Nanda Nursing Diagnosis For Diabetes Mellitus

>>>> great. hi my name is anne deutsch. i'll be doing the presentation on sectiongg. i want to thank the cms and econometrica forthe opportunity to present this work in this section. i have been involved in this work for aboutten years at this point. i was part of the team that reviewed all ofthe assessment tools that were being used in post acute care, and helped to developthe item set, the care item set. these items are derived from that item set.

so the slides are up for gg at this point. so, again, this is a section about functionalabilities and function goals. next slide. so, the objectives for this section are toillustrate a working knowledge of section gg, functional abilities and goals. we want you to be able to articulate the intentof the items. and i know we've already gotten some questionsas part of the preparation for this program. we want you to be able to interpret the codingoptions for each new item, and when they would be applied.

and we also want you to be able to accuratelyapply the coding instructions in order to come up with accurate scores. i did want to mention a couple of items thatyou have on your tables. first of all, you have cards like this ateach of your tables. so as i'm going through my presentation, ifyou have any questions that you'd like to ask about any of the items, or maybe someof the examples trigger a question, please feel free to fill out these cards. i believe the econometrica team will be pickingthose up at breaks. they'll be looking for those.

and that will help us to be able to addressyour questions. we did this at the training that we did forthe long term care hospitals back in the fall of last year. it was very helpful to get kind of this asa major theme of questions. so we're able to address that at the training. so there's no limit. you're welcome to submit as many cards asyou want. also, i want to mention that there is an irfqrp, irf quality reporting program help desk. i would encourage you to ask questions afterthis training if you have follow-up questions.

and i think you'll hear more about that latertoday and tomorrow. the other item that i'd like you to have handythat i think will be helpful is a copy of the irf-pai. so everybody should have gotten a packet. within that packet is a copy of the irf-pai. so we are talking obviously about sectiongg, which starts on page six of the irf-pai. the first page has the prior functioning,probably the most helpful time for you to look at it is when we get to the items onpage seven, and page eight, and page nine. okay, and with that, i will get started.

so, as i said, the items in section gg arenew. and again, they are effective with dischargesoctober 1, 2016. and there's really a few types of questionsin there. so within the first page, you have gg0100which is prior functioning everyday activities. you also have gg0110 which is prior deviseuse. you also have gg0130 with self care activities,which has both admission information, admission performance, discharge rules on the admissionside, and then discharge. and then there's also mobility questions collectedboth at admission and discharge. so the intent of this section is again tofocus on prior functioning.

the second intent is to have items that describefunctional status of patients based on functional status on admission. and that also is collected at discharge sowe can see improvement in function. the function also has on the admission sidegoals that are the person's expected function by discharge. so there's really three types of questionsoverall. there's the prior functioning questions witha very basic rating scale. because we know you can't get a lot of detailedinformation from patients about prior functioning. there are questions about performance on bothadmission and discharge.

and then there's questions about expectedor anticipated functional status by discharge on the admission assessment. so we'll go through those, but the performancei will generally speak of, it can apply to admission or discharge. a lot of the examples i have are either admissionor discharge, you can probably tell which one they are. but it doesn't really matter, it's scoringthe same. the admission and discharge self-care mobilityactivities assess the patient's need for assistance with self-care and mobility activities.

so i used the word "activity" a lot. i just want to be sure you have the definitionfor that. we actually use the international classificationof functioning definition of activity. and in that definition, an activity refersto the execution of a task or action by an individual. so, activities are things like eating, oralhygiene, walking. so when i talk about an item or an activity,i'm talking about the items on that page seven and page eight and nine. so as you know, many patients who are admittedto an irf have self-care and mobility limitations.

and because of these limitations, there arerisks for additional mobility and functional decline. so complications due to limited mobility suchas pressure ulcers. so that's obviously an important reason whythis functional status data is important to collect in an irf setting. so we're going to start off with gg0110. so if you're looking at the irf-pai itself,this is on page six. so i'm not sure if your preference is to takenotes right on the dataset, or if you're using the slide to take notes, but either way.

either way it's on page six, if you want tolook at exactly how it looks. so in the area of prior functioning, you'llsee that we have a 3-level rating scale where 3 is independent, 2 is need some help and1 is dependent. we also have the option that it maybe unknown,or that the information is not applicable. so again, the rationale for prior functioningis that knowledge of the patient's prior functioning, prior to the current illness, exacerbationof illness, injury may inform treatment goals. and in fact, when we, as part of the functionalstatus quality measure that stacy mentioned earlier today, we actually analyzed data fromthe post acute care payment reform demonstration where these data were collected.

and we found that when you look at prior functioning,it really did affect how much functional gain or the patient's discharge status. when we were developing the care item setwe did go around to a lot of the post-acute care centers, as well as acute care centers. and many centers were already asking aboutprior functioning. it was just asked about in many differentways, it wasn't standardized. and so what we're basically doing as partof this section gg is we're standardizing the way this is collected across inpatientrehabilitation facilities, as well as in other settings.

and one of the -- we only included in thedataset the items that we are needing for risk adjustment on the admission assessment. so obviously, prior functioning you don'tneed to collect ones any way. it could be if it was the medical record fromacute care. because maybe the therapist had seen the patientin acute care, that information, you know, maybe available to you. but what we found in the post-acute care setting,many therapist and nurses were asking about this specifically. so, this information can be gathered a coupleof ways.

first of all it can be obtained by interviewingthe patient. or if the patient isn't able to provide thisinformation, it could come from a family member or significant other. also, it could be in the medical record, maybeif you're irf-pai coordinator or irf p desk coordinator, whatever your title is, you mayactually be relying on looking at the medical record, because maybe the therapist are askingthis information. or maybe it's in the acute care medical record. so gathering this information from the medicalrecord is also an appropriate strategy to get the information.

so just to go over in detail, and again, thisis right on your irf-pai dataset, so you don't have to write down these definitions, but,this information is collected only at admission to the irf setting. and the codes are code 3 independent whichmeans that the patient completed the activity by him or herself with or without an assistivedevice that does not affect their score on this particular item. and basically, with independent, the persondid not get assistance from another helper. code 2 means that the person needed some help,and in this case, that is defined as the patient needed partial assistance from another personto complete activities.

and code 1 is dependent. the helper completed the activity for thepatient. we also have the code 8 unknown. if the patient's usual ability prior to thecurrent illness, exacerbation or injury is unknown. so maybe the person is not able to respond. maybe the person has some kind of communicationproblem, and a family member hasn't been able to provide that information, you can use thecode unknown. code 9 is also available.

it means not applicable. this could be coded if the patient did notperform that activity prior to the current illness, exacerbation or injury. so again, you'll be recording the person'susual ability to perform mobility or ambulation prior to the current illness, exacerbationor injury. if no information about the patient's abilityis available after attempt to interview the patient or family, and after reviewing thepatient's medical record, code 8 unknown. we actually have had some questions that havecome in through the help desk about this particular item, why is there a code 8 unknown?

and for those of you who are familiar withreporting for example, the pressure ulcer items on the current irf-pai, you may be awarethat there are data specifications that give you the list of what are the "allowable" codesthat can be entered for each of the items. and in addition to what is provided manually,you can also enter a dash, which indicates that there's no information. so we've had several -- i will talk aboutdashes in a little bit. but i did want to mention that we've gottenquite a few questions. why would you use unknown as opposed to adash? and actually, if you do try and attempt toget the information, you should code 8 unknown.

you would only put a dash if there was noattempt to get any of the information. and i would really encourage you to put the8 unknown. because under the quality reporting program,if more of the items if you enter a dash, that means that you're not providing the informationthat's being asked by cms. and you're at risk for a penalty, potentially. so we'll come back to this. okay. i see there may be some questions about this. please write down your questions.

i will repeat it just because i just wantto be sure it's clear. so if you are trying to get prior functioningdata and you have made an attempt to try to get it from the patient, the medical recordsor family member, you can't get it, you should code it 8. try to avoid dashes. i will talk about dashes in a little bit. okay, so we have some examples to go overthat some of these are in the manual, some of them are new. but it will give us an opportunity to kindof go through these together.

and again, these may trigger questions, soi encourage you to write these down on your cards. so, on slide 13 you'll see for self-care,we have a coding scenario and example. ms. r was admitted to an acute care facilityafter sustaining a right hip fracture and subsequently was admitted to your irf forintensive rehabilitation. prior to the hip fracture, ms. r was independentlyeating, bathing, dressing, and using a toilet. ms. r used a raised toilet seat due to arthritisin both her right joints. the patient and family indicated that therewas no safety concerns and she performed these everyday activities in her home.

how would you code gg0100 and what is yourrationale? the answer to this particular one is that she would be coded independent. we just wanted to reinforce that the use ofdevice doesn't make a difference. she is independent. it's really focused on whether there was assistancebeing given. and in this example it said that the patientdid this at home without assistance to a helper. the patient may use an assistive device, andit could still be coded as independent. okay, another example, we have a little bitharder one here.

so in this example it’s related to stairs. mr. p has continued to show signs and symptomsof possible delirium since admission to the irf. the irf staff has not received any responseto their phone messages for mr. p's family members requesting a return call. mr. p has not received any visitors sincehis admission. the medical record from the prior facilitydoes not indicate mr. p's prior functioning. there's no information to code gg0100c, butthere have been attempts for locating this information.

so this is the point that i was trying tomake before. how would you code this? 8. awesome. so at this point, you have -- i'm the firstperson to do the polling. so, i will spend a little bit of time. so on each table, there should be two gadgets. maybe you can hold them up so that -- thereshould be two gadgets on each table. so whoever wants to fight for them, whoevergets the penny maybe.

(laughter) take responsibility for maybe representingwhat the group might think about how to code. so there will be two responses that come infrom each table. i'll just go through the answers, and thenas we go along, there will be other opportunities to do the polling. so you can pass around the gadget as you'dlike. but in this example, so i'll go over it. so this case there was an attempt to get information,but they weren't able to get the information. but there was an attempt. so, a would be pressed if you think the rightanswer is dash.

b would be coded if you think the code 2 iscorrect. c would be coded if you think code 1 dependentis the correct answer. d would be used if you think, 8 unknown isthe right code. and e, 9, not applicable is another option. go ahead and press what you think is the rightanswer. so you got it all right. thank you for listening. terrific! so that was an easy one.

these are going to get harder, so hang inthere. all right. so, the next practice coding is related tostairs. so, as you can see there's like four areaswithin the prior functioning. so self-care, indoor mobility ambulation,we talked about that, stairs, and also functional cognition. so in this particular one we're talking aboutstairs. and the correct code is 08. and at the bottom of the slide in this rationalis exactly what i said before about the dash

use. so i will read it just to be absolutely sure. so a dash is not used as the information wassought but not available. had there been no documentation and no attemptto get the information, then a dash would have been used. okay, the next section is gg0110 prior deviceuse. so again, when we collected data from thepost acute care payment reform demonstration, we found that in addition to prior functioning,individuals who had used devices prior to the current illness, injury or exacerbation,their prior use did affect functional improvement.

and so we have included some of those itemson the irf-pai. so the items that you check off all that apply. and the options are, manual wheelchair, motorizedwheelchair or scooter, mechanical lift, walker, orthotics/prosthetics, and if none of thoseapply, we need a response of none of the above so that we know that you've provided a response. so if you try to submit an irf-pai and nothingis checked, the system will reject the record, because we want to be sure that everythinghas a response. there have been questions that we have hadon the help desk about why pain is not on the list.

and i will tell you that it’s part of thepac prd we were told that pain might be important, and so we did include it in our data collectionoriginally. and it was not a significant predictor. and so again, we didn't -- it wasn't necessaryin order to calculate the quality measure. and so we did not put it on the dataset. we were very aware that the collection ofdata takes time. and so we are putting on the dataset the dataelements that are necessary to calculate the quality measures. so there are absolutely other things thatcould be collected, other things that we looked

at in terms of what could affect functionalimprovement, and pain actually did not end up being a significant predictor. so it's not on the dataset. i hope that makes sense. so, the rationale for this item, just to buildon what i said about the risk adjustment, knowledge of the patient's use of devicesand aids immediately prior to the current illness, exacerbation or injury may informtreatment goals. so similar to the prior functioning, there'sreally two main ways to gather this information. so one option is to ask the patient or family.

another option is if it's in the medical record,that information can be obtained from either your medical record, has one of your otherteam members collected the information. or it's possible that the information wasavailable in the acute care medical record. and either source is acceptable. so this again is only collected on admission. and we have gone over the devices. they are manual wheelchair, motorized wheelchair,scooter, mechanical lift, walker, orthotics/prosthetics. if none of those apply, please check noneof the above. at this point we're going to turn to the self-careitems.

so if you are taking notes on the irf-pai,we are moving to page seven. and if you’re looking at the slides, we'reon slide 23. so as mark mentioned there's quite a few itemsin this section, between these pages. so i'll be definitely covering the self-careactivities before break. we're scheduled to stop, maybe i think 10:15. we'll take a break and we'll just pick upwhere we left off. i think we'll probably get through self-care. if you again have questions, i would encourageyou to start writing those down. the econometrica team will be collecting thoseduring the break.

if there's things that are coming out quiteoften, and i know about that, i can address that as soon as we come back from the breakor immediately after lunch. so i do appreciate that input. so in the area of self-care, there are sevenactivities, or seven items. this section is referred to gg0130. and within this section, you will see thatthe items include eating, oral hygiene, toileting hygiene, shower, bathe self, upper body dressing,lower body dressing, and putting on and taking off footwear. if you're looking at the irf-pai, you willsee that there are two columns.

so the first column is where you put in theperson's admission performance. so that can be any of the codes that we'llbe talking about. and then in the second column, so this isstill the admission assessment, you're putting in the discharge goal. so this is an expectation of where the personmaybe at the time of discharge. so the rationale for these items, is as weexplained several times, the irfs may have self-care limitation as the time of admission. and they are at risk for further decline. so, in terms of the steps for assessment,i'll be spending quite a bit of time going

through this. because i think there's some important points,and some supplemental information that i can provide based on questions that have alreadycome into the help desk about this assessment process. so, first of all, assessment of the patient'sself-care status should be based on direct observation of the patient. it could be supplemented by the patient'sself-report, family report, direct care staff maybe providing information that may be documentedin the patient's medical record. or it may be something that you're able toget through interview.

