When HIPAA and public access laws conflict

The Health Insurance Portability and Accountability Act – HIPAA-- was enactedin 1966 . Subsequently,  the U.S. Department of Health and Human services developed a rule governing individually identifiable health information,  known as the Privacy Rule, and published it in 2002.

The Standards for Privacy of Individually Identifiable Health Information  -- the Privacy Rule -- establishes, for the first time, a set of national standards for the protection of certain individual information. The Department of Health and Human Services (HHS) issued the Privacy Rule to implement HIPAA’s requirement.

The Privacy Rule standards address the disclosure of individuals’ health information by those organizations subject to the Privacy Rule,  as well as standards for individuals' rights to understand and control how their health information is used.  HHS’s Office for Civil Rights (OCR) has responsibility for enforcing the Privacy Rule with respect to voluntary compliance activities and civil money penalties.

HIPAA placed such emphasis on privacy, in fact, that it was determined that nursing homes residents’ names and pictures could be displayed outside their doors only if the facility obtained authorization from them.  In the case of residents who were not capable of authorizing the display of their name and picture, the facility would need to seek authorization from a family member or other personal representative.

Does that mean that as a resident of a skilled nursing facility your entire experience will be kept private?  Well, yes.  And no.

Skilled Nursing Facilities found themselves having to walk a fine line under the new law, as HIPAA also provided a mandate for nursing facilities to post survey results, and to provide the public with a means of access to those results. Many turned to HHS for clarification.

HHS determined that the HIPAA Privacy rule “has not changed the statutory requirement for nursing homes to post survey results in a place readily accessible to residents, family members and legal representatives.”  It also noted that “the HIPAA Privacy Rule has not altered the state or Secretary’s obligation to provide the general public with a means to access these survey results as well.”

“(T)he HIPAA Privacy Rule has not altered the state or Secretary’s obligation to provide the general public with a means to access these survey results as well,” wrote Thomas E. Hamilton ofHHS’s Center for Medicaid and State Operations/Survey and Certification Group.  The regulations that clarify the department’s HIPAA requirements, he said,  provide that “protected health information (survey results) may be used and disclosed without the authorization of the subject of that information (nursing homes) to the extent a law mandates such use or disclosure. “

Hamilton noted that the nursing facility survey process was designed with three interests in mind:

  • to provide information to assess nursing facilities’ compliance with federal standards,

  • to inform the surveyed facility and the general public about any deficiencies determined and the bases for those deficiencies,  and

  • to protect the confidentiality of personal and clinical records of nursing facility residents.

In furthering these goals, he noted, “every effort is made during the survey process to minimize the use and disclosure of nursing facility residents’ health information during the survey process.”  However, Hamilton noted that “deficiency statements … need to provide sufficient evidence to support any deficient practice findings, as these citations serve as the ultimate basis for the non-compliance finding.”  And, he added, “While the residents selected as part of the survey sample are referred to by code rather than by name, social security number, or some other easily identified identifier, it may be possible in rare circumstances to determine the identity of a resident through the documentation of a deficient practice.”

“(HHS shares)  concerns about the privacy of nursing facility residents’ medical records, “ Hamilton concluded, “but we must balance that concern with our statutory duties to regulate the nursing facility industry through the use of surveys and public access to the results of those surveys.

“We regret that in rare circumstances the statements of deficiencies may inadvertently release information that can be traced to a particular resident of a surveyed facility. While we regret such inadvertent releases, however, we firmly believe that they do not constitute violations of the HIPAA Privacy Rule’s spirit or provisions. “

So that’s what we mean by walking a fine line: under the Privacy Rule, the skilled nursing facility must assure that individuals’ health information is properly protected, yet must provide the information needed to provide high quality health care and to protect the public's health and well-being.  


Centers for Medicare and Medicaid

HC Pro

Our CARE tool: making outcome assessment accurate and efficient

The Medicare Payment Reform Demonstration developed by the Centers for Medicare and Medicaid in response to the Deficit Reduction Act of 2005 used standardized patient information to examine the consistency of payment incentives for Medicare populations treated in various settings. The demonstration included acute care hospitals and four post-acute care settings: long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs).  

