• News New Blog Banner

  • 'Fundamentally Flawed': APTA's Comments on CMS' Plan Around PTAs, OTAs Target Potential Harms

    The big picture: a bad plan for determining when services are delivered by a PTA or OTA
    The US Centers for Medicare and Medicaid Services' (CMS) proposed physician fee schedule rule for 2020 includes provisions that would require providers to navigate a complex system intended to identify when outpatient therapy services are furnished by a physical therapist assistant (PTA) or occupational therapy assistant (OTA). If adopted, the plan would trigger a payment differential in 2022 based on how many minutes of services are provided by the PTA or OTA. (See this PT in Motion News story for a more detailed overview of the proposed rule.)

    CMS proposes to accomplish this by way of new PTA and OTA modifiers (CQ and CO, respectively) to be included on claims beginning January 1, 2020. The proposal also requires providers to add a statement in the treatment note that explains why the modifier was or wasn't used for each service furnished that day. In short, the system is rooted in total minutes of service, and would require the use of the applicable modifier that would indicate when a PTA or OTA provided outpatient therapy services for 10% or more of the total time spent furnishing the service.

    The proposal is more than just problematic—it's a threat to patient access to care, a vast overreach of CMS authority, and a documentation nightmare that flies in the face of CMS' "patients over paperwork" initiative to ease administrative burdens on providers. We laid out our concerns in a comment letter to CMS that describes the plan as "fundamentally flawed."

    Some of what's being proposed, CMS reasoning behind it—and what we have to say

    CMS: When the PTA participates in the service concurrently with the PT for a portion of total time, the modifier should be used when the minutes furnished by the therapy assistant are greater than 10% of the total minutes spent by the therapist furnishing the service, which means that the entire service would be subject to the 15% payment adjustment in 2022. This is being done to comply with Section 1834(v) of the Social Security Act.
    APTA: The intent of the therapist assistant provisions in the Social Security Act was to better align payments with the cost of delivering therapy services given that therapist assistant wages are typically lower than therapist wages. It was not meant to apply an adjustment to a PT's services furnished when the therapist assistant provides a “second set of hands” to the therapist for safety or effectiveness.

    The proposal completely ignores the efficacy of team-based care (CMS uses the term “concurrent“) and runs counter to the evolution—ostensibly supported by CMS—toward value-based care. "It is nonsensical to diminish reimbursement for services when safety precautions are implemented, and the overall value of the care is increased," we say in our letter. Bottom line: only services furnished in whole or in part independently by the assistant should count toward the 10% standard.

    CMS: If the PTA and the PT each separately furnish portions of the same service, the modifier would apply when the minutes furnished by the PTA are greater than 10% of the total minutes—the sum of the minutes spent by the therapist and therapy assistant—for that service.
    APTA: This proposal directly contradicts CMS' response to comments in the 2019 fee schedule final rule. In the rule, CMS explained how its claims processing system allows for the differentiation of the same procedure code when the same service or procedure is furnished separately by the therapist and assistant.

    In our letter, we write that “the agency clearly is contradicting itself now, several months later, in proposing to require that the CQ/CO modifier apply when the minutes furnished by the assistant are greater than 10% of the total minutes—the sum of the minutes spent by the therapist and therapist assistant for that service, thereby not allowing for the same procedure code to be reported on 2 different claim lines.”

    But that's just part of the problem. The system CMS is proposing for how providers arrive at this is anything but simple—in fact, we say that it's "outrageous that CMS expects therapy providers—particularly those who do not employ administrative staff and must perform all the coding and billing themselves in addition to delivering treatment to patients—to engage in division, addition, multiplication, and rounding merely to determine whether to affix a modifier to the claim."

    CMS: Beginning in 2022, if the PTA services exceed the 10% limit, reimbursements will be cut by 15%.
    APTA: The cuts pose a grave threat to the delivery of services, particularly in rural and underserved areas, especially when it's combined with the geographic indices that affect payment in these areas—on top of other potential reimbursement reductions in future years. We recommend that if CMS moves ahead with this proposal, it should exempt providers in rural and underserved areas from the requirements.

    CMS: In addition to the use of new modifiers, providers will need to provide a written statement explaining why the modifier was or wasn't used—and it has to be done for each service furnished that day.
    APTA: In our letter we call this plan "wholly unbelievable." Aside from the facts that the modifier proposal itself is extremely complicated and the extra documentation is not required by law, the addition of a statement requirement is clearly an undue administrative burden and a direct contradiction of the CMS "Patients Over Paperwork" initiative.

    We write that the plan "conveys a sense that CMS is being vindictive toward outpatient therapy providers, creating a divisive environment for therapy providers enrolled in the Medicare program." Our comment letter goes on to provide 6 additional reasons why the documentation requirement is a bad idea, including the ways in which it complicates 15-minute timed billing, exceeds requirements of Medicare administrative contractors, and applies a standard to PTs, OTs, PTAs, and OTAs that isn't applied to physicians, physician assistants, and nurse practitioners.

    What's next?
    This letter is the first of 2 comment letters on the fee schedule that APTA will be providing to CMS in the coming weeks. Deadline for comments is September 27, and the final rule will likely be issued by November 1. APTA and several other providers associations will be meeting with CMS officials in mid-September to share concerns and provide recommendations.

    You have an important role to play. Visit APTA's "Regulatory Take Action" webpage to access a customizable template letter on the PTA/OTA modifier, fill it in, and make your voice heard. It's easy—and crucial.

    Stay tuned for additional opportunities for comment on other elements of the proposed rule.

    4 Videos (and a Podcast) to Get You Ready for Pain Awareness Month

    September is National Pain Awareness Month—a perfect opportunity to spread the word about the important role physical therapists (PTs) and physical therapist assistants (PTAs) play in the management of pain, and the unique knowledge they bring to the table.

    Need a reminder of why patient access to physical therapy for pain is so crucial, or inspiration to get you thinking about your own activities during National Pain Awareness Month? Here are some standout videos—and a podcast—that do just that. All but 1 were produced by APTA.

    A Journey Out of Pain and Addiction, and a PT's Crucial Role
    What it's about: In his keynote address for the 2019 APTA NEXT Conference and Exhibition, US Army Master Sergeant (Retired) Justin Minyard recounted the injuries he received during rescue attempts first at the Pentagon during the 9-11 attacks and then while on a mission in Afghanistan. But the heart of Minyard's story is about what happened afterward: the multiple fusion and other surgeries, the intense pain, his slide into addiction, and his eventual freedom from opioids. He readily acknowledges that his recovery was thanks in large part to the work of an interprofessional team that included a dedicated physical therapist.