there is a 3-day assessment period. but i'd like to emphasize, we're trying toget an idea about the person's baseline functional status. so when a patient's first admitted to an irf,or to any setting, their kind of getting used to the environment. they're getting used to the staff. so, somebody might not necessarily feel safethat i can transfer that person. and so it may be the first transfer is a bitawkward because they're kind of, you know, making sure that i'm not going to drop them.

also, you know, you're kind of getting toknow them. also people may be just a little bit anxiousabout the new environment. and so we don't want you to necessarily say,the first time that the person, let's say gets into bed, maybe they've come over ina stretcher. so getting from the stretcher into the bed,that's not an assessment. so this truly is an assessment. allow the person to be as independent as possible. so if you have maybe somebody who is new torehab, and they want to do everything to help the person, you know, make sure that theyknow to let the person be as independent as

possible. i know when i first started working in rehab,i wanted to be nancy nurse, be very, very helpful. i had great mentors who slapped my hand saying,you're not doing them a favor if you help them do everything. that is core rehabilitation. that is absolutely what you should be takinginto account when you're doing the scoring. it really needs to be an assessment whereyou allow the person to be as independent as possible.

so we'll come back to this, and hopefullyyou'll have some questions about this too. but i do want to emphasize this assessmentpiece. we also get questions about who may be allowedto do these assessments. so, there are obviously licensure issues,professional practice. so we basically don't provide informationlike a nurse should do this, an ot should do this, a pt should do this. it is up to your facility to determine whomight be able to gather this information. but obviously, in addition to following facilitypolicy, you would also be following state and federal policies.

so if any of you have sent the question tothe irf qrp help desk about pressure ulcers, who can assess this? is it the doctors, is it the nurse. who overrides who? we have the standard answer, it's based onfacility policy as well as state and federal regulations and policies. so patients again should be allowed to beas independent -- be able to function as independently as possible, as long as they're safe. if helper assistance is required because thepatient's performance is unsafe, or of poor

quality, score according to the amount ofassistance. so, i do actually have an example that's comingup. i think it's from the manual, where the personis -- the patient says, i don't feel safe, you know. i want you to stay with me. so if the nurse or the therapist does staywith the patient, then there is helper supervision. if the therapist or nurse or for whateverreason decides, you know, for whatever reason that they're not needing to be there, then,you know, the patient's anxiety, you know the score would be lowered.

if the clinical judgment was that the persondidn't need to be there, then the score would be that the person was independent. so it's basically, you know, whatever is happeningis what should be scored. but we'll come back to that example in a littlebit. activities may be completed with or withoutan assistive device. use of an assistive device to complete anactivity would not mean that the person has a higher or lower level score. if the patient's self-care performance variesduring the assessment period, report the person's usual status.

and we have in the manual that it's probablynot going to be the most independent episode that happened, or it's not going to be themost dependent episode that happens. and here is a bit more of an explanation ofthat. so, i mentioned before that when a patient'sadmitted they might not know. they're just kind of getting their bearing,figuring out what rehabs all about, who the staff are. so that's probably not a time that the personis really able to function at their baseline assessment. in addition, you're anxious, the patient'sanxious to get rehab started.

and so it may be that on let's say day three,the person's already showing some functional improvement in certain areas. maybe the therapist has given them a devicethat's new. they've taught them how to use it, the person'smastered it pretty quickly. now they're more independent. we don't want to capture therapeutic interventionimprovement within the baseline. so hopefully this makes sense. we're after a baseline assessment. it's before interventions.

it's what the person is presenting as they'rebeing admitted. we absolutely know that it's really toughto get all of these assessment items done within the first day. many people come at what, 4:00-5:00 in theafternoon for you on a friday. i know that's the most popular day for patientsbeing admitted to irfs. so you're probably not going to be able toassess them on many of the activities and get a good feel for them on friday night ormaybe even saturday morning. so we allow three days for the assessment. i know we've had questions that have comein.

so if we score eating every time somebodyeats, is it the mean? is it the mode? is it the whatever? so we really want you clinical judgment aboutthe person's baseline assessment. so you don't need to score every time theperson performs an activity. let's say if a family member comes in, maybeit's a family member who comes in that wants to really help this person, wants to be helpful,and they like feed the person, even though the person could actually do it by themselves. i wouldn't report that as anything that couldbe scored.

because it's not an assessment. the person wasn't allowed to be as independent-- function as independently as possible. so we can come back to this, but hopefullythat provides some clarification. the bottom line is, we're after a baselineassessment. and if that happens to be in therapy, youknow, it maybe that the therapist is the one that's performing the assessment in your setting. and maybe the nurse is more involved in thedischarge assessment. or maybe things are a little bit more consistent. but certainly on admission, there may be alot of variation.

when you're doing education of staff, it'sthe baseline assessment that we're after. so moving onto number six, refers to facility,federal and state policies and procedures to determine which irf staff members can completean assessment. the patient assessments are to be done incompliance with facility, state and federal regulations and requirements. so we'll go through the rating scale. so, if you're looking at the irf-pai it'sat page seven. you have it at the top of your page, it'sthe same rating scale that's used for mobility. so it's also at the top of page eight andpage nine of the irf-pai.

so again, it's completed at admission dischargein terms of performance. and it is a 6-level rating scale, where 6means that the person is independent. and the definition of independent is thatthe patient completes the activity by him or herself with no assistance from a helper. at level 5 the person requires setup or cleanup assistance. and this means that the helper sets up orcleans up the patient. and then the helper is only providing thisassistance prior to or following an activity. so obviously set up before, clean up afterthe fact. level 4 is the patient requires supervision,steadying or touching assistance.

and in this case, the definition is that thehelper provides potentially verbal cueing or touching, or sometimes in the medical recordyou'll see contact guard. and that type of assistance is needed forthe patient to complete the activity safely. i do want to highlight that that level ofassistance, the supervision, or the touching, steadying assistance or contact assistancecould be happening throughout the activity, or it could be that it's only intermittently,occurring during the activity. so it maybe one person gets one cue, and anotherperson gets 50 cues to get dressed in the upper body. they would still both be scored at level four.

at level 3 the person requires partial ormoderate assistance. here the patient -- the helper does less thanhalf of the effort. the helper does less than half of the efforts,they lift, holds or supports the limbs but provides less than half of the effort performthe activity. at level 2, we call this substantial or maximalassistance. here the helper does more than half of theeffort. the helper perhaps lifts or holds the trunk,or limbs and provides more than half of the effort to perform the activity. and then level 1, the person is dependent.

the definition of dependent for this ratingscale is that the helper performs all of the effort. so if the patient does a little bit of effort,they get bumped up to a level 2. the patient does none of the effort at level1. so i'm going back to the definition. patient does none of the effort to completethe activity, or the assistance of two or more helpers is required for the patient tocomplete the activity. in some instances, especially on admission,some of the more challenging mobility items or maybe some of the self-care activity, thepatient may not be able to perform.

and so, we're interested in why the patientwas not able to perform the activity. and there's three different codes to indicatewhy the activity, the patient was not able to perform the activity. code 7 is used if the patient refuses to performthe activity. we did not see this used that often duringthe testing of these items. code 9 is not applicable. and code 88 which is the most commonly usedcode is used when the patient did not perform the activity due to a medical condition orsafety concern. so for example, when we get to the mobilityactivities, we have items related to stairs,

getting in and out of car transfers, karenmentioned that earlier. it may be that it just doesn't make senseto perform those clinical assessments at the time of admission. it's certainly appropriate to just put a codeof that's, 88 just not where the patient is. and as karen mentioned, maybe by dischargeit's an important activity for this patient. so next i'd like to give you kind of the think-throughof how to score based on this rating scale. you can basically just think through thesequestions, it will help you get to the right score. i'll be going through this for self-care,we'll revisit it for mobility.

starting off with self-care the key codingquestions are, one, does the patient need assistance. does the patient need assistance? when i say assistance, i'm referring to physical,verbal, non-verbal cueing, setup and cleanup. all of these things are assistance. does the patient need this assistance, anyof those types of level of assistance to complete the self-care activity that we're trying toscore. so if it's eating, does the person need assistanceto eat? if the answer is, no, the code will be 6 independent.

if the answer is, yes, the person does needassistance, then you go to the next question. does the patient need only set-up or clean-upassistance? if the answer is yes, then you would code5 setup or clean-up assistance. if the answer is, no, you flip over to slide31. and you'll see the next question is, doesthe patient only need verbal or nonverbal cueing or steadying or touching assistance? if the answer is, yes, the code is 4 supervisionor touching assistance. as i said it could be intermittent, it couldbe throughout. there's a range of function that could bepicked up here.

it could be both supervision and contact guardare level 4. if the answer is, no, the person needs morethan that, then the next question is, does the patient need lifting assistance or trunksupport with the helper providing less than half of the effort? if the answer is yes, then that's a code 3partial moderate assistance. if the answer is, no, we'll go over to slide32. and the question here that's next is, doesthe patient need lifting assistance or trunk support with the helper providing more thanhalf of the effort? if the answer is, yes, the code is 2 substantialmaximal assistance.

if the answer is, no, then you go to the lastquestion, which is does the helper provide all of the effort to complete the activity? or is the assistance of two or more helpersrequired to complete the activity? if the answer is, yes, then the code is 1dependent. so, as part of today's training, we'll begoing through examples. i know there are many examples that have comein through our help desk already that are actually great examples. so thank you for those of you who submittedthose. our plan to make sure that we're sharing asmuch as possible is that we will develop either

frequently asked questions, or we will updatemanual pieces in order to provide all of these great examples that have come in. so you know, today's the start, but we really,really do encourage you to contact cms through the irf-prd help desk if you have questions. because if you have the question, probablysomebody at another table, or maybe even at your table may have a similar question. so thank you for submitting those. i do again want to go over the definitionsof these activity not tempted code, just to go in more detail here.

so in the event that a patient does not performan activity, either because, let's say the patient refused, the code is 7. and again this is refusal. i did get one help desk question that's probablyrelevant here. the question that came in was, well, whatif a patient maybe has very poor balance, and they don't want to get up and walk. so they are refusing, but you know, thereare safety concerns? and so, in that instance, it would be clinicaljudgment about whether you think the person truly is refusing, and they should be gettingup.

or you may say, well, in this case, you know,their concern is legitimate. so then you would code it 88 not tempted dueto medical condition or safety concern. so it's really judgment in that instance aboutrefusal as opposed to your judgment that the person has legitimate concerns about safety. so we talked about…..so 9 not applicableis if the patient did not perform the activity we don't expect this to be used that much. but some people did use it when we did testingof these items. so we have left this as a valid code. again 88 is the main reason that you'll becoding this particular area of not tempted.

not tempted means that the activity was notattempted due to the person's medical condition or a safety concern. for example, if somebody has experienced aspinal cord injury or a stroke or a back injury and is not about to walk at this point intime, maybe you are indicating a code of 88 to say this person is unable to walk. so we have some coding tips. again based on our experience through thetesting and some of the questions that have come in over time. so the first one is when we're viewing themedical record, interviewing staff and observing

the patient, be familiar with the definitionof each activity. so we'll be going over the definitions today. on the admission assessment code the person'susual performance using the 6-point scale, or one of the three not attempted codes, that's7, 9, and 88. so, on the admission assessment, you'll alsobe reporting a goal. so we will get to that right before the breakor after the break. but basically, when setting goals, it didn'treally kind of make sense to say that the goal was that the patient would refuse todo an activity. so that's not a viable code for goals.

(laughter) actually you can only code 1-6,of the person, when you're coding goals. so it maybe that the goal is for the personto maybe be independent with eating by the time the patient is discharged. so that would be a 6 for eating. so none of the activity not attempted codescan be used as a goal. you can't refuse as a goal. you can't say 88 is a goal and that the person'smedically unable. if the person is not expected to be able todo an activity, you would code a 1 it would be dependent for that particular area.

so we'll talk about that probably after break. on discharge, you use the same 6-point scalethat you used on admission. and of course you can still use the activitynot attempted scores for discharge. because it may be in some instances somebodyis again still very limited in their mobility activities. and so perhaps they cannot go into and outof a car at this point, and so, a code of 88 might still be the appropriate code forthat person at discharge. so the next coding tips, when reviewing themedical records, interviewing staff or observing the patient -- sorry.

we did that one already. so on the next slide, do not record the patient'sbest performance and their worst performance, but rather report the person's usual performanceduring the assessment period. we talked about that a little bit already. do not record the patient's assessment ofthe patient's potential capability to perform the activity. so, yeah. we had a car in here, they actually wouldbe able to get in and out, i think we'll code them such-and-such.

the activity does need to be performed. i've had a question come in about, if there'snot, you know a practice car in the facility, can you use easy street, yes. you can also take somebody out to the parkinglot, transfer in and out of their car; that certainly is very acceptable. so you don't need a car in your facility. but if the person didn't -- that was not assessed,then you would need to make a judgment about why it wasn't done. the patient refused, is it not safe at thispoint and time for the person to perform the

activity, and that would be coded 88. if two or more helpers are required to assistthe patient to complete the activity, code 1 dependent. one of the questions that has come in aboutthis particular issue that i thought was a really good one to mention today is, if thepatient's able to do some of the effort, so you want to give them credit for that, butyou still need two people. so maybe one person is providing some -- theperson's got a gait belt, maybe somebody's providing some trunk support as part of thatperson walking, but you're very concerned about their safety and fall risk.

so maybe somebody else is following with awheelchair just to be sure, so if there's two people required, it's going to be a 1. so when i said before, the person does a littlebit of effort they're going to be bumped up to a level 2, the exemption to that is there'stwo or more helpers required there will be a level 1 that kind of overrides. if the patient does not attempt the activityand the helper does not complete the activity for the patient, code the reason the activitywas not attempted. so we have had several questions on the helpdesk too about the 88 versus code 1. so if the activity is done, and it's doneby the helper, it's a level 1.

if the activity is not done, so stairs, orcar transfers, activity not attempted would be coded 88. finally, on the coding tips to clarify yourunderstanding of the patient's performing of an activity, ask probing questions of staffabout the patient beginning with the general and proceeding with more specific. so we're certainly aware that you will becollecting information perhaps from other staff to get an idea of the person's baselinefunctional status on admission. and also their discharge assessment will probablyrequire, you know, to what extent is this individual patient consistently performing,let's say the activity of eating?

and so when you're asking questions, you wouldbe able to ask questions of perhaps you have some nursing assistant who are actually helpingsomebody with bathing. and so you would be asking that individual,you know, what was the patient able to do, what did you help in? again the underlying important question, firstand foremost is, was the patient allowed to be as independent as possible? so was it an assessment? if the person, again family member, is justhelping the person, that doesn't count as an assessment.