The demonstration provided standardized information on patient health and functional status, independent of site of care, and examined resources and outcomes associated with treatment in each type of setting, thus allowing CMS to better understand the extent to which similar patients are treated in different settings. The information on resource use within each setting was also needed to understand differences in patient treatment, outcomes, and costs of care in order to create appropriate payment reform recommendations.

As the demonstration was enhanced, a standardized patient assessment tool was developed for use at acute hospital discharge and at post-acute care admission and discharge. Using this tool, named the Continuity Assessment Record and Evaluation (CARE) Item Set, data was collected that served as a major source of information. The CARE Item Set measures the health and functional status of Medicare beneficiaries at acute discharge, and measures changes in severity and other outcomes for Medicare post-acute care patients. It is designed to standardize assessment of patients’ medical, functional, cognitive, and social support status across acute and post-acute settings.

The goal was to standardize the items used in each of the existing assessment tools while posing minimal administrative burden to providers. The CARE Item Set builds on prior research while it targets variations in a patient’s level of care needs.  

Blue Sky Therapy complies with the outcome assessment requirements through our CARE tool software, Rehab Optima.  With this software, we are able to complete outcomes on mobility and self-care items for our patients to determine progress made from evaluation to discharge.  This also allows us to compare our outcomes within a national data base. 

We are able to filter the information based on:

· diagnosis,

· individual patient,

· discharge location and/or admission location,

· payer source, and

· other variables.

The cumulative data produced from this system can be used to participate in industry initiatives including quality measures and payment reform in addition to educating payers, customers, patients and referral sources on the value of the services we provide.

Managing billing for contract, in-house, and outpatient therapy is also easier with this software. With it, we can provide accurate documentation while increasing therapists’ efficiency in reporting outcomes and developing treatment paths. 

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

This information is not intended to replace the advice of a doctor. Blue Sky disclaims any liability for the decisions you make based on this information.




Payroll Based Journal reporting: How will it affect you?

Section 6106 of the Affordable Care Act (ACA) requires facilities to electronically submit direct care staffing information, including agency and contract staff, based on payroll and other auditable data.  The data, when combined with census information, can then be used to not only report on the level of staff in each nursing home, but also to report on employee turnover and tenure, which can impact the quality of care delivered.

The Centers for Medicare and Medicaid Services has developed a system known as Payroll-Based Journal (PBJ) that will help facilities to submit staffing and census information. This system will allow staffing and census information to be collected on a regular and more frequent basis than currently collected.  It will also be auditable to ensure accuracy.    All long-term care facilities will have access to this system at no cost to facilities.

CMS publicizes that it has long identified staffing as one of the vital components of a nursing home’s ability to provide quality care.  Over time, CMS has utilized staffing data for a myriad of purposes in what it says is an effort to more accurately and effectively gauge its impact on quality of care in nursing homes.  Staffing information is also posted on the CMS Nursing Home Compare website, and it is used in the Nursing Home Five Star Quality Rating System to help consumers understand the level and differences of staffing in nursing homes.  

In case you weren’t aware of the background, here it is: For the past five years, the Centers for Medicare & Medicaid Services has provided a one-to-five-star rating for nursing homes that participate in the government programs. The system gives nursing homes a rating in three important categories: nurse staffing, annual inspection results, and quality measures. The facilities then receive a composite rating combining those categories.

Critics of the system have noted that nursing homes had been allowed to self report much of their data, and some facilities may have “enhanced” their ratings.

So, in 2015, in an effort to improve transparency and reduce fraudulent reporting, Congress passed “The Improving Medicare Post-Acute Care Transformation Act,” or IMPACT. Among other things, this act requires nursing facilities to use staffing data based on payroll and other verifiable, auditable data, and send the data electronically to the Department of Health and Human Services.

There are items that will need further clarification.  It has been pointed out, for example, that nursing homes may have difficulty determining just what constitutes payroll and staffing data. For example, many facilities utilize temporary staff, for one of many reasons: some facilities may be located in areas where it is difficult to find full-time, trained personnel, and some nurses don't want full-time jobs.