    Why you should listen: Minyard's brutal honesty and his ability to tell a story with both humor and pathos pull you in from the start. And the gratitude he has for his PT—he describes her as not just his physical therapist "but my psychologist, my sounding board, my marriage counselor, my educator of my options, and my kick in the ass"—will remind you of why you love the profession.

    Beyond Opioids: Transforming Pain Management to Improve Health
    What it's about: This video of a February 2018 Facebook Live panel discussion hosted by APTA provides a wide range of perspectives on physical therapy's role in pain management. Panelists include a patient advocate, a representative from the US Centers for Disease Control and Prevention, a member of the US House of Representatives, the President of the American Academy of Pain Medicine, and 2 PTs working on the front lines of pain management.

    Why you should watch: It's fascinating to watch the ways in which panelists' individual perspectives weave a unified message: that there's a need for increased and more open communication, better identification of risk factors for opioid abuse, greater use of multidisciplinary approaches to pain management, and more education delivered to patients, providers, employers, and entire communities.

    Congressional Briefing on Treating Pain
    What it's about: This video, a straightforward recording of an APTA-sponsored Congressional briefing held in May 2019, makes the case for better policy support for nonpharmacological approaches to pain management through the perspectives of 2 PTs and Cindy Whyde, a high school teacher whose son Elliot struggled with opioid addiction after receiving the drugs for a football injury.

    Why you should watch: Cindy Whyde's story is a heartbreaking (and frustrating) testimony to how far the health care system still has to go when it comes to patient education on and access to nondrug pain management approaches. Jen Bambrough, PT, DPT, and Sarah Wenger, PT, DPT (Wenger was also a panelist for the Facebook Live event), discuss how more thoughtful, collaborative, and patient-centered strategies can and do work.

    How Physical Therapy is Helping to Fight the Opioid Crisis
    What it's about: In September 2018, Prevention magazine editor Sarah Smith interviewed Sarah Wegner, PT, DPT, about the ways PTs and PTAs can help patients explore nonpharmacological management of pain.

    Why you should watch: It's a great interview aimed at a general audience, and Wenger is articulate and passionate about the profession. The half-hour program also explores the training, knowledge, and skills PTs must acquire, and why this combination is so well-suited to pain management. A great intro to physical therapy for the consumer—particularly the consumer struggling with pain.

    "You've Got No Bigger Fan Than the Surgeon General"
    What it's about: This APTA interview with US Surgeon General Jerome Adams, MD, MPH, took place just after he finished an address at the association's Component Leadership Meeting in January 2019. Adams' address at the meeting amounted to a resounding endorsement for physical therapy as a key player in the battle against pain and the opioid crisis. The video interview afterwards recaps his main points.

    Why you should watch: It never hurts to have friends in high places, and Adams is an enthusiastic supporter of physical therapy. His commitment to bringing the profession to the table, pressing for more multidisciplinary approaches to pain and addiction, and bringing the message of responsible opioid stewardship into communities comes through loud and clear.

    [Editor's note: stay tuned for more APTA activities during National Pain Month coming up in mid-September,]

    Physical Therapy Education Leader Rosemary Scully Dies

    Rosemary Scully

    Physical therapy thought leader Rosemary Scully, PT, EdD, FAPTA, whose tireless passion for learning left a lasting imprint on physical therapist clinical education, has died. She was 83 years old.

    Scully was born in West Virginia and earned her first degree—a baccalaureate in physical education—from West Virginia University. She later received a master's degree in physical therapy and a doctorate in education from Columbia University in New York. Along the way, Scully dedicated herself to applying what she had learned to improve the physical therapy profession, particularly related to education.

    Her work and educational efforts eventually took her to the University of Pittsburgh, where she led the university's physical therapy program until her retirement in the early 1990s. Scully's legacy lives on at Pitt through the Scully Scholar Lecture Series, an annual event that features some of the most prominent voices in the physical therapy profession.

    Scully authored several influential reports, studies, and books, including "Cooperative Planning for Clinical Experience in Clinical Therapy" and the comprehensive textbook, Physical Therapy, published in 1989. In addition, she was a coeditor of the Studies in the Health Related Professions series of publications, and within that series, a coauthor of several books focused on physical therapist and physical therapist assistant faculty characteristics.

    A member of APTA since 1958, Scully was vice speaker of the APTA House of Delegates from 1977 to 1983. In 1989, she received the association's Lucy Blair Service Award, and was named a Catherine Worthingham Fellow in 1992.

    Scully's love for the physical therapy profession—and particularly for the learning opportunities it presents—shone through in a recap of an oral history she provided to APTA in 1999. In that recap, published in the association's PT Magazine in 2000, Scully described what she viewed as one of the profession's greatest assets.

    "I was very fortunate to find physical therapy, a profession where I could, as an individual, do whatever it is that I wanted to do, while at the same time, other folks in the same field are doing entirely different kinds of things," Scully said. "I was always pleased with its diversity. Physical therapy is eclectic. It brings in all different kinds of people: wonderful folks who are pioneers and push the field forward."

    What a Difference a Day Makes: Researchers Say That for TKA, Post-Op Same-Day Physical Therapy Reduces Opioid Use and Shortens Length of Stay

    In this review: Same-Day Physical Therapy Following Total Knee Arthroplasty Leads to Improved Inpatient Physical Therapy Performance and Decreased Inpatient Opioid Consumption
    (The Journal of Arthroplasty, August 2019)

    The message
    Total knee arthroplasty (TKA) patients who received physical therapy on the same day as their surgeries were able to walk more while in the hospital and had lower rates of opioid consumption during their stay compared with patients who didn't receive physical therapy until the day after their surgeries. The same-day patients also tended to have shorter lengths of stay and higher rates of discharge to home.

    The study
    Researchers at the New York-based Columbia University Medical Center tracked 687 patients with knee osteoarthritis (OA) who received TKA at the facility between July 2016 and December 2017. A total of 295 "PT0" patients received postoperative physical therapy on the same day as their surgeries (POD0), consisting of a 30-minute session that included information, education, knee exercises, and activities-of-daily-life training. The remaining 392 "PT1" patients received the same session, but not until the day after surgery (POD1). Patients weren't randomized into the groups; instead the "PT0" and "PT1" groups fell into place, depending on whether factors such as patient motivation, fatigue, or pain during physical therapy prevented same-day physical therapy.

