Example Of Nursing Care Plan

â»â» good morning! thank you mark, i'm terry eng. it's a pleasure to be here today. i think some of you were at the november trainingand perhaps participated in our february webinar. so welcome back. so as mark as indicated i'm going to be presentingpart of section gg with my colleague anne deutsch. anne and my's presentation will focus on continuingto develop your knowledge and skill in completing the section gg data elements.

we will accomplish this by reviewing the informationintent of section gg explaining and applying the coding instructions using practice scenariosand responses to frequently asked questions. this slide shows the section gg items thatwere implemented using the ltch care data set version 3.0 on april 1, 2016. gg0100 prior functioning everyday activitiesand gg0110 prior devices are included on the admission assessment. gg0130 self-care and gg1070 are data elementsto be collected on both the admission and the planned discharge assessment. this slide shows the data elements that werechanged from version 2.0 of the ltch care

data set with the implementation of version3.0. only the numbers changed, not the data elements. so for instance, gg0170a is still roll leftand right. 0170b is sit to lying. and 0170c is lying to sitting on side of bed. so it's just the numbers that changed. the intent of section gg is to assess a patient'sprior functioning, their admission and discharge self-care, and mobility performance, and todetermine the patient's discharge goal or goals for self-care and mobility on the admissionassessment.

for the purposes of section gg, an activityrefers to the execution of a single task or multiple tasks that comprise an activity oraction by an individual. as you know, limited mobility places patientsat risk for a variety of complications and may affect their ability to care for themselves. the first data element in section gg functionalabilities and goals is gg0100 prior functioning everyday activities. as previously mentioned, this is a new itemin version 3.0 of the ltch care data set. this is how the item gg0100 appears on theltch care data set version 3.0. in gg0100b you're going to code the patient'sneed for assistance with walking from room

to room with or without a device such as a cane,crutch or walker prior to the current illness, exacerbation or injury. gg0100 assesses the patient's functioningand everyday activities prior to the current illness, exacerbation or injury that may informtreatment goals. a question that often arises for this itemis, what time frame is prior to admission and current illness? a related question to this or an example is,what if the patient that is admitted had an injury 30 years ago, and is now admitted witha wound? as indicated on this slide, the time framefor “prior to admission” refers to the

patient's functioning and device use immediatelybefore the current illness, injury or exacerbation. if the patient's episode of care started withan acute care hospital stayed followed by a ltch stay, the patient's prior functioningwould be based on the patient's status immediately before the illness, injury or event that ledto that acute care stay. so in the example i'm suggesting to you, thepatient had a spinal cord injury 30 years ago, and is admitted to the ltch for treatmentof wounds. the item gg0100b indoor mobility ambulationcode would be coded based upon the patient's need for assistance with indoor ambulationprior to the admission for the wound. to obtain this information you would interviewthe patient and/or family or review the patient's

medical records that describe the patient'sprior functioning with everyday activities. you're all, i'm sure, familiar with the codingfor this item by now, but i will just briefly go over it. if the patient completes the activities byhim or herself with or without an assistive device, and with no assistance from a helper,you should code this item as 3, independent. if you code the item as 2 if the patient needspartial assistance from another person to complete activities. if a helper completed the activities for thepatient you would code the item as 1 dependent. if you are unable to complete the item asyou do not have or are not able to obtain

the information you would code the item as8, unknown. the item is coded as 9 if indoor mobilityambulation is not applicable. for example, if a patient used a wheelchairand did not walk prior to the current illness, or injury, you would code gg0100b prior functioningeveryday activities indoor mobility as 9, not applicable. for this item, code 9 indicates that the activitywas not applicable to the patient prior to the current illness, injury or exacerbation. if the patient used a device prior to thecurrent illness, you would indicate the type of device in gg0110 prior device use.

one of the questions that we've received inthe help desk is what is the difference between 8, unknown and our friend the dash, not assessed,no information. you would code this item with the dash ifthere was no attempt to obtain this information to indicate not assessed or no information. the item is coded as an 8 if the informationis not available from these sources. the next section in gg is prior device use. this is a risk adjuster for the functionaloutcome measure and it is important to document device use for this item. this slide shows how the new items appearon version 3.0 of the ltch care data set.

it is a required element for completing theadmission assessment. similar to the data elements for prior functioningdaily activities, this data element assesses the patient's use of assistive devices andaides prior to the current illness, exacerbation or injury that may inform treatment goals. a question that arises for a prior deviceuse is, what time frame is prior to admission or current illness? as previously mentioned, the timeframe for“prior to admission” refers to the patient's device use immediately before the currentillness, injury or exacerbation. if the patient's episode of care started withan acute care hospital stay, followed by an

ltch stay, the patient's prior device usewould be based on the patient's status immediately before the illness or injury that led to theacute care stay. these items are included in the data set asprior functioning and prior device use were found to be important factors associated withfunctional improvement for ltch patients. these items are also included on the ltchcare data set for the purpose of risk adjustment for the quality measure change in mobilityamong patients requiring ventilator support. as with the other items you would obtain theinformation through interviews with the patient and/or family and review of the medical recordsthat describe the patient's prior device use. for this admission assessment item, you aregoing to check all of the assistive devices

or aides your patient -- that your patientused immediately prior to the current illness. you would check z, none of the above if thepatient did not use any of the listed devices or aides immediately prior to the currentillness. the next section is gg0130 self-care. this data set item is also new with version3.0 of the ltch care data set and is a required for both the admission assessment and theplanned discharge assessment. this is how the new data elements appear inversion 3.0. and in this section, you will be doing twothings. you're going to be assessing the patient'sperformance of these four activities on admission,

and you are going to code a discharge goalor goals for the patient for each of these activities using the coding scale on the left. and i'll go over the coding in future slides. in this section, self-care is assessed withthe patient's usual performance at admission, regarding their ability to eat, complete oraland toileting hygiene, and wash their upper body. the self-care activities are assessed duringthe 3-day assessment period, and are required elements for both the admission and planneddischarge assessments. as previously noted, these items are importantbecause ltch patients will have self-care

limitations on admission to the ltch, andare at further risk for functional decline during the stay. the next couple of slides depict the processfor assessing each of these self-care activities and some specific points to consider whencoding these items. information used to assess this domain maybe obtained from direct observation, patient and family self report, and direct care staffreports documented in the patient's medical record during that 3-day assessment period. patients should be allowed to perform theactivities as independently as possible, as long as they are safe.

the items should be scored according to theamount of assistance that is required by a helper if the patient's performance is unsafeor of poor quality. of note, on this slide, is number 4: use ofassistive device to complete an activity should not affect the coding of the activities. clinicians should code the patient's functionalstatus based on an assessment that occurs soon after the patient's admission. the code should reflect the patient's baselinefunctional abilities at the time of the admission. and as i've already said, the patient shouldbe allowed to perform activities as independently as possible, as long as they are safe.

the assessment should occur prior to the startof therapeutic intervention in order to capture the patient's true baseline status. this is because interventions, as we knowcan affect the patient's functional status. the score should reflect the patient's statusprior to any benefit from therapy. if the patient's self-care performance variesduring the assessment period, report the patient's usual status, not the patient's most independentperformance, and not the patient's most dependent episode. one of the questions that we also receiveon an ongoing basis is who can actually complete this assessment? and we're asked if a physical therapist, occupationaltherapist, a speech language pathologist needs to complete the assessment on all patientsso that the section can be completed.

we're also asked if a registered nurse withtraining on section gg can complete the functional assessment. as we've probably said in the past, cms doesnot provide guidance on who or who can not complete the assessment items. and as we've discussed, each facility deliverspatient care according to their unique characteristics and standards. so that's each -- so each facility self determinestheir policies and procedures for who in your organization can complete the assessment. taking into consideration state and federalrequirements. as you know, physical therapist, occupationaltherapists, speech language pathologists are

typically involved in the assessment of self-careand mobility items. we've also received questions on what usualstatus means. for the admission assessment, clinicians shouldcode the patient's functional status based on a functional assessment that occurs soonafter the patient's admission. the code should reflect the patient's baselinefunctional abilities. during the assessment patients should be allowedto perform activities as independently as possible, and as i've said as long as theyare safe. and then, the assessment should start priorto any therapeutic intervention in order to capture the patient's true baseline status.

this is because interventions can affect thefunctional status. a patient's functional status can be impactedby the environment or in situations encountered at the facility. observing the patient's interactions withothers in different locations and circumstances is important for a comprehensive understandingof the patient's functional status. if the patient's status varies, record thepatient's usual ability to perform each activity. and as i said, don't record the patient'sbest performance and do not record the patient's worst performance, but rather patient's usualperformance. for the planned discharge assessment, thepatient's discharge code should reflect the

status at the patient's discharge. if an activity was not attempted at discharge,you would code the reason. this slide shows the scale for coding thepatient's usual performance for each activity. you would code the item 06 for independentif the patient completes the activity by him/herself with no assistance from a helper. you would code item 05 if the helper setsup or cleans up. in other words, the patient completes theactivity but the helper assists only prior to or following the activity. and that's an important distinction for coding05.