These nurses, known as “pool” labor, therefore do not appear on nursing homes' payroll systems as employees. Instead, the facilities pay the pool provider with a single check. It is thus unclear how nursing homes will account for these employees in their payroll data reports (the IMPACT law specifies that nursing homes should include agency and contract staff in their reporting).

With the new PBJ requirements, the CMS did make a rating system change that should be helpful both to consumers and nursing homes: it now filters out administrative resources at nursing homes, as that information may distract from identifying the actual level of hands-on care at the bedside of each facility. But therein lies another question about the use of salaried administrative personnel in direct care nursing roles. For example: a director of nursing’s job doesn't count toward the rankings. But if a nurse calls in sick one day, and the director of nursing substitutes on that shift, there is no way to show this through the normal payroll reporting procedure. Any facility that doesn’t properly account for these staffing situations could experience a reduction in the overall five star ranking, and a drop in stars can have a significant impact on the perceptions of residents, family and managed care payers.   

CMS began collecting staffing and census data through the PBJ system on a voluntary basis beginning on October 1, 2015; it will be mandatory beginning on July 1, 2016.  Registration for voluntary submission began August 2015; training is provided on registration for both voluntary and mandatory submissions.

This file provides general background and information about the submission requirements, such as sample submission screens, submission deadlines, and definitions of job categories. Questions regarding the PBJ Policy Manual should be directed to nhstaffing@cms.hhs.gov.

Information about future implementation of the PBJ steps will be communicated over the next several months.


Centers for Medicare and Medicaid Services




The importance of measuring how we reach efficient outcomes

We have already discussed the importance of measuring outcomes: Medicare uses the "functional outcomes" data on claims submitted by physical therapists and other providers to determine the need for services, the quality of care, and the value of the service received by the beneficiary.

But tracking outcome measures alone is not always sufficient to reach the goals of better quality and efficient costs. Providers must also track the evidence-based process measures that drive better outcomes.

What exactly are these evidence-based process measures? First, it helps to understand the three types of measures we use in healthcare analytics:

Outcome measures: These are the quality and cost targets you are aiming at improving; they are often reported to government and commercial payers. Some examples of metrics for outcome measures include mortality rates, readmissions rates, and surgical site infection rates.

Balance measures: These are the metrics a health system or provider must track to ensure that an improvement in one area isn’t negatively impacting another area. For a hospital-related example, let’s say length of stay (LOS) in labor and delivery is the outcome metric. The hospital wants to reduce LOS and save money. The balance metric might be patient satisfaction. If mothers feel rushed toward discharge, outcome there might be a negative impact on patient satisfaction even while improving LOS.

Process measures: These measures are the specific steps in a process that lead, either positively or negatively, to a particular outcome metric. For example, let’s say the outcome measure is LOS. A process metric for that outcome might be the amount of time that passes between when the physician ordered the discharge and when the patient was actually discharged. You might then look at the turnaround time between final take-home medication being ordered and medication delivery to the unit. If it takes the pharmacy three hours to get the necessary medications to the floor — potentially delaying the discharge — you’ve pinpointed a concrete opportunity for healthcare process improvement.

Process measures used by physical therapists essentially represent a provider’s efforts to incorporate evidence-based best practices into its improvement efforts; they improve quality and cost by enabling organizations to reduce the amount of variation in care delivery. An example: the patient complains of pain. You need to find the source and alleviate it. You need to do it efficiently and effectively; that’s your outcome measure. How are you actually going to drive improvement? Simply by implementing and tracking the right process metrics.

Process measures in this example are the steps that should be performed every time the patient experiences the specific pain. The plan of treatment will be journalized, and the results of each

step recorded. You are thus measuring the effectiveness of your treatment process; very soon, the "weak link" in your treatment plan will make itself visible.

By tracking process measures, you can pinpoint the root cause of previous failures. If you don’t have a well-designed process in place to treat patient pain, it should be no surprise if you don’t perform well on that outcome metric.


American Physical Therapy Association

Health Catalyst.com

Are you ready for ICD-10? CMS is.