    All patients were asked to participate in 2 physical therapy sessions on postoperative day 1 if willing and able. Researchers evaluated ambulation distance, morphine equivalents consumed, pain levels, length of stay, and discharge disposition among the PT0 and PT1 groups. They also analyzed demographics, treatment details such as length of surgery, and preoperative function and outcome measures using the Knee Injury and Osteoarthritis Outcome Score (KOOS) and the Knee Society Score (KSS).

    Findings

    • The PT0 group experienced an average 76% increase in "physical therapy performance" (number of steps taken) compared with the PT1 group. Authors of the study think the difference may be attributable to the idea that "early interaction with the physical therapist (PT) motivates and affirms patients that they can ambulate with full weight-bearing immediately postoperatively." That confidence-building, they write, paves the way for better progress in subsequent sessions.
    • While self-reported pain levels between the groups were similar, the PT0 group consumed about 25% less opioids than the PT1 group while in the hospital.
    • Average length of stay for the PT0 group was less than for the PT1 group—2.7 days compared with 3.2 days for the PT1 patients. The PT0 patients also tended to be discharged to home at a greater rate than the PT1 group, with 81.7% of the PT0 cohort sent home, compared with 54.8% of the PT1 patients.
    • Factors including gender, pain scores, preoperative KSS and KOOS, and age-influenced results, but did so similarly between the 2 groups. The groups showed no major differences in baseline characteristics.

    Why it matters
    TKA is an ever-increasing procedure predicted to rise to a rate of 1.3 million surgeries a year by 2030. Expenditures are high, with hospital length of stay and postacute care figuring heavily into costs—2 factors that seem to be positively affected by starting physical therapy the same day as surgery. Additionally, as authors point out, "any intervention that can demonstrate decreased opioid consumption is beneficial."

    Related APTA resources
    The association offers a TKA clinical summary, the Knee Outcome Survey-Activities of Daily Living test, and the Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement through the PTNow resource area, and individuals considering TKA can find a consumer-friendly guide at MoveForwardPT.com, the American Physical Therapy Association’s official consumer website. APTA's highly successful #ChoosePT campaign is helping to spread the word about effective nonopioid approaches to pain management, while the association continues to work for increased patient access to physical therapy for pain through direct advocacy and publications, such as its white paper on physical therapy's role in pain management. And be on the lookout: APTA's own clinical practice guideline on TKA is coming soon.

    Keep in mind…
    The research didn't employ a formal randomization process.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    APTA's Comments on FCC Telehealth Proposal Stress Inclusion of PTs and Wider, More Innovative Use

    The big picture: a telehealth subsidy for providers?
    The Federal Communications Commission (FCC) has proposed a pilot project that aims to increase the delivery of telehealth to rural and low-income Americans by way of a $100 million, 3-year funding initiative. The program, known as the Connected Care Pilot, would subsidize a large portion of provider costs for broadband through the Universal Service Fund (USF) program.

    However, there are still plenty of details to be worked out, including which providers would qualify for the subsidies, whether the funding would be limited to telehealth services for a limited list of patient conditions, and how compliance with the program would be monitored.

    APTA provided FCC with its take on the proposal through a comment letter that emphasizes the inclusion of physical therapists (PTs) as qualified providers, and urges the FCC to think more expansively about the range of conditions that would be appropriate for telehealth services.

    Some of what's being proposed—and what we have to say about it

    FCC: Wants to establish a system that gives providers flexibility in determining which patients would be best suited to receive telehealth services.
    APTA: Agreed. "Providers are in the best position to determine which of their patients would benefit the most from access to telehealth services," our letter states, and adds that "it would be counterproductive to limit which patients providers can treat via telehealth."

    FCC: Believes the pilot program should be limited to care for conditions that tend to require several months of treatment, such as behavioral health, opioid dependency, chronic health conditions, and high-risk pregnancies.
    APTA: It's a good start, but the program should also prioritize conditions that require frequent visits with a provider, such as common orthopedic and neurological conditions, total knee arthroplasty, and stroke. These conditions can involve multiple visits per week, which can be burdensome for patients.

    FCC: Asks for feedback on whether participating patients should be required to contribute to the nonsubsidized share of the costs, with certain limits on what they'd be asked to pay.
    APTA: Bad idea. It could be a disincentive to some patients and will impede the wider adoption of telehealth in the long run. Besides, patients already have to pay for their own internet connection, and the FCC proposal doesn't cover costs of any other end-user devices.

    FCC: Wants to limit the program to certain nonprofit or public health care providers such as teaching hospitals, medical schools, community health and mental health centers, local health departments, nonprofit hospitals, rural health clinics, skilled nursing facilities, and a "consortia" of health care providers associated with these facilities.
    APTA: That's too narrow. The program should include providers who have not always been associated with telehealth—especially PTs, whose services are "well-suited to the medium," as stated in our letter. On top of that, the profession already is paving the way for its role in telehealth through the Physical Therapy Compact now enacted in 26 states.

    FCC: Asks for parameters around choosing which applications to accept, in addition to overall cost, and whether the applicant would serve program goals and has the capacity to operate and evaluate the outcomes of the program.
    APTA: The program also should factor in whether the proposed program is using telehealth in innovative ways. Our comments encourage FCC to push the boundaries of what telehealth has to offer.

    FCC: Thinks it may be a good idea to award additional points to projects that would serve areas or populations that have "well-documented health care disparities"—places such as tribal lands and rural areas, and populations such as military veterans. The agency also proposes that additional points be to awarded to projects that are "documented to benefit from connected care, such as opioid dependency, diabetes, heart disease, and high-risk pregnancy."
    APTA: We agree and disagree. While targeting areas and populations that are experiencing health disparities is an excellent idea, awarding extra points to only primary or mental health care is far too limiting. Our comments encourage FCC to be more inclusive in its consideration of provider types considered, "and score them on their ability to positively impact patients' lives, not on the specific discipline of medicine they practice."

    FCC: Wants to establish metrics for evaluating progress that could include reductions in emergency room or urgent care visits, decreases in hospital admissions or readmissions, changes in condition-specific outcomes, and patient satisfaction.
    APTA: Measurement is important, but don't reinvent the wheel; there are plenty of existing metrics. The US Centers for Medicare and Medicaid Services is a good place to start—the agency has developed a host of quality-reporting measures through its Quality Reporting Program.

    What's next?
    Once the FCC reviews the feedback it has received, it will issue a final rule outlining the details of the pilot including when and how to apply to participate. APTA’s Regulatory Affairs team will monitor any developments.

