infor- a growing area in health policy development, the evalu- mation technology or the recruitment of individuals to ation of health care professionals and facilities, and re- study in the health professions. source allocation. DOMAINS OF HEALTH POLICY The third domain covers the cost and financing of health policies, or the economics of the decision. This Access, quality, and cost are the three major domains domain is the arena in which the priorities or values that are commonly used to evaluate health services in upon which the policy is based are highly debated. In the our country4 (Figure 31-3). The first domain of access United States, the cost and financing of health care has encompasses health policies that ensure individuals have been a long-standing, and often contentious, public de- accessibility and availability of health care services to bate. Distributing a finite set of resources in a way that meet their own needs and the needs of the broader com- is acceptable to the public, health care providers, payers, munity in which they live. We define this domain first as and policy makers is the primary challenge in health it is the entry point into the health care delivery system policy today. Financing or cost in health policy can in the United States. The implementation of health pol- broadly be divided into its inputs, that is, how we icy decisions begins with accessibility and availability finance health care, and its outputs, that is, how we dis- policies. Individuals’ abilities to access health care from tribute the resources that are available to the system. The an available and qualified health care professional is inputs into health care in the United States come primar- essential to the overarching goal of most health policies, ily from taxes that are paid to support federal programs that is, to improve the health status of the population the and the funding of private insurance by employers and policy seeks to serve. employees. The outputs or health care expenditures are primarily to hospitals, physicians and health care profes- The second domain of health policy is quality and sionals, and prescription drugs. Balancing the supply of outcomes. Once an individual can access services from the inputs with the demand of the outputs is critical to available and qualified health care professionals, policies our economy and public health. are needed to ensure that the services meet basic stan- dards for care and do not jeopardize the individual’s Further investigation of the three domains of health policy uncovers many examples in the current environ- Cost and Access and ment of policies that affect physical therapists and health financing availability care providers in each domain. Each domain has specific policy ramifications for the physical therapist whose practice is oriented toward an older adult population. The three domains of health policy are also interrelated; for example, policies that affect accessibility and avail- ability of services have an impact on the quality and cost. Successful health policy systematically balances the three domains to achieve the best possible outcome for the desired population. Quality and Accessibility and Availability outcomes The public’s ability to access health care services from FIGURE 31-3  D​ omains of health policy. the individual of their choice has long been a health policy issue. If health policy’s goal is to improve the health status of the population it seeks to serve, then ac- cessibility to services and the availability of health care professionals to serve this objective are critical issues for policy makers to address in their efforts to author and

586 CHAPTER 31  Health Policy and Advocacy in the United States: A Perspective for Geriatric Physical Therapy implement health policy. Access can be looked at in three expansion of Medicaid, access to health care insurance ways: denial of care, delays in service provision, and exchanges to purchase coverage, and an individual and disparities in health care. All three elements have been employer mandate to enforce coverage. These proposals identified as problems in the United States health deliv- would also attempt to reform current insurance through ery system. health policies to eliminate practices such as denial or rescission of coverage based on health status or a preex- Access to comprehensive health care services is cur- isting condition or placement of limitations on benefits rently limited and denied to a significant portion of such as annual or lifetime caps, to enhance access to Americans. In 2007, the U.S. Census Bureau estimated services. that 45.7 million Americans, or one in seven individuals, lacked health care insurance for the calendar year.6 Health policy to eliminate arbitrary limits on benefits is Other studies, including one by Families USA, estimated of particular interest to rehabilitation health care profes- that this number grows to 86.7 million individuals when sionals that serve a geriatric population. Since 1997, a per one considers those persons who lacked health insurance beneficiary per year financial limitation on therapy ser- for some period of time over a 2-year calendar period in vices has been placed on seniors and individuals with dis- 2006 and 2007.7 Although debate exists on the exact abilities under the Medicare program. This “therapy cap” number of individuals who lack health insurance, it is in 2010 limits a patient to $1860 of physical therapy and unquestionable that the ability of these individuals to speech–language