if we use toilet transfer as an example ofan activity coded as 05 for setup assistance, it would look like this. the helper places the raised toilet seat onand off the toilet as needed by the patient. the patient does not require any other assistanceto perform this activity. that helper is providing setup assistancein this example. and you would code the item 05 setup or cleanup. if a helper provides verbal cues or touching,or steadying assistance as the patient completes the activity, you would code the item as 04,supervision or touching assistance. assistance may be provided throughout theactivity or intermittently.

partial/moderate assistance code, 03 is usedwhen the helper does less than half of the effort. the helper lifts or holds or supports thepatient's trunk, or limbs but provides less than half of the effort. the item is coded as 02 when the helper doesmore than half the effort. that is the helper lifts or holds the trunkand limbs and provides more than half the when the helper does all of the effort, andthe patient does none of the effort to complete the activity, the item is coded 01 as dependent. this item is also coded as a 01 if the assistanceof two or more helpers is required for the

patient to complete the activity. you should use these codes to complete theassessment for items if the patient refuses to complete the activity and a helper doesnot complete the activity for the patient and so the activity was not attempted. for example, 07, the patient refused. an example might be that the patient refusedto wash their upper body. 09, the patient did not perform the activityprior to the current illness, exacerbation or injury. and code 88 is used when an activity was notattempted due to a medical condition or safety

concern. so for instance, if a patient has a swallowingdisorder, and is ordered not the take anything by mouth, you would not ask the patient toparticipate in demonstrating how they perform eating. the next few slides presents some questionsregarding coding of self-care activities. as you can see from this slide the questionrelates to coding according to the amount of assistance the patient requires to performthe activity. so, for instance, does the patient need assistanceto complete the self-care activity? if no, you would code that as independent.

does the patient need only setup or cleanupassistance from one helper? if the answer is yes, you would code thatas a 05, setup or cleanup. does the patient need only verbal or nonverbalcuing or steadying or coaching assistance from the helper? if yes you would code that as 04, supervisionor touching assistance. does the patient need lifting assistance ortrunk support from one helper -- with the helper providing less than half of the effort? if the answer so that question is yes, youwould code it 03, partial/moderate assistance. does the patient need lifting assistance ortrunk support from one helper with the helper

providing more than half of the effort? if the answer to that question is yes, thenyou would code it as 02, substantial/maximal assistance. does the helper provide all of the effortto complete the activity or is the assistance of two or more helpers required to completethe activity? if the answer to that question is, yes, thenyou would code the item 01, dependent. i've already gone over these codes. but just to reiterate, this is how you wouldcode these items when an activity was not attempted.

this slide reinforces these codes that youwould use to indicate why the activity was not attempted. this slide just provides some coding tips. when reviewing the medical record, interviewingand observing the patient you should be familiar with the definition of each activity. for example, when assessing eating, item gg0130a,determine the type and amount of assistance required to bring the food and liquid to themouth and swallow food once the meal is presented on a table or a tray. another tip is to ask probing questions thathelp to clarify your own understanding of

the patient's performance of an activity. let's go back to the toilet transfer examplei presented earlier for an example of a probing question. the nurse says, “i understand that ms. musually use as wheelchair to get to her toilet. please describe how ms. m moves from her wheelchairto the toilet? how does she move from sitting in a wheelchairto sitting on the toilet?” the certified nursing assistant responds,“it is hard for her but she does it with my help.” the nurse says, “can you describe the amountof help in more detail?”

the nursing assistant says, “i have to giveher a bit of a lift using a gait belt to get her to stand, and then remind her to reachfor the toilet grab bar while she pivots to the toilet. sometimes i have to remind her to take a stepwhile she pivots to or from the toilet, but she does more of the effort herself.” in this example, the nurse inquired specificallyabout how ms. m moves from sitting in a wheelchair to sitting on the toilet. the nurse specifically asked about instructionsand physical assistance. if this nurse did not ask probing questions,she would not have received enough information

to make an accurate assessment of the actualassistance that ms. m received. it is important to record the patient's actualability to perform each activity, not their potential to perform each activity. the scores for the self-care activities arebased on the amount of assistance the patient requires. as previously mentioned, the activities maybe completed with or without assistive devices when scoring the items. this slide provides a few important pointsabout the use of the dash on the ltch care data set as you know the dash indicates noinformation, and cms expects the use of the

dash in completing the ltch care data setwill be a rare occurrence. however, there are appropriate circumstanceswhen a dash may be used in completing these items, which i will speak to later on in thispresentation. you would not use a dash to code an item ifthe patient refused to perform the activity, the activity was not applicable to the patient,or the activity was not attempted due to the patient's medical condition or safety concern. so you would use the 07, the 88, or the 09as previously described. providers have asked us if you are only requiredto enter one goal for section gg, and if so, how do you code items that do not have a goal?

as you are only required to enter at leastone discharge goal on the ltch care data set, discharge assessment record for the remainingself-care and mobility items that are not given a discharge code you should enter adash response. you should not use the dash response for anyof the ltch data admission assessment performance items as these are required items using the6-point coding scale. a follow-up to this question is, does theuse of the dash only apply to the admission performance coding and not the discharge goalcoding? to clarify the ltch care quality reportingprogram requires at least one discharge goal to be entered on the ltch care data set dischargeassessment for any of the self-care gg0130

or the gg0170 items. this discharge code should be coded usingthe 6-point scale and maybe numerically higher, a equal to or lower than the performance code. we will walk through some examples later onin the presentation that illustrate numerical differences between the admission performancecode and the discharge goals. now we'll move into gg0130a: eating. eating is defined as the ability to use suitableutensils to bring food to the mouth and swallow food once the meal is presented on a tableor tray. it includes modified food consistency includesthickened liquids for a patient experiencing

swallowing difficulties. gg0130a eating applies to eating by mouthonly. you would not code this item if the patientrequires assistance with tube feeding administration. if the patient eats by mouth and relies ontube feedings to supplement nutrition or fluid intake, you would code the item gg0130a eatingbased on assistance with eating by mouth only. now we're going to move into some coding scenarios. please feel free, because we're a small group,and i know there's a number of people online. but feel free to call out the answers, ifyou'd like to. so in this scenario, ms. m's medical conditionsinclude chronic respiratory disease, sepsis

and morbid obesity that affect her enduranceand strength. she prefers to feed herself as much as sheis capable. after eating a quarter of her meal by herself,ms. m usually becomes extremely fatigued and requests assistance from the certified nursingassistant to feed her the remainder of the meal. how would you code gg0130a? i'll move on. it seems we have a very silent group. you would code this item as 02, substantial/maximalassistance.

and you would code this way because, ms. mis able to feed herself about a quarter of the way through her meal. but then becomes fatigued and requires assistanceto complete the meal. and as in this scenario, the helper did morethan half of the effort. in the next scenario, mr. c is unable to eator drink by mouth since he had a stroke one week ago. he receives nutrition and fluids through agastrostomy tube which are administered by the nurses. how would you code this scenario and whatis your rationale?

this is actually one that you participatein. so if you'd like to enter your responses. let's see how we did. code 88, that is correct. the patient does not eat or drink by mouthat this time due to his recent onset of stroke. if eating and drinking by mouth do not occurdue to a medical condition then the activity is coded as 88. moving on to self-care oral hygiene gg0130b. oral hygiene is the ability to use suitableitems to clean the patient's teeth or dentures

if applicable. and oral hygiene includes the ability to removeand replace dentures from and to the mouth and manage equipment for soaking and rinsingthem. to illustrate how the oral hygiene items shouldbe coded, we will walk through a few coding scenarios. ms. f brushes her teeth while sitting on theside of the bed. the certified nursing assistant gatheringher toothbrush, toothpaste, water and an empty cup and puts them on the bedside table forher before leaving the room. once ms. f is finished brushing her teeth,which she does without any help, the certified

nursing assistant returns to gather her itemsand dispose of the waste. how would you code gg0130b? and what is your rationale? this item would be coded as 05, setup or cleanupassistance because the helper provides setup and cleanup assistance. the patient brushes her teeth without anyhelp. the next scenario is one that you will beable to participate in. and the scenario is that mr. w is edentulouswithout teeth, and his dentures no longer fit his gums.

the helper applies toothpaste onto his toothbrush,mr. w begins to brush his upper gums, but can not finish due to fatigue. the helper completes the activity of oralhygiene by brushing his back upper gums and his lower gums. so how would you code this item? you could code 04, supervision or touchingassistance. code 03, partial/moderate assistance. code 02, substantial/maximal assistance. or code 01, dependent.

i'm going to move ahead as it looks like peoplehave entered their responses. and people have 94% of people selected 02,substantial/maximal assistance. and that is correct. and the rationale being that the patient beginsthe activity, but the helper had to complete the activity by performing more than halfthe effort. in this slide, we present an example of aprobing question that will assist the nurse in determining accurate assessment of thepatient's ability to complete the oral hygiene activity. in this case, the nurse asks, does ms. k helpwith brushing her teeth in the certified nursing

assistant responds she can help clean herteeth. the nurse says how much help does she needto brush her teeth? the nursing assistant says she usually getstired after starting to brush her upper teeth. i have to brush most of her teeth. how would you code this scenario? sorry if i'm a little slow on the technicalthings. (laughter) the response, 93% of the peopleresponded, c, 02 substantial/maximal assistance. this is correct. in this example, the nurse inquired specificallyhow mrs. k manages her oral hygiene.