okay, so i talked about the dash, here weare. so for those of you who are familiar withthe irf-pai and the quality reporting program, you are probably aware that a dash can beentered into most of the items. if you try and submit an irf-pai record andyou leave items blank in the quality indicator section, it will get rejected, because wewant to be sure that we have information on each of the items. and so if you do not have information, youwould be entering a dash. so cms in general expects dash use to be rarefor the most part. i will talk about goals in just a minute,because there are some special circumstances

with entering goals that i want to be clearabout. so, do not use a dash for the self-care ormobility item if the activity was not assessed because the patient refused. if the patient refused, put in 7. if the item or activity was not applicable,enter code 9. if the activity was not attempted due to medicalcondition or safety concern code 88. do not enter a dash. to say you don't have the information. code those activity not attempted.

as i said before, use of dashes for qualityitems may result in a payment reduction as part of the quality reporting program. be cautious about using dashes in general. we've tried to give you codes that you cancode things other than dash. hence my emphasis on the prior functioningand the code unknown. because you did attempt to get the information,we want to give you credit that you tried to get the information. so i do want to speak a little bit about goals. so stacy did put up the quality measures before.

and i wanted to highlight that there are actuallyfive functional assessments related quality measures that were adopted for the irf qualityreporting program. so four of those quality measures are focusedon functional improvements in the area of self-care mobility. so there's one measure in qf 2633 which isfocused on improvement in self-care. it's actually called change in self-care. there's a second measure in qf 2634 whichlooks at change in mobility or improvement in mobility for the patients. the third measure focuses on self-care, andthis instance we're looking at the percent

of patients who need or exceed a nationalbenchmark by discharge. that's based on the discharge self-care score. and then there's an analogous mobility percentof patients who meet or exceed the mobility discharge score. the fifth measure is a process measure. it is an application of nqf 2631. and for this particular measure it requiresthat a functional assessment data were collected for patients on admission and discharge, andthat function was included in the patient's care plan.

and the way that you are documenting thatfunctioning is part of the patient's care plan is by documenting at least one self-careor mobility goal. you are more than welcome and we would lovefor you to report goals in areas where there are care plans. so if somebody is expected to let's say improvein eating and oral hygiene and dressing the upper and lower body and footwear, pleasedo report goals. it can be very useful for internal qualityimprovements. in terms of the irf quality reporting program,the requirement is that you submit at least one goal covering self-care or mobility.

so if you put one goal for self-care you'recovered. if you put one goal for mobility you're covered. if you put one goal for self-care and mobilityyou're more than covered. and if you have questions, please submit them. so because you cannot enter or you cannotsubmit an irf-pai without every item, every quality indicator item filled in, if you decidenot to report a goal, let's say for eating, so you're going to report let's say a dressinggoal, you decide not to report a eating goal, you can enter a dash as a goal. and that, you're still meeting the requirementof the irf quality reporting program if you

have at least one goal entered. but dashes are allowed in this instance. but you're still meeting the requirement. so if you have questions, write them downso that i can address it. just to reinforce one more time. if the patient has goals related to multipleself-care or mobility items, we would love for you to report goals. you can use it for your own quality improvementefforts. i know that some people do that as part asfor example, carf accreditation.

but for the quality reporting program, themonitoring will be to make sure you're providing at least one goal. okay so now we'll move into detail on theself-care activities. and we'll start off of course with eatingwhich is gg0130a. so eating. and if you're looking at your irf-pai, takingnotes, this is on page seven right in the middle of your page. and we will talk first of all about the firstcolumn, which is the admission performance. we'll cover the setting goals right beforethe break or right after the break.

so eating is defined as the ability to usesuitable utensils to bring food to the mouth and swallow food once the meal is presentedon a table or tray. it does include modified food consistency. so we have some coding scenarios, and thiswill reinforce some of the definitions issues, and some of perhaps the documentation thatyou would be looking for in order to accurately score this item. so in this particular example, ms. s has multiplesclerosis affecting her endurance and strength. ms. s prefers to feed herself as much as capable. after eating three fourths of her meal byherself, ms. s usually becomes extremely fatigued

and requests assistance from the certifiednursing assistant to feed her the remainder of her meal. in this instance perhaps you're getting informationfrom the certified nursing assistant. but obviously in this instance it looks likethe certified nursing assistant did allow the person to be as independent as possible. it looks like this might be an admission assessmentpossibly. how would you code gg0130a, and what is yourrationale? that's correct. so, in this particular example, eating wouldbe coded as 3 partial/moderate assistance.

the rationale is that the certified nursingassistant provided less than half of the effort for the patient to complete the activity ofeating. i do want to highlight that if somebody doesnot eat by mouth, they will not be coded on the eating item. you have to eat by mouth in order to be coded. if the person is only on g-tube feedings,you would code the eating activity does not occur because of safety concerns. so it's the swallowing problem or somethingelse, they're not eating by mouth, they're getting food alternatively perhaps througha g-tube you would say the activity of eating

does not -- did not occur. one point of clarification, this has comeup through the help desk. if somebody is on g-tube feedings plus theireating by mouth, would you code eating? the answer is, yes. so basically, you would only say that theactivity of eating didn't happen if they are solely getting nutrition and fluids throughan alternative means. another question that comes up is does thisinclude drinking liquids, and the answer is, yes. so if someone requires supervision or maybesome cueing because they have a swallowing

problem, whether it's related to actuallyfood or liquids, that would be supervision and that would be coded a 4 for supervision. so it is food and liquid. so, we have another example here, and i kindof gave you the answer anyway. mr. r is unable to meet by mouth due to hismedical condition. maybe he's got a swallowing problem, he'sexperienced a stroke. he receives nutrition through gastrostomytube which is administered by the nurses. so you get to tell me the answer. and so, again, if you can pull out your pollingdevices.

so again, two people from each table willbe able to score this. and the options that you have for this gentlemenwho is on g-tube feedings is code 1 dependent you press a for that. you could code 2 substantial/maximal assistance;that would be a b. if you think 9 not applicable that would bea c. and if you code 8 not attempted due to medical condition or safety concern; thatwould be a d. all right, 98% of you got that correct. the correct response is 8 not attempted dueto medical condition or safety concern. so again, he was not eating anything by mouth.

so it wasn't safe for him to eat. i do want to mention, i don't think i mentionedthis earlier. if you press the wrong button, you can actuallypress again, and your first answer will be canceled and your new answer, which of coursewill be the right one will be accepted. (laughter). if you press the wrong one by mistake justpress it again. that's the kind of thing i would do. so we'll move onto the next example. so we put some of these as polling, and someof them, you know, we're just going through

the answers together, so we'll just kind ofgive you a little bit of variety. so, the next practice coding scenario -- sorry. that was actually the rationale. apologize. we talked about the rationale already. so coding tips again, just to reinforce, eatingis eating and drinking by mouth. do not code tube feeding administration ifthat's the only thing the person has. next is oral hygiene, gg0130b. so in this instance, oral hygiene, i willread the definition, if you're looking at

your irf-pai this is on page seven. it includes the ability to use suitable itemsto clean teeth, dentures if applicable, the ability to remove and replace dentures fromand to the mouth, and manage equipment for soaking and rinsing them. so again, you're familiar with the ratingscale. if you want to reference back as we're goingthrough coding scenarios just look at the top of page seven on the irf-pai. so in this coding scenario ms. t is recoveringfrom a severe traumatic brain injury and multiple bone fracture.

she may have been in a motor vehicle accident. she does not understand how to use oral hygieneitem, nor does she understand the process of completing oral hygiene. we have a wonderful certified nursing assistantwho understands the rehab process and allows and she ends up, because the person is notable to do it, she brushes her teeth and as part of it she explains to the patient eachstep of the activity to engage cooperation from the patient and his teeth. however ms. t requires total assistance forthe activity of oral hygiene. how would you code gg0130b which is oral hygiene,and what is your rationale?

level 1. how many of you got that right? great. so in this case, and this is slide 49. oral hygiene would be coded 01 dependent. the rationale is that the helper providesall the effort. we had a great certified nursing assistantwho was explaining stuff, but the certified nursing assistant did do all of the activity. so we have another example for oral hygiene.

so in this case, mr. w does not have any teeth. his dentures no longer fit his gums. so, oral hygiene obviously still is important,given for somebody who does not have teeth. and so mr. w begins to brush his upper gumsafter the helper applies toothpaste onto his toothbrush. he brushes his upper gums but cannot finishdue to fatigue. the helper completes the activity of brushinghis back upper gums and then does the entire lower gums. so you, i heard a lot of answers that soundedgood.

so i will give you the opportunity to scorethis. so if you think the answer is 4 supervisionor touching assistance, enter a. if you believe the answer is 3 code b. if you believe the answer is 2 code c. andif you think the answer is 1 code d. you ready? 86% coded 2. that is correct. so just to be clear on that particular answer,he gets coded 2 because the patient was able to do the front -- i guess part of his uppergums. but the helper did the other side and thenthe entire lower gums.

so, maybe that wasn't clear in the example. and that maybe threw people off a little bit. but i would say that's over half of the effort. that's why the helper assistance was substantial/maximalassistance and coded level 2. next we'll move to toileting hygiene, thisis gg0130c. so toileting hygiene, if you're looking atirf-pai. that's defined as the ability to maintainperineal hygiene, adjust clothes before and after using the toilet, commode, bedpan orurinal. if managing ostomy includes wiping the openingbut not managing equiptment.

so we have an example here. so mrs. j uses a bedside commode. the certified nursing assistant provides steadying,touching or maybe you call it contact guard assistance as mrs. j pulls down her underwearbefore sitting down on the toilet. when mrs. j finishes voiding or having a bowelmovement the certified nursing assistant provides steadying assistance, as mrs. j wipes herperineal area and pulls up her underwear without just to recap. mrs. j pulls down her underwear. and then the certified nurse assistant isproviding steadying assistance.

mrs. j wipes herself, her perineal area andpulls up her underwear without assistance. so how would you code that particular item? i heard a lot of 4s. so in this instance, it was steadying assistancethat was provided. so toileting hygiene would be coded or supervisionor touching assistance. and the rationale is that the helper is providingsteadying assistance. okay we have another example and the goodexamples do tend to be a little bit longer because they're more complex. so, i'll take this a little bit slow to makesure we digest the information.

ms. q has a progressive neurological diseasethat affects her fine gross motor coordination balance and activity. she wears a hospital gown and underwear duringthe day. maybe this is friday night admission, it'ssaturday morning she hasn't gotten into physical therapy yet. ms. q uses a bedside commode, she steadiesherself with one hand and tries pulling down her underwear with the other hand, but needsassistance from the helper to complete the activity. she got started so she'll get credit for atleast doing a little bit of the effort here.

but it looks like it's a nursing assistantwho is actually helping to pull down her underwear. 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 the anal hygiene. ms. q is too fatigued at this point, and requestsfull assistance to pull up her underwear. so she did a little bit in terms of pullingdown her underwear. but the aide did help. when she voided she was able to do that wipingon her own. but the nurse’s aide does have to do perianalhygiene, and the other thing is that the nurse’s aide had to do the pulling up of the underwear.

so this one is a little bit tougher. the options are, a; that the score is 4, supervisionor touching assistance. b would be level 3 partial/moderate. c would be substantial/maximal assistance. and d would be dependent code 1. do you need a minute? so 88% put a code of 2. i agree. so, excellent.

so the rationale is that the helper providedmore than half of the effort in this case because the patient just pulled a little bitof her underwear down. the helper did that. the helper completely pulled up her underwearafter the hygiene. and then some of the hygiene was done by thepatient and some of it was done by the helper. so overall we felt that that was half of theeffort. okay so next we're going to move to showerand bathing self. so just to read the definition. the ability to bathe self and shower or tubincluding washing, rinsing or drying of self.

does not include transfer into and out ofthe tub or shower. i will give you a warning, we have some ofour examples getting in and out of the tub is included. we're trying to trick you. so don't get tricked. (laughter) i'm giving you a warning. so it is just washing the body. in the definition we do talk about gettinginto the tub or shower because that often is what the goal is, that the person wouldbe able to do that at home.

but you can assess washing, rinsing and dryingif somebody's doing a bed bath, or if they're doing it at the sink. i know that's a question that's come in. so it is washing the entire body. so we have a coding scenario here. mr. j sits on a tub bench after he washes,rinses and dries himself. the certified nursing assistant stays withhim to ensure his safety as mr. j has had instances of losing his sitting balance. so maybe when he's trying to wash his feethe leans a little bit too much forward.

so there's somebody there to keep an eye onhim for safety. the certified nursing assistant provides liftingassistance as mr. j gets into and out of the tub bench. 4. so remember i told you i was going to trickyou. so that last bullet is actually not relevant. we actually don't code getting in and outof the tub. so it's just washing, rinsing and drying thebody. so, i did hear a lot of 4s.

so that's great. you did not get tricked by me. in this particular instance the helper isjust providing supervision assistance. and again, the transfer into and out of thetub or shower is not considered when coding okay, another kind of long scenario. so we'll talk through this a little bit slowlyand in chunks. so ms. e has had several progressive neurologicconditions, has a progressive neurologic condition that has affected her endurance as well asher fine and gross motor skills. she is transferred to the tub or shower withpartial or moderate assistance.

when showering she uses a wash mitt that wasprovided by the acute care facility prior to the admission to the rehabilitation facility. so she probably had ot services while in acutecare. ms. e showers while sitting on the tub benchand washes her arms and chest. the certified nursing assistant must thenhelp her wash with her remaining body, parts of her body due to fatigue. ms. e uses a long handed shower to rinse herself,but tires halfway through the task, so the certified nursing assistant dries ms. e'sentire body. so just to recap in this instance, ms. e washesher arms and her chest.

she does some of the rinsing. and the helper is washing quite a few of herbody parts, and helping with the entire drying and helping with some of the rinsing, abouthalfway through. so here's an opportunity for you again todo some scoring. so if you pass the gadget around. so everybody needs to take a turn. so if you think the correct answer is 4 pressa. if you think the correct answer is 3 code b. if you think the correct answer is 2 codec. and if you think the correct answer is

1 code d. okay. are you done? excellent. so, looks like 93% coded c which is 2. and that is the correct response, excellent. so the rationale is that the helper assistsms. e with more than half of the upper related to bathing/shower, and that includes againthe bathing, rinsing and drying, and hopefully you didn't get distracted by the tub/showertransfer. next i want to talk about upper body dressing.

