"The Unlimited Capitation
Kit"
By Carole Lewis, PhD, MSG, MPA, GCS
Yippy! The cap is up for two years. If I were to make a toolbox of what should be in my "Unlimited Capitation Kit", I would include the following items.
One-page documentation form. Lengthy forms are a thing of the past. A form that shows impairments and functional deficits, including all the necessary elements for payment (medical necessity, reasonable and necessary, skill and on-maintenance),will help.
Tools to objectively measure deficits. Important tools include a slide algometer to measure pain and a goniometer. But the most important piece of equipment therapists must look into is dynamometers.
Several companies make hand-held muscle strength dynamometer. By not using dynamometry, we are doing a severe disservice to our patients, and in turn our profession.
For example, you observe a patient getting out of a chair all the while thinking, "he must be weak in his quads"; so you do a manual muscle test on his quads. Low and behold, he tests 5/5. If you then take a dynamometer and test his quads, you would find him to score 40 pounds. For a gentleman in his 70s, his quadriceps muscle should only score 80 pounds; therefore, he is really only able to generate 50 percent of his strength. So buy a dynamometer and compare outcomes to the age-related norms. We will not be reimbursed for treating the patient who scored 5/5 because we cannot justify treatment, but we can easily treat and document efficacy with the same patient scoring 40 pounds out of 80 pounds.
Objective impairment measures. Impairment grades are not functional grades, and any collection of published accepted grades is imperative for this toolbox. Posture from the Reedco Posture Score sheet, goniometry for range of motion and inches of swelling are just some of impairment grades. Generate a list of grades and list them in your policy and procedure manuals.(1,2)
Objective functional measures. Many of these objective functional measures are pencil and paper that can be done by the caregivers or the patient. Some of them are performance tests, that must be completed by the therapist. The Tinetti tool is one of these.(1) It shows that as patients improve in gait, they are less at risk of falls and fractures.
Objective functional measures show a functional deficit that relates to a functional problem. There are numerous functional tools available, but we must use those that justify care and demonstrate functional improvement.
Guide on writing good notes. A guide for therapists on how to write good notes would be the next component of the Unlimited Capitation Kit. The four components for writing good notes to justify need for skilled therapy are medical necessity, reasonable and necessary, skill and non-maintenance.
Good protocols. The final area of the Unlimited Capitation Kit is good protocols.(3,4) Well written protocols provide a concise, time based, easy-to-use guide for formulating a rehabilitation program that will best serve the patient. Safe Steps is a gait and balance protocol that is slightly different. (3) It not only examines functional tools (for example, the one-legged standing balance test, functional reach, and the Tinetti test), but for each item that the patient scores a deficit a list of interventions are given to design a framework on which the individualized program can be built. If the patient scores poorly on external nudge, for example, the protocol sections lists several treatment options, such as lower extremity strength training, lateral sway stability and vestibular stimulation upon which to base the foundation for therapeutic exercises.
The Unlimited Capitation Kit is just an idea, but I believe that therapists need to pursue something analogous to this, so that we can give our patients the most effective and worthwhile care.
References