the nurse asked about physical assistanceand how the patient performed this activity. if this nurse did not ask probing question,she may not have received all the information that she needed to make an accurate assessment. and you can tell from the cna's response theprobing question that she required assistance from the cna for over half of that effort. now we will move onto toileting hygiene. gg0130c. as shown in this slide, toileting hygieneis the ability to maintain perineal hygiene, adjust clothes before and after using thetoilet, commode, bedpan or urinal.

if the patient is managing an ostomy, thiswould include wiping the opening, but not managing the equipment. to illustrate how the toileting item shouldbe coded, we walk through a few coding scenarios. ms. j uses a bedside commode. the certified nursing assistant provides steadyingtouching assistance as ms. j pulls down her underwear before sitting down on the the toilet. when ms. j is finished voiding, or havinga bowel movement the certified nursing assistant provides steadying assistance as ms. j wipesher perineal area and pulls up her underwear without assistance.

how would you code gg0130c? and what’s your rationale? this item would be coded 04, supervision ortouching assistance because the helper provides steadying or touching assistance to the patientto complete the toileting hygiene. now we'll move onto a scenario for your participation. this one's a little more complicated. ms. q has a progressive neurological diseasethat affects her fine and gross motor coordination, balance and activity tolerance. she wears a hospital gown and underwear duringthe day.

she uses the bedside commode. she steadies herself with one hand and triespulling down her underwear with the other hand, but needs assistance from the helperto complete this activity due to her coordination impairment. after voiding ms. q wipes her perineal areawithout assistance while sitting on the commode. when ms. q has a bowel movement, the certifiednursing assistant performs perineal hygiene, ms. q is too fatigued at this point and requiresfull assistance to pull up her underwear. 67% have coded 02, substantial/maximal assistance. and 33% coded b, 03 partial/moderate assistance.

02 is the correct answer. and the rationale for code number 02 is thatms. q needed assistance with pulling down her underwear prior to toileting and requiredthe cna to perform perineal care and pull up her underwear, this is an example of thepatient requiring more than half of the effort from the helper. the next scenario is also an opportunity foryou to participate in. the nurse says, “i understand ms. j wearsthis hospital gown and underwear, describe to me how mrs. j usually does her toiletinghygiene. is she able to manage her clothing beforeand after going to the bathroom?

and is she able to wipe herself?” the nursing assistant responds, “she needshelp getting to the bathroom and some help to wipe herself.” the nurse says, “she needs assistance tocomplete her perineal hygiene. does she manage her underwear before and afterusing the toilet without you giving her physical assistance, cues or setting her up with thetoilet paper?” the nursing assistant replies, “no, i haveto physically hold on to her gait belt and support her as i pull her underwear down. she wipes her perineal area and then i pullup her underwear garments afterwards.”

64% of responders chose code 02, substantial/maximalassistance. and 29% chose code 03 partial/moderate assistance. and the correct answer is, 02, substantial/maximalassistance. and the rationale for this is that, ms. jrequires assistance from a helper for more than half of her activity. she is able to walk to the toilet, but sherequires assistance with pulling her underwear down prior to toileting. she requires assistance with her perinealcare and pulling her underwear up at the completion of toileting.

so it's the factor around the clothing thatrequires the code to be 02. next we'll talk about washing the upper body,gg0130d. washing the upper body is defined as the abilityto wash, rinse and dry the face, hands, chest and arms while sitting in a chair, or bed. to illustrate how the wash upper body itemsshould be coded we will walk through a few coding scenarios. in this scenario, mr. d has amyotrophic lateralsclerosis and has upper extremity weakness and uncontrollable twitching. mr. d is very motivated to performing theactivity of washing his upper body.

the nurse always offers to work with mr. dhand-over-hand for the activity to manage his twitching while he washes, rinses anddries his face, hands arms and chest. mr. d requires the nurse to move his handsand contain his tremors during this activity. thus the majority more than half of the activityeffort is performed by the nurse. how would you code gg0130d in this scenario,and what is your rationale? you would code gg0130d as 02 as mr. d requiredassistance from the helper for more than half of the effort, including hand-over-hand forthe activity to steady his twitching while he washed, rinsed and dried his face, hands,arm and chest. the next scenario i'll ask for your participation.

ms. l has severe rheumatoid arthritis andperipheral vascular disease that affect her hands with joint pain, weakness, numbnessand tingling. ms. l uses as wash mitt to wash her upperarms and part of her chest. a certified nursing assistant helps to washand rinse her face and part of her chest. ms. l rinses her arms and chest after thecertified nursing assistant places a rinsed mitt on her hand, she soaks her hands in soapywater and rinses them under the faucet that is set up for her use. ms. l slowly dries herself with a towel. b is correct.

you code this scenario as 03 as ms. l requiredpartial/moderate assistance. she was able to rinse her arms and chest afterthe nursing assistant placed the rinsed mitt in her hand. she was able to soak her hands in soapy waterand rinses them under the faucet that is set up for her use. she was able to dry herself. the cna in this scenario provided less thanhalf the effort for ms. l to complete this the next scenario for your participation isthis one. the nurse says, “how does mr. c usuallywash his upper body specifically; does he

wash, rinse and dry his face, hands, chestand arms while sitting in a chair or bed?” the nursing assistant says, “he has to sitin the bed because he's too weak in the morning to get to the sink and i have to help himto do most of it.” the nurse asks, “what can mr. c completefor himself when washing, rinsing and drying his upper body? does he need instruction, safety reminders,setup or physical help?” the nursing assistant responds, “i haveto give him a basin of water, washcloth and open his soap container, lather his wash ragand place it in his hand. i encourage him to wash his arms, but he alwaysgets tired after washing one of his arms.

i then do all of the remaining washing, rinsingand drying of his upper body. i've tried giving him a little rest breakbefore asking him to continue washing himself, but he then complains of feeling cold andwants me to finish washing him. after washing his upper body, i have to cleanupthe wash basin, washcloth, and soap for him.” well, we just moved right ahead didn't we. (laughter) i was afraid of doing that, i'vebeen trying to be very careful. that's weird. okay. sorry about that.

so coding this scenario as a 02 is correct,as the certified nursing assistant must perform more than half of the effort. also the cna lifts or holds his arms as heis too fatigued to complete. mr. c was also able to wash one of his armsbut became fatigued after completing this activity and the cna also had to give hima basin of water, washcloth, open his soap container, lather his wash rag and place itin his hand. she did all of the remaining washing, rinsingand drying of his upper body. then after washing the upper body the cnahad to cleanup the wash basin, washcloth, and soap for the patient.

now we will turn to instructions regardingcompleting the self care discharge goals on the admission assessment. we often receive questions about this section. and one of those questions is, how many goalsdo i need to develop? how do i code the discharge code for one theitems if there is not a goal for the item? or am i not able to -- or if i'm not ableto determine a goal? the requirement is that the patient must haveat least one goal between self-care items and mobility. as previously described, you would use the6-point scale to code the patient's discharge

goal. for instance, using oral hygiene as an example,the admission assessment performance may have been a 05, setup or cleanup assistance, butthe discharge goal is for the patient to be independent. you would enter 06 for the discharge goalin the oral hygiene section. if this is the only goal for this patientin the self-care section, you would enter a dash for eating, toileting, and wash upperbody. using a dash in this instance is appropriateand it would not affect your apu determination. as previously stated, you would refer to yourfacility, federal and state policies and procedures

to determine which licensed staff membersmay establish the patient's discharge goal. a few questions we've received are about howdo you determine the goal or goals for the patient? for instance, how should the clinician selectthe most appropriate goal to select, where you expect the most progress? the goals are based upon the admission assessment,discussions with the patient and family, clinical judgment, and professional standards of practice. therefore, goals should be established aspart of the patient's care plan. i actually went back to some of my -- i'llcall them nursing 101 books and looked up

the definition of goals that we should bedeveloping for our patients. and goals are clear, realistic statementsof outcomes of patient care. the establishment of goals should be ideallymutually planned by both the client and the clinician. goals should be formulated on the basis ofthe patient's aspirations, and reflect an assessment of the patient's capabilities. the goals should also be measurable. this slide gives examples of things to considerwhen establishing the discharge goal, ideally in collaboration with the patient or familymember.

patient preferences should also be consideredwhen establishing these goals. the patient's medical condition should betaken under consideration and there are other things that should be taken under considerationas indicated on this slide. but in terms of the patient's medical condition,for example, if we have received a question about entering a functional goal for patientswith debilitating chronic illness where function is expected to decline the answer to thisquestion is, yes, for all patients, code at least one self-care or mobility goal. this includes patients with degenerative neuromuscularconditions. expected self-care and mobility skills atdischarge would be based on the patient's

care plan. a degenerative disease with anticipated decline? overall function may result in the patient'sfunction discharge goals and they would code the same as the admission score or one ormore coding levels lower than the admission score. goals can be based on the patient's care plan. this slide illustrates an important point. if the patient's status changes during thestay, the patient's care plans goal may be updated.