but i just want to check, mark do i keep going? my timer is almost up? we'll go through quarter past. so we'll stay on schedule. fine, okay. great, sorry. i'm getting signaled i have less than a minute. so i just wanted to be sure i didn't causeproblems. so, with this particular -- thank you whoever'supdating that.

so we're going to move to self-care upperbody dressing now. so for upper body dressing, this is definedas the ability to put on and remove a shirt or pajama top. it includes buttoning if applicable for thatpatient. we have some coding scenarios here. so mr. k had a spinal cord injury that asaffected both movement and strength in both upper extremities. he places his left hand into one-third ofhis sleeve. so he does attempt to do some of the effort.

but that takes a lot of time and effort. and he's unable to continue with the activitybecause it's maybe frustrating for him. maybe this is just an admission assessment. so this is kind of early on. the certified nursing assistant then completesthe remaining upper body dressing for mr. k. so if he's just wearing a shirt and he's juststarting to thread, how would you code the activity gg0130f? and what is your rationale?

answer is 2. so the rationale is that the patient can performsome of the effort, a small amount of the and so, he will get credit for that. so he is not dependent. he is a code 2 substantial/maximal assistance. so you know, in the cases where you have thepatient who maybe is admitted dependent on a activity and makes some progress towardslet's say bed mobility or upper body dressing, they will be able to get a higher score bydischarge. so we have another example of upper body dressing.

so in this case, mrs. y has right-sided upperbody weakness as a result of a stroke that she experienced. she has worked in therapy to relearn how todress her upper body. so this is probably a discharge assessment. during the day she only requires a certifiednursing assistant to place her clothing next to her bedside. mrs. y can now use compensatory strategiesto put on her bra and top without any assistance. at night she removes her top and bra independentlyand puts the clothes on the nightstand and the certified nursing assistant puts themaway on the dresser.

okay so the certified nursing assistant isputting clothing within reach for her. so that would be setup assistance. and also the certified nursing assistant isputting them away. that's on the clean up side, so what do youthink? 5. i do want to highlight. because i do see this in medical records alot. so in the last bullet you see that it says"at night she removes her top and bra independently". so, if somebody needs setup they're actuallynot independent.

but i know i do see this a lot in medicalrecords. nobody fell for that one, so that's good. but probably, you know, it should be clearin medical records in this case that it was setup assistance, the person was not independent. because independent implies that the personcan do the setup and the cleanup for themselves. so you can go ahead and press -- so you cango ahead and press your button. you did give the answer. but just to reinforce. give you a minute here.

see we didn't put the independent answer. but hopefully nobody does that. okay, great. so 98%. probably 1 person maybe pressed the wrongbutton. so it is set up or clean up assistance. (laughter) okay. we have another example here. i'm sorry, this is the rationale.

so setup we already kind of talked throughthis. okay, so now we're going to move to lowerbody dressing. so, with lower body dressing, the definitionof lower body dressing is the ability to dress and undress below the waist, including fasteners,but does not include footwear. so as you may -- footwear. as you may remember when i went through thelist of self-care activities, there is actually a separate item for footwear. so the lower body dressing would include thingslike underwear, pants, belt, if somebody wears a belt, or sweat pants if somebody uses sweatpants, skirt, things like that.

but you do not include footwear. no socks, no afo's, no shoes. so we have the coding scenario here. mrs. z requires supervision while standingto pull up her underpants and pants due to balance problems. mrs. z has a history of falls and has toldher nurse she is worried about falls due to how would you code gg0130g, which is lowerbody dressing? okay, that's correct. so in this instance the helper provides supervisiondue to safety concerns.

you're right, that is a level 4. okay we have another coding scenario here,a little bit more complicated. mr. b was admitted to rehabilitation followinga total hip replacement. he's over 85, and he is obese. during the acute hospital stay, mr. b wasunable to use adaptive equipment for dressing due to severe arthritis in his hands. mr. b cannot independently thread into hispants or underwear unto his feet due to hip precautions. once the helper begins to thread his pantsand underwear, mr. b pulls them up to his

knees, stands and pulls them up around hiship and adjust the clothing. the helper zips up his pants. the helper puts on his socks and shoes. do not be distracted by socks and shoes, right. ignore that. so you have a minute to code that. the options are 6 independent, 5 setup orcleanup assistance, 4 supervision touching assistance, c partial/moderate 3. so it looks like we may get a distributionhere of scores.

so 92% of you coded 3 which is the correctresponse, partial/moderate. so very good. so in this instance the rationale is thatthe helper provides assistance with threading mr. b's feet into his underwear or pants andzipping his pants. mr. b performs the remaining lower body dressingtasks for this activity, putting on and taking off slacks and shoes is not included in thisitem. again we're going to be covering that itemnext. there's a whole separate item for that particulararea. the helper performs less than half of theeffort to complete the lower body dressing.

so coding tips, again, socks and shoes aregoing to be coded under footwear. so moving to footwear. we have about five minutes left. so putting on taking off footwear includesthe ability to put on and take off socks and shoes or other footwear that is appropriatefor safe mobility. mrs. f was admitted to rehabilitation fora neurological condition and experiences visual impairments, fine motor coordination and enduranceissues. she requires setup for retrieving her socksand shoes which she prefers to keep in her closet.

mrs. f often drops the socks and shoes asshe attempts to put them on her feet or as she takes them off. often the certified nursing assistant threadsher socks and shoes over her toes then mrs. f can complete the task. she basically puts her foot right into thesocks. so she's doing some of the effort, and thenalso she's actually putting on her shoes. mrs. f needs the certified nursing assistantto initiate taking off of socks and unstrapping the velcro used on her shoes. how would you code this item and what is yourrationale?

okay, this particular item is coded 3 partial/moderatefor this example. the helper provides assistance with initiatingputting on, taking off ms. f's footwear due to her limitations. but mrs. f is doing a fair bit of the upper. so, the helper, i hope that was clear in theexample, the helper was just kind of getting things started. so that was the rationale, okay. i think we will do this, just so that we cankind of wrap up this section. but i know we're going to take a break veryshortly.

mr. m is undergoing rehabilitation for right-sideupper body and lower body weakness he experienced from a stroke. mr. m has made significant progress towardsthe independence and will be discharged home. this is a discharge assessment. mr. m wears ankle foot orthosis that he putson his foot and ankle after he puts on his socks, but before he puts on his shoes. i want did to mention that if someone usessome sort of prosthetic or orthosis, that is considered like a piece of clothing. so, it's not setup.

it would actually be considered as part ofthe effort. so, in this case, he wears it and he putsit on his foot or ankle by himself. so, he's already doing some effort there. he always places his afo socks and shoes withineasy reach of his bed. while sitting on the bed he needs to bendover to take on and off his afo socks and shoes and occasionally loses his sitting balancerequiring touching or steadying assistance for performing any of these tasks within theactivity. so somebody is there. how would you code it?

so the options are 5, setup or cleanup assistance,which would be a. code 4, supervision or touching assistance which would be coded b. partial/moderateassistance which would be coded a c on your gadget. and 2 would be, you press d. okay. it looks like a fair number of people haveput in. it looks like 95% coded b which is 4 whichis the correct response. that's excellent. the rationale is that basically, mr. m putson and takes off his socks, afo shoes by himself. however, because of occasional loss of balance,which is very common with somebody with his

condition, needs help in terms of touchingassistance for bending over. >>>> so, discharge goals. so if you are looking at the irf-pai, thepage that you should focus on this point is page seven. the first column has the admission performancewe talked about. and for for each of the activities that arelisted in the self-care area there is a space in order for you to be able to report a dischargegoal. so we'll be talking about that next. so i'm going to spend quite a bit of timetalking about goals now.

what i'm describing to you apllies to bothself-care and mobility. so i’ll speak generally about it. there are some examples to help you thinkthrough it. when we get to mobility, i'll touch on itagain. but this is really the main time that i willfocus on goals. this slide just shows you that we're focusedon the second column. i just want to kind of reinforce that forgoals, as i stated earlier, we use the 6-points rating scale to code the patient's dischargegoals. do not use code 7, 9, or 88 to code dischargegoals.

as i mentioned earlier, if you choose notto report one or more goals, enter a dash. because the irf-pai submitted with blank spaceswill get rejected. so with regard to goals, this is somethingthat's very commonly done in rehabilitation. and it needs to be a licensed clinician thatestablishes a patient's discharge goals based on several factors. this is completed on the admission assessmentonly. so when setting goals, certainly there arelots of pieces of information that you might take into account. but some of that may include the admissionassessment.

so when you're writing up a care plan youwould take into account thinking about interventions and thinking what about the patient's functionalstatus maybe in the self-care activities by discharge. you take into account obviously the admissionassessment that is happening, discussions with the patient's family. obviously this is important that the patientand the family are on board with whatever the goals may be. and sometimes that's challenging. certainly in some instances, the patient maywant to walk, and maybe that's just not perhaps

feasible by discharge. and so it will be potentially some discussionswith family and the patient, and may take a fair bit of time. in some instances it may be easier. professional judgment and professional standardof practice may be used when setting goals. i do want to highlight that the process measure,the quality measure, which is the application of 2631, which is related to completing thefunctional assessment and reporting at least one goal, cms is at this point, as part ofthe quality reporting program is looking to see if that information is recorded.

they are not calculating as part of that measure,they're not calculating the percent of patients who meet or exceed goals. but that's certainly something that you cando. and it's certainly something that's commonlydone in an inpatient rehabilitation facility. so again just reinforcement goals should beestablished as part of the patient's care plan. so, in inpatient rehabilitation, in general,patients are expected to improve in function. certainly, there are instances where thereare patients who may be admitted and let's say the self-care items may not be in thearea where functional improvement is expected.

so perhaps somebody is admitted, they havelocked-in syndrome. perhaps there is a lot of communication therapy,speech language pathology or helping the person to provide interventions so the person cancommunicate with them and their family. and so, perhaps the items that we're talkingabout today, eating, may not be expected to improve. but in many cases, these are the items wherepatient improvement are expected in inpatient rehabilitation. so i will be going over examples and talkingthrough function functional improvement examples. i want to highlight that maintenance in somecases, where it may be appropriate when you

might be reporting. i just want to assure you that that’s acceptable. in some cases you may have a patient thathas a lot of mobility issues. let's say somebody doesn't have a problemwith eating. maybe eating tends to be the easiest itemfor a lot of people, unless they have swallowing problems. so it maybe that eating is independent onadmission. and if you are writing a goal for eating. maybe the goal is to maintain 6 to be independent.

that's certainly acceptable. you may have some items where functional improvementis a goal and some items where maintenance is a goal. so again lots options that may be reportedhere. so the first example i wanted to talk through,which is relevant for irf is that the goal is that the person will be improving on theactivities that are being assessed in the self-care or mobility areas. so, the code reported on the patient's dischargegoal in this case would be higher than patient's admission.

because we have an independent scale wherehigher scores indicate more independence. so in this example mr. m stated that he prefersto bathe himself rather than depending on helpers or his wife to perform this activity. so there's communication with the patientin terms of their expectations. so on admission anyone assessing -- the clinicianassesses mr. m's performance to shower and bathe himself. the clinician codes mr. m's admission performanceas 2 substantial/maximal assistance because the helper performs more than half of theeffort. the patient expresses a wish to improve hisfunctioning in this area.

so the clinician reflects upon the patient'sprior self-care functioning, current multiple diagnoses, the treatments that are expectedto be provided during the irf stay, the patient's motivation to improve, the patient's anticipatedlength of stay, and the patient's medical prognosis, and you know, other things. but those are obviously some things that arerelevant. the clinician discusses discharge goals withthe patient and family, they anticipate that by discharge mr. m will require a helper todo less than half of the effort for assisting to complete this activity. so in this case the patient started at a 2and the goal is the patient improves to be

a level 3 partial/moderate. so that's one example. another example, and this is one where forwhatever reason the goal is to maintain function for this particular area. and so, the discharge goal in this case, amedically complex patient who is not expected to progress to a higher level of functioningduring the irf stay for a particular activity, the clinician determines that the patientwould be able to maintain his or her admission or functional performance level. the clinician discusses the functional goalswith the patient and family and they agree

that maintaining function for a specific activityis a reasonable goal. in this example the discharge goal would becoded the same as the admission performance in other words, column one and column twowould be the same. so, on admission, ms. e has stated her preferencefor participation twice daily in her oral hygiene activity. ms. e has severe arthritis, parkinson's diseaseand diabetes neuropathy and renal failure. these conditions result in multiple impairments,that is, limited endurance, weak grasp, slow movement and tremors. the clinician observes ms. e's admission performanceand discusses her usual performance with clinician,

caregivers and family to determine the necessaryinterventions for skill therapy; that is positions of an adaptive toothbrush cup, verbal cue,lifting and supporting ms. e's limb. the clinician codes ms. e's admission performanceas level 2 substantial/maximal assistance. the helper does more than half of the effortin this instance and that's the rationale for a code of 2. so by discharge, due to ms. e's progressiveand degenerative condition, the clinician and patient feel that while ms. e is not expectedto maintain improved status in the area of oral hygiene performance, maintaining functioningin this instance is desirable and achievable as it a discharge goal.

the clinician would then, report 2 substantial/maximalassistance as the goal. so again the admission performance is a 2and the goal for discharge is a 2. okay, so again if you have questions, we wouldappreciate if you fill out the cards. please make sure you put your name and emailaddress so that if we don't get to it during this session today or tomorrow that we cancontact you. the next section that we're going to moveto is section gg0170 mobility. again we have a 3-day assessment period. and these items, if you are looking at theirf-pai and if you're writing notes on the irf-pai, it's going to be on page eight aswell as page nine.

i do want to highlight that on pages eightand nine we do have a third column. and i wanted to explain the rationale forthat so that when we get to that section you'll be ready for why it's formatted the way itis. the first column is similar to self-care inthat we would like you to report the patient's admission -- the admission or discharge performance. the second column is on the admission formand relates to the discharge goal for mobility. and then the third column on the admissionasks specific questions that we consider basically gateway questions. so in order to minimize the burden we havebasically screening questions asking if the

patient is walking. and then also on the second page, asking ifthe person is in a wheelchair. so if the person is not walking, then thatallows you to skip all the walking and stairs items. if the person is not using a wheelchair, youcan skip over the wheelchair items. so in this instance, you're not leaving theitems blank. you can still submit the irf-pai. it's just basically if you code that the personis not using a wheelchair, the computer knows to insert a special code so that there isa code being submitted on your behalf there.