    Labels: None

    Study: Mothers Who Exercise During Pregnancy Give Their Infants a Motor Skills Boost

    In this review: Effects of Aerobic Exercise During Pregnancy on 1-Month Infant Neuromotor Skills
    (Medicine and Science in Sports and Exercise, August 2019)

    The message
    Infants of mothers who engaged in aerobic exercise during pregnancy tend to show better motor development at 1 month compared with infants of nonexercising mothers, according to authors of a new study. The researchers believe that aerobic exercise during pregnancy could be a hedge against childhood overweight and obesity.

    The study
    Researchers analyzed data from 60 healthy mothers (ages 18 to 35, with an average age of 30) and their infants. During their pregnancies, 33 women participated in 45-50 minutes of supervised aerobic exercise, 3 days a week. The remaining 27 women in the control group were asked to engage in a 50-minute supervised stretching and breathing program 3 days a week, but were otherwise advised to continue with "normal" activities. The infants of both groups were then evaluated for motor skills development at 1 month using the Peabody Developmental Motor Scales, second edition (PDMS-2), a tool that tests reflexes, locomotion, and a child's ability to remain stationary. The measure also provides a composite score, known as the Gross Motor Quotient (GMQ).

    APTA member Amy Gross McMillan, PT, PhD, was lead author of the study.

    Findings

    • The PDMS-2 scores, expressed as percentiles, were higher for the exercise group in the areas of stationary (45.5 compared with 39.5 for the control group), locomotion (55.7 compared with 50), and overall GMQ (56.3 compared with 52.5). They were lower in the reflex category (63.1 for the exercise group, compared with 66.2 for the control).
    • In the control group, male infants performed better than female infants in most tests—a finding that researchers expected given what's known about the role of testosterone in male infant development. However, in what authors describe as an "intriguing" finding, female infants in the exercise group tended to close that gap and even outperformed males, albeit slightly, in reflex, stationary, and GMQ scores.
    • There were no significant between-group differences in maternal age, BMI, number of live children, or education; and all infants included in the study were born healthy and full-term with no congenital abnormalities.
    • In the exercise group, compliance averaged 83%, with 81% of the exercising mothers reaching at least 70% compliance during pregnancy.

    Why it matters
    With childhood obesity and overweight rates continuing to rise, the pressure is on to promote healthy rates of physical activity (PA). Authors of this study point to previous research that links better motor skills in infancy to higher rates of PA through childhood and adulthood, and write that "the promotion of exercise during pregnancy may positively impact childhood health outcomes."

    More about the findings
    Authors aren't sure what exactly is happening through aerobic exercise in pregnancy, but they speculate that it may have to do with the release of growth hormone and intrauterine growth factor-1, which do not cross the placenta but can increase the supply of nutrients to the fetus. Additionally, they believe that the improved blood flow and oxygenation associated with aerobic exercise may also contribute to the differences.

    Keep in mind…
    The research involved only healthy women and didn't control for other factors that contribute to mother and infant health, including sleep, diet, sedentary behavior, occupation, and the infant's environment after birth.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Study: Knee, Hip OA May Increase Risk of CVD-Related Death, Underscoring Need for Emphasis on Physical Activity in OA Treatment

    In this review: Cause-specific mortality in osteoarthritis of peripheral joints
    (Osteoarthritis and Cartilage, June 2019)
    Abstract

    The message
    Researchers from Sweden found that among individuals studied, those with hip or knee osteoarthritis (OA) died from chronic ischemic heart diseases and heart failure at a greater rate than both the non-OA population and those with OA in other peripheral joints. No other significant correlations were found between the presence of OA and other causes of death, including diabetes, dementia, neoplasms, or diseases of the digestive system.

    The study
    Researchers tracked 469,512 health records from individuals in southern Sweden who were between the ages of 25 and 84 in 2003, including individuals who received an OA diagnosis between 1998 and 2003. Authors of the study then compared causes of death among the OA and non-OA group reported over an 11-year span, from 2004 to 2014. The researchers wanted to find out the degree to which the presence of OA in a peripheral joint (or joints) increased the hazard risk for various individual causes of death.

    Findings

    • Among all individuals studied, the most common causes of death were neoplasms and cardiovascular diseases (CVD), accounting for 66% of all deaths.
    • Compared with the non-hip/knee OA groups, those with hip OA were 1.13 times as likely to die from CVD, while the knee OA group was found to be 1.16 times as likely to die from CVD. Those differences increased as the individuals aged.
    • The CVD-related deaths among the hip and knee OA groups were primarily related to heart failure and ischemic heart disease, and rates didn't differ significantly between men, women, and when adjusted for other demographic variables.
    • Researchers found no correlation between OA and other causes of death studied: diabetes, hypertension, cerebrovascular disease, neoplasm, dementia, and liver disease.
    • Among the knee OA group, 26% underwent knee replacement during the study period. Of the hip OA group, 55% had a joint replacement procedure; however, the mortality results were similar even when both replacement groups were excluded from the hazard ratio analysis.

    Why it matters
    The bulk of research related to OA and causes of death tend to focus on all-cause mortality. This large-scale study took a more granular approach to identify possible relationships between types of OA and specific causes of death. Authors believe the findings further underscore the importance of emphasizing physical activity in the treatment of OA.

    What APTA's doing
    APTA is a strong supporter of the importance of physical activity in the treatment of OA. The association offers resources on encouraging healthy, active lifestyles at APTA's Prevention, Wellness, and Disease Management webpage as well as information on arthritis management through community programs. Members also can dive deeper into the issues by joining APTA's Council on Prevention, Health Promotion, and Wellness in Physical Therapy, and by checking out evidence-based resources such as this clinical practice guidelines on hip pain mobility deficits, available at the association's PTNow website. Patient-focused resources are available through APTA's MoveForwardPT.com website; additionally the Osteoarthritis Action Alliance offers a free booklet to help consumers participate in its "Walk With Ease" program.

    Keep in mind…
    Researchers were unable to adjust for body mass, a factor related to both the presence of OA and higher all-cause mortality. Additionally, the individuals with OA included those at all stages of the disease, and were limited to those who received an OA diagnosis—authors acknowledge it's likely that the non-OA group included individuals with undiagnosed OA.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    The Good Stuff: Members and the Profession in the Media, August 2019

    "The Good Stuff" is an occasional series that highlights recent media coverage of physical therapy and APTA members, with an emphasis on good news and stories of how individual PTs and PTAs are transforming health care and society every day. Enjoy!