The United States spends more than $150 billion annually on health care administration; for the average physician, two-thirds of a full- time employee is needed to carry out billing and insurance- related tasks.

To ease these financial and administrative burdens, the Health Insurance Portability and Accountability Act (HIPAA) and the Patient Protection and Affordable Care Act (Affordable Care Act) established administrative simplification requirements aimed at lowering costs, creating uniform electronic standards, and streamlining exchanges between health care providers and payers.

The result: a new revision to the International Classification of Diseases.

The Centers for Medicare & Medicaid Services (CMS) was charged with carrying out and enforcing the administrative simplification requirements for HIPAA-covered entities, which include health care providers that conduct certain transactions in electronic form, health care clearinghouses, and health plans.

On October 1, the nation’s health care system moved to the International Classification of Diseases, 10th Revision: ICD-10. After thorough testing, the Centers for Medicare and Medicaid Services announced their readiness to accept properly coded ICD-10 claims.

With this change, nursing homes and other providers can capture more details about the health status of patients. By setting the stage for improved care and public health surveillance, ICD-10 promises to help move the nation’s health care system to better, smarter care.

CMS has cautioned that it will take a few weeks before the full picture of ICD-10 implementation can be seen, because few health care providers file claims on the same day a medical service is given. Most providers batch their claims and submit them every few days.

Medicare claims take several days after submission to be processed, and by law must wait two weeks before issuing payment. Medicaid claims can take up to 30 days to be submitted and processed by states. Therefore, it will likely be after completion of a full billing cycle before the transition to ICD-10 can be analyzed. During the first weeks, CMS is busy monitoring the transition in real time and addressing any issues that come to attention through the ICD-10 Coordination Center.

In the Coordination Center, a group of Medicare, Medicaid, billing, coding, and information technology systems experts are set to offer help if you have problems. For general ICD-10 information, there are many resources on CMS’s Road to 10 webpage. The first line for help for claims questions is the Medicare Administrative Contractor. You can also contact the ICD-10 Coordination Center or ICD-10 Ombudsman Dr. Bill Rogers, who will act as an impartial advocate.

If you have a Medicaid claim question contact your State Medicaid Agency. Responses typically will be sent within 3 business days of receipt.

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to person-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

Resource: The Centers for Medicare and Medicaid

Culture-change movement concentrates on patient-centered care

The culture-change movement is a broad-based effort to transform nursing homes from impersonal health care institutions into true person-centered homes offering long-term care services. The movement encompasses almost three decades of consumer advocacy coupled with legal, legislative, and policy work aimed at improving both the quality of care and the quality of life in nursing homes.

In the 1980s, the National Citizens’ Coalition for Nursing Home Reform, a consumer advocacy group concerned about substandard care in nursing homes, emphasized residents’ rights and the importance of resident assessment. Later, with support from interested government and advocacy groups, the coalition conducted focus groups to learn how nursing home residents themselves defined quality.

In 1985, at a coalition symposium, residents told federal officials that "quality of care," — which encompasses such considerations as the medical treatments a resident receives and physical care routines including assistance with bathing, using the toilet, and eating— and "quality of life" — how one is treated: for instance, having one’s privacy respected or having one’s dignity maintained — are inseparably linked and, from the resident’s perspective, equally important. This principle figured prominently in subsequent legislation and regulations.

The Institute of Medicine reacted by recommending major regulatory changes that emphasized the home part of the description more than the nursing aspect of nursing home. Subsequently, Congress incorporated a sweeping set of nursing home reforms, known as the Nursing Home Reform Act, into the Omnibus Budget Reconciliation Act of 1987. The newly enacted law required that each nursing home resident "be provided with services sufficient to attain and maintain his or her highest practicable physical, mental, and psychosocial well-being." The law made nursing homes the only sector of the entire health care industry to have an explicit statutory requirement for providing what is now called "person-centered care."

As a result, some providers began to move away from the institutional model of nursing home care and toward a more homelike environment in which residents could have a say in their day-to-day lives. In 1997, leaders in the industry began to advocate for person-centered care and create a movement for "culture change" in the nation's nursing homes.

