Med A, Med B and HAE; Clearing up the Continuum Confusion
Confused about your Medicare benefits? You’re not alone. But breathe easy and read on as I clear up the Continuum Confusion and help you understand the When, Why and Wheres of Med A and B coverage and how HAE/PT can better help you manage your health, wellness and rehabilitation.
Confused about your Medicare benefits? You’re not alone. But breathe easy and read on as I clear up the Continuum Confusion and help you understand the When, Why and Wheres of Med A and B coverage and how HAE/PT can better help you manage your health, wellness and rehabilitation.
The Care Continuum:
My work in rehabs, outpatient centers and home health agencies has made me increasing aware, and frustrated by, the issues that arise when patients are treated within the constraints of the current medical model. Let’s jump right in by letting me describe for you a what a typical patient experience looks like after a fall.
Mary falls at home, breaks her hip and winds up at the hospital. She undergoes emergency surgery to fix the hip, stays in the hospital for a week until she is ready medically stable enough to leave. If she is lucky, and has family support and a lives in a safe environment, she may go straight home with home health services. If home is unsafe or she cannot yet care for herself, she may go to a rehab hospital or skilled nursing facility for another week or two. Once she is home, home health sees her for four to eight weeks to help her heal from the surgery, to get a little stronger and work on the skills necessary to return to her baseline level of function. (Side note: ‘baseline level of function’ does not necessarily mean she was functioning in the best possible state in the first place). In an ideal world, Mary can now go to outpatient PT to continue her recovery.
However, for many patients, this is where the problems start. Home health PTs are required by Medicare to discharge as soon as a patient is no longer homebound, if they have met their goals or if they are no longer making progress. Mary, and so many other patients like her, are often left simply with the instructions to schedule therapy at an outpatient center and continue with their home exercise program until then. But the reality is that even though Mary may no longer be technically be homebound, getting to an outpatient clinic may remain quite difficult. It requires getting dressed, may involve getting up and down stairs, walking outdoors and finding someone to take her - with a lot of pain in the process. Multiply this by two to three visits a week for another six to twelve weeks and then add in the reality of life in New England. This may be feasible in spring and fall, but what if you’ve fallen over the winter? Now you’ve got ice, snow and everything in between to contend with. You’re probably starting to see where I’m going with this. Before we talk solutions, I will review some Medicare basics, because quite honestly, it’s taken me twelve years as a therapist to even begin to understand them, so I can only imagine the frustration patients feel every day having to make sense of this themselves.
Medicare A Benefit:
Your Med A benefit pays for services you receive while you are in a hospital, or if you require services after a hospitalization and you are ‘homebound’ and cannot access services in the community. To be considered homebound, leaving home must require considerable and taxing effort. You either require the help of another person or medical equipment to enable you to leave home, or leaving home places you at risk of injury or medical complication. Basically, you only leave home to go to the doctor, to attend a religious service or a family event and only on occasion. It also allows you for you to take trips to the barber shop or hairdresser, which I’ve always found amusing. This part of your coverage pays for services received at the following places:
Inpatient Care Hospital:
Inpatient Rehab at a Rehab Hospital or Skilled Nursing Facility Care
Home Health Services
Hospice Care
Medicare B Benefit:
Your Med B benefit covers ‘medically necessary’ outpatient physical therapy services. The term medically necessary means a clinician must that certify you require skilled Physical Therapy services to treat impairments and limitations due to illness or injury. Medicare pays for 80% of these costs; you, or your supplemental plan, is responsible for the remaining 20%. You can choose where you use your outpatient benefit. There is no cap on how much Medicare will pay for outpatient services per year, as long as your therapist demonstrates the treatment is medically necessary - and that you have potential to reach your goals and are continuing to make progress. This part of your coverage will pay for you to receive care at the following places:
Outpatient Rehab
Mobile PT (like HAE/PT!)
Beyond the Benefit:
When you no longer qualify for physical therapy services because you have either met all of your goals, or no longer have a skilled need, you can either discharge from therapy and continue with your home program on your own - or you may consider continuing on with a therapist either on a maintenance program or for other wellness programming. The options here are varied, but very worthwhile to consider. You can choose to continue with a clinic physical therapist or a Mobile physical therapist like HAE/PT, under a Medicare-covered Maintenance program if this applies to you , or pay privately for continued services as a Wellness Program if it does not. You could also attend local exercise classes or a join a gym. Either way, it is imperative you find a way to continue to stay active and on your exercise program after therapy ends to maintain your gains, prevent future decline - and stay healthy!