so it's a skip. it's not -- on paper it might appear its leftblank but in the it system it will be recoded to a special code. so i just wanted to be sure i highlightedthat now because on that third column on admission, you're not coding 1-6 like the rest of them. so just to kind of recap codes, in the firstcolumn you can code 1-6 plus the activity not attempted. in the second column, you can code 1-6 asgoals. and in the third column there's the specialscreening questions, they have specific codes.

we'll get to that when we talk about walkingand wheelchair. so, i mentioned screening questions in theinstance of wheelchair mobility. we also have follow-up questions. so in some instances, it may be that a personwho is going to be going home mobilizing using a wheelchair, they may use both a motorizedwheelchair for longer distances, and perhaps a manual chair for shorter distances. so we ask you after the two wheelchair itemswhat type of wheelchair the person uses or if they used a scooter. so we will cover that when we get to thatsection.

so the rationale for the mobility items, obviouslyvery similar to what you heard earlier today in terms of self-care. and that many patients, essentially all patientsadmitted to a irf, would have mobility limitations. and a patient who has mobility limitationsis at risk for further decline in function if they're not physically active. so obviously patients are getting, very oftengetting intensive rehabilitation in the rehabilitation -- inpatient rehab setting. that's for assessment, similar to what wecovered before. so the assessment can be based on direct observation,it can be based on patient self-report.

it could be based on reports from other caregivers,including clinicians, care staff, family or something that's documented in the medicalrecord during the 3-day assessment period. i know a couple of people came up during thebreak and were asking me about the role of certified nursing assistants? they're not permitted to do assessments. but you as the rn or pt or ot obviously cando assessments. but you can use information or facts thatthey provide to you, but as i stated earlier, it's really important that the -- whetherit's a family member or an aide whatever, who’s reporting to you about how the persondid with walking or how they did with bathing,

it's important that you determine whethera true assessment was done. and this is particularly important in areaslike wheelchair. so i'll bring that up just as a quick example. because this really -- i think this is a goodexample. so, if you gave me a wheelchair in a hospitalthat was not built for me and is just the hospitals like "can't maneuver" i would bedependent on a wheelchair. that really doesn't reflect my functionalstatus. because that's not what i'm -- not being workedon. so just coding me and putting me in a wheelchair,pushing me down the hall and coding me at

a level 1 is not an assessment. and it's not relevant for me at this point. so that wouldn't count. if you're using wheelchair to take patientsto therapy, we're not interested in having that being reported. if the person has experienced a stroke orperhaps a spinal cord injury and is learning how to use the wheelchair. and when they're being discharged they'remaneuvering, and they have learned how to, whatever type of wheelchair it is, they'vemaneuvered a joy stick or whatever, that is

what should be considered an assessment forwheelchair. so i think sometimes there's been a lot ofeffort to report every time something happens. and it's not all based on assessment. so again, assessment is critically important. and i think i gave this example before. if a family member comes in and absolutelydoes everything for the patient, then you know, that's not helpful information to knowthe person's functional status. you have a family member who wants to helpa lot. so you would use your professional judgmentto say okay, i'm going to base it on what

the pt said the person was able to do or thespeech language pathologist, let's say if it was eating, or a nurse. so again, this reinforcement, allows the personto be as independent as possible but keep them safe, obviously. helper assistance is required potentiallybecause of poor or unsafe quality. so this particularly is relevant with walking. so if somebody is very unsteady and you know,maybe you think they should have supervision, but they kind of wobble a little bit. so there's touching assistance to happen.

the score would go down based on that to alevel 4 for the touching assistance. activities may be completed with or withouta device. so we don't differentiate a difference becauseof the device used. you just code if the person needs help andthey may or may not use a device. use of devices to complete an activity thatwould not affect the care. if a person's mobility performance variesduring the assessment period, report the patient's usual status, not the patient's most dependentperformance, not the patient's most independent or dependent episode. again refer to facility, federal and statepolicies and procedures to determine which

irf staff members may complete an assessment. the rating scale we described in detail before. so again, there will be some reinforcementas we go through the items. you code again, the usual performance with6 being independent, 5 being setup or cleanup assistance, 4 being supervision or touchingassistance. 3 being partial/moderate assistance, 2 beingsubstantial/maximal assistance and 1 for dependent. again the codes that can be used for the assessmentat admission discharge include these codes that the activity was not attempted. 7 being used when the patient refuses to performan activity.

9 when the patient is doing an activity that'snot applicable or the patient's not doing an activity because it's not applicable. and then code 88 if the patient did not attemptan activity due to medical condition or safety concerns. again, during our testing, we saw a lot ofthe harder mobility items like walking on uneven surfaces, car transfers, picking upan object from a standing position, often not done on admission. those are mobility items and will be coded88 on admission in many instances. and that's perfectly acceptable.

so the coding questions, just to go throughkind of the logic to help you think through this. and the assistance could be verbal, physical,non-verbal cueing, setup, and cleanup assistance to complete the mobility activity. so maybe it's getting from a sitting to alying position. so does the person need any kind of help froma helper? if the answer is, no, the code would be 6independent. if the answer is yes, you would ask the nextquestion which is does the patient need only setup or cleanup assistance?

if the answer is yes, you code 5 setup orcleanup assistance. if the answer is no you will go to slide 107,does the patient need only verbal/non-verbal cueing or steadying, touching assistance? if the answer is yes, you code 4 supervisionor touching assistance. if the answer is no you go down to the nextquestion, which is does the question need lifting assistance or trunk support with ahelper providing less than half of the effort? if the answer is yes, you code 3 partial/moderateassistance. if the answer is no, go onto the next questionwhich is does the patient need lifting assistance or trunk support with the helper providingmore effort than the patient?

if the answer is, yes, you could code thata 2 substantial/maximal assistance. if the answer is no, go to the last questionwhich asks does the helper provide all of the effort to complete the activity? or is the assistance two or more helpers requiredto complete the activity? if the answer is yes, that would be then codeda 1. if the activity was not attempted, again the3 codes are patient refused. if the patient refuses to complete the activity9 for not applicable. if the patient did not perform this activityprior to the current illness, exacerbation or injury.

and 88 if it was not attempted due to medicalcondition or safety concern. when reviewing the medical records or interviewingstaff or observing patient, again the definition of the activity is really important. so we'll spend time on each of the activitydefinitions as part of this training. the admission assessment, you're coding usualperformance using the 6-point scale or the three activity not an attempt to code. it's exactly the same as what we talked aboutunder self-care. for the discharge goals you'll be recordingthat on admission, you can only use the 1-6 codes.

at the time of discharge you will be coding1-6 or the, 7, 88, or 9. do not record the patient's best performanceor the patient's worst performance. again this is the intent on admission is toget a baseline assessment. and that may be happening in therapy. at discharge, it may be that there's differencesin the person's functional status, and maybe for the most part they're walking quite well. but maybe getting up at the middle of thenight they are unsafe. and so, you know, they do maybe have a lowerability at night. that information would certainly be sharedwith the family at discharge.

but it may not be always what you're reportingon the irf-pai. so it really depends. we're after the usual. i think i talked about baseline a lot in termsof the admission assessment at discharge, in general, one core is going to really tellyou the whole story about the person's functional so when you're talking to perhaps the nextsite of care, or explaining to the family how much help a person needs, you're not goingto say well, they're a supervision setup for each of the self-care activities and you know,there's more to the story than that. so certainly, that information is very relevant,absolutely should be documented.

on the irf-pai what you'll be reporting isthe usual status. so kind of generally where the person is onadmission and discharge. again, similar to the self-care activities,you know. you wouldn't say well, i think the personbased on their ability to get on and off the toilet, i think they can probably get in andout of a car. if a activity is not assessed then you justput the code of 88, or in some cases a dash if the activity wasn't tested and it wasn'trelated to a safety concern. if two or more helpers are assisting a patientthe code would be 1. and if the patient does not complete the activityand the helper does not complete the activity,

code the reason the activity was not attempted. clarify your own understanding and observationsabout the person's performance of an activity, ask probing questions if you're relying oninformation from other staff. and examples of using probes when talkingto staff are provided in the training manual. i think we have a couple in this slide setalso that we'll be going over. we talked about the dash already. so, just to kind of reiterate, for the admissionperformance, it would be unusual to code a dash. basically, you should be coding the 7s, the9s, the 88s if a activity was not attempted.

try to avoid the dashes. because again, that is something that is partof the quality measure that we expect that you at least address the items in terms ofthe patient performed the activity or the reason that they were not able to performthe activity. as one the things that i do want to mentionbecause this is related to coding, in some instances when a patient is admitted to airf, the plan is obviously to have a complete stay. but in some circumstances, i think the nationaldata is about 10% of the time, there is an unplanned or unexpected discharge or an incompletestay.

we recognize that that's challenging, thatthere's a medical emergency often in those instances and that you need to get the patientto the next setting or to the emergency department. and so function at that point in time is notthe priority. so, when we were actually designing the originalitems many years ago, we did talk to a lot of staff and irfs, and ltchs as well as inhome health, and basically said, how do you code function when there's these kind of medicalsituations that occur? so some hospitals were basically, some irfsin particular, were saying well we just code what their last assessment was in therapy. and then other people said, we just put lowcodes because that person's not functioning

very well, they have a pulmonary embolism,or a suspected pulmonary embolism and we had to get them moved out. we looked at the data, the scores were allover the place. and so we felt that when we were calculatingthe quality measures, it was an incomplete stay, it's not a full course of rehabilitation,it would be hard to judge the improvement based on an incomplete stay. the bottom line is, if somebody is dischargedthey have an unplanned stay you can code an 88 to indicate that the person was too ill. when we calculate the quality measure, i mentionedbefore we're going to look at functional improvement

for patients in your irf as part of qualitymeasure 2633 which is the self-care. and we, as part of the quality measure thatwent through the national quality forum, we exclude people who have incomplete stays. and we just felt that there's other qualitymeasures that deal with readmissions and all that kind of stuff. and that it's really hard to judge, especiallywhen there's wide variations in discharge to acute, across the facilities. some facilities it would be a lot of, maybelower scores, or inconsistent scoring. so bottom line, we can talk about this ifyou have questions, put them on the cards.

bottom line, we didn't think it was fair toreally look at functional improvement when somebody didn't have a full course for theirentire stay, and had this unplanned situation. so on the irf-pai, you would code 88 at dischargeto indicate the person's too sick. for those of you who work in other settings,you may be aware that in the ltch setting, there are the admission and discharge dataare reported separately. and at discharge, there's actually a planneddischarge form and an unplanned discharge form. and in the skilled nursing home setting there'sdifferent datasets out there. so, in the ltch setting, you watched thattraining, or you're familiar with that setting,

you wouldn't maybe know that the unplanneddischarge form does not have the function items on it. on the irf-pai, you're reporting it on allpatients, including patients who passed away. so if the patient passes away you can code88 for the discharge function items for gg, self-care mobility, and also if there's anunexpected discharge. if you're particularly interested, and i'msure we can put this in faq, we do have a definition of course of what incomplete stayincludes. it includes people discharged to acute care,as well as people -- length of stay less than three days.

we have a whole criteria as part of the qualitymeasure that got approved and it's something that we got a lot of support from irf industryexperts when we were putting the quality measure together. i'll make sure that in our faq we kind ofput that together so you're kind of aware. because a discharge, if a patient doesn'tperform an activity for the quality measure, we recode to assume that the person's dependent. because when you have to calculate the qualitymeasures, so it's important that you're kind of aware what happens with the data and howthat affects it from a quality measure perspective. so i'll remember to cover that in this part.

so now we'll get into the items. the first activity in the mobility sectionrelates to bed mobility. we have actually quite a few of bed mobilityactivities. again during the development of these items,we visited and talked to a lot of post-acute care facilities, and bed mobility items werecommonly done but not reported in a standardized way. so this was our -- the result of our attemptto standardize this area. rolling left to right is defined, you canlook at this on page eight of the irf-pai. it's defined as the ability to roll from lyingto back, to left to right side and return

to lying on the back. so we have a coding scenario just as an example. the physical therapist helps mr. r turn onto his right side by instructing him to bend his left leg and roll onto his right side. he then instructs him how to position hislimbs to return to lying on his back, then repeat the similar process for rolling ontohis left side and then return to lying on his back. mr. r completes the activity without physicalassistance from the helper. again we've got a physical therapist who'sinvolved and providing some instruction.

how would you code this particular item? what's your rationale? sounds good. so i agree. i would also code this person as a level 4based on the input from the therapist. so the physical therapist provides verbalcues, we call them instructions in this example, as he rolls from his back to his right side,and returns to lying on his back. the physical therapist does not provide anyphysical assistance. so that's why it's a 4.

so, now we have a practice coding scenario. and it's a little bit longer, so bear withme here. mr. r has a long history of skin breakdown. the nurse instructs him to turn on to hisright side providing step-by-step instructions to use the bed rail. bend his left leg and then roll onto his rightside. patient attempts to roll with the use of thebed rail, but indicates he cannot do the task. the nurse then rolls him onto his right side. next the patient is instructed to return tolying on his back, which he successfully completes.

mr. r then requires physical assistance fromthe nurse to roll onto his left side, and return to lying on his back to complete theactivity. so, how would you code this example? so, code options are 6 independent, whichwould be coded an a. b would be 5, setup or clean up assistance. c would be 4 supervision or touching assistance. 2 would be substantial or maximal assistance. all right, so it looks like 95% coded d. andyou are correct. i would code it as 2 also.

so, in this case, the rationale is that thenurse provided more than half of the effort for the patient to complete the activity ofrolling left and right. the next activity also related to bed mobilityis sit to lying. so, in this case, sit to lying is definedas the ability to move from sitting on the side of the bed to lying flat on the bed. so we have just an example that we'll be goingover together. ms. h requires assistance from a nurse totransfer from sitting at the edge of the bed to lying flat on the bed because of paralysison her right side. so maybe she's had a stroke.

the helper lifts and positions ms. h's rightleg. so there's some lifting happening. ms. h uses her arm to position her upper body. overall ms. h performs more than half of theeffort. how would you code this item? i heard a lot of 3s out there. i do agree with that. that's how we coded her. a helper lifts ms. h's right leg, and helpsposition her from a seated to a lying position.