These leaders, along with consumer advocates, researchers, and regulators, founded an organization called the Pioneer Network, which partners with the Centers for Medicare and Medicaid Services (CMS) to explore ways to overcome regulatory barriers to culture change and to provide information to congressional staff on the importance of supporting innovation in long-term care.

Awareness of the culture-change movement grew slowly at first: as late as 2005, a Commonwealth Fund survey of health care opinion leaders showed that 73 percent of respondents were unfamiliar with culture change. But in 2008, when the survey was repeated, only about 34 percent reported unfamiliarity with the movement. Providers in particular became very aware of culture change, in part because of the CMS’s "Eighth Scope of Work" contract

with the nation’s quality improvement organizations. That contract specifically used the term "culture change" and required that quality improvement organizations work with nursing homes in each state to collect information on resident and staff experience and satisfaction with care.

Proponents of culture change support principles governing resident care practices, organizational and human resource practices, and the design of the physical facility. According to these principles, an ideal culture change facility would feature:

Resident direction. Residents should be offered choices and encouraged to make their own decisions about personal issues such as what to wear or when to go to bed.

Homelike atmosphere. Practices and structures should be more homelike and less institutional. For instance, larger nursing units with 40 or more residents would be replaced with smaller "households" of 10 to 15 residents, residents would have access to refrigerators for snacks, and overhead public address systems would be eliminated.

Close relationships. To foster strong bonds, the same nursing aides should always provide care to a resident.

Staff empowerment. Staff should have the authority, and the necessary training, to respond on their own to residents’ needs. The use of care teams should also be encouraged.

Collaborative decision-making. The traditional management hierarchy should be altered to give frontline staff the authority to make decisions regarding residents’ care.

Quality improvement processes. Culture change should be treated as an ongoing process of overall performance improvement, not simply as a superficial.

Culture change has shown promise in making care for nursing home residents truly person-centered, while alleviating such problems as high staff turnover. Policymakers can encourage culture change adoption through regulation, reimbursement, public reporting, and other mechanisms.


The Commonwealth Fund

Health Affairs

Major CMS initiative planned for hip and knee replacements

The Centers for Medicare and Medicaid Services is proposing a Comprehensive Care for Joint Replacement (CCJR) payment model, to begin in January 2016,  that aims to hold hospitals accountable for the quality of care they deliver to Medicare fee-for-service beneficiaries for hip and knee replacements from surgery through recovery. 

Hip and knee replacements are some of the most common surgeries that Medicare beneficiaries receive. In 2013, there were more than 400,000 inpatient primary procedures, costing more than $7 billion for hospitalization alone. 

The quality and cost of care for these hip and knee replacement surgeries vary greatly, despite the existence of incentives for hospitals to avoid post-surgery complications that can result in pain, readmissions to the hospital, or lengthy rehabilitative care.

For example, the rate of complications such as infections or implant failures after surgery can be more than three times higher at some facilities than others, increasing the chances that the patient may be readmitted to the hospital. And the average Medicare expenditure for surgery, hospitalization, and recovery ranges from $16,500 to $33,000 across geographic areas.

Health and Human Services Secretary Sylvia M. Burwell says the CMS proposal furthers the administration’s commitment to transform the country’s health system to deliver better quality care and spend health care dollars in a smarter way.

“We are committed to changing our health care system to pay for quality over quantity,” Burwell has said. “By focusing on episodes of care, rather than a piecemeal system, hospitals and physicians have an incentive to work together to deliver more effective and efficient care.”

CMS says the initiative will offer incentive for hospitals and doctors to provide patients with the right care the first time and find better ways to help them recover successfully. Put simply, it will reward them with additional payment for helping patients get and stay healthy, and require them to repay Medicare for lower-quality treatment episodes — those that result in pain, lengthy therapy, or readmission to the hospital.  

Beneficiaries would retain their freedom of choice to choose services and providers. Physicians and hospitals would be expected to continue to meet current standards required by the Medicare program. All existing safeguards to protect beneficiaries and patients would remain in place.