pathology services and $1860 of occu- access available health care services has been substan- pational therapy services per calendar year. Although tially curtailed, if not completely blocked. Access to Congress has interceded several times since 1997 to place health care insurance is a major determinant of individu- a moratorium on therapy caps or to provide a clinically als’ ability to obtain health care services. based exceptions process, efforts to fully repeal the cap have been unsuccessful. This particular health policy has Health policies in the United States previously ramifications for Medicare beneficiaries and their abilities attempted to address this problem of limited access to access clinically appropriate rehabilitation services pro- by implementing a safety net through the authorization vided by physical therapists and other rehabilitation of the Emergency Medical Treatment and Labor Act health care professionals. (EMTALA). On a very basic level, all Americans have access to health care services through EMTALA. Con- During the health care reform debate of 2009 and gress enacted EMTALA in 1986 to ensure public access 2010, health policies under consideration sought to ad- to emergency services regardless of ability to pay. Section dress the expansion of services that should be available 1867 of the Social Security Act imposes specific obliga- to our populations by enacting policies to ensure the tions on Medicare-participating hospitals with emer- availability of qualified health care professionals to pro- gency services to provide a medical screening examina- vide these services. To ensure the United States has a tion (MSE) when a request is made for examination or qualified workforce available to meet the need created treatment for an emergency medical condition (EMC), through increased access, the health care reform law including active labor, regardless of an individual’s abil- (Public Law 111-148) authored a framework to develop ity to pay. Hospitals are then required to provide stabi- a comprehensive plan of workforce initiatives to match lizing treatment for patients with EMCs. An appropriate these health policies. transfer should be implemented if a hospital is unable within its capability to stabilize a patient, or if the pa- Expanding health care to include prevention and tient requests a transfer.8 Although this EMTALA re- chronic care management programs would have a sig- quirement provides access to health care through emer- nificant impact on the health policy goal of improving gency services, it does not address the continuum of the health status of Americans at a lower per capita or health services or ensure the accessibility of services. system cost. Policies to prevent falls are another example Many times these services are limited solely to emer- of increasing the accessibility of prevention services that gency cases, bounded by geographical considerations, geriatric physical therapists might provide. The Centers and do not meet the health care needs of individuals. In for Disease Control and Prevention (CDC) report that addition, this access has substantial ramifications for the more than one third of adults age 65 years and older fall costs of health care services and jeopardizes the precari- each year in the United States and also that falls are the ous balance of access, quality, and cost. leading cause of injury-related deaths among older adults.10 To reduce cost and improve health quality, pro- On March 23, 2010, President Barack Obama signed grams and initiatives to reduce falls in older Americans into law health care reform legislation, the Patient Pro- are critical prevention initiatives and health policies for tection and Affordable Care Act, now Public Law 111- physical therapists who serve this at-risk population. On 148. This law has been estimated to increase coverage to April 23, 2008, President George W. Bush signed legisla- 32 million more Americans, representing 95% of the tion, the Safe Seniors Act (now Public Law 110-202), population.9 This will provide near universal coverage to that amends the Public Service Act and authorized the health care services beyond those provided in the emer- Department of Health and Human Services to imple- gency room. This coverage is achieved through an ment a comprehensive plan to reduce falls in older

CHAPTER 31  Health Policy and Advocacy in the United States: A Perspective for Geriatric Physical Therapy 587 Americans. To implement this plan, the Department of services. Increasing the availability of health care re- Health and Human Services must conduct research, im- sources and providers to rural populations is a critical plement a national awareness campaign, and improve health policy issue because of the poor health status and the diagnosis, treatment, and rehabilitation of individu- limited resources available to this population. als at risk for falls or repeat falls. Recruiting and retaining qualified health care profes- Access to health care services is further complicated sionals, such as physical therapists, in rural areas is a by disparities across racial and ethnic groups and by policy challenge. Various proposals are examples of geographical and socioeconomic factors. Currently in health policy whose objective is to ensure accessibility the United States, one in three Americans identies them- and availability of health care in underserved areas. If selves as being African American, American Indian/ pending legislation, the Physical Therapist Student Loan Alaska Native, Asian, Native Hawaiian/Pacific Islander, Repayment Eligibility Act is adopted, physical therapists Hispanic/Latino, or multiracial. This number is expected will be eligible for the National Health Services Corps, a to increase by 2050 to one in two.11 In its report, Un- federal program that places qualified health care profes- equal Treatment, the Institute of Medicine outlined the sionals and physicians in underserved areas. The incen- extent of racial and ethnic disparities that exist in health tive to recruit and retain health care professionals to this care, including access to services. Although there has program and to service in underserved areas is student been substantial progress in public policies to advance loan repayment. In 2010, a health care professional civil rights, health care has continued to demonstrate who is selected and completes the required service in the gaps in access to quality health care services for under- National Health Service Corp is eligible for up to represented racial or ethnic minorities.12 $50,000 in student loan repayments. Achieving universal coverage in the United States does Critical to the accessibility of individuals and pro- not guarantee that services will be accessible if a suffi- grams is their availability. Health policy can authorize cient number of health care providers are not available decisions and reach determinations to make health ser- to provide the services that are now accessible. Com- vices more accessible, but there could be a limitation on pounding the gaps in access for minorities is the corre- the resources to make these services available. Currently, sponding gap in representation of these minorities as workforce shortages in health professions highlight the health care professionals. In physical therapy, despite a differing concepts of accessibility and availability. As sustained effort through minority initiatives by the pro- formalized medicine developed in the United States, fessional society and leaders in the field, racial and ethnic health policies were grounded in the authorization of minorities only represent 7% of the populations sur- services by medical doctors. This requirement limited veyed for the American Physical Therapy Association access to health services through a finite number of indi- membership profile. Of this 7%, more than half identify viduals who were authorized to direct this care and cre- their ethnic group representation as Asian.13 Physical ated disparities, delays, and denials of access of health therapy is similar to other health professions in that services. Furthermore, the growth of specialization in whites continue to represent the vast majority of practic- medicine and health care reduced the number of primary ing professions. This disparity can be a contributing fac- care providers available in the health care system, creat- tor to the unavailability of services for underrepresented ing another limitation on access to services. population subgroups. Health policy should consider directing resources toward the recruitment and retention Health policies over the past several decades have of underrepresented populations to meet the growing made care from health care professionals more readily problems of accessibility and availability of health care accessible. These policies have capitalized on the increas- for racial and ethnic groups as part of a commitment to ing educational and clinical training qualifications of social justice within the professions. some health professionals. Health policies have recog- nized osteopathic physicians, some doctorally educated Where one lives also has a significant effect on one’s practitioners, and advanced clinical practice nurses qual- ability to access health care services. Currently, one ified to serve as entry points to the health care system. in four Americans lives in a rural area. Rural areas These policies have increased access but also increased have been demonstrated to have higher rates of poverty, demand for services with corresponding strains on the a larger percentage of older Americans, and a dimin- availability of qualified practitioners. ished health status. Not only is access to health services limited in rural areas, these communities have fewer Balancing the public’s safety with individual auton- physicians, health care professionals, hospitals, and omy and self-determination has been critical to the deci- health resources than urban and suburban areas of sions that policy makers have had to make in meeting the United States.14 Limited access and scarce available the objectives of health policy. A prime example of this resources and professionals to meet the increasing health responsibility is seen in the licensure of health care pro- care needs in rural areas are a major public health issue fessionals to serve the health needs of the population. for the United States. Health care policy to address Licensure has been seen as the purview of the police this issue should continue to improve accessibility to powers of individual states. The core of licensure is found in the limitations on practice that are promulgated

588 CHAPTER 31  Health Policy and Advocacy in the United States: A Perspective for Geriatric Physical Therapy to protect the public’s health, safety, and welfare. Licen- professional knowledge.”15 The United States health sure signifies to the public that one is qualified to prac- care delivery system has been plagued by issues of qual- tice a certain profession and has met the qualification ity and its impact on the health status of Americans or standards. Traditionally, licensure provides the public outcomes. In 2001, the Institute of Medicine issued a protection through title and term protection and through landmark study, Crossing the Quality Chasm, and stated scope of practice of the individual authorized to use the “The U.S. health care delivery system does not provide title and term to the public. Physical therapy has achieved consistent, high quality medical care to all people.”16 licensure laws in all 50 states, the District of Columbia, This report, along with other health policy studies, indi- Puerto Rico, and the U.S. Virgin Islands. This legislative cated a high degree of variance in health care delivery in achievement provides term and practice protection, al- the United States. In 1998, a Rand report found that though overlap in term and practice protection with U.S. adults receive about half of recommended health complementary and competing professions exists. care services.17 Other studies have found that women, older adults, members of racial and ethnic minorities, In recent decades, emerging professions have used poorer, less educated, or uninsured are less likely to re- licensure as a form of professional recognition over and ceive needed care, largely as a result of lack of access to above its purpose of public protection. In many in- care in addition to variance in quality. stances, professional recognition is a prerequisite for payment in return for providing health care services, and The Institute of Medicine in another report, To therefore licensure is a priority of emerging professions. Err Is Human, found that almost 100,000 deaths occur Licensure laws, considered as a type of health policy, each year in the United States health care system as a seek to appropriately limit a profession and its practitio- result of medical errors.18 The data are clear that we ners to their education and training in the best interests need health policies to reduce the errors and improve the of the public. However, using a policy whose objective is poor quality of health care services in our delivery sys- public protection through appropriate limitations on tem. Improving the quality of health care is a multidi- practice for the purposes of gaining recognition or open- mensional issue and challenge for health care policy ing access to payment pulls this form of health policy makers. With one of the most expensive health care sys- into conflict and public debate. tems in the world, getting an adequate return on this investment and changing the health status of our popula- Licensure is also an important consideration from the tion are the key elements of quality in health policy. perspective of availability. Licensure limits the pool of individuals who are recognized as able to meet the health The six dimensions of quality or quality improvement care needs of the population. This limitation is important in health care as defined by the Institute of Medicine are as it ensures a level of patient safety and public confi- safety, effectiveness, patient-centeredness, timeliness, dence in the health care delivery system. However, licen- efficiency, and equity (Figure 31-4).16 sure, and its corresponding scope of practice restrictions, limits access to the public and the availability of individu- Safety is the practice that ensures patients are not als to meet the health care needs of the population. harmed by the health care they receive or where they Health policy must seek decisions and determinations Timeliness to improve access to health care with an equal commit- ment to improving the availability of qualified health care Efficiency Effectiveness professionals. Access to health care for older Americans is a subset of issues in health policy debate. Currently, all Quality Americans over the age of 65 have access to health care coverage through Medicare, Medicaid, or both. Access to Equity Patient services is reported to be good for a vast majority of older centeredness Americans, but the availability of health care profession- als to serve their health needs will continue to be a pres- Safety sure point for policy makers to address. FIGURE 31-4  I​nstitute of Medicine’s multidimensional nature of Access to and the availability of health care services is basic to health policy. Policies to achieve improved ac- quality in health care. cess or to increase availability must be balanced to en- sure patient safety, enhance quality, and to utilize scarce resources in an efficient and effective manner. Quality and Outcomes “Quality is the degree to which health services for indi- viduals and populations increase the likelihood of de- sired health outcomes and are consistent with current