and specifically told you she did more thanhalf of the effort. next coding scenario, this is for polling. in this case, ms. h requires assistance fromtwo certified nursing assistants to transfer from sitting at the edge of the bed to lyingflat in the bed due to paralysis of her right side, obesity and cognitive limitations. one of the certified nursing assistants explainsto ms. h the steps of the sitting to lying ms. h is then fully assisted to get from sittingto lying position on the bed. ms. h makes no attempt to assist when askedto perform the incremental steps of the activity. so how would you code this patient?

press a if you believe the code is 4 supervisionor touching assistance. code 3 for partial/moderate assistance. code 2 for substantial/maximal assistance,and code 1 if you believe dependent is the right code. we got more than a hundred percent. right. i agree, code 1. two people, level 1. oh, so there was a comment about it not beinglicensed clinicians.

so basically the clinician might be askingwhat the patient ability was. and so if that's what's happened in this case,it was explained that the patient was obese, had cognitive problems and so, if it's theclinician's judgment that the patient, you know, was allowed to do as much as possible,that would be fair. but your point is right, that you know, justbecause you know, somebody says, well the person was dependent, it's your clinical judgmentto make sure that the assessment truly has been done. so the next activity is lying to sitting onside of the bed. we're just moving all over the bed here.

so the definition here is the ability to safelymove from lying on the back to sitting on the side of the bed with the feet flat onthe floor and with no back support. so in this case, we have one example thatwe'll go over together as a group. and then we'll maybe get into polling. mr. b pushes up to the bed, up on the bedto attempt to get himself from a lying to a seated position as the occupational therapistprovides much of the lifting assistance necessary for him to sit upright. the occupational therapist provides assistanceas mr. b scoots himself to the edge of the bed and lowers his feet to the floor.

overall the occupational therapist indicatesthat she performs more than half of the effort. how would you code this item lying to sittingon side of bed? i also coded this a 2. the helper provides lifting assistance morethan half of the effort. and so she should be coded at a 2. so now we have a polling question. ms. p is being treated for sepsis and hasmultiple 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 and lower extremity

-- in her lower extremities upon movement. so the reason why somebody can or cannot doan activity is not what we need to worry about. we just code what assistance was providedduring the assessment. so how would you code this example? so, option a is code 4, supervision or touchingassistance. b is 3 partial/moderate assistance. code 2 is substantial/maximal assistance. i'll give you a minute. 98% coded a d. and that is indeed the correctresponse, 1 dependent.

in this case code 1 was accurate or correctbecause the helper fully completed the activity of lying to sitting on side of the bed forthe patient. the next activity that we will be talkingabout is sit to stand. and sit to stand if you look at the irf-pai. sit to stand is defined as the ability tosafely come to a standing position from sitting in the chair or on the side of the bed. mr. m has osteoarthritis and is recoveringfrom sepsis. mr. m transitions from a sitting to a standingposition with the steadying touching assistance of the nurse’s hand on mr. m's trunk.

how would you code sit to stand? okay, i heard some 4s. in this case, it would be a 4. and again, it's the touching assistance. so in clinical records, people write all kindsof things like, contact guard, i'm not sure what the practice is at your facility, butall of those would be considered touching and in terms of supervision, i know in someplaces, people differentiate between close supervision and distance supervision, they'reboth supervision in this particular coding rating scale.

so either one is acceptable as supervision. but certainly, clinical record might providemore details or supplementary information. okay, so here we have an example of a nurseinterviewing certified nursing assistant. as i said, there's some examples in the trainingmanual. this is just one of them as we pull out forthis particular item or activity. so the nurse says, please describe how ms.l usually moves from sitting on the side of the bed or chair to a standing position? once she is sitting, how does she get to astanding position? so the cna says she needs help to get to sittingup and then standing.

and so, the nurse has to kind of ask a littlebit more information in order to make sure she is focused on the actual activity thatshe's needing to score. so i'd like to know how much help she needsfor safety, rising up from sitting in the chair or sitting in the bed to get to a standingposition. so then the certified nursing assistant reply's"she needs 2 people to assist her to stand up from sitting on the side of the bed orwhen she sitting in the chair". so, how would you code this? response 4 would be press a. 3 press b. for a 2 press c. and for 1 press d. i'll giveyou a minute here.

100% on that. and the right answer is indeed what was reportedby everybody. so she would be coded a d dependent becausethe assistance of two helpers was provided. one of the help desk questions that we gotrelated to this particular item sit to stand is what if the patient is not walking andthat person is in a wheelchair? so you would actually code this one as 88. if the person does not get up to a standingperson. okay, next we're moving into transfers. so the first type of transfer is the car/bedto chair transfer.

and in this instance the definition is theability to safely transfer to and from a bed to a chair or a wheelchair. many ways that this maybe done in inpatientrehab. so it could be the person is getting up fromthe bed and pivoting into the chair. or it could be a slideboard is used, that'scertainly acceptable also. for the coding scenario that we'll be goingthrough as a group in the chair/bed to chair transfer, this example is about mr. f. andhis medical conditions includes morbid obesity, diabetes, mellitus, and sepsis, he recentlyunderwent bilateral above the knee amputations. mr. f requires full assistance with transfersfrom the bed to a wheelchair using a lift

device. two certified nursing assistants are requiredto safely transfer him from the bed into a wheelchair. mr. f is unable to assist in the transferfrom the bed to the wheelchair. how would you code him? i hear a lot of 1s. and i agree with that. so, two helpers plus he did not help at all. so he is dependent.

so now we've got a polling question comingup. and again, this is the chair/bed-to-chairtransfer. so in this example, ms. p has metastatic bonecancer, severely affecting her ability to use upper extremities during her daily activities. ms. p is motivated to assist with her transfersfrom the side of the bed to her wheelchair. ms. p pushes herself up from the bed to beginto transfer while the therapist provides firm support. once standing, ms. p shuffles her feet, turnsand slowly sits down into the wheelchair with a therapist providing trunk support.

so if you were doing the transfer, you probablyknow how much help a person needed. it's kind of hard to write this scenario andgive you an idea. so we do provide some additional input thatthe therapist provides less than half of the effort in this instance. how would you code this patient? so i will give you a minute. the options are 4 supervision or touchingassistance which would be coded a. 3 partial/moderate assistance would be coded b. substantial/maximalassistance would be coded 2 and dependent would be coded d. so i'll just give you aminute.

it looks like most people submitted. so in this case it looks like we have 88%coding b, which is the correct response. the rationale is that the therapist providedless than half of the effort to complete the next we're moving onto toilet transfer. so again the definition is on page eight ofthe irf-pai. this refers to getting on and off a toiletor commode. so, we have an example to just go throughtogether. mrs. y is anxious about getting up to usethe bathroom. she asks the certified nursing assistantsto stay with her in the bathroom as she gets

on and off the toilet. the certified nursing assistant stays withher as requested and provides verbal encouragement and instructions, cues to mrs. y. i see 4 fingers. thank you, i agree. i think i mentioned this as an example earlier. if the patient says, i want somebody withme and the staff person decides that's appropriate, then you would reflect that. and then for whatever reason, maybe somebodyis very anxious, and the decision is that

that person is going home alone and that thestaff feels that person is in need, say and nobody is there, it could be that person endedup being coded independent. but in this instance, the judgment was thatsomebody should stay with the person. she was anxious, probably that's going tobe most of the situations, and so, i would agree the code of 4 would be reported formrs. y. so we've got another polling question fortoilet transfer. mr. h has paraplegia and complete pneumonia,as well as copd. so he's got respiratory problems, maybe someendurance problems. he prefers to use the bedsides commode whenmoving his bowels, due to severe weakness,

a history of falls and dependent transferstatus, two certified nursing assistants assist during the toilet transfer. how would you code the toilet transfer? so a would be pressed if you believe 4. b if you think 3. 2 if you believe substantial/maximal assistance. code 1 if you think 1 is the right code. 98% coded 1. i do agree that that is the right answer.

and the rationale is that two helpers wererequired to complete the activity. so now we're getting into some of the activitiesthat relate to i guess they're a lot more relevant at discharge. again, some of these activities may not beperformed at admission. so you might be coding 88s to indicate theactivity was not able to be assessed because of the patient's medical condition. so car transfers, whether somebody is goinghome to drive, or if as karen mentioned they're going to be going to medical appointmentsin a cab, or in a friend's car, they still need to learn how to get in and out of thecar.

so very relevant for many, many, patients. so car transfer is defined as the abilityto transfer in and out of the car or a van on the passenger side. it does not include the ability to open orclose the door or fasten the seat belt. it's really just to transfer getting intoand out of the car. so we have a polling question for car transfer. during her rehabilitation stay ms. n workswith an occupational therapist on transfers into and out of the passenger side of thecar. on the day before discharge, mrs. n requiresverbal reminders for safety and light touching

assistance as she transfers into and out ofthe car. the therapist instructs her on strategic handplacement as she transitions from sitting on the passenger seat. she needs light touching as she moves herfeet into the car once seated. the same amount and type of assistance isneeded for her to transfer from the car seat to a standing position, so getting out ofthe car; the therapist opens and closes the door. so how would you code this? if you think the answer is, 6, press a. ifyou think the answer is 5 setup or clean up

assistance press b. if you think it's supervision or touchingassistance press 4. and if you think it's 3 partial/moderate assistancepress d. in that example, it did talk about opening and closing the door. but as i read in the definition, that's notincluded. so don't get tricked by that. okay, all right. 100% say c is the right answer. and that is indeed the correct responses clevel 4 supervision or touching assistance.

so the rationale is that the helper providestouching assistance to the patient. and again, opening closing the door is notincluded. it sounds like somebody got distracted bythat. okay, so now we're moving into that thirdcolumn. so, i indicated before that we have the gatewayquestions or screening questions. and it allows a situation that you can skipover some items so that the computer can actually insert responses on your behalf. so the first item that's indented is doesthe patient walk question. so this is h1.

and we can see clearly here how this looksdifferent than the rest of the items. so, i'll just read the question and then wehave a coding scenario to go through. so if you actually look at the irf-pai, you'llsee that each one asks does the patient walk. the first response option is no. and walking goal is not clinically indicated. so this is an instance where somebody maybehas experienced a spinal cord injury or somebody who's had a very severe stroke. and it's not expect that the person wouldbe able to actually walk by discharge. so if you mark this then you would not beable in the it system to be able to report

performance or a goal. if you respond 1, so the answer to the questiondoes the patient walk, if the answer is 1, then the answer is no. and walking goal is clinically indicated. so if you mark this, you would skip over theadmission assessment, but you would be able to enter a goal. so if you want to be able to enter a walkinggoal and the person's not walking on admission, you enter code 1. and then the third category of responses,does the patient walk, yes.

and if you say yes, then responses are requiredon all the walking and stairs items that follow that we'll be talking about in just a minute. you may enter goals. if you are not entering a goal because you'veentered a goal elsewhere, you might put a dash if you're not wanting to put a goal relatedto walking. so i'll go through that because i see somefaces that maybe i wasn't clear. so the question is, for each one, does thepatient walk? and there's two-ways to say no. you can say no, the person doesn't walk andthey're not expected to walk by discharge,

that's code 1. if the person isn't currently walking andthey -- sorry, code 0. 0, sorry. okay, let me start again. (laughter) thank you. does the person walk? so 0, no. and the person is not expected to walk bydischarge. if the answer -- if you code 1, that meansthat the person doesn't currently walk and

walking is an expectation perhaps by discharge. and that allows you to enter a goal, that'swhy you would want code 1. thank you very much. and if the person is walking now, then youcode 2 for yes and that means you can code all of those walking and stairs items. and the object and the goals can also be entered. so here we have an example. mr. z currently does not walk, but a walkinggoal is clinically indicated. so, if you want to look at the irf-pai tosee the codes, either 0, 1, or 2, how would

you code this particular item? i agree, you got it right. patient does not currently walk, so the admissionperformance codes would -- you could not enter them, because you indicated they don't walk. so it wouldn't make sense that you would codethat they would be doing anything than what they couldn't. so there's quite a few items that you're ableto skip over. the walking goal is clinically indicated youcan enter a goal for any of the walking, stairs or pick up object items.

okay we have a polling example next. so, again this is, does the patient walk? so in this instance, we've got mrs. y whocurrently walks with great difficulty due to her progressive neurological disease. it's not expected that mrs. y will continueto walk. mrs. y also uses a wheelchair. in this instance, you're just reporting whethershe can walk or not. so how would you code, 0, 1, or 2? 2.

so this is -- 0 would be no and walking isnot clinically indicated. code 1 for no and walking is clinically indicatedthat's b. and code 2 for yes which would be a c. so does the person walk? so 94% indicated c, which is correct. so in this instance it was a little bit ofa distraction that she has a condition where she's going to get worse, but all we're askingis does the person currently walk. we only ask about goals if the person is notcurrently walking. so, say that again. if the patient currently walks, the expectationat discharge is not going to influence your

response. if the person's currently walking you codea 2, even in this case where somebody may not be expected to walk by discharge. in most cases, people will be walking on admissionand the goal will be improvement. but we put this example in to make sure thatwas very clear that it's just -- does the person walk. so we've got -- yeah, so here's the rationale. again the patient currently walks. so the answer is yes, the person does walk.

okay, so next if the person is walking thenyou would be filling out these next set of items so there's a series of items relatedto walking and going up and down stairs and picking up an object. so the first distance is 10 feet. so we're getting to the bottom of page eight,i'll just read the definition. so walking ten feet starts once the personis standing. so we've already covered getting from a seatedto a standing position. so once the person's standing, it's theirability to walk -- i'm sorry, the ability to walk at least 10 feet in a room, corridoror similar space.

so it's any location. given the short distance, it may be in theperson's room if they've just gotten up out of bed. it could be in the therapy gym too, obviously. so here we have a practice coding scenario. and so this will be polling. so get out your gadgets in a minute. so in this instance, mrs. c has parkinson'sdisease and walks with a walker. the physical therapist must advance the walkerfor mrs. c with every step.

the physical therapist assists mrs. c by physicallyinitiating the stepping movement forward advancing mrs. c's foot during the activity of walking10 feet. the assistance provided to mrs. c is morethan half of the effort to walk the 10-foot distance. how would you code this item for this patient? so a would be code 4 supervision or touchingassistance. b if you believe code 3 partial/moderate assistance. c to code 2 substantial/maximal assistance. and d code 1 for dependent.