Through the five-year payment model, health care providers in 75 geographic areas will continue to be paid under existing Medicare payment systems. However, the hospital where the hip or knee replacement takes place would be held accountable for the quality and costs of care for the entire episode of care — from the time of the surgery through 90 days after discharge. All eligible hospitals in 75 geographic areas — calledMetropolitan Statistical Areas (MSAs)  across the country will be included. 

The MSAs are counties associated with a core urban area with a population of at least 50,000.  Counties with no urban core area or an urban core area of less than 50,000 population were not eligible for selection. Eligible MSAs must have had at least 400 eligible hip and knee replacement surgeries between July 2013 and June 2014.

Depending on the quality and cost performance during the episode, the hospital may receive an additional payment or be required to repay Medicare for a portion of the episode costs. As a result, hospitals have an incentive to work with physicians, home health agencies, and nursing facilities to make sure beneficiaries get the coordinated care they need in order to reduce avoidable hospitalizations and complications. Hospitals will receive tools such as spending and utilization data and sharing of best practices to improve the effectiveness of care coordination.

Bundled payments for joint replacement surgeries will build upon successful demonstration programs already under way in Medicare. This model is also consistent with the private sector, where major employers and leading providers and care systems are moving toward bundled payments for orthopedic services.

A file of frequently asked questions about the model can be accessed here.  The complete proposal is available at https://www.federalregister.gov/public-inspection.  

Source: The Centers for Medicare & Medicaid Services  

Reimbursement for skilled care

Will Medicare cover physical therapy treatment received in a skilled nursing care facility? And if so, which ones?

Yes, if physical therapy is deemed necessary for full recovery, Medicare will cover the treatment.

Under certain conditions and for a limited time, Medicare Part A — which handles payments for hospital care — covers physical and occupational therapy as well as speech-language therapy provided in a skilled nursing facility, often referred to as an SNF.

Medicare makes it easy for you to know if your procedure will be covered: just log on to https://www.medicare.gov/coverage/skilled-nursing-facility-care.html  and type in the name of the procedure you are considering.

Medicare-covered services include, but aren't limited to:

  • Semi-private room (a room you share with other patients)
  • Meals
  • Skilled nursing care
  • Physical and occupational therapy (if needed to meet your health goal)
  • Speech-language pathology services (if needed to meet your health goal)
  • Medical social services
  • Medications
  • Medical supplies and equipment used in the facility
  • Ambulance transportation (when other transportation endangers health) to the nearest supplier of needed services that aren’t available at the SNF
  • Dietary counseling

Medicare covers swing bed services in certain hospitals and when the hospital or critical access hospital has entered into a "swing-bed" agreement with the Department of Health and Human Services under which the facility can "swing" its beds and provide either acute hospital or Skilled nursing-facility-level care, as needed. When swing beds are used to furnish SNF-level care, the same coverage and cost-sharing rules apply as though the services were furnished in a skilled nursing facility.

If you're in a skilled nursing facility but must be readmitted to the hospital, there's no guarantee that a bed will be available for you at the same facility if you need more skilled care after your hospital stay. Ask the SNF if it will hold a bed for you if you must go back to the hospital. Also, ask if there's a cost to hold the bed for you.

Your Medicare insurance will pay for your care if you meet all of these conditions:

  • You have Part A and have days left in your benefit period;
  • You have a qualifying hospital stay;  
  • Your doctor has decided that you need daily skilled care given by, or under the direct supervision of, skilled nursing or therapy staff. (If you're in the SNF for skilled rehabilitation services only, your care is considered daily care even if these therapy services are offered just 5 or 6 days a week, as long as you need and get the therapy services each day they're offered.)
  • You get these skilled services in a SNF that's certified by Medicare;
  • You need these skilled services for a medical condition that was either:
    • A hospital-related medical condition, or
    • A condition that started while you were getting care in the skilled nursing facility for a hospital-related medical condition.

Your doctor may want you to under observation to help decide whether you need to be admitted to the hospital as an inpatient or can be discharged. During the time you're getting observation services in the hospital, you're considered an outpatient — you can't count this time toward the 3-day inpatient hospital stay needed for Medicare to cover your SNF stay.