however, the ltch care data set section ggdischarge goals coded at admission would not be changed. the admission and discharge ltch care dataset documents serve as a snapshot of the patient's status at that point in time. the discharge goal that was established onadmission and coded on the admission ltch care data set should not be updated. the quality measures listed on this slideadopted into the ltch qrp are process measures that require the collection of at least oneself-care or mobility goal. this slide shows an example of a situationwhere the discharge goal code is higher than

the admission performance goal. so as you can see, mr. m prefers to wash himselfrather than depending on helpers or his wife. the clinician assesses mr. m's admission performancefor wash upper body and codes mr. m's admission performance as 02, substantial/maximal assistance. in this scenario, mr. m is assessed upon admissionto require partial moderate assistance to wash his upper body. if the clinician determines that the patientis expected to make gains in function by discharge, the code recorded for the discharge goal willbe higher than the admission performance code. in this case, a discussion with the patientand family reveals that they anticipate that

by discharge, mr. m will require a helperto do less than half the effort in assisting him to complete washing his upper body. therefore, the discharge goal for mr. m wouldbe scored at 03, partial/moderate assistance. if the clinician determines that the patientis expected to gain, make gains in function by discharge, the code reported for the dischargegoal will be higher than the admission performance code. a question that we've received is, will therebe a problem if the goal is the same as the patient's current status? the clinician determines that a medicallycomplex patient is not expected to progress

to a higher level of functioning during theltch stay. however, the clinician determines that thepatient would be able to maintain his or her admission functional performance level. the clinician discusses functional statusgoals with the patient and his family, and they agree that maintaining functioning isa reasonable goal. in this example, the discharge coded goalis coded at the same level as the patient's admission performance goal. in this scenario, ms. e has severe arthritis,parkinson's disease, diabetic neuropathy and renal failure.

these conditions result in multiple impairments. the clinician observes ms. e's admission performanceand discusses her usual performance with clinician, care givers and the family to determine thenecessary interventions for skilled therapy. the clinician code's ms. e's admission performanceas 02, substantial/maximal assistance. due to ms. e's progressive and degenerativecondition the clinician and patient feel that while ms. e is not expected to make gainsin oral hygiene performance, maintaining her function at the same level is desirable andachievable as a discharge goal. the clinician anticipates her discharge performancewill remain 02, substantial/maximal assistance. in this example the discharge goal is codedat the same level as the patient's admission

performance code. this slide shows an example of a situationwhere the patient's discharge functional goal will be lower than the admission performancescore. ms. t's participation in skilled therapy isexpected to slow down the pace of her anticipated functional deterioration, the patient's dischargegoal code will be lower than the admission ms. t has a progressive neurological illness. she prefers to use a bedside commode for aslong as possible, rather than using incontinent undergarments. the clinician codes the admission performanceas 03 partial/moderate assistance.

in this example, ms. e is currently able touse a commode for toileting, so her admission performance is scored as 03 partial/moderateassistance. the clinician determines that ms. e is expectedto rapidly decline and that skilled therapy services may slow the decline to function. by discharge, it is expected that ms. t willneed assistance with toileting hygiene, and that the helper will perform more than halfthe effort. the clinician codes her discharge code as02 substantial/maximal assistance. in this scenario the discharge code is lowerthan the patient's admission performance code, ms. t's discharge goal should be scored asa 02, substantial/maximal assistance.

now, we are going to move into the case studywhich you've already familiarized yourself with. so we will debrief in 10 minutes and ask allof you to discuss the case study and the relation to the patient's admission performance, dischargegoals for self-care, eating, oral hygiene, toileting hygiene, and washing upper body. are there any questions about the case study? it looks like everybody's had sufficient time. it's just about ten minutes, so we'll walkthrough the case study and we'll start by going over how to code the -- how you allcoded the admission performance.

then we'll walk through the discharge goals. so for the admission performance for thisparticular case study, how would you score mr. f's admission assessment on eating? independent is the correct answer. because he's able to feed himself withoutassistance of a helper. we'll move onto oral hygiene. i'm assuming all of you got these all right,right? and this is also 06, independent because heis able the brush his teeth without the assistance of a helper.

next we move on to his admission performancefor toileting hygiene. and if you scored it as 02, substantial/maximalassistance, that is correct. he's able to -- mr. f is able to perform hisown perineal hygiene after supplies have been set up for him. he requires assistance from one staff memberto pull his pants and underwear up and down. the helper is completing more than half theeffort of the toilet hygiene task, as it includes clothing management. and last, how did you score his performanceadmission performance on washing upper body? if you scored it as 05, setup or cleanup assistance,that is correct.

mr. f is able to bathe his upper body, includingwashing, rinsing and drying his face, hands and chest without the assistance of helpersafter he's been set up. now we'll move onto the discharge goals fromthe case study for mr. f. how would you code his eating discharge goal? you code it as independent that, is correct. the goal for mr. f identified in the medicalrecord was to independently set up and eat meals and snacks. for oral hygiene, if you selected independent,that is also correct. the patient's goal is identified in the medicalrecord as independent with completing oral

care. toileting hygiene if you selected 06, independent,that is also correct. and wash upper body, if you selected independent,that is also correct. as mr. f's goal was to complete bathing seatedin a shower chair, as i previously mentioned, the use of a device should not factor intocoding of the item. this ends the presentation on eating, oraland toileting hygiene, washing the upper body and establishing functional discharge goals. and i would ask that you please submit yourquestions electronically, or write them on one of the provided cards.

and when anne completes her section of gg,we will entertain those questions. i will now turn the program over to my colleague,anne deutsch, who will discuss the mobility items of section gg. â»â» hello. hi, my name is anne. i'll be talking about mobility. and i thought it would be good now that you'vehad a hour and a half to stand up, so you're not sitting down the entire time. everybody should stand up if you're able soyou can get a bit of blood flowing.

i felt bad coming up here talking about mobility,the importance of mobility and making all of you sit for two and a half hours. so thank you very much. especially, i think the pts are probably itching. feel free to stand up anytime during the presentation. great. so terry covered self-care, mobility -- i'msorry, self-care and goals. i'm going to be covering mobility. a lot of the same guidelines apply in termsof goals, in terms of the scoring.

we've tried to streamline the slides a littlebit so there's not a lot of repetition. but we do of course have some examples totalk through for each of the activities, mobility activities that we're talking about. and we're scheduled to go until noon. i think we're running a little bit ahead ofschedule. so there's plenty of time for questions ifyou have any. i know some have already been submitted aboutgg. so i'll try to touch on a couple of things. but please free to continue to ask, submitquestions, and come up to the podiums.

and terry and i will take those questionstogether. so the mobility section is gg0170. and as with the self-care, there's a 3-dayassessment period. if you're looking at the actual form, youwill see that it is set up similar to self-care in that on the left side of the page is therating scale, the 6-level rating scale plus the activity not attempted codes. the first column, which is highlighted inyellow here is where you put the admission information. the second column is where you put the dischargegoal.

and then, one thing that's unique about themobility section is that, we wanted to reduce burden by having gateway questions. so for example if a patient isn't walkingor a patient is not using a wheelchair, you can indicate that, and then you're able toskip over the walking items, or the wheelchair items for the wheelchair. so basically there's three columns that yousee here on the admission form. so again, first column is admission performance. the second column is where you would put goals. and the third column, because you're not usingthe 6-level rating scale, we kind of put those

over into a third column. and there's specific codes to those, and we'llgo over that. so again, the rationale for these items isthat many patients admitted to ltchs have mobility limitations and early mobilizationis obviously a really important issue, i know in nursing school that was kind of one ofthe test questions, i think, every nurse has to answer, what are some of the negative consequencesof limited mobility and bed rest? and there's been a lot of research since iwent to nursing school, demonstrating how significant the problems are and in addition,some of the research led by johns hopkins and other groups have really looked at thebenefits of early mobilization, and it's amazing,

much more than i think i ever learned in nursingschool how important mobilization is. so similar to what what we learned about inthe self-care that terry mentioned. just wanted to kind of reiterate some of theseissues on the mobility side. so assessments for the mobility items-- andthese do need to be assessments-- can be done based on direct observation of the patient. can be based on patient self report if that'sappropriate. and obviously the patient is able to conveythe information. information also from other clinicians, carestaff, family members may also compliment supplement what information is used in orderto get a full picture of the person's mobility

activity level. patients should be allowed to perform activitiesas independently as possible. i know, in some circumstances, if a patientmight be, perhaps, getting some therapy and so something is done in a hurry, and the patientis not allowed to be as independent as possible in that circumstance, that's not an instancewhere an assessment can be done, because basically the person isn't doing as much as they canfor themselves. there's something else going on, and so thatwouldn't be something that would be considered because a person was not allowed to be asindependent as possible. another step for assessment to take into considerationis that helper assistance -- if helper assistance

is required because the patient is unsafeperforming an activity, or it's poor quality. so for example, walking, if somebody is unsafewith walking, they could actually walk, and let's say you know, there's i guess two examplesi can give. one example may be somebody is recoveringafter perhaps a brain injury of some sort. and so perhaps the person is actually physicallyable to walk, but they would -- walk so well, they might walk out of your ltch. and so that's obviously not a good thing withoutsupervision in that circumstance if they're not kind of aware of their surroundings. so supervision in that case might be providedbecause of the cognitive limitations.