There has got to be a better way…
While these above explanations hopefully clear up the confusion, I want to talk more about the Care Continuum and why I started HAE/PT. After seven years of seeing ‘Marys,’ and so many patients like her, I started to think there had to be a better way. What if there was a PT who continued to come to you, to work not only on healing from your injury, but more importantly, on the thing that got you here in the first place - the deconditioning, progressive weakness and increased fall risk that happens with aging if you don’t stay active! While balance training may be a part of home health PT, it often is just that - a small part. Overall fitness assessment and training is even further out of the realm typically provided by home health services. The role of hospitals and home health is to dealing with the priority needs - addressing your acute injuries or illness exacerbations and reestablishing your functional independence. HAE/PT was born of the idea that we can do better. We can do by better addressing your whole health, your overall fitness level and by helping you to decrease your risk of falls. We can do better by educating you on your health conditions and how you better manage them - and prevent them from getting worse. We can do better by giving you the tools - and the ongoing support - that you need to keep yourself healthy, happy and whole. What if you could have a physical therapist, who gets to know you like your doctor does? A physical therapist who you could check in with when things start to slide a little, or if you start to feel worse or better yet, if you’re still doing great and just want to make sure you’re still performing your Wellness Program effectively. This is why I started HAE/PT. I want to be able to be this physical therapist for you.
Have more question or want to get in touch with me or to set up a phone consultation? Just ‘say HAE!
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Ten Things I’ve Learned About Therapy That I Didn’t Learn in School
Since Covid-19, like many of us, I’ve had lots of time to think. And what I started to find myself thinking about, is what it would look like if I could practice physical therapy the way I wanted to do it - without any corporate oversight or pressure to take more patients or schedules or guidelines or the rest of the ‘stuff’ that comes with being an employee. What would it look like if it was just me, and my patient, working together to meet their goals? During this exercise, I started to reflect on what I’ve learned in the past twelve years since PT school and how it impacts the way I practice. What I’ve come up with is the following - a list of ten insights I’ve gained about the provision of physical therapy that influence how I treat every day. The punchline? Not one of them has to do with exercises, range of motion or any of the other skills we had to master to become PTs.
Since Covid-19, like many of us, I’ve had lots of time to think. And what I started to find myself thinking about, is what it would look like if I could practice physical therapy the way I wanted to do it - without any corporate oversight or pressure to take more patients or schedules or guidelines or the rest of the ‘stuff’ that comes with being an employee. What would it look like if it was just me, and my patient, working together to meet their goals? During this exercise, I started to reflect on what I’ve learned in the past twelve years since PT school and how it impacts the way I practice. What I’ve come up with is the following - a list of ten insights I’ve gained about the provision of physical therapy that influence how I treat every day. The punchline? Not one of them has to do with exercises, range of motion or any of the other skills we had to master to become PTs.
Use your brain - literally. Use neuroplasticity to your favor. Learn about it, love it and make it a part of everything you do. To make change in the brain, you must perform activities intensely, repeatedly and specifically. They must have meaning to the person doing them. They must be specific; learning how to play basketball won’t make you a good swimmer. They must be intense; the typical ‘do a set of 10 ankle pumps’ isn’t doing anyone any favors. Activities must be performed in a way that provides challenge - if you aren’t working near the point of failure, neuroplastic change cannot occur. And the activities must occur repeatedly. This can be applied to every thing you do as a therapist, from strengthening, to functional mobility to balance reeducation. Turns out, practice does make perfect.
It’s not the hand you’re dealt, but how you play your cards. The most inspiring patients I’ve worked with have been those that remain positive and engaged in their lives despite facing the most challenging of circumstances. My years spent working neurorehab taught me that traumatic physical events don’t have end life as you know it, but it may be start of a new one. Yes, life will never be the same after such injury, but different can still be good. I love to be a part of that redirection - helping a patient start to look forward instead of back and focus on how their rehabilitation can help lay the groundwork for their new life.
Age means very little. I’ve met seventy year olds who look like they’re a hundred and centenarians who look (and act!) like they’re seventy. My favorite advice on living a long life came from one of my very oldest ladies: “Avoid men, and drink lots of white wine.” Another told me she has lived to be a hundred by reading the Smithsonian every day and highlighting the important facts. Then there are those who mistreat their bodies and are disabled by chronic illness quite young. Regardless, don’t judge a book by its cover - or a patient by their wrinkles. They may surprise you.
Educate. The average patient knows very little about the body they live in - from their ‘rotary cuff’ to their ‘prostrate’ gland. But knowledge is power. How can we expect them to take care of themselves without knowing why they need to in their first place. Being told to cut out salt to avoid CHF doesn’t mean much until you can understand why it causes volume overload. Who would work through the pain of ROM after a knee replacement if they don’t understand the process of healing and formation of scar tissue? Take the time to teach and it will pay off in dividends.
Ask the right questions. I can figure out what someone needs better through a carefully crafted subjective, than an hour of special tests. Asking if you’ve had any falls doesn’t tell you much. But asking where they happen, how they tend to land, how they were feeling before (and the 800 other questions I tend to ask) allows me to identify the patterns and then efficiently address the issue.