Let’s say you come to the emergency department and are formally admitted to the hospital under a doctor’s order; you stay for three days and are discharged on the fourth day.  Because you met the 3-day inpatient hospital stay requirement, your stay is covered.

If, on the other hand, you came to the emergency room and spent a day getting observation services before being admitted for two more days, your stay won’t be covered because you were considered an outpatient while getting the emergency and observation services. You only have two days of hospital stay on record, thus are ineligible for compensation. An inpatient stay begins on the day you’re formally admitted to a hospital with a doctor’s order. That’s your first inpatient day. The day of discharge doesn’t count as an inpatient day.

If you stop getting skilled care in the skilled nursing facility, or leave the SNF altogether, yourcoverage may be affected depending on how long your break in skilled nursing care lasts.

  • If the break in your skilled care lasts more than 30 days, you need a new 3-day hospital stay to qualify for additional SNF care. The new stay doesn’t need to be for the same condition that you were treated for during your previous stay.
  • If the break in your skilled care lasts for at least 60 days in a row, this ends your current benefit period and renews your SNF benefits. This means that the maximum coverage available would be up to 100 days of SNF benefits.

Your doctor or other health care provider may want you to get services more often than Medicare covers. Or they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs.  Don’t be afraid to ask questions! You have the right to understand why your doctor is recommending certain services and whether Medicare will pay for them.



Surgeon general to call for national walking campaign

Don’t misunderstand us, but … take a walk.

Really, it’s some of the best advice you’ll get, according to U.S. Surgeon General Vivek Murthy. He’s called for a national campaign centered on walking, an activity aimed at combating chronic disease and obesity. 

According to Murthy, the government will partner with schools, nonprofit organizations and the private sector to promote walking and to surmount obstacles that stand in the way of simply taking a walk.

The Surgeon General’s “call to action” seeks to make walking a national priority, promote development of communities where it is safe and easy to walk, develop walking programs, and conduct research on walking.

Walking is an example of the kind of physical activity that is slowly vanishing from our homes, schools, and workplaces. The time has come, Murthy says, to build activity back into our daily lives, and walking is one of the easiest and most available forms for most people.

He referred to the open letter, titled “The Soft American, written in 1960 by President-elect John F. Kennedy, expressing his concern over the loss of Americans’ physical vigor. His subsequent challenge to the Marines, to hike 50 miles in 20 hours, gave rise to a fad of 50-mile hikes that largely faded after he was assassinated.

Fifty-five years later, obesity rates have more than doubled. One of every two adult Americans is living with a chronic disease such as diabetes, cancer or heart disease — conditions that could be alleviated by a program of walking, Murthy says.

Just 150 minutes a week of brisk walking or other moderately intense physical exercise can reduce the risk factors that lead to such disease, including high blood pressure and obesity, and allow us to enjoy a higher quality of life and improved mental and emotional health. But only about half of U.S. adults get that much exercise, the Surgeon General says.

Walking has a lower risk of injury than high-intensity exercise and can be fit into anyone’s daily life.  It counts, for example, if we take the stairs and stop for “activity breaks” at work. At home, a walk with the spouse is better than having conversations on the couch in front of the TV.

Many communities are unsafe for walking because of crime, heavy traffic, or road design that is poorly suited to pedestrians, and Murthy suggests that communities be planned so that walkers and people in wheelchairs can find safe, accessible places to exercise.

And be forewarned: walking’s only the starting point to the Surgeon General’s goal of a more physically fit America. He says he hopes to expand to other activities, such as strength-training. So … get ready to flex those muscles!

We at Blue Sky Therapy are ready to assist your therapy – we’re the experts!

Blue Sky Therapy has a continued commitment to patient-driven quality, excellence, integrity and innovation in everything that we do. That’s why we are scrupulous about planning the treatment of each and every client, and carefully documenting the outcome!

This information is not intended to replace the advice of a doctor. Blue Sky disclaims any liability for the decisions you make based on this information.