    PT compassion: Paul Erwin, PT, DPT, provides care and friendship to Yousef Zein, a 16-year-old refugee from Syria who has a brittle bone condition. (lancasteronline.com)

    What's best in the long run: Mike Moravec, PT, DPT, provides tips on the best ways to prep for a marathon. (Scottsbluff, NE, Star-Herald)

    "So every kid can play": Maria Fragala-Pinkham, PT, DPT, MS, helps to lead an adaptive baseball program for kids in the Boston area. (WBZ4 News, Boston)

    When cryotherapy's not cool: Michael Conlon, PT, explains the proper use of cryotherapy and what may have led to Oakland Raider Antonio Brown experiencing frostbite from the treatment. (The Ringer)

    5 signs your baby may need physical therapy: Magdalena Oledzka, PT, DPT, PhD, discusses infant characteristics that may indicate the need for pediatric physical therapy. (Romper)

    Softening fall rates: Lindsey Nordstrom, PT, DPT, stresses the importance of falls prevention in helping to curb the rising number of falls being experienced by adults who are older. (La Salle, IL, News-Tribune)

    Brace yourself—or not: Robert Gillanders, PT, DPT, discusses the pros and cons of knee braces. (Creakyjoints)

    Taking control of arthritis pain: Randy Siy, PT, makes the case for physical activity's role in managing pain related to arthritis.(WJZ13 News, Baltimore)

    Aching for a healthy back: Karen Joubert, PT, DPT, offers daily routines to help alleviate back pain. (KTLA5 News, Los Angeles)

    Pelvic tilt: Carrie Pagliano, PT, DPT, explains structural pelvic tilt and how to address it. (Openfit)

    When PTs rein: Sara Montgomery, PT, DPT, shares thoughts on how the Equine Assisted Therapy Alaska hippotherapy program is improving area kids' lives. (KTUU2 News, Anchorage, AK)

    Who ordered a side of pain? Kati Mihvec-Edwards, PT, DPT, discusses strategies for runners who experience side stitches. (Popsugar)

    Exercise and recovery poststroke: Elizabeth Regan, PT, DPT, and Stacy Fritz, PT, DPT, PhD, discuss findings from their research into the benefits of aerobic exercise for individuals poststroke. (US News and World Report)

    Pulmonary rehab's breath of fresh air: Noah Greenspan, PT, DPT, provides a vibrant, nonconformist, and fun setting for patients who visit his New York-based pulmonary rehab clinic. (COPD News Today)

    A weighty topic: Matt Ernst, PT, MPT, offers tips on safe backpack weight, fit, and use for kids returning to school. (WKRC Local12 News, Cincinnati)

    Exercise and DMD: Claudia Senesac, PT, PhD, outlines how to create effective exercise programs for boys with Duchenne muscular dystrophy. (Muscular Dystrophy News Today)

    Blanket rules? Theresa Marko, PT, DPT, MS, explains the potential recovery benefits of weighted blankets. (Muscle & Fitness)

    Got some good stuff? Let us know. Send a link to troyelliott@apta.org.

    Stay Inspired, Motivated, and In-the-Know With These APTA Podcasts

    APTA continues to assemble a collection of free, easy-to-download podcasts that deliver plenty of variety, from personal stories that remind you of why you love what you do, to nuts-and-bolts information that could be crucial to your professional survival.

    Where to start? Here are some suggestions—but you can also check out APTA's podcasts webpage to browse an extensive list of offerings.

    Podcasts that inspire
    A recent example: "A Journey Out of Pain and Addiction, and a PT's Crucial Role"

    What it's about: In his keynote address for the 2019 APTA NEXT Conference and Exhibition, US Army Master Sergeant (Retired) Justin Minyard recounted the injuries he received during rescue attempts first at the Pentagon during the 9-11 attacks and then while on a mission in Afghanistan. But the heart of Minyard's story is about what happened afterward: the multiple fusion and other surgeries, the intense pain, his slide into addiction, and his eventual freedom from opioids. He readily acknowledges that his recovery was thanks in large part to the work of an interprofessional team that included a dedicated physical therapist (PT).

    Why you should listen: Minyard's brutal honesty and his ability to tell a story with both humor and pathos pull you in from the start. And the gratitude he has for his PT—he describes her as not just his physical therapist "but my psychologist, my sounding board, my marriage counselor, my educator of my options, and my kick in the ass"—will remind you of why you love the profession.

    More inspiration: APTA's "Defining Moment" podcast series is the audio companion to PT in Motion magazine's regular feature of the same name, which highlights stories from members about those moments when they felt that special—often life-changing—connection to the physical therapy profession. [Editor's note: If you want to share your defining moment, contact Associate Editor Eric Ries at ericries@apta.org.] For inspiration you can share with your patients, the popular Move Forward Radio is your go-to option: an interview series that features patients, PTs, and physical therapist assistants (PTAs) discussing physical therapy's role in a wide range of issues. Recent podcasts include explorations of physical therapy and people with Alzheimer's disease, foot health, and the treatment of pelvic pain in people who are transgender.

    Podcasts that energize
    A recent example: Just about any podcast from the APTA Pulse series

    What they're about: Some of the liveliest discussion in the profession is taking place at the student level, and the APTA Pulse series of blogs and podcasts brings that energy to you. The Pulse podcast series features mostly students, with the occasional more-seasoned PT, PTA, or other expert. Notable podcasts include "Failure Is a Bruise, Not a Tattoo," "Stereotype Threat," and "Healthy Mental Living: Tips From a Counseling Psychologist."

    Why you should listen: It's a great way to re-charge your enthusiasm for the profession.

    More energy: Want more insight on the PT and PTA student perspective? APTA's Student Assembly records its "#XchangeSA" live chats, which have ranged from discussions about performance therapy and training to building your professional brand. And if you haven't read or heard it already, APTA President Sharon Dunn's address to the 2019 APTA House of Delegates will put some wind in your sails when it comes to the challenges of taking on the high cost of PT and PTA education, dismantling the productivity mindset, and making involvement in the association accessible to all.

    Podcasts that inform
    A recent example: "Ordering of Diagnostic Imaging by Physical Therapists: A 5-Year Retrospective Practice Analysis"

    What it's about: In this interview for APTA's journal PTJ (Physical Therapy), Editor-in-Chief Allan Jette, PT, PhD, FAPTA, interviews researcher Aaron Keil, PT, DPT, about his groundbreaking study on civilian PTs who are able to order imaging.