that actually would be coded at the level04 supervision, it's because of to cognitive issues in this case. so this person, perhaps, is one example. another example might be somebody who hasexperienced a stroke, and perhaps -- they are walking, but they have developed somedifficulty walking, and maybe they are at risk for falls. so somebody has to be with them to remindthem to lift their foot right up. otherwise they would perhaps trip and havea fall. and so, somebody might be providing instruction,cuing, coaxing to remind that person to follow

what they have learned in therapy. so that might be, again, another example ofsupervision. so with all of the activities that we're talkingabout, the level of assistance is the key issue that we're talking about. but the treatment would be focused obviouslybased on whatever is going on behind the score. another issue in terms of steps for assessmentis that activities may be completed with or without assistive devices. again we're just looking at the amount ofhuman assistance with these activities. so if somebody walks, requiring supervisionand they use a cane, or somebody walks with

supervision does not use any assistive device,the person would -- those two individuals would have the same score. if a patient's performance varies, then youtake into account first of all that we need the information to be based on assessmentof the activity where the person is allowed to, again perform as independently as possible. if there is variation though, you do not scorethe person's best performance, or their worst performance. but it would represent basically on admissionthe person's baseline status. and for discharge it would be the person'sstatus as they are leaving the ltch.

as terry mentioned, cms does not provide specificguidance on who would actually complete the data. but you would follow facility, state and federalpolicies related to which staff members are appropriate members to be able to completethe information. so one of the things, as part of the casestudy you'll see if you haven't noticed already is, some of the mobility items are assessedby the occupational therapist in your case study, and some of them are assessed by thept. and that's pretty common that the self-caremobility items are not necessarily split by discipline.

we have examples where nurses are involvedas well as sometimes we have some examples where a nurse is gathering information froma certified nursing assistant. so again, you would follow facility, federaland state policies in order to determine which assessment information helps determine thescore. so in terms of coding instructions, so again,the information is coded on the admission form. and so, in this instance, it's the a0250 codeof 1 which refers to admission. and then also, at discharge, a0250 would bethe code 10 for the planned discharge. we certainly understand that in some circumstances,patients may have unexpected discharges for

several reasons. somebody perhaps has a medical complicationthat comes up and they need to be returned to an acute care -- a short stay acute-caresetting. perhaps somebody need to have some additionalsurgery. we know it's obviously very difficult to doa functional assessment in those circumstances. the priority is to get the patient back tothe other setting if that's appropriate. and so, there's no functional assessment itemson the unplanned discharge form. the coding is the same 6-level scale thatyou learned about in self-care. so again, 06 is independent; 05 is setup orcleanup assistance; 04 is supervision or touching

assistance; 03 is partial/moderate assistance;02 is substantial/maximal assistance and level 01 is dependent. in the circumstances where the activity hasn'tbeen attempted or hasn't been completed you are able to code these other numbers to documentthe circumstances of why the activity was and those include that the patient refusedwhich is coded 07. the item is not applicable for the patient,09. and 88, which is commonly used when somebodyis very ill, is indicating that the person had a medical issue or there was a safetyconcern. in terms of coding tips, again view documentationrelated to the three-day assessment period.

talk with direct care staff. if you are gathering information from anotherclinical person, or a nursing assistant, or a pt aide, you may be needing to ask probingquestions in order to get exactly the information you need. and then you can observe the person, obviouslyperforming the mobility activities. it's important to know the definitions ofeach of the activities. so for example, terry talked about toiletinghygiene. i'm going to be talking about toilet transfers. so those would happen together in many circumstances.

and so, then you have to, kind of, step backwhen you're thinking about the coding and say, okay, well, was the steadying assistanceprovided during the transfer, or was it while the patient was pulling their pants up anddown? or was it actually the person required steadyingassistance or contact-guard assistance while both of these activities were occurring? and so it may be that both are coded level04: supervision touching assistance. but again, it would be two separate activitiesbased on the form. so the scores should be again based on theamount of assistance provided from a helper. and activities may be completed with or withoutassistive devices.

so the dash, just reinforcement again fromself-care. a dash indicates no information. in general we would not expect to see dashesused on admission or discharge. because on admission if a activity wasn'tattempted or it wasn't applicable for a patient. you're able to code those, 07, 09, and 88codes. so hopefully there's not a circumstance whereyou need to put a dash. on the discharge side, again if somebody hasa medical emergency, and they're leaving the ltch, you would be completing an unplanneddischarge form and you're not required to collect the function data on that form.

again, please don't use the dash if a patientrefused; you've got a special code for that. if it's not applicable, code 09. and if it's not performed due to medical orsafety concerns, code 88. so use of the dash on admission and discharge,again, puts you at risk for a payment reduction. that's why terry and i wanted to emphasizethat today. as part of the goals, completion of at leastone self-care or mobility goal is required for the two quality measures. so across those two quality measures, onegoal for self-care or a mobility item is required. we would love for you to report as many goalsthat are relevant for the patient that are

in their care plan. but in terms of what is required for the qualitymeasure, it is 1. while a dash would be again used in rare circumstancesfor the admission discharge, if you determine that some of the mobility items are not relevantfor an individual patient, it's not part of their care plan, you can certainly put a dashas probably many of you are aware, you can not leave items blank when you submit thedata to cms through the qies system. so you do have to put something in. so for goals, if you're not reporting a goalbecause it's not relevant for a patient, a dash can be used there, and that would notaffect your apu.

i guess i'll stop here to see if there's questionsat that. because that's actually really important. no? okay, great. so now we're getting into the items. and so, similar to what terry did, i'll begiving you some examples. and then we'll go over some of them, well,we'll go through all of them together. some of them are polling. so you'll have the opportunity to use yourdevice to put in the codes and we'll see how

everybody is doing. so the first activity, which is the a item,is mobility roll left to right. and this is defined as the ability to rollfrom lying on the back to the left and right side and return to lying on the back. so this is one of the polling examples. so, get your little devices ready. and by the way, i do want to highlight, maybe a bit confusing, that on these devices, you do have the numbers, the 1, 2, 3, 4. but of course there's no 88.

so when you see the response options you mightthink that something is let's say the correct code is 2 you have to look to see if 2 isa, b, c or d. because the codes that we're going to be displaying in terms of your responsesare based on the letters, not on the numbers. so we have mr. r, who is an ltch patient. he has a history of skin breakdown. the nurse instructs him to turn on his rightside, providing step-by-step instructions on the use of his bed rail, teaches him tobend his leg and then roll to his right side. the patient attempts to roll with the useof the bed rail, but indicates he cannot do the task.

so he is, you know, just not able to do it. the nurse then rolls him onto his right side. next the patient is instructed to roll -- toreturn to lying on his back, which he successfully does. mr. r then requires physical assistance fromthe nurse to roll onto his left side and to return to lying on his back to complete theactivity. so i will give you a moment to consider whatthe correct score might be for this. and if you believe the correct score is independent,you would press, a. if you believe the correct code for him is 05, you press b.

if you believe, 04 is the correct code, pressc. if you think 02 is the correct code, pleasepress d. so i'll give you again just a moment to think through that. so he was given some instructions, but hestill needed assistance to turn on to the one side. and then he was able to get back onto hisback, and he needed assistance to turn on to the other side. so terry went through, kind of, the key questionsthat you would think through in terms of coding all of these activities across self-care mobility.

so he needed help, yes. it was more than touching supervision assistance. it was obviously more than setup assistance. and so then the question kind of, you know,becomes, who was providing more of the effort? was the patient providing more of the effortin that case the code is 03. if the helper is providing more than halfof the effort, the code would be 02. so are you ready? great, to the correct code is indeed level2 the patient -- and there's a check mark. so the patient in this circumstances neededquite a bit of help from the helper.

and we felt based on our discussions, whenwe were coming up for the score for this particular gentleman, that he was providing less thanhalf of the effort. the helper was providing more than half ofthe effort, and that leads to a code of 02. so again, more than half of the effort bythe nurse. the next item is sit to lying. so again, we're doing bed mobility activities. on the ltch care data set the definition ofsit to lying is the ability to move from sitting on the side of the bed to lying flat on thebed. so sometimes you'll see in the clinical notes“supine”.

in fact, that's the word used in the casestudy but for the care tool, “sit to lying” is the terminology that's used. so we have one scenario that we'll do togetherhere. so in this circumstance, it's ms. h who isour patient at the ltch, she requires assistance from a nurse to transfer from sitting at theedge of the bed to lying flat onto the bed because of paralysis on her right side ,soperhaps she had a stroke. the helper lifts and positions ms. h's rightleg. ms. h uses her arm to position her upper body. overall ms. h performs more than half of theeffort.

how would you code the item “sit to lying”and what is your rationale? anybody want to say out loud what they think? 03. yeah, i agree. in this circumstance, it said that she wasdoing more than half of the effort. there was some lifting going on. so it's more than touching assistance. so that's why this would be coded a level03. so lifting ms. h's left leg.

okay, we have another one, which is actuallya polling one. so get your clickers ready. ms. h requires assistance from two certifiednursing assistants to transfer from sitting at the edge of the bed to lying flat on thebed due to paralysis on her right side, obesity, she also has cognitive limitations. one of the certified nursing assistants explainsto ms. h each step of “sit to lying”. ms. h is then fully assisted to get from sittingto a lying position on the bed. ms. h makes no attempt to assist while theactivity is performed, while the incremental steps of the activity occur.