Learn everything you can from the people around you. Find a coworker, a mentor, or a PT community and suck all the knowledge you can out of them. Watch your colleagues work. Take note of their ideas and store them away in your toolbox. Read. Take classes. Never stop learning. I am sure I drove my professors and Clinical Instructors crazy with my non-stop questions, but I always got my money’s worth. If you find yourself in a rut, or using the same old exercise routine with patients, that’s the best time to take a class. Pre-kids, I took every class I could get the time off to take. My priorities changed for a while while they were little, but this forced Covid-sabbatical I’ve found myself on has given me the time and reason to start up again. I joined the APTA for the first time in years and signed up for my GCS exam. I’ve been ingesting Podcasts, online courses and journal articles nonstop. I haven’t been this excited to treat in years. If you every find yourself in a rut, make time to learn.
Go with your gut. Advocate for your patients. If something doesn’t seem right, chances are, it’s not. This can be anything from vital signs that make you nervous, a patient who ‘just seems off’ or a coworker who isn’t giving a patient what you think they need. Don’t just let it go, because it may be life or death for your patient. This is a competence I didn’t develop fully until I worked in home care. By nature, working in home care entails constantly triaging and independent decision-making. Sure, you can call a manager for advice, but at the end of the day, it’s your eyes, your hands and you have to make the call. Every time I send a patient out by ambulance, I apologize, but tell them I’d rather be safe than sorry, any day of the week, rehospitalization rate be damned. You may feel embarrassed the two of three times the patient ends up fine and gets sent home, but let me tell you, that third time it turns out to be a pulmonary embolism, you’ll never second guess yourself again.
Treat holistically. You’re treating a person, not an impairment or even a functional limitation. Their needs will always span past ROM, strength deficits or even pain. A lot of people just need to be heard. Many rarely find people who know how to listen without judging, or don’t want to burden their loved ones with their stress so they hold it all in. Others desperately need community referrals or education about their medical condition or any other list of non-PT activities you may find yourself doing. During home care visits, I’ve taken out trash, opened up stuck jars, looked up addresses on google - and more often than not, it’s these small things that are more helpful than even the most well planned session you can provide.
Talk to your patients. It’s the science that brings us here, but it’s the people who keep us around. You’ll learn amazing things from your patients. The oldest among them have seen things and experienced things that you can’t even fathom. They’ve bought houses for $5000 that are now worth half a million. They’ve met spouses at USO events and then went off to war. They’ve had babies at home. They’ve experienced unimaginable losses. They have stories that could be written into New York Bestsellers and they give amazing advice. One of my favorite questions to ask my older couples is what is their best advice for a successful marriage. My all-time favorite response came in very simple older gentleman who responded “just stay married.” Think on that one for a bit…
Don’t be afraid of change. I’ve always been the kind of person to keep a job forever - I literally held the same job from the age of eleven until I finished college. Straight out of graduate school, I took a job with the rehab hospital I had been interning for. Twelve years later, I’ve held six different positions between six different hospitals, skilled nursing facilities, outpatient centers, home health agencies and private practices. I would never have predicted this trajectory for myself, but between moves, and babies and life, this is where I’ve ended up. But the beauty with all of this change is that I’ve gained something special from each place I’ve worked. It is this mix of experiences that has made me the clinician I am today. I’ve gotten to see what life is like along the continuum for patients after they experience an illness or catastrophic event from the rehab to the discharge home to the transition back to community. I’ve learned from amazing mentors and colleagues and made friends and strong networks. I’ve developed a different set of skills to function in each setting, and had the ability to adapt these to benefit patients I treat in the next. I truly think the rich variety of experiences has made me a stronger therapist, a more mindful clinician and helped me be more empathetic to the patients with whom I work. The funny thing is, among all these travels, never once have I considered opening my own practice. I’ve been asked by friends and family if I’d ever considered it, and my answer has always been a staunch no (‘I want to work, come home and not deal with any extra stress I don’t have to.’) But, as we’re all too keenly aware, this year, the notorious 2020, has forced us all to take stock, assess our lives and make changes we never expected to have to make. Leaving my home health job of seven years was something I hadn’t even been considering. I love the work, I love the company, it worked well with my life and I honestly assumed I’d be there till I retired. But, with my needs at home taking priority, I found myself on extended leave, at home, ‘crisis schooling’ my kids. Ten weeks at home later, with nothing to do but think, sleep and watch Netflix, I found myself considering heading in a different direction. What if I could combine all the things I loved about treating in outpatient with all the things I loved about treating in home into one? What if I could do this on my own, fit the hours in around my family’s needs - and be able to work through the upcoming and very uncertain year? As you can imagine, the next thing I knew (and if you know me at all, I’m sure you can imagine because you know I’m a crazy person once I come up with an idea), I decided to launch HAE/PT and created a new plan for myself. So, long story short, without change, we can’t grow. Don’t be afraid of change - it’s a part of life, it’s definitely a part of being a PT and in closing, I’ll leave you with one of my favorite passages: “Will you be troubled by every passing wind, or will you be the calm in the storm?” By accepting change, you’ll not only be the calm, but you’ll be able to make it work to your advantage.