    Why you should listen: Don't be scared off by the academic-sounding title. With the growth of direct access to PT services comes more serious discussion about the PT’s role in primary care—and the importance of the PT's ability to order diagnostic imaging as a crucial part of that primary care role. It's an issue that needs to be on your professional radar.

    More information: Each month PTJ produces podcasts, like the one highlighted above, that help you get a first-person perspective on some of the latest research in the profession, making the PTJ podcast page worth a regular stop. Another helpful research-oriented podcast: easy-to-follow expert tips on finding evidence and research on APTA's PTNow Article Search and Rehabilitation Reference Center.

    And even more information: If you're interested in keeping up with fast-moving world of payment (particularly related to Medicare and Medicaid), don't miss APTA's "Insider Intel" recordings of its live phone-in series. You won't find Insider Intel on the association's podcast page—they're collected separately—but they're definitely worth tracking down. MIPS, SNF payment, home health rules, new payment models, the physician fee schedule—it’s all there. And you can register for upcoming live events while you're checking out the recorded ones.

    Military System Study: PTs in Primary Care Provide Safe Treatment and Are Less Likely to Order Ancillary Services or Make Referrals

    While civilian health care policymakers and stakeholders in the US continue to debate whether physical therapists (PTs) should be included as primary care providers, the country's military health systems have marched ahead with the concept. A new study adds to the evidence that the idea is working, both in terms of patient safety and reduced health care utilization.

    Authors of the study, published in Military Medicine (abstract only available for free) and first presented as a poster at the 2019 APTA Combined Sections Meeting, frame their research as an exploration of the potential for PTs to address the nationwide physician shortage by lowering costs and increasing access to care. They assert that the potential for more team-based, effective care could be at least partially realized if civilian PTs were treated like their military counterparts and included as primary care providers. It's a position that APTA strongly supports in its strategic goals and is consistent with APTA's own investigations into the PT's role in primary care settings. In addition, in 2018 the association conducted a practice analysis aimed at determining the feasibility of primary care as a specialty area recognized by the American Board of Physical Therapy Specialties and the American Board of Physical Therapy Residency and Fellowship Education.

    The study tracked 3 years' worth of patient data from the Malcom Grow Medical Clinic and Surgery Center (MGMC), a facility at Maryland’s Andrews Air Force Base that treats active-duty personnel and their families. MGMC patients with musculoskeletal complaints can choose their care pathway, receiving care through either a family health clinic (FHC) or the facility's physical therapy clinic (PTC). Authors describe the PTC as engaging in "advance practice" physical therapy that, in addition to its direct access status, allows PTs to order diagnostic imaging and lab studies, make referrals, and prescribe a limited range of medications.

    Researchers were interested in answering what they say is 1 of the main reservations about the PT as primary care provider—that patients would face increased risk of harm—and along the way wanted to find out what they could about the PT's use of ancillary services such as imaging and referrals. They analyzed data from nearly 250,000 provider encounters (207,241 from the FHC and 41,656 from the PTC), including information from an internal patient safety reporting database (PSR) that tracks "safety events" in which patients were exposed to or experienced various degrees of harm. Here's what they found:

    • Over the 2015-2017 study period, the FHC recorded 56 documented safety events, compared with 16 reported in the PTC. Adjusting for overall caseload, patients in the FHC were determined to be 1.9 times as likely to experience an actual or "near-miss" safety event (a potential safety event that never reaches a patient) as were the PTC patients.
    • While both clinics reported the majority of their safety events as near-miss, the PTC's near-miss events made up 75% of its total safety events during the study period, compared with a 50% rate at the FHC. A 72% near-miss rate is the MGMC’s benchmark.
    • Imaging was the most frequently used ancillary service in the PTC, but use rates were still significantly lower than the FHC rate, with 1 study per every 37.13 encounters in the PTC and 1 per 4.99 encounters in the FHC. Because of the frequency of imaging use in the PTC, authors believe that "pursuing diagnostic imaging authority may be of utmost importance if pursuing advanced practice physical therapy within a practice act or within a health care organization."
    • No adverse events were associated with the 1,817 thrust manipulations (197 in FCH, 1,621 in PTC) or the 2,910 dry needling procedures (PTC only) provided to patients during the study period.
    • Referrals to other providers were lower among PTs, with a rate of 1 per every 51.88 encounters, compared with 1 per every 3.06 encounters at the FHC.
    • Both the rate of prescriptions and orders for lab studies were dramatically lower among PTs, who wrote prescriptions at a rate of 1 per every 1,487 encounters and ordered lab studies at a 1 per 1,301 rate. Providers in the FHC had rates of 1 per 0.99 for prescriptions and 1 per 2.91 for lab work.

    Authors warn against interpreting the lower PT rates of additional service use as an endorsement of PTC superiority; instead, they are an indication of differences in necessary care pathways in the 2 clinics. Providers in the FHC, they write, must order lab tests "for other functions such as tracking disease progression or identifying proper [pharmaceutical] dosages," something that's not done as frequently in the PTC. Similarly, they write, "the number of images ordered by the PTC may be deflated if the patient had already received the imaging at the FHC."

    Setting aside those factors, they argue, the data show what they hypothesized—"that [physical therapy] has a similar safety profile to primary care within the specified domains of advanced practice [physical therapy]." Additionally, they write, their study supports findings from earlier research that found "significant reductions in health care utilization including pharmaceuticals and imaging services when patients accessed physical therapy first."

    APTA members Lt Col. Lance M. Mabry, BSC, USAF (Ret.), PT, DPT; Jeffrey Notestine, PT, DPT, ATC; Col. Josef Moore, MSC USA, PT, PhD; and Jeffrey Taylor, PT, DPT, PhD, were among the authors of the study.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    APTA Exhibits at 2019 NCSL Legislative Summit

    APTA was again a leading exhibitor at the National Conference of State Legislatures (NCSL) annual Legislative Summit, this year held August 5-8 at the Music City Center in Nashville, Tennessee. Numerous state lawmakers from across the country visited the APTA booth, where staff and members of the Tennessee Physical Therapy Association educated them about the Physical Therapy Compact, direct access to physical therapist services, the role of physical therapy in pain management, high patient copays for physical therapy, and other issues important to the physical therapy profession at the state level. T. J. Cantwell from the Physical Therapy Compact was also on hand at the booth to provide information on the interstate licensure compact for physical therapy, which 26 states have so far enacted.

    NCSL is a bipartisan organization that serves the legislators and staff of the nation's states, commonwealths, and territories. This year's annual conference attracted almost 5,000 state legislators, regulators, association representatives, corporations, and public policy experts from around the country.