96% of the participants say c. and i do agreewith that response code 2. the rationale is that the patient providesmore than half of the effort for the patient to complete the activity. so next we have walk 50 feet with two turns. and so, you know, again, when we were workingon developing the item set one of the therapist talked about the importance of walking whileturning. and so, that is an item that is included inthis dataset. and you will see it under wheelchair again. so walking 50 feet with two turns is definedas it starts once a person is standing.

so similar to the other walking item, theability to walk at least 50 feet and make two turns. so in this instance, mrs. l is unable to bearher full weight on her left leg as she walks 60 feet down the hall with her crutches. this person had some kind of fractured leg. and so she's making two turns, her husbandsupports her trunk. so maybe she's turning around the corner inthe hallway or into her room. the husband in this case is the helper. and he provides less than half of the effort.

so a would be a code of 4 supervision or touchingassistance. b would be 3 partial/moderate assistance. c would be a code 2 substantial/maximal assistance. and d would be code 1 dependent. i will give you a minute. all right, so 95% coded b which is code 3partial/moderate assistance. and i do agree with that. in this instance it was a family member thatwas helping. so obviously similar to what i mentioned before,you would use clinical judgment to determine

whether that was something that was indeedan assessment. and in this case if it was, you would codeit 3. so, in this case there was trunk support. next item is walking 150 feet. and so this is actually the last item at thebottom of page 8. so in this instance once this starts again,once standing and refers to the ability to walk at least 150 feet in a corridor or similarplace. so, you know, it's probably not the room anymore,just many more just because of the distance. this is going to be a polling question.

so polling question. mr. r has endurance limitations due to heartfailure and he's only walked about 30 feet during the 3-day assessment period. he has not walked 150 feet or more duringthe assessment period, including with the physical therapist who has been working withmr. r. the therapist speculates that mr. r could walk this distance in the future withadditional assistance. so, how would you code this particular item? a code 1 for dependent. b code 7 patient refused.

code c, 9 not applicable. code d, 88 not attempted due to medical conditionor safety concern. so, i know this is going to generate somequestions. (chatter) i'll give you a minute to thinkabout it. you can do some thinking through it. and we'll talk through it. we ready? well d excellent. 89%.

so i would agree with that. i know that we've had questions on the helpdesk about why isn't this dependent? and because we have the different distancesfor walking and somebody wouldn't carry somebody or, you know, walk for them 150 feet. you would code 88 for this particular activity. i expected a little more of the distributionon that based on some of the questions that have come into the help desk. the same thing would apply by the way forstairs. so we have 12 stairs as an activity lateron you'll see.

so if the person can't do it, maybe somebodycan do one step or four steps but not 12 steps. so you would code activity not attempted ifthere's not an attempt to go the 12 steps or in this case 150 feet. okay, so the activity was not attempted. okay now we're moving to another walking item. but in this case, it's walking 10 feet onuneven surfaces. so i will read this definition. so we're actually now turning onto page nineat the top where the definition of walking 10 feet on uneven surfaces refers to the abilityto walk 10 feet on uneven on or sloping surfaces

such as grass or gravel. and this does start once the person is ina standing position. so as with all the other walking items. so this item actually was added when we wereagain doing the development of the item set, which started about ten years ago. we looked to the international classificationof functioning and they included walking on uneven surfaces. and talking with clinicians and some patientrehab facilities create a bit of an obstacle course.

i know in chicago you wouldn't want to dischargea patient to walk up and down michigan avenue without being able to do something like this. it is certainly acceptable that you may takea patient outdoors to assess uneven surfaces. some locations have gardens where you cantake somebody to walk on grass. those are all very acceptable ways to assessthis activity. again, i'm expecting that this will -- thiswon't be done very often on admission. that was definitely what we saw during thetesting of these particular items. so we have a polling question that we'll bedoing together. so, in this instance we've got a patient calledmrs. n who has severe degenerative disease

and is recovering from sepsis. upon discharge mrs. n will neet to be ableto walk on uneven surfaces and sloping surfaces because maybe she's going to get her mailand her driveway is sloped. and so that's going to be something that isimportant for her to be able to do before she's discharged safely near the end of herirf stay. so let's say it's the day before dischargeand this is the discharge assessment. the physical therapist takes mrs. n outsideto walk on uneven surfaces. so again it could be grass, it could be slopingareas, something that's uneven and challenges her a little bit.

mrs. n requires the therapist weight-bearingassistance several times during walking in order to prevent mrs. n from falls as shenavigates walking over 10 feet of uneven surfaces. so how would you code mrs. n. if you believe the correct response is 4 pressa for supervision or touching assistance. 3 for partial/moderate assistance would beb. 2 substantial/maximal assistance would be coded c. and a code of 1 dependent wouldbe d on your gadget. so please vote. are you ready? it sounds like there's a lot of discussion.

okay, so it's between b, 3 and 2. okay, those are reasonable. the correct response actually is a 3. in this instance we felt that the patientwas doing more than half of the effort. however, for those of you who coded 2 if yourinterpretation was that the patient was doing less than half of the effort, then i mean-- we understand the coding. i think sometimes it's hard to write thesescenarios and not be giving away the answers. so, maybe this wasn't the clearest of examples. but basically based on your previous responsesif the helper is doing most of the effort,

it's a 2. if the patient is doing most of the effort,it's a 3. so now we're going to move onto mobility,one step, which is basically a curb. so obviously, anybody who is out in the communityand the goal of rehabilitation is to get people back into the community, so walking up anddown one step or a curb is important. okay, if you have questions, please writethem down, i'll be happy to -- i've got lunch to go over them with my team. we would be happy to address your questions. so again, goal of rehabilitation is to getpeople back into the community.

so going up and down one step is often a dailyactivity for people. it can be a step in the therapy gym or itcan be a curb if you take people outside. and the definition on the irf-pai, so thisis on page nine, the ability to step over a curb or up and down one step. so we do have a polling example, practicecoding scenario for this one step or curb. mrs. z had a stroke and needs to learn howto step up and down one step to enter and exit her home. the physical therapist provides standby assistanceas she uses her quad cane to aide her balance in stepping up one step.

the physical therapist provides touching assistanceas mrs. z uses her cane for balance and steps down one step. so the standby assistance while the patientwas stepping up and then touching assistance when she was going down. so a little bit more assistance on the waydown. so again, this is polling. press a if you think the correct responseis 3 supervision or touching assistance. if you think 3 is the right answer, partial/moderateassistance code b. code 2 would be c. and code 1 would be d. i'll give you a minute.

96% say a. i do agree with that response. that's what our team came up with is 4 supervisionor touching assistance. the helper provides touching assistance asmrs. z completes the activity of stepping okay, so next we will go into four steps. so in this particular instance, four stepsis defined as the ability to go up and down four steps with or without a rail. and we have a practice coding scenario herefor four steps. mr. j has lower body weakness and the physicaltherapist provides touching assistance when he ascends four steps.

while descending four steps the physical therapistprovides trunk support, that's more than touching assistance, as mr. j holds onto the railing. so what do you -- how would you code mr. j? so press a if you believe a code of 5 setupor cleaning assistance would be the correct code. press b if you think supervision or touchingassistance would be the correct code. press c if 3 you believe is the correct codefor partial/moderate assistance. and d press 2 if you think substantial/maximalassistance would be correct. i will give you a bit of time.

thank you. 100% go with c which is 3. and that is the correct response. okay, and the rationale is obviously touchingassistance. since you all got that right, i think we'lljust wrap up with the last stairs item and then we will break for lunch. we'll pick back up after lunch with the restof the items and have time for some questions. so again, please fill out the question forms,and provide your name and email address to help us if you'd like a direct response inaddition to us being able to address them

here. so twelve steps. the definition of the 12 steps on the irf-paiis the ability to go up or down 12 steps with or without a rail. so it is the same as the other step item,just more steps in this instance. this is a polling question. ms. y is recovering from a stroke resultingin motor issue and poor endurance. ms. y's home has 12 steps with a railing andshe needs to use the stairs to enter and exit her home.

the physical therapist uses a gait belt aroundher trunk and supports less than half of the effort as ms. y ascends and descends the 12steps. what do you think? how would you code walking up and down the12 steps for this patient? press a if you think the correct responseis code 5 setup or clean up assistance. press b if you think a code of 4 supervisionor touching assistance. c if you think 3 part/moderate assistance. d would be a code 2 for substantial/maximalassistance. i'll give you a short time.

looks like 96% coded c. and that is the scorethat the team came up with for partial or moderate assistance. the rationale being that the helper providedless than half of the effort in providing the necessary support for mrs. y to ascendand descend the twelve steps. so we are picking back up with slide 203. we’ll be talking about the item mobility,picking up object. and that is item p in section gg0170. so i do want to be sure to give you the definition. the definition is the ability to bend, stoopfrom a standing position to pick up a small

object such as a spoon, from the floor. so if somebody is not able to stand up, thisitem can’t be completed. you would code an 88. it does need to be from a standing position. that's a question that we have had come inthrough the help desk. i just have one coding scenario for us todo together here. mr. p has a neurological condition that hasresulted in coordination problems. he wants to be as independent as possible. so that's his goal.

mr. p lives with his wife and will soon bedischarged. he tends to drop objects and has been practicingbending or stooping from a standing position to pick up small objects such as a spoon fromthe floor. the occupational therapist needs to remindmr. p of safety strategies when he bends to pick up objects from the floor. and she needs to steady him with touchingassistance to prevent him from falling. so how would you code this item on the ratingscale and what is your rationale? i heard a lot of 4s out there. that's right.

so the helper in this case, a therapist providedsupervision or touching assistance, specifically it was steadying touching assistance. okay, we have another example to go over. ms. c has recently undergone a hip replacement. when she drops items she usesed a long-handledreacher that she has been using at home prior to admission. she is ready for discharge and can now ambulatewith a walker without assitance. when she drops objects from her walker basketshe requires the certified nursing assistant to locate her long-handled reacher and bringit to her in order for her to use it.

she does not need assistance to pick up theobject after the helper brings her the reacher. as i mentioned before it doesn't matter ifpeople use a device or not to perform an activity, certainly very acceptable. in this instance, someone needs to bring thereacher device to her in order for her to be able to actually complete the activityof picking up an object from the floor. how would you code this and what is your rationale. i heard a lot of 5s. i would agree with that. so the helper provides some setup assistance,because the person cannot perform the activity

without somebody bringing the reacher to her. so, now we are actually moving into anotherscreening question. so if you look at your actual irf-pai youwill see that this is on admission. it's that third column in on the dischargeassessment. it's indented in from the assessment of thedischarge assessment. so this particular question is a gateway questionor a screening question and asks about whether the patient uses a wheelchair/scooter, soeither one. and, you know, again as i mentioned before,we are really interested in assessments, not whether somebody was just put into a wheelchairto be taken to therapy.

so if somebody has experienced a severe enoughcondition that they are in a wheelchair, they will be building mobility still related towheelchair. you would absolutely be assessing that item. it is certainly appropriate that a patientmay be going home and be both walking and using a wheelchair. so walking and wheelchair will be filled outon the irf-pai. there is no restriction about only walkingor only wheelchair. if the person is walking, you say yes thatperson's walking. you score the appropriate items.

if the person is also using a wheelchair,you code the wheelchair items. if a person is not able to walk at this pointin time and they only use a wheelchair, then you would be coding wheelchair. the item then again just asked does the patientuse a wheelchair or scooter, and if the answer is no, then you actually skip out of the nexttwo items, because they are both wheelchair items, they're not applicable. and the computer will fill it out. it basically is just a way for you to skipover those two items. if you say yes then that opens up those twoitems.

so we will talk through those items next. so the first item is wheelchair 50 feet withtwo turns. and the definition is, it starts when theperson is seated. so that will be true for both wheelchair items. so it starts when the person is seated inthe wheelchair or scooter, and it's the ability to wheel at least 50 feet and make two turns. so we have a practice coding scenario. so if you can find your gadget to press yourcodes. we have an example, one seated in a manualwheelchair, ms. r wheels about 10 feet then

asks the therapist to push the wheelchairan additional 40 feet to her room and her bathroom. so there is some turning happening as partof this. and the 50 feet is what happens. but the patient does a little bit and thenthe therapist -- yeah the therapist is needed to help her to do some of the effort. so how would you code this item gg0170r. the one option for a would be code 4. b would be code 3.

c would be 2. and d if you think the right answer is 1. so 93% coded c. and i do agree that 2 substantial/maximalassistance would make sense in the last example. so the helper provides more than half of theeffort in this instance. so, as i mentioned before in this case, inaddition to the screening or gateway question, we also have follow-up questions. so in order for us to really understand what'sgoing on with the patient, we like to know what type of wheelchair the person uses. so basically, we have this rr1 on the admissionthat we ask you to indicate whether the wheelchair

or scooter was 1 manual or 2 a motorized wheelchair. the next item is again another wheelchairitem. but this time the distance is 150 feet. so, if we're looking at the irf-pai the definition,once seated in a wheelchair or scooter, the ability to wheel at least 150 feet in a corridoror similar space. so we have just one example to go over together. mr. g always uses a motorized scooter to mobilizehimself down the hallway. the therapist provides cues due to safetyissues, specifically to avoid running into walls.

how would you code this item, wheel 150 feet? that would be coded a 4 supervision or touchingassistance. so in this case there's verbal cues that arebeing provided to the patient in order for the activity to be done safely. again, there's a follow-question up here,what type of wheelchair is used when wheeling 150 feet is the item. so the same codes apply, 1 for manual and2 for motorized. so those are all the mobility items. as we spoke earlier about goals, so in additionto the self-care items being able to code

goals, there's also space on the admissionform to code discharge goals for patients in the area of mobility. so that is in the second column of the admissionassessment. and it covers two pages, just like the itemsdo. and basically the guidance that we providedearlier related to self-care is also the same and so, i'm not going to go through that indetail, but i did want to just reinforce that only codes 1-6 can be coded as goals. because it wouldn't necessarily make sensefor refusal to be a goal. and if the patient can't perform an activity,you can code that as a 1 for a goal.