so i will give you the options here in termsof the codes. if you think the correct answer is 04, pressa. if you think the correct response is, 03, press b. if you believe the correct response is 02,please press c. if you believe the correct response is 01,please press d. and i'll give you a moment to think through this. you can press your button. i will move to the answer. so it looks like 88% coded 01, which is thecorrect response.

so in this circumstance, the patient neededthe assistance of two people to perform the she had quite a few issues going on. cognitive limitations, i think she was alsoobese so the assistance of two people in this circumstances were required. in addition, it said that basically she didnot help with the activity, that she was dependent on the staff to help entirely. so even if there wasn't two people helping,she would have been a 01 because it was totally done by the staff. i know we just actually wrapped up irf trainingin the last couple of days.

and one of the questions that came up relatedto the score of level 01 for the irf setting, which also apply to the ltch setting is, wouldtwo helpers always mean level 1? and our response is that, if the assistanceof two helpers is required then, yes, it would be a level 1. so here's again the rationale, the two assistantsbasically made that a level 01 automatically. the next activity on the ltch care data setin mobility is “lying to sitting” on the side of the bed. and the definition of that item is the abilityto move safely from lying on the back to sitting on the side of the bed with feet flat on thefloor and no back support.

so we have one example to do together, andone that will be a polling. so in this case, we've got mr. b who is admittedthe your ltch and he pushes himself up on the bed to attempt to get himself from a lyingto a seated position as his occupational therapist provides much of the lifting assistance necessaryfor him to sit up right. so, you know, thinking through the questionsthat terry asked us to think about in terms of coding. we already know he's below a level 04 becausehe's got lifting assistance provided by a helper. the occupational therapist provides assistanceas mr. b scoots himself to the edge of the

bed and lowers his feet to floor, overallthe occupational therapist performs more than half of the effort. how would you code this item? what do you think? 02….great. so i agree. i also think this is a level 02 substantial/maximalassistance. and the rationale is that in this case, theoccupational therapist, the helper provided lifting assistance.

now, we have a poll questioning. so we have ms. p who's admitted to your ltch,she's being treated for sepsis, and multiple infected wounds on her lower extremities. full assistance from the certified nursingassistant is needed to move ms. p from a lying position to sitting on the side of the bedbecause she usually has pain in her lower extremities on movement. how would you code this patient for this item? if you believe the correct response is 04,please press a. for code 03 ,press b. for code 02, please press c. and if you believethe correct code is 01, please press d. i'll

give you a minute. or a short amount of time. alright. so it looks like 85% reported a code 01 andi agree. again, full assistance was being providedfor the patient. and so that would be coded 01, dependent. the rationale again that it was being -- theassistance was being provided by a certified nursing assistant. and that report was given to the nurse orthe therapist who was coding.

the next activity is “sit to stand”. so, for this particular activity, the definitionis the ability to safely come to a standing position from sitting in a chair, or on theside of the bed. we have one example to go through togetherhere. mr. m has osteoarthritis and is recoveringfrom sepsis. mr. m transitions a from sitting to a standingwith steadying, in other words touching assistance being provided by a nurse on mr. m's trunk. how would you code this item with this patient? anybody?

four. i agree. touching assistance, sometimes also in theclinical notes you may see contact-guard, steadying, any of those kinds of words wouldbe considered level 04, touching assistance. so now we have a poll question up next andthis is an example of a nurse who is gathering information from one the other staff membersand so the nurse says, please describe how mr. l usually moves from sitting on the sideof the bed or chair to a standing position once she is sitting, how does she get to astanding position? so the cna replies she needs help to get tositting up and then standing.

so we need -- we know at this point that ahelper is needed. and she needs help. but we don't know the amount of help. so the nurse has to ask another question toget a little bit more information. so the nurse says, “i'd like to know howmuch help she needs for safely rising up from sitting in the chair or sitting on the bedto get to a standing position.” so the cna replies, “she needs two peopleto assist her to standing up from on the side of the bed or when she's sitting on a chair.” so we have this additional detail that obviouslyreally helps us to understand that there's

a significant amount of assistance being provided. so if you could select the response that youbelieve is correct. if you believe the correct code is 04, pressa. if you think the correct response is 03, if you believe the correct response is 02,press c. and if you believe the correct response is 01, press the d. i will give you a bitof time to do that. it looks like 88% of you coded d, which ibelieve is the correct response of 01, dependent. and the rationale here is that there's twohelpers required to do the one activity. and again, the nurse had to probe to get thatinformation. but that's the key information needed to codethat activity.

the next activity is “bed to chair transfer”. this particular item is defined as the abilityto safely transfer to and from a bed to a chair. but it may also include for an individualwho is in a wheelchair getting from the bed into the wheelchair. so we have one example to go through togetherin this scenario, mr. h is admitted to your ltch. his medical conditions are stroke, diabetes. he recently underwent bilateral above theknee amputations.

mr. h transfers from the bed to a wheelchairin this example using a transfer board, also known as a slideboard. the therapist assists mrs. h by providingintermittent verbal cuing to assist with hand placement and intermittent contact-guard. how would you code this item for mr. h? so, again. he's transferring from the bed into a wheelchairbecause he's had surgery where he's had bilateral above the knee amputation. and so he's using the slideboard.

and he looks like he's still learning howto do the transfers, so there's intermittent cueing. 04. i agree with that. the supervision code would be the right codebecause supervision includes instructions as well as just, you know, being there forsafety issues. so this is a polling question next for youto use your devices. mr. c is admitted to your ltch and he is sittingon the side of the bed. he stands and pivots in the chair as the nurseprovides contact guard assistance during that

transfer. the nurse reports that one time mr. c onlyrequired verbal cues for safety, but usually mr. c requires touching assistance. so this might be a discharge assessment wherethe gentleman is about to go home. he still, perhaps, is gaining in his levelof independence in this particular activity. but he, only in this scenario, once was ableto perform doing the assistance with verbal cues. mostly he requires touching assistance. how would you code this?

so if you believe the correct response is04 code a. if you believe the correct response is 03 press b. if you believe the correct response is 02press c. and if you believe the correct response is 01 press d on your device. i'll give you a few seconds to do that. it looks like 86% of you coded 04 and i agreewith that. basically, the gentleman required touchingassistance as his usual performance. next we're moving to toilet transfer. and as i mentioned, the toileting hygieneactivity and the toilet transfer activity

would kind of happen together. but it's important to know what part of thetwo activities kind of where they split, and think through, is assistance given just whensomebody's pulling their pants up and down and they can transfer on and off the toiletwith touching assistance, or is the touching assistance needed as the person is gettingon the toilet or getting up off the toilet? toilet transfer is defined obviously verysimply, the ability to safely get on and off the toilet or commode. if a person is unable to get out of bed andthey do not use a toilet, you would just code this an 88.

the activity was not attempted due to medicalor safety concerns. so we have one example to do together. mrs. y is in your ltch, she's very anxiousabout getting up to use the bathroom. she asks a certified nursing assistant tostay with her in the bathroom and she gets on and off the toilet. the certified nursing assistant stays withher as requested and provides verbal encouragement and instructions that would be cues, to mrs.y. how would you code this item for this patient? any thoughts?

yeah. so in this circumstance. the patient actually requested that the helperstay with her. and the helper did stay with her. and so, the code of supervision in this case,code 04 would be used which covers supervision and touching assistance. if somebody let's say was about to go home,they were anxious and they said, oh, you know, i want you to stay with me, but for whateverreason, the staff said, “oh, no, no, no, you're fine.

you're going home soon. you do this on your own.” if somebody did not stay with her, the personcould have, if that's appropriate, the person could be coded independent. i just wanted to distinguish in this case,the patient said she wanted somebody to stay with her, the person did stay with her, sothat's why we're coding supervision. but again, you know, if somebody's anxious,that didn't actually affect the scoring in this case. it was really the assistance was provided,therefore it's coded 04.

we have another example to do that's a pollingquestion together. mr. h has paraplegia incomplete, pneumoniaand copd. so he's got quite a few thing going on. he prefers to use a bedside commode when movinghis bowels. as i mentioned in the definition of toilettransfer, getting on and off off the commode is absolutely appropriate. you can code based on getting on and off thecommode just at the bedside. due to his severe weakness, history of fallsand dependent transfer status two certified nursing assistants assist with the toilettransfer.

so if you believe the correct code for thisgentlemen is 04, press a. if you believe the correct code is 03, press b. if you believe the correct code is 02, pressc. and if you believe the correct code is 01, press d. i'll give you just a bit of time. looks like 88% of you coded this d, level01 which is the correct response. and the rationale, again, in this circumstanceis that two helpers were needed for the patient to perform one activity. so next we're moving to one of the items that'sactually that third column on the admission assessment.

on the discharge assessment it's actuallythe second column, because on the discharge assessment, you're not reporting goals. so the question, and you actually see it visuallyhere. so in this particular item, we're asking,does the person walk? the response codes that are allowed for thisitem are, 0, 1, and 2. so again, the 01-06 codes can not be enteredhere. that's why this is over in the third columnon the data set. so, we just are asking at this point in timeso either admission or discharge, is the person walking?

the data does not-- the response for thisdoes not have to match up on admission and discharge. so you may have a patient perhaps who on admissionis not walking, and so you would code no, if the person is not walking. and let's say the person, the plan is thatthey would be walking by discharge. you would actually code 1, no. the person is not currently walking, but awalking goal is clinically indicated for this person. so at discharge you might be coding that thisperson is indeed walking hopefully if the

patient has a successful stay and the therapyis beneficial to this patient. but i do want to say that the admission codefor this, and the discharge code do not have to be the same. so for example, if you have a patient whois admitted and they are walking on admission, but let's say they have a condition wherethey might have let's say a progressive neurologic condition and perhaps, they might be usinga wheelchair by the time they leave the ltch, you might be coding on admission that theyare walking and then at discharge you might be coding that they're not walking. so there's no requirement that the codes haveto agree on admission discharge.

you code what's actually going on with theperson on admission. and then you -- at discharge you code what'sactually going on with the person at discharge. so just to go through the codes, i gave youone example. but i need to go through each of the codeswith you. so again simple question, does the patientwalk now? and if the answer is, no, and it is expectedthat the person will not be walking during the stay, a goal is not clinically indicatedyou would code 0. and the full code 0 in this circumstance means,no and walking goal is not clinically indicated. if you do code 0, you will see that you areable to skip over some of the items.

and you actually move to asking about wheelchair. and there's, again, a similar question aboutuse of wheelchair. if the person is not walking, but the expectationis that the person may be able the walk by discharge, so there may be a goal, then youwould code 1, no, to indicate the person's not currently walking. but a walking goal is clinically indicated. if you're coding 1, that means that the walkingitems-- you can skip over those on the performance column. but you would be, when you code 1, you wouldbe able to code a goal for walking because

you just told us a goal may be clinicallyindicated for this person. so you are able to enter goals related towalking. the third response is, does the patient walk? yes. so that means that you would be able to codethe walking items, the next item being walking 10 feet. and you were able to enter goals also. so, the next -- we'll be going through eachof the items next, but we do have an example to go through together, just -- actually acouple of examples to go through together

for this walking item. it seems like it should be simple but we actuallydo get quite a few questions about these items. so, the first example is mr. z currently doesnot walk. so what code out of 0, 1, or 2 would you codefor this individual? again, he does not currently walk. but a goal is clinically indicated. a couple of people put up their finger, 1that's correct. so again, in this case he's not currentlywalking. but we do want to be able to perhaps put ina goal related to one of the walking items.

so the walking items can be skipped. but you can put in the goals. second example, ms. y currently walks withgreat difficulty due to her progressive neurologic condition disease. it is not expected that ms. y will continueto walk. ms. y also uses a wheelchair. so whether somebody use as wheelchair or notdoesn't affect coding of walking. that's just, kind of, extra information. so don't be distracted by that.

you basically are just coding, is ms. y walking? so this is a polling question. so you would code either a 0, a 1, or a 2. if you believe the correct response is 0,press a. if you believe the correct response is 1, press b. if you believe the correct response is 2,press c. we'll give you a moment or less than a moment. so it looks like 69% coded c. so, the correctresponse is indeed, c. so, again, we're coding this on admission.

it says he's currently walking. and so, that's why we say, yes. she is walking. if you were -- maybe it wasn't clear in theexample that this was the admission. so on admission you would code that she iswalking. if this was the discharge assessment, youwould -- and let's say, you know, she really wasn't walking at discharge. so, again, she had a progressive neurologiccondition, it was expected she wouldn't be able to walk at discharge.

let's say when discharge does happen, she'snot walking, then you would code a 0 for her at discharge. i hope that's clear. next we have another polling question. i'm sorry, this is the rationale for the correctcode too. now we're actually moving onto the next item. so we're getting to the walking items. the first item being “walking 10 feet”. so walking 10 feet, the assessment would startonce the person is standing as you, real life

we've already talked about the bed mobility. we've talked about sit to stand. now the person is in a standing position,so we would like to know their ability to walk at least 10 feet, it can be in a room,in a corridor or a similar space. if the person has perhaps just come to a standingposition, they're right near their bed. or maybe if they use a wheelchair and they'reeither in therapy or in a hallway, they've gotten up out of a wheelchair and they maybe walking in a hallway. so it's just 10 feet. so we have a polling scenario for this particularitem.

and we have mr. n who is admitted to yourltch. and he's recovering from multiple orthopedicsurgeries due to bone fractures following a motor vehicle accident. he will be returning home tomorrow, so thisis a discharge assessment. and he now walks with a walker. the therapist provides close supervision asmr. n walks 15 feet. the therapist also provides intermittent verbaland nonverbal cueing as he walks this distance. how would you code mr. n who requires thetherapist provide close supervision as well as verbal and nonverbal cueing to walk 15feet?

is 03, press b. is 01, press d. i'll give you a few seconds. i do get with 100% of you. terrific! that is a code 04. and the rationale, as you could probably tellme, is that he requires close supervision, which is part of the definition of supervision,as well as verbal, nonverbal cueing which is also apart of the definition of supervision. so next we have another walking item, in thiscircumstance though the patient is required

to walk 50 feet with two turns. the definition of this particular item againstarts once the person is standing, because we've already covered the sit to stand. and it's the person's ability to walk 50 feetwith two turns. one of the questions that was asked at theltch training, i guess in baltimore in november, i think, was what's a "turn"? so we do have a turn definition here. a turn is defined as 90 degrees. turns may be in the same direction.

so somebody might make two 90-degree turnsto the right, or two 90-degree turns to the left. or the turns could be to the right and oneto the left. the 90-degree turns should occur at the person'sability level and include the use of an assistive device. so for the walking item, the assistive devicemight be a cane. the definition of turn that i'm mentioninghere, also applies to the wheelchair item, which has 50 feet with two turns. so, again, it's 90 degrees.

so that would be you know, around a typicalcorner, getting into their room, potentially getting into a bathroom. so here we're on the walking item with 50feet with two turns. and this is a polling question where we havems. l who's admitted to your ltch, she is unable to bear her full weight on her leftleg. as she walks 60 feet down the hall with hercrutches and makes two turns around the corner. so two 90-degree turns, her husband supportsher trunk. he provides less than half of the effort. how would you code ms. l who's in your ltch.

if you believe the correct response is 04,please press a. if you believe the correct code is 03, please press b. if you believe the correct code is 02, pleasepress c and if you believe the correct code is 01, please press d. i will give you a coupleof seconds to code this. 91% of you coded b. and i do agree. the patient's husband in this circumstancewas the helper. maybe she's about to go home and the husbandis getting ready to provide the assistance. he'll be providing at home. and he was providing some trunk support, butit was the patient -- the patient was doing

more than half the effort, the helper wasdoing less than half of the effort, which was a level 03. next we have walking 150 feet. again, this is going to be, the situationwhere the person is already in a standing position when you start your assessment forthis particular activity. and the person needs to be able to go 150feet in a corridor or similar space. so this is another polling question wherethe gentlemen mr. w is recovering from a brain injury. he will be discharged home tomorrow.

so this is the discharge assessment. and he's been in your ltch for 30 days. he walks 150 feet or more while the physicaltherapist provides contact-guard, touching so, if you believe the correct response is06, please press a. if you believe the correct response is 05, please press b. if you believe the correct response is 04,press c. if you believe the correct response is 03,please press d. and i will be giving you a few seconds to press your buttons okay. it looks like 93 of you pressed c. and i doagree with that response.

code 04 is the correct response because thepatient completed the activity with touching okay, so now we're moving into the gatewayor screening question related to wheelchair scooter use. so basically this is analogous to the walkingitem where we're over in that third column, so you're not coding 1-6 here. you're just coding whether the person usesa wheelchair or not. so the only available codes in this circumstanceare 0, and 1. so the question is, does the patient use awheelchair or a scooter? if the answer is, no.

code 0. if the answer is yes, you would code 1. so-- sorry. so we don't have an example on this one. sorry. i got confused for a second. we don't have a example but it's very similarto what you saw with the walking. so there's two questions related to wheelchair. if the person is not using a wheelchair, thenyou're going to actually skip over these items.

and as you can see in the instructions, ifyou say, no, the person does not use a wheelchair or scooter, you actually skip over to thenext section, which on the ltch care data set is bladder continence. there has been some questions again by whatwe really mean by a wheelchair. because, unfortunately, this is not as simpleas it seems like it should be. if somebody is only using a wheelchair toget transported, let's say, to x-ray, but they are otherwise walking and you're notworking on wheelchair mobility skills in therapy, and so it is purely the wheelchair is usedfor transport. you would not code that, because usually ifsomebody's just put into a wheelchair, it's

not their wheelchair, it's just like a routinewheelchair, you could put me in a wheelchair and i would be a level one because i can'tmaneuver one of those wheelchairs that’s just sitting around the hospital. so that's not really helpful information thatyou would think about in terms of an assessment. so i hope that helps. let’s say we do have a patient who has,perhaps, experienced a stroke and has some significant mobility issues or somebody who'sexperienced an incomplete spinal cord injury and they are actually using a wheelchair;the goal is for them to build their skills in terms of wheelchair.