    APTA Exhibits at 2019 NCSL Legislative Summit
    From left: Katy Neas, APTA executive vice president of public affairs; Michael Lewis, APTA state affairs specialist; T. J. Cantwell from the Physical Therapy Compact; and Sarah Suddarth, PT, DPT, vice president of the Tennessee Physical Therapy Association.

    Labels: None

    JAMA: Americans Aren't Any More Physically Active Than in 2007—And They're Increasingly Sedentary

    Here's some news you shouldn't take sitting down: since the release of national physical activity (PA) guidelines in 2008, Americans haven't really made a dent in improving PA rates, while "significantly" increasing the amount of time spent on sedentary behavior. Those findings were the major revelations from a first-of-its-kind study that factored work, leisure-time, and transportation-related PA (most PA studies have focused on leisure-time activity only).

    The study, published in JAMA Network Open, analyzed results from 27,343 adults who participated in the National Health and Nutrition Examination Survey (NHANES) from 2007 to 2016. Researchers wanted to find out what percentage of Americans met the US Department of Health and Human Services' activity guidelines, and how that rate may have changed since the release of the guidelines in 2008. Those guidelines, updated in 2018, recommend at least 150 minutes per week of moderate-intensity PA or 75 minutes of vigorous PA (or an equivalent combination of both).

    What they found wasn't encouraging. Over the 10-year study period, the percentage of Americans who reported meeting the PA guidelines remained nearly flat—from 63.2% in 2007-2008 to 65.2% in 2015-2016.

    Even worse, researchers noted a significant increase in sedentary behavior over the same time period, from 5.7 hours per day in 2007-2008 to 6.4 hours per day in 2015-2016. The increase was recorded in nearly every demographic subgroup in the study, and was highest among individuals with college-or-higher educations and individuals who are obese.

    There were a few bright spots in the findings. The guideline-adherence rates for non-Hispanic black individuals rose by nearly 10 percentage points, from 52.7% to 62.6%. Other groups that recorded notable improvements included Americans 65 and older (44.3% to 49.1%), women (55.3% to 59%), current smokers (63.9% to 68.4%), and individuals with obesity (55.4% to 61.5%).

    Generally, however, there was more bad news than good. Not only did PA guideline adherence remain static overall, it actually declined, albeit slightly, for some groups including individuals 50-64 (61.3% to 60.4%) and those who are overweight (66.8% to 65.4%). The decline was most steep among individuals with less than a high school education, whose rates dropped from 53.3% in 2007-2008 to 49.4% in 2016-2017.

    Making matters worse, of course, was the rise in sedentary behavior, which was particularly notable among individuals 40-49 (from 5.4 hours to 6.2 hours), non-Hispanic whites (5.9 to 6.6), Americans with a college degree or above (5.8 to 6.5), people with obesity (5.8 to 6.4), and individuals with family income less than 1.31 times the poverty level (5.3 to 6).

    "Both insufficient [PA] and prolonged sedentary time are associated with a high risk of adverse health outcomes, including chronic diseases and mortality," authors write. "Our findings highlight a critical need for future public health efforts to aim for not only an increase in [PA] but also a reduction in sedentary time."

    APTA is a strong supporter of the HHS guidelines and the importance of PA. The association's prevention and wellness webpage provides resources on how physical therapists and physical therapist assistants can help individuals become more physically active. Additionally, the association's Council on Prevention, Health Promotion, and Wellness connects members interested in physical therapy's role in improving health. APTA is also an organizational partner in the National Physical Activity Plan Alliance and has a seat on its board of directors; the association also has a representative on the board of the National Coalition for the Promotion of Physical Activity.

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    Physical Therapy Gets Low (Tech)

    There's a place for virtual reality treadmills, robotic exoskeletons, and motion-capture sensors—just not in Eva Norman's car trunk.

    Eva Norman, PT, DPT, president of a mobile wellness practice in Minnesota, is one of the physical therapists (PTs) and physical therapy device industry professionals who share their thoughts on "unplugged" equipment for "In Praise of Low-Tech Tools," an article in the August edition of PT in Motion magazine.

    Norman's business model, which brings providers including PTs to patients and clients, includes the use of what she calls a provider "toolbox," aka a car trunk. That toolbox contains items such as ankle weights, foam pads, resistance bands, and foam rollers—the "evergreen" tools of the rehab trade, according to Norman. She emphasizes that "all of the tools we use must be practical for our purposes—portable, easy to use, durable, and low-cost for people to purchase for themselves."

    Author and PT in Motion Associate Editor Eric Ries explores how PTs are using low-tech tools, and conveys manufacturers' views on the staying power of stability balls, hand exercisers, yoga mats, and the like. Bottom line: They aren’t going away anytime soon.

    A big reason for the enduring popularity of low-tech tools is that they work, of course. But Ryan Bussman, marketing director of Orthopedic Physical Therapy Products, tells PT in Motion that there's another reason: They allow PTs to do what they truly love.

    "Physical therapists always will prioritize putting their hands on patients, and the sorts of tactile tools that go along with that," Bussman says in the article. "Will they still have uses for the 'sexy' stuff? Absolutely. Those things have their time and place. But the simple stuff will always be around."

    "In Praise of Low-Tech Tools," featured in the August issue of PT in Motion magazine, is open to all viewers—pass it along to nonmember colleagues to show them 1 of the benefits of belonging to APTA. Also open to all: "Greetings From PTs and PTAs Who Travel," an article on the life of the travel PT and PTA, and "Recruiting Tomorrow's PTs and PTAs," a look at the ways PTs, PTAs, students, and educators work to bring newcomers into the profession.

    #Fail? Study Says Physical Therapy's Reach on Social Media Comes up Short

    When it comes to using social media to promote the profession, physical therapy may be missing out: that's the conclusion of a recent study that analyzed physical therapy-related tweets and found that, for the most part, Twitter discussions about the profession are occurring in an "echo chamber"—if they even rise to the level of a discussion in the first place.

    The study, published in APTA's journal PTJ (Physical Therapy), looked at a random sample of 1,000 tweets from a collection of 30,000 tweets gathered over a 12-week period. Researchers sorted out each message according to its author, intended audience, tone, and theme, and—when it occurred—the "pattern" of the twitter conversation, which includes shares as well as actual online exchanges. The collection was based on 9 search terms: physical therapy, physiotherapy, physical therapist, physiotherapist, #physicaltherapy, #physiotherapy, #physical therapist, #physiotherapist, and #physio. Hashtags associated with "known physical therapy campaigns," such as APTA's #ChoosePT, were not included in the searches. [Editor's note: the article appears in the August edition of PTJ, which is the journal's 1,000th issue—help celebrate by checking out the PTJ website for original research, perspectives, podcasts, and more.]