, or the expectation is that the person cannotperform -- would not be able to perform that activity by discharge. you put 1 as a goal. and again, license clinicians can establishpatient goals for discharge at the time of we did have a question that came in duringthe break about whether you can change goals. so i will address that now, because that'sactually a really good question. so we do have this 3-day assessment periodfor the assessment, if you need that amount of time or to set goals. so after a goal is established and documentedeither as part of the care plan in the chart,

or perhaps it's on the irf-pai at that pointin time, if circumstances change, you cannot go back and change it. however, we certainly recognize cms certainlyrecognizes that in some instances patient goals may change, or perhaps there wasn'tenough information available within those perhaps there was new information that becameavailable after that. so within the chart you may certainly updatethe care plan. but on the irf-pai, you would not change afterthe 3-day assessment period. and again, i just want to again enforce thatthe quality measure that is focused on reporting goal data, cms at this point, the qualitymeasure is that you complete an admission

and discharge functional assessment for theselected items, and that there's a minimum of one goal reported. so cms is not calculating the percent of peoplewho met goals. that's certainly something that you can dointernally for quality improvement, get credit for the work that you do and document it insome way. but it's not a part of the quality measure. i did want to -- i think i mentioned thisbefore, but i will reinforce this. so in the case of somebody has an unplanneddischarge -- actually we have a scenario here where mr. c was admitted to the irf with healing,complex post-surgical -- post-surgery open

reduction internal fixation fractures as wellas sepsis . he had complications during the irf stay and unexpectedly need to return tothe acute care hospital resulting in his discharge from irf. so, let's say final program interruption,he's gone for more than three overnights. so in this case, as i mentioned before youwould be able to code 88 for the activities in self-care mobility to indicate that hewas too sick to have these activities performed. if you'd like to report goals, because maybeyou did assess them for whatever reason at that point in time, it won't be rejected,but again, to reinforce for the quality measures, we're looking at functional improvement.

patient who has unexpected discharges includinga discharge to acute care would be excluded from calculating the quality measure improvementin self-care and improvement in mobility. so regardless of what you put here, that won'tbe counted for or against you for that particular -- and the rationale behind that is that theperson did not have a full course of rehabilitation. so there was this unfortunate complicationthat occurred for this patient. so in summary for this section, so thank youfor bearing with me for most of the morning and often, this section focuses obviouslyon self-care and mobility activities, knowledge about a patient's status prior to the currentevent is very relevant to treatment goal -- current event is very relevant for the treatment goals.

that's why this was important to include onthe dataset at this point in time. karen mentioned earlier today about the importanceof that action plan in your packets. in terms of action plans related to this section,we would recommend that you review the importance and rationale of obtaining and documentingfunctional status as part of the training, including things like walking on uneven surfacesand car transfers. we recommend you review the 6-level ratingscale and the activity not attempted codes with your staff as you provide your training,and that you provide -- and that you evaluate your current documentation to ensure thatinformation that is in the medical record will allow you to complete this information.

i know when i have looked at some medicalrecords, sometimes it's very hard to actually get information on the type of wheelchair;it's not always in a standard location in some of the records that i've looked at. part of one of the projects that i'm workingon. also things like oral hygiene aren't specificallycalled out. so those kinds of things are definitely informationthat you'll want to look to see how easy is it for this information to be pulled out,if somebody, you're irf-pai coordinator and you're relying on other people to do the assessments. can you get the information?

or is it going to be a certain disciplinethat's -- maybe assigned some of these items. and they'll be looking at part of their formalassessment to document it in a certain location. and finally, we recommend practicing witha variety of coding examples, so there's some in the training manual, there's some additionalones that we provided here today. we will also be putting out some additionalinformation in the feature. so that is certainly something that we knowwe would like to provide you with in the near future so you can have some more practice. so, at this point, i wanted to address someof the questions that have come in, and i'm actually going to ask one of my colleagues,roberta constantine, to come up and help me.

while roberta is on her way up her i'll doher introduction. so, roberta is a senior public analyst atrti international. we've known each other for a long time onvarious projects related to quality measurement and inpatient rehab facilities. she's a nurse by training. she's worked in several different locationsin the area of cardiac care and roberta was also part of the original team developingthe care item set. so she and i have done a lot of travels togetherover the last decade or so. >>>> hi, everyone.

good afternoon, thank you very much. we also wanted to give anne's voice a littlebit of a break. not only that, we thought we would enter it,having somebody with a strong boston accent, so hopefully everybody will be able to understandme. we thought we would throw that into the mix. (laughter) so we're not going to have timefor all the questions. the questions are great. a lot of the circumstances as we were readingthrough the questions, it seemed like more than anything else it was points of clarification.

but please know that, you know, we'll be gettingthrough more of the questions over the course of the training, and anything that we don'tget to, we will definitely be answering those questions and putting it up on the cms website. what we thought we would do at the first passis just try to look at some of the questions that seem to be sort of frequent themes. and one of them has to do with walkers. so i'm going to try to be very agile in bringingthis up, bringing the question up -- yep. and this question is, so it's gg0110. the question is, is a hemi walker consideredas a walker or none of the above?

and the answer is, a hemi walker is considereda walker. in fact there's another question, it's not-- we also got a question about a rolling walker. so, anything that has "walker" at the endof it is a sure bet that it's going to be a walker. (laughter) so a couple of questions came up. so just to let you know, it's actually a standardwalker, a heavy walker, a rolling walker, a platform walker. so when in doubt "walker" that's your clue.

but, no, that's a great clarification. another excellent question that came in, andwe saw it again, had to do with what, especially i'm sure in rehab, everybody wants to getout of, and that is a hospital gown. so the question had to do with dressing. a hospital gown. the question had to do with dressing. let me see if i can scroll up to the firstone. so here we are. upper body dressing; and the question is,since pajamas count, do hospital gowns also

count? so the answer is, hospital gowns do not count. anything but, so pajama-- sometimes you getquestions about a sweatshirt if something has buttons. it's what's typical clothing for the patients. so anything but the hospital gown does countas clothing. and similar to that, in the same genre wasfootwear. so we talked about anti-falling socks. but there were a few questions regarding specificallywhat was included in footwear.

so if i scroll down this way -- i'm tryingto do this on the fly. one question had to do with footwear -- okay. thanks for your patience as i scroll. in the irf-pai manual section gg there areno coding examples for lower body dressing. but does item 130h include anti-embolic stockingsand the answer is yes, it does. and when in doubt, it's footwear. i'm sorry, footwear. >>>> so, as roberta said we'll provide someadditional examples. and so, i think i mentioned this when i wastalking about dressing in general.

i don't remember if it was upper body dressingor lower body dressing, or anti-falling stockings would be considered a piece of clothing andit fit footwear better than lower body dressing. prosthesis or orthosis would be lower bodydressing. i think you had questions about that too. yes, there was another question in regardsto a knee brace as well. and would that be considered clothing? and again, anything along those lines wouldbe considered as clothing. so i think we had walker, patient gown, footwear,liquids was also something that came up a number of times and tube feeding.

so let me see if i can find that. so the question is, how do you score? if a patient has po as well as tube feeding,how would you score that? the answer is, yes, you would score that forthe eating item. another question that came up under liquids-- and we'll clarify this also. this is good for helping us think about additionto the manual as well. on 17 we have, i think it was a question ifsomebody only had liquids would you still code them for eating? the answer is, yes, code whatever assistanceis related to liquids.

basically if somebody eats by mouth or botheats and drinks by mouth, code that. if the person is only on tube feeding, oryou know, some kind of alternative means, then that's what you would code that the activitydid not occur for eating. >>>> and probably last in the group of questions,there was some clarification as far as some examples in regards to usual performance. and regarding the use of usual performance,does cms have an expectation for how many times an item will be expressed or observedthere. are many items that will be seen once duringthe 3-day assessment period? so, obviously, what you really want to door think about when assessing the usual performance,

like, obviously something like eating or whatever,you would expect to see maybe multiple times. but maybe a patient, whether it's being, walkingdown the hallway or whatever, you wouldn't see necessarily more than once if at all duringthe 3-day assessment period. and that's when you really want the use yourbest clinical judgment. i mean, our goal is you want to get a baselineof the patient. again, before therapy is started when yourexpectations are for improvement, but you might not see an activity occur during thefirst day, and especially depending on when the patient was admitted. you know if they're admitted late or nightor something like that, or very early in the

morning or whatever, and there's a lot goingon with the patient gets admitted to the irf. so there was a question about when the threeday ends, is that based on hours or days. the three days end at 11:59 on the third day. it's calendar day. so, if somebody's admitted on friday at 9:00at night. friday is day one, saturday is day two, andsunday is day three 11:59. sunday that's when the assessment time stops. sunday is day three. another question was about showering and bathing.

for definition it means the ability to batheself in a tub or shower. if it's only a bed bath how would you codethis item? again, that's allowable. if the patient is washing up either at thebedside or they're in the bathroom at a sink, you can code that item. we had another question about verbal cueing. and the question was whether intermittentverbal cueing just a little bit or constant verbal cueing made a difference in the score? and the answer is no.

there can be a tiny bit of verbal cueing orconstant cueing and that would still be at the same level related to the supervision. we have another one about what if the goalabout what if the person is in the community using a wheelchair and walking when they'rein their home, how would you score walking and wheelchair. if both item activities are being worked onduring the inpatient rehab stay, absolutely code one of them. there's in only do walking or only do wheelchair. code whatever is relevant for that person.

you may certainly report walking and wheelchairfor the same patient. >>>> another question was, can you pick informationfrom one discipline to submit the codes? for example, whether it's the bed or a wheelchairtransfer, ot/pt in nursing, we all do it, which obviously in inpatient rehab facilities,it's a team approach. but this is where you do -- everybody shouldhave input in regards to the code. you would get information whether it be froma certified nurse’s aide, or nursing. but i think on the facility-level you wantto decide who ultimately is going to be the one who decides the code. and everybody has different processes, meaningany demonstration i've been in, each facility

really has their own way that they handletheir policy and procedures and how they deliver care. so it's important for the facility would bethe one who then decides that themselves. but we would expect multi-disciplinary teamsthat we would get a lot of input from across the disciplines. >>>> we have another question about a patientwho maybe has a special system for feeding, and so maybe eating is not something that'sgoing to be something they would be able to do at discharge. so is it acceptable to have another goal oflevel 1 dependent, the answer is absolutely

in that circumstances there maybe goals relatedto wheelchair mobility or other types of activities. but maybe eating is not something that theperson will be able to show improvement. and so it's absolutely acceptable to say thatthe person is dependent on in admission and dependent is a goal. â»â» another question is upper body dressing. it doesn't specify specifically sort of gatheringof the clothing items in whether to take that into account when coding. it needs to be more specific. are we just -- that's a good question andcomment.

-- are we just to assume. that's a good question and comment. this would be definitely part of the setupor cleanup assistance. so even though, i guess you can -- you oftenthink about sort of setting somebody up to bathe or whatever. but if you're gathering clothing and bringingit to the bedside that's part of that assistance. >>>> we had some general questions askingwhy certain activities like tub/shower are not on this particular -- in this particularsection. so, in part, you know, there are a lot ofactivities that are done in the rehab facility.

we're not asking for everything to be on thisdataset. because it could be very long if we had everythingthat could be possibly done. so we would absolutely encourage you to dothings that are relevant for your patients. but in that circumstance you don't need toreport it to cms. so tub/shower transfer, definitely somethingthat would be done, assessed, it's just not something you need to report to cms. yeah, i think, yeah, there was some -- i thinka question maybe that came in through the help desk that i don't think i addressed duringmy presentation. i just wanted to highlight that.

so the question was about what prior functioningtime frame was. so we talked about in the first couple ofquestions prior to the current illness, juror exacerbation. so the questions come in, what does that reallymean? i think we had an example where a patienthad a spinal cord injury like 30 years ago. and that the person had a pressure ulcer andmaybe some other complications. and they were admitted to either the irf directlyor to acute care and then the irf. so in this instance, it's really the pressureulcer situation complication that triggered the admission.

and so in this instance, the prior functioningis right before that kind of pressure ulcer event happened. and again, the purpose of us collecting thatdata is so that you can set goals based on the prior functioning. so i hope that kind of makes sense. that you would say okay, this person had aspinal cord injury 30 years ago. so whatever functional limitations that wouldbe associated with that, you would want to report that so we can risk adjust for that. and that person might be in a wheelchair,so obviously you want all that documented

so we can add adequately adjust for functionalimprovement. another example someone experiences a stroke,that's a common diagnoses in rehab. it would be immediately prior to the stroke. if somebody's had -- they're admitted fora stroke, and this is maybe the third time that person had a stroke, it would be rightbefore the most recent stroke. if someone is having surgery, it would beright before they're admitted to acute care for the surgery. so i hope that all makes sense. >>>> and there was another question for code03, is when the helper performs less than

50%. for code 02 it's when the helper performsmore than 50%. what do you code when the helper performsexactly 50%? >>>>that's a good one. so everyone has such wonderful backgrounds. this is really where it comes up to your clinicaljudgment. you don't have eyes looking at you makingsure it's actually 50%. but we really think, step back and just thinkabout sort of the big picture. and in that case, what does make more sense?

do you think it's more of a partial/moderateor more of a substantial/moderate assist? that's up to you. we had another question which was whetherthe information that's gathered during a pre-assessment could be used to complete some of the items. so the self-care mobility activities thatare gg0130 and 170, people's status can absolutely change, you can be doing your own assessment. but if in the pre-assessment there's informationabout prior functioning, absolutely you can use some of that. and i know when gina and karen present laterthey'll talk about things like influenza.

and certainly something like influenza statusmight be in some of that pre-patient assessment. that would absolutely be fine. so i hope that was the question that the personasked. they just generally had this question aboutpre-assessment. so i think prior functioning would be fine. i don't see the other information -- i don'tthink that that would be something that you would substitute for an assessment. >>>> another question was asked that says,are you saying there will be no risk of penalty for any dashes used for goals as long as onegoal is entered?

so, that is correct. however, we encourage you to -- if you'resetting more goals for the patient, if that's realistic, then we would hold it as part ofa good assessment and clinical practice that you would enter all of the goals that youset for the patient. i think those were the ones that we captured. so you know, we will be going through thesein more detail. we just had a short time to look through these. we will definitely be putting out more information. your questions are really appreciated to makesure that -- appreciated to make sure we're

meeting your educational needs. we just want to reinforce that cms does havea help desk for the inpatient rehab facility quality reporting program, and that i thinkthat will probably be presented maybe later today or tomorrow. and we encourage you to write questions, putfrequently asked questions on the website and maybe an update with a lot of this information. so, with that pso. so hopefully though we sort of hit the topfive to ten where we got a lot of questions. and again, that gg is a large section to getthrough.

so congratulations. you're finished with that. everyone's had lunch. so you're ready for the next section. so, thank you all. thank you for your questions. all right thank you. ...applause…