they may or may not be walking. it may be that you have a individual who'swalking, but for longer distances they need to use a wheelchair. so you are working on wheelchair skills. in this circumstance, you would be actuallycoding both walking and wheelchair for this individual patient. so you're welcome to code walking and wheelchairif that's relevant for the patient. and again, goals are also available for bothof those sets if that's relevant for that so the first item that we have related towheelchair mobility, there's actually two

items. first one is “50 feet with two turns”. so this assessment, very analogous to thewalking item in that it only begins once a person is seated in a wheelchair. we already talked about the person gettingfrom a bed into a chair, that aspect has been coded separately. and so now, once the person is in a seatedposition in a wheelchair, we'd like to know the amount of assistance required as theygo 50 feet with two turns. it can be a motorized wheelchair or a manualwheelchair.

you'll actually tell us a little bit aboutthat as a follow-up question. but it is basically the 50 feet and two turnsand again, similar to all the other activities, how much assistance was needed from a helper? so we do have a polling question here. so once seated in a manual wheelchair, ms.g wheels about 60 feet and makes two turns into her room and into her bathroom so 90-degreeturns. and again the turn definition is the samefor walking and wheelchair. the therapist provides instruction to ms.g so that she's able to maneuver around the corner into the bathroom.

so in this case, it's a manual wheelchair,but she maybe needed help to know which wheel to turn. so there's assistance being given by a therapist. so how would you code this particular item? if you believe the correct code is 04, pressa. if you believe the correct code is 03, if you believe the correct code is 02 pressc, and if you believe the correct code is 01, press d. okay. 100% of you got -- pressed a, which is code04 and i agree with that. so, again, you've got the rationale, you couldprobably tell me.

as i mentioned, there are follow-up questions. these items, after each wheelchair activity,asks what type of wheelchair or scooter the person used? and so you would just indicate that it's 1a manual chair or 2 a motorized chair. the last activity is “wheeling 150 feet”. again it starts once a person is seated inthe wheelchair or scooter. and the distance is of course as the titlesuggests, 150 feet down a corridor or similar space. mr. g always uses as motorized scooter tomobilize himself down the hallway.

the therapist provides cues due to safetyissues to make sure she doesn't run into the walls. so how would you code this item for mr. g? so therapist is providing cues. 04? correct. verbal cues are being provided. so the follow-up question, also applies here. so in some circumstances, it may be that somebodyuses a manual wheelchair for shorter distances,

but uses a motorized wheelchair or scooterfor longer distances. so we do ask that you code for each time awheelchair is used for the 50 feet as well as the 150 feet. same responses, 1 for manual, 2 for motorizedwheelchair. here you see on the admission form you havethe opportunity to describe the goals that are going on for the patient as a number. only the 1-6 codes can be used. so if somebody is maybe not expected to dosomething at discharge, you can code it as dependent as the goal because a lot of theseare daily activities.

and so many of these activities would be happening. so they're all relevant for patients. so terry spent a lot of time, i think, goingover the self-care goals. all the same rules apply here. again, you know, there is this requirementbased on the quality measures for at least one goal to be reported for self-care or mobility. we would love for you to report the goalsthat are relevant for your patient. and so you may report multiple goals basedon the care plan. remember that if one goal is not reportedthat that puts you at risk for not being compliant

with the quality reporting program. i just have one thing i wanted to go overin the unplanned discharge situation. and i did mention this early on but just toreinforce it. we have an example where a gentleman has lotsof things going on. he's got healing complex post-surgery issuesgoing on. he's had sepsis, and he has a medical complicationthat occurs. so he unexpectedly returns to the acute-caresetting. so in this circumstance, you would be fillingout the unplanned discharge form. and so you're not actually reporting any functiondata.

so i just wanted to kind of reinforce thatpoint. we know you need to prioritize on gettingthat patient back to acute care so you can't do a clinical functional assessment at thatpoint in time. so now we've gotten to point that we can goback to the case study. so, similar to what terry asked you to do. if you could look through the case study andlook at the relevant mobility items and it seemed like you didn't need the full ten minuteslast time. so i will be, maybe, walking around, seeingif you have questions, or kind of seeing how you're doing with progress.

we have about 16 minutes left between me endingand your lunch. so i'm happy to just, you know, give whatevertime you need. we can go through the answers together. and then there's a couple of wrap up slides,and then you'll be ready for lunch. and please, feel free to stand up if you needto. you've been listening to me for almost anhour, i think. so thank you very much and, again if you canpull out your case study for the mobility items and you have a coding sheet in yourpacket. so we'll just be going through the mobilityitems together in a minute.

well, in a few minutes. okay, it seems like most people are ready,ready for lunch maybe. (laughter) so, we will get started going throughthe responses together. so we're doing to admission assessment together. and the first item is the rolling left toright. and i won't go through -- i guess if you havequestions, please you know, feel free to put up your hand or come up to the microphone. but i will kind of generally go through thesequickly, if i think people were able to get the right response.

so, the first -- and these are of course -- youhave to kind of look at your coding sheet if you put it on there. because as you would expect, clinical notesare not going to fit in this order. so pay attention to that, if you're kind ofscanning your case study and you wrote the scores there. the first item on the case study is walking. but obviously we get to walking later on thisform. so that's part of the challenge of abstractingdata. so the first item is roll left to right.

and we coded that as independent. because he did not need any assistance. next one is, sit to lying, which was coded1, dependent, because i think there was two people. by the way there was a get question from somebody. thank you, chris. i'm sorry i didn't catch your name. heather asked a great question just clarifyingif two people are needed, is that always going to be 01?

they gave me an example of perhaps a patientwho is just very, very obese, they are starting to do stuff, but because of safety, both staffsafety and patient safety, two people are required would that be always coded 01. and my answer was yes, and part of my rationaleis think about that person, let’s say, that was discharged and the person's going home,there's a significant burden on the family to take care of that person,probably there'sa hoyer lift that might be ordered or something for that person at home. so two people required during the facilitystay at discharge translates into a significant assistance requirements for family if thatperson's going home.

so that is correct. that is code 1. the next activity is lying to sit on sideof bed. so this was coded a 02. so, hopefully the case study was clear onthis one. the person had lifting assistance of the twolegs. it's kind of hard sometimes to write thesecase studies. but there was significant burden. and our team thought that the patient wasdoing less than half of the effort.

i think you know, when you're doing the actualtransfer or the clinical assessment, you will have to make a judgment about more than half,less than half of the effort by the helper. and that will help you to determine the correctcode. so if you interpreted that to be the helperproviding more than half of the effort, level 02 is the correct response. the next one is sit to stand. i think this was another one where there weretwo helpers required and so that was coded 01. and the getting in and out of the chair bedwas coded 06, independent.

toilet transfer was coded 04, that was theactually, i think in the ot assessment if i remember correctly. does the person walk? code 02, yes. the person is walking independent with 10feet, dependent with walking 50 feet with two turns and walking 150 feet, the correctcode was 88 because it wasn't attempted. so i actually had a good question from thegentlemen who stepped out. so he asked about the coding 9 versus coding88. so if the patient was not performing an activityprior to the current event.

so let's say somebody had a below the kneeamputation, they weren't walking prior to their current stroke, you would code 09 toindicate the activity was not applicable. the person wasn't doing it prior to the currentstroke. but if the person in this case, i think wasexhausted, and it was legitimate that the person -- it was just very challenging forthem, so it was a medical safety concern, that's coded 88. question about wheelchair/scooter, no theperson does not use a wheelchair or scooter in this case study, so you would respond,no. you're able to skip over the rest the items.

we just put skip as the responses. obviously on a paper sheet you can leave itblank. the it system is built that you do not needto enter -- in fact you cannot enter. so if you say the person doesn't use a wheelchairby mistake, you won't be able to enter any wheelchair scores. so, in summary, and we've got 3 minutes forme to do the summary before your lunch. so gg assesses need for assistance. i hope i've emphasized that and that terryalso emphasized that throughout her presentation. so hopefully we've been consistent.

knowledge about patient's functional status,obviously really, really, important. and we appreciate you paying attention topatient's functional status. it's such a vital issue for all patients. new items were added to the data set, obviouslyin this area self-care mobility. in terms of action plans, so as you're doingeducation with your staff, you know, you've already gotten started. so you may be having new staff, or you maybe doing some reinforcement. review the importance and rationale of obtainingdocumentation on the patient's functional abilities.

for the nurses remind them about what theylearned in nursing school 101. review the 6-level rating scale as well asthe activity not attempted rating codes. evaluate current documentation to make surethat whatever wording is included in your current clinical documentation is helpfulfor anybody who's reviewing that and consistent with the information. you can use things like contact-guard andall that, just make sure everybody understands that it's considered the same as touchingassistance for the data set. ensure that there's a mechanism in place withassigned responsibility for collecting each data element in section gg as well as goals.

and practice coding a variety of scenarioswith staff. so there's some examples in the manual inaddition to what you have here. and the faqs and i'm sure there will be somefaqs based on the training provided here in chicago. so, with that, i will see if there's any questionsor -- there is question time at the end of the day. any questions now? we have about a minute before lunch? i think mark is ready to tell us what to donext.

thanks, mark