The Washington Post

Physical Therapy in the treatment of Alzheimer’s Disease

Studies indicate that 5 percent of people over age 65—about 5.2 million—and more than 40 percent of those over the age of 85 have Alzheimer's disease. As they battle the challenges of memory loss and other cognitive problems, these people can find the simple tasks of daily living to be increasingly difficult.

The physical therapist can play an important role in helping Alzheimer’s sufferers.  Partnering with families and caregivers, physical therapistscan help patients with Alzheimer’s disease keep moving safely and, through exercise, delay worsening of the condition.

Alzheimer's disease is a progressive condition that damages brain cells and affects how we speak, think, and interact with other people. It's the most common cause of dementia, a brain disorder that causes a decline in memory and the ability to perform daily activities, and is  the fifth leading cause of death among adults over age 65 in the United States — after heart disease, cancer, stroke, accidents, and respiratory disease.

There are 10 reliable and important warning signs of possible Alzheimer's disease.  Look for:

  • Memory changes that disrupt daily life
  • Difficulty making decisions, especially in planning or solving problems
  • Difficulty completing familiar tasks
  • Confusion about time and/or place
  • Trouble understanding visual images or the way things physically fit together (spatial relationships)
  • Finding the right words to say when speaking or writing
  • Misplacing items and losing the ability to retrace your steps
  • Poor or decreased judgment about safety
  • Withdrawal from work or social activities
  • Changes in mood or personality

People with Alzheimer's disease also may get lost in once-familiar places. In the later stages of the disease, they may get restless and wander, especially in the late afternoon and evening (known as "sundowning"). They may withdraw from family and friends or see or hear things that are not there. They may be suspicious that others are lying, cheating, or trying to harm them.

In the later stages of the disease, Alzheimer's sufferers may develop difficulty performing simple tasks of daily living.  Eventually, they may need assistance with feeding, bathing, toileting, and dressing. Usually, they will retain the physical ability to walk until the very last stage of the disease; however, they may need supervision or an assistive device to help them get around safely.

 How can a physical therapist help? Research shows that:

  • Physical activity can improve memory.
  • Regular exercise may delay the onset of dementia and Alzheimer's disease
  • Regular exercise may delay the loss of later-stage patients’ ability to perform activities

In the early and middle stages of the disease, physical therapists will focus on keeping people mobile and help them continue to perform their roles in the home and in the community. In the later stages, physical therapists can help patients to keep doing their daily activities for as long as possible, which reduces the burden on family members and caregivers.

People with Alzheimer's disease develop other conditions related to aging, such as arthritis, falls, or broken bones. Physical therapists are trained to treat these Alzheimer’s –related conditions. The therapist may use various teaching methods, techniques, and unique approaches, including:

  • Visual, verbal, and tactile cueing: The physical therapist provides "cues” such as pointing to objects or gesturing. For instance, lifting up both arms can signal the person to stand up.
  • Mirroring: With this technique, the physical therapist serves as a "mirror," standing directly in front of the person to show them how to move.
  • Task breakdown: Physical therapists give step-by-step instruction by breaking down the task into short, simple "pieces" to be completed separately.
  • Chaining: The physical therapist can provide step-by-step instructions by linking one step to the next step in a more complicated movement pattern.
  • Hand-over-hand-facilitation: The physical therapist takes the hand or other body part of the patient and moves that body part through the motion of completing a task or motion.

Alzheimer’s sufferers usually can walk well into the late stages of the disease, but balance and coordination problems may lead eventually to walking difficulties. The physical therapist will train the muscles to learn to respond to changes in the environment, such as uneven or unstable surfaces.

The family and caregiver may need instruction in how to safely move, lift, or transfer the  Alzheimer's patient to prevent injury to the caregiver as well as the patient. In addition to hands-on care, physical therapists provide caregiver training to improve safety and to decrease the risk of injury.  

Research has found that physically active people are less likely than sedentary people to have cognitive decline or dementia as they age. Some research suggests that increased cardiorespiratory fitness might even prevent brain atrophy. Your physical therapist can design an exercise program to help you improve your odds for healthy aging.