Comprehensive Approach to Treatment Planning in Cardiac and Pulmonary Rehabilitation

 
ITP
Treating the
Treatment
Plan
 
Gayla Oakley RN, CCRP, MAACVPR
Dir. Cardiology Services and Prevention
Boone County Health Center
Albion, Nebraska
 
                  Why                           How
o
 
This Photo
 by Unknown Author is licensed under 
CC BