Improving Fall Risk Assessment and Intervention David Risius, MSPT Rehab Coordinator Baptist Health Home Health Network

But first …

Jimmo v. Sebelius Update Original Settlement January 2013 Plaintiffs (Center for Medicare Advocacy) alleged that Medicare claims involving skilled care were being inappropriately denied by contractors based on a rule of thumb (Improvement Standard)

Jimmo v. Sebelius Update Claims were being summarily denied due to a beneficiary’s lack of restoration potential even though they did in fact require a covered level of “skilled care” in order to prevent a slow or further deterioration in his or her clinical condition.

Jimmo v. Sebelius Update CMS denied establishing a rule of thumb “Improvement Standard” The court never ruled on the validity of the plaintiffs’ allegations Medicare coverage has always been dependent not on the beneficiary’s restoration potential, but on whether skilled care is required

Jimmo v. Sebelius Update It is always necessary to document three things for each visit – Skilled care is required and provided – Services are reasonable and necessary – Beneficiary is homebound

Jimmo v. Sebelius Update What this settlement did NOT do: – Expand Medicare coverage What this settlement DID do: – Clarify existing policy so that claims will be adjudicated consistently and appropriately

Jimmo v. Sebelius Update CMS response to settlement – Coverage manual updated in December 2013 – No “Improvement Standard” is to be applied in determining Medicare coverage for claims that require skilled care – Enhanced guidance on appropriate documentation

Jimmo v. Sebelius Update March 2016 plaintiffs filed a Motion for Resolution of Non-Compliance with the Settlement agreement Plaintiffs argued that providers and contractors continue to illegally deny Medicare coverage CMS asserts that they have completed the education campaign required by the Settlement

Jimmo v. Sebelius Update Plaintiffs argue that the campaign has clearly failed to educate the provider community and the Medicare decision making system Plaintiffs are requesting CMS take additional steps for education about the Settlement There has been no response from CMS

Identifying the Fall Risk Population

Fall Facts One out of three adults over 65 fall each year Less than half tell their doctor Falling once doubles your risk of falling again 2.5 million adults over 65 are treated in EDs for fall injuries and 700,000 are hospitalized Falls are the most common cause of TBI Fear of falling is real

Fall Costs in 2013 $34 billion

Direct Medical Cost Hospital / Nursing Home care Physician and other professional services Rehabilitation Community based services Use of medical equipment Prescription drugs Insurance processing

Fall Cost Average hospital cost for a fall injury is $35,000 Medicare pays 78% of nationwide fall costs Fall injuries are among the 20 most expensive medical conditions

Hip Fractures 250,000 people over 65 are hospitalized each year with hip fractures 95% are caused by falls Women account for 75% of all falls Women fall more often than men but men have a higher fatality rate from falls

Fall Risk Assessment CMS does not mandate that clinicians conduct fall risk screening for all patients, nor is there a mandate for the use of a specific tool

Definitions Multi-factor – involving or dependent on a number of factors or causes Standardized – test that is administered and scored in a consistent manner Validated – accuracy of the test is proved

Standardized Validated Tests The multi-factor fall risk assessment must include at least one standardized validated tool that – Has been scientifically tested in a population with characteristics similar to that of the patient being assessed and shown to be effective in identifying people at risk for falls – Includes a standard response scale

Fall Risk Assessment Age of the patient guides how to answer M1910 The MAHC-10 can be used for patients over 65 because it meets the requirements for standardized, validated, and is multi-factorial

Fall Risk Assessment Completing the MAHC-10 does not meet the M1910 requirement for patients less than 65 MAHC-10 is not validated for that patient population MAHC-10 may be used for the multi-factorial portion and another fall risk assessment should be used for the standardized and validated requirement Use the standardized validated test score to answer the M1910 OASIS C1 item

Other Standardized Tests TUG Tinetti 30 Second Chair Stand Test Functional Reach Berg Balance Scale Dynamic Gait Index Falls Efficacy Scale Falls Risk Assessment Tool

Fall Risk Factors Intrinsic Factors – originating or due to causes or factors within the body Extrinsic Factors – coming from the outside of something

Intrinsic Factors Impaired balance Cognitive impairment Muscular weakness Low vision Orthostatic hypotension Medications Urinary incontinence

Extrinsic Factors Throw rugs or loose carpet Pets Clutter Thresholds Improperly installed equipment

Now what? Fall risks can be easy to identify Fall risks can be difficult to identify What is the best way to intervene?

Fall Risk Interventions Two key words to guide your agency plan – Comprehensive Involve all disciplines PI groups Case conferences OASIS time points (SOC/ROC, Recert) After a fall

Fall Risk Interventions – Individualized All staff involved with the patient has a role All staff has to process fall risks – Where is the patient most likely to fall – What actions might cause the fall – What intrinsic factors need to be considered – What extrinsic factors need to be considered