CHAPTER 31  Health Policy and Advocacy in the United States: A Perspective for Geriatric Physical Therapy 589 receive it. Effectiveness is the use of evidence and prac- Functional Independence Measure, and the Medical tice standards to match the care delivered with the best Outcomes Study–Short Form (SF-36). These instruments available scientific data with resource allocation and provide ways for clinicians to measure improvement in utilization. Patient-centeredness is respect for individuals patient outcomes following intervention.4 and their wishes in the health care experience. Timeliness is ensuring that health status is not detrimentally Currently, outpatient physical therapists can partici- affected by waiting times and delays in access. Efficiency pate in quality reporting under the Medicare program is the reduction of fraud, waste, and abuse in the health called the Physician Quality Reporting Initiative. Al- care system. Equity is ensuring that disparities in the though this program is currently limited to physical health care system are reduced.16 therapists in private practice, it provides a glimpse of efforts to improve our health care delivery system by One dimension especially worth exploration because measuring outcomes and rewarding quality. The Physi- of its relevance to physical therapy is the dimension of cian Quality Reporting Initiative measures at this stage effectiveness. Effectiveness can be divided into the ele- are limited primarily to process measures but allow the ments of overuse and underuse. The use of interventions federal government to begin to improve quality of health in physical therapy that are not proven to provide thera- care by moving incentives toward measures of treatment peutic value is a classic overutilization issue. Many quality and patient outcomes. Physical therapists cur- physical agents are consistently utilized without the evi- rently have access to eight different quality reporting dence to support their use leading to overutilization. The measures, and the battery of appropriate measures will lack of use of those interventions for which there is bet- most certain expand in the coming years. ter support leads to underutilization. Manual therapy and manipulation for individuals with some presenta- Ensuring quality in health policy decisions is a diffi- tions of low back pain could be considered as examples cult exercise in balancing the multiple dimensions of of underutilization. quality and then reconciling quality with its impact on the domains of access and cost. Health care is at its very Looking at quality across the six dimensions is critical core personal and individualized. The uniformity that in health policy as it illustrates the complexity of mea- ensures quality in many other areas of our economy is suring “quality.” These six dimensions also have varying not always applicable to health care. Assembly lines in impacts on the other domains of access and cost and manufacturing created advancement in many of the di- must be balanced with these domains. The highest qual- mensions of quality from efficiency, timeliness, unifor- ity might be the most costly and hardest to access. Clini- mity and safety, but many of these approaches in health cians must always keep these six dimensions in focus as care would not likely have the same result. they strive to deliver high-quality care. Cost and Financing of Health Care Measuring quality can proceed along several lines, such as structure, process, and outcome. Structure looks The third domain of health policy is the cost and financ- at the system in which the health care experience occurs ing of health care. The cost of health care continues to and those features that enhance quality of care. An ex- be a significant health and public policy issue for the ample of a structural measure of quality is the use of United States. The National Health Expenditures data health information technology. Process measures investi- showed that health care spending grew 6.1% in 2007, gate the method of delivery and assure that critical steps costs the average person in our country $7421, and ac- are taken. An example of a process measure of quality counts for 16.2% of our economy as measured by the can be found in ensuring that a critical question is posed gross domestic product (GDP). Health costs are also as part of the patient history, such as has the patient projected to grow significantly without significant fallen in the past month. Outcome measures, the patient- changes through health policy. Health care spending is critical level of quality measurement, document the im- expected to grow by appropriately 6% annually over the pact of the intervention on the patient’s health status. In next decade, reaching 20.3% of the economy as mea- physical therapy, the functional improvement of the pa- sured by GDP in 2018.19 The recently passed health care tient is the primary focus of many outcome measures. An reform legislation (Public Law 111-148) seeks to “bend example of a treatment outcome measure for population this cost curve” down from its current projection, and its subgroups would be the reduction of falls in patients ability to do so will be closely monitored in the years who have undergone a standardized balance program. to come. The challenge of interpreting outcome measures in order to compare patients with different risk profiles can often The increasing cost of health care is consistent across complicate interpretation of findings across groups. many sectors of the industry, although to varying de- Assessment tools and outcome measures in physical grees. In 2007, Medicare spending grew 7.2%, Medicaid therapy have existed in many forms, for example, the spending increased by 6.4%, and personal health care Outpatient Physical Therapy Improvement in Movement spending grew by 5.8%. Besides the variance in spending Assessment Log, the Uniform Data System of Medical growing between federal programs and personal health Rehabilitation and its outcome measurement tool, the care spending, geographical differences in health care