    Here's what they found:

    • Of the tweets that generated shares and discussions, most were what the Pew Research Foundation calls "tight crowd" and "brand cluster"—discussions that "tended to cluster on the periphery, dominated by a small group of highly connected people with few isolated participants," according to authors.
    • A substantial number of tweets, authors write, were from "disconnected participants" whose messages "resulted in no interaction with anyone other than the tweet's original author." The exceptions tended to be when APTA, other national organizations, and celebrities tweeted about physical therapy. As an example, authors offered up a 2016 physical therapy-related tweet by wrestler and actor John Cena, which at the time of the study had 1,550 retweets and 4,403 likes.
    • Almost half the tweets (48.5%) were characterized as "marketing" in nature. Employment-related tweets were a distant second at 17.7% of the total, followed by patient experience (15.7%), education (15.7%), advocacy (14.6%), conversation (14.3%), opinion/editorial (13.8%), physical therapist (PT) education (11.3%), research (7.7%), and continuing education (3.2%).
    • Recruiters and corporations were responsible for 86% of all employment-related tweets. PTs, physical therapist assistants (PTAs), and clinics were the authors of the majority of messages related to patient education, continuing education, and marketing.

    The big takeaway, according to authors, is that if PTs and PTAs want to heighten the profession's profile on social media, they need to do more than just show up.

    "The results of the present study reveal that simply being present on social media may not be enough," authors write. "The power of social media is in the conversation, and information becomes influential through 'likes,' 'retweets,' 'shares,' and 'mentions.' Physical therapy professionals and the hospitals and clinics that employ them need to understand the function and structure of online health conversations so they may influence and effectively engage in these conversations."

    Moving physical therapy discussions beyond what the researchers describe as a social media "echo chamber" will require a more savvy approach, according to the authors. They suggest "leverage[ing] the power and reach of broadcast networks and popular events" such as the Olympic Games, and using more generic hashtags (#rehabilitation, for example), as well as hashtags that "infiltrate another distinct mode of professionals" (#sportsmedicine, for instance) as ways to increase the reach of their messages.

    Authors acknowledge that the samples they studied provide a "limited" and "superficial" view of the entirety of physical therapy-related social media activity, and further admit that the average of 300 physical therapy-related tweets per day is a drop in the bucket compared with Twitterverse activity as a whole. Still, they argue, the profession needs to understand—and leverage—the power of social media as a provider of health information.

    "Online health information seekers have a high level of trust [in information accessed online] and often use it to make health decisions," authors write. "Rehabilitation-related information is not immune to this influence."

    Research-related stories featured in PT in Motion News are intended to highlight a topic of interest only and do not constitute an endorsement by APTA. For synthesized research and evidence-based practice information, visit the association's PTNow website.

    IRFs Receive 2.5% Increase From CMS in FY 2020; Additional Reporting Requirements in FY 2022

    In a final rule from the US Centers for Medicare and Medicaid (CMS), inpatient rehabilitation facilities (IRFs) will see a 2.5% payment increase in the 2020 fiscal year (FY), which begins October 1, 2019—an approximate boost of $210 million. But they'll also need to prepare for some expanded reporting measures in the years to come—including a requirement to report data on social determinants of health.

    Reporting requirements won’t change much in FY 2020. However, beginning with the FY 2022 IRF Quality Reporting Program (QRP), IRFs will be required to provide certain standardized patient assessment data (SPADE) to CMS. The additional SPADE requirements are aimed at bringing IRFs up to speed with provisions of the 2014 IMPACT Act, a law that mandated more uniformity in reporting across postacute care (PAC) settings. In a fact sheet on the final rule, CMS writes that the addition of these SPADES "will improve coordination of care and enable communication."

    Specifically, CMS will adopt the SPADES on pain interference on sleep, therapy, and day-to-day activities, provisions being added in light of the opioid crisis. CMS is considering adding future SPADEs including dementia, bladder and bowel continence, care preferences, advance care directives and goals of care, caregiver status, veteran status, health disparities and risk factors, and sexual orientation. Also on CMS' radar: assessments related to opioid use, and frequency, exchange of electronic health data, and interoperability.

    Beginning in FY 2022, IRFs will be required to report patient data on admissions and discharges dating back to October 1, 2020, in the following areas: cognitive function and mental status; special services, treatments, and interventions; medical conditions and comorbidity; impairment; and a new category—social determinants of health (SDOH). IRFs have been reporting on some components of these areas since 2018, mostly related to function, pressure wounds, and skin integrity.

    To gather cognitive function and mental status data, IRFs will be now required to use the standardized items of Brief Interview for Mental Status (BIMS) and Confusion Assessment Method (CAM). APTA supported these in its comments but advised caution, expressing concerns that the assessments aren't sensitive enough to pick up mild-to-moderate cognitive impairments. The new SDOH would gather data on race, ethnicity, preferred language, interpreter services, health literacy, transportation, and social isolation—factors that CMS writes "[have] been shown to impact care use, cost, and outcomes for Medicare beneficiaries."

    CMS also finalized 2 new process measures; one having to do with whether a provider receives a current reconciled medication list at discharge or transfer, and another relating to whether the patient, family, or caregiver receives a similar list upon discharge from a PAC setting.

    Among other elements of the final rule:

    CMS backs away from weighted motor score. While CMS had proposed to use a weighted motor score to assign patients to case mix groups, it finalized the use of an unweighted motor score starting in FY 2020 “to ease providers’ transition to the use of the quality indicator data items for payment purposes beginning on October 1, 2019.” APTA had expressed in its comments concern about moving to a weighted motor score, specifically about the de-emphasis on patient mobility and that the proposed motor score weight index may compromise access to physical therapy in the IRF setting.

    The compliant IRF list is gone. CMS will stop publishing a list of IRFs that successfully met reporting requirements on its Inpatient Rehabilitation Facility Quality Reporting Program website.

    Reporting for some baseline nursing facility residents will decrease. Specifications of the discharge-to-community PAC measure would be altered to exclude baseline nursing facility residents.

    IRFs will make the call on who's considered a "rehabilitation physician." The final rule will loosen the definition of "rehabilitation physician," allowing individual IRFs to establish their own definitions.