590 CHAPTER 31  Health Policy and Advocacy in the United States: A Perspective for Geriatric Physical Therapy costs also show a level of inconsistency. In 2010, the stakeholders who bring different perspectives and inter- highest state in the country, Massachusetts, spends more ests to this challenge. If health policy is intended to bal- than double in personal health care costs ($6683) than ance quality, access, availability, and cost, then the pro- the lowest state in the country, Utah ($3972). In Medi- cess to achieve this balance in a manner consistent with care spending, this variance continues with the highest professional perspectives and beliefs is advocacy. state, Louisiana, spending double compared to the low- est state, South Dakota.19 This disparity in the cost of ADVOCACY health care across the United States is one of today’s health policy priorities. Advocacy is the pursuit of influencing outcomes— including public-policy and resource allocation deci- Increasing utilization and costs have been seen in sions within political, economic, and social systems physical therapy as well. Data from a 2002 Advanced and institutions—that directly affect people’s current Med/Computer Sciences Corporation (CSC) study re- lives.21 In the United States the advocacy process is ported that 3.75 million individuals utilized therapy clearly articulated in the United States Constitution services (physical therapy, occupational therapy, and and its First Amendment. The First Amendment, rati- speech–language pathology services) under the Medicare fied on December 15, 1791, outlines the freedoms of program. Of these individuals, 88% received physical religion, press, and expression and states: therapy services. From 2000 to 2002, therapy services experienced 4.4% growth in users compared to only Congress shall make no law respecting an estab- 1.9% growth in the total number of beneficiaries. Total lishment of religion, or prohibiting the free exercise expenditures for therapy services were $3.4 billion at an thereof; or abridging the freedom of speech, or of average patient cost of $896, an increase from $581 in the press; or the right of the people peaceably to 2000. The increasing number of individuals accessing assemble, and to petition the Government for a therapy services and amount paid per patient present redress of grievances.22 health policy challenges for rehabilitation therapy pro- fessionals in the area of cost and financing.20 This right of individuals to bring issues before govern- ment entities sets the framework for a majority of health Health policies center primarily on how to contain policy initiatives and decisions. Through the process of the outputs or expenditures. The government and pri- advocacy, individuals or groups approach recognized in- vate insurance companies issue policies to regulate prac- dividuals, organizations, or governments that are autho- tice and to set mechanisms of payment aimed to control rized to issue such policies and empowered to promulgate the cost or limit the demand for health care services. specific guidelines, rules, regulations, or laws. Advocacy These policies can have detrimental impacts on the qual- exists at the level of the individual and the group. Self- ity of care or access to services. The major pressure point advocacy is an important personal attribute that is a rec- in health care today are the policies of cost containment ognized characteristic of a competent adult. In addition and their impact across all domains of health policy. to self-advocacy in which one acts on behalf of oneself, it Physical therapists experience cost-containment strate- is also an essential characteristic of health care profession- gies in two forms, regulations and mechanisms of pay- als to advocate as individuals in the best interest of the ment. Regulations that set criteria for what is payable by patient or client. Self-advocacy and patient-focused advo- the government or private insurance help to control cacy are core principles in health care and in physical costs. These regulations can set criteria for the use of therapy. APTA’s Code of Ethics, Principle 3, states, “A support personnel, set minimum time requirements for physical therapist shall comply with laws and regulations certain interventions, and limit what interventions can governing physical therapy and shall strive to effect be utilized for certain diagnoses. Mechanisms of pay- changes that benefit patients/clients.” This principle ment are designed to help control costs and manage re- clearly establishes that compliance with public policies source allocation in physical therapy. Mechanisms of governing health care and health professions is required payment range from fee for service, where a fee is for ethical practice, but also indicates that there is an charged for each intervention utilized, to case-rate pay- ethical obligation to advocate for changes in laws and ments, where a single preset fee is paid for a certain regulations that benefit patients.23 clinical condition to cover all services provided, whether the actual cost of care falls within the case rate or not. Margaret Mead once remarked, “Never doubt that a small group of thoughtful, committed citizens can change As defined at the beginning of the chapter, health the world; indeed, it’s the only thing that ever does.”24 policy comprises the decisions, usually developed by This statement is the core of advocacy at the systems or government policy makers, for determining present and community level. Health care professionals have long future objectives pertaining to the health care system. banded together to advance their profession and hope- Balancing access, quality, and cost are extremely difficult fully change the world through the policies they seek to in health care. The consumer wants the highest quality advance. One of health policy’s first focal points began at the lowest cost immediately available. The complexity as advocacy to license health care professionals in order of this balancing act is only compounded by the varied

CHAPTER 31  Health Policy and Advocacy in the United States: A Perspective for Geriatric Physical Therapy 591 to provide assurance to the public that health care was becomes the case statement and represents step 1 in the being delivered by qualified individuals who met basic 6-step advocacy framework. standards for practice. The second step is to compile the necessary research, An Advocacy Framework data, and background on the issue. Problem identifica- tion only pinpoints the issue an individual or group Legal, legislative, and regulatory advocacy is the process seeks to change. It is then necessary to collect data and of educating, implementing, influencing, and enacting conduct the research to begin to build the case for policy changes to effect the desired outcome, whether change. Public health data, consumer opinions, surveys, that is to improve the health through health policy initia- and other data are needed to build the foundation for tives or to enable professional advancement. As a health the reasons for seeking the change. Defining the issue care professional, advocacy is a critical role for physical and supporting it with strong and sound evidence in- therapists to provide and essential for the enactment of creases the potential for success. This step requires con- policies that enable physical therapists to practice to the siderable understanding of the legal and policy back- full extent of education, experience, and expertise. Ad- ground of the issue. One of the essential elements of this vocacy in public or health policy includes the process of second step is identification of the policy that will need setting a plan to influence an authorized body to issue a to be changed to achieve the desired outcome and also decision. the venue in which the change can occur. The legislative body is often the venue of last resort. Many times, poli- Advocacy is the process to get to a policy decision. cies can be changed at the regulatory level and this is an The advocacy process is cyclical and continuous as it important assessment of step 2 in the advocacy frame- depends on the particular policy decision sought and its work. The regulatory process, although as complex and congruity with shifting priorities for both the advocate as difficult to navigate as the legislative process, can and the decision maker. To effectively advocate for make many policy determinations and provide some changes that match a desired outcome, a systematic plan flexibility in approaches and outcomes. This step can of action is required. Although there are many different involve consultants and attorneys who are experienced textbooks and articles to assist with formulating an in identifying the options and policy bodies involved in advocacy plan, one approach is outlined in the 6-step making the decision to effect the outcome of a change in advocacy framework (Figure 31-5). health policy. The first step is problem identification or development Following the data-gathering step, principles, priori- of the idea. This step is critical as it defines the deficit ties, and outcomes are outlined in the third step. This that advocacy efforts will seek to correct through policy step can be used to establish short, intermediate, and change. This step is not limited solely to the process of long-range goals. In the mid-1990s, the biomedical re- problem identification and then outlining a path to the search establishment determined from their data that solution. New ideas can also be developed within the funding at the National Institutes of Health was insuffi- advocacy process. The formulation of these new ideas cient. This community developed the policy principle also represents the initial step in this process of problem that federal funding to the National Institutes of Health identification. The clear articulation of the problem should be doubled over a 10-year period. This principle described the desired outcome, but also set incremental Identify problem goals that needed to be achieved over several years of annual appropriations to meet the ultimate goal. The Assess and evaluate Conduct research steps taken over legislative victories across several years and gather data resulted in success. The third step is critical for identify- ing key advocacy champions and constituencies. Build support, Establish principles, manage opposition priorities, and The fourth step in the advocacy process is the estab- outcomes lishment and implementation of an action plan. This step articulates what needs to be done in order to present Develop and the case for change to the body that has the authority to implement an make a determination consistent with the desired out- advocacy plan come. This process can involve an in-depth strategic plan or be an informal process. The action plan should con- FIGURE 31-5  6​ -step advocacy framework. sider the individuals or parties involved in making the decision, how the case should be presented to them, a timeline for the desired determination, and the process that the policy will be subject to before it can be issued. The plan should be built upon the research and data gathered in step 2 and consistent with the priorities out- lined in step 3. Part of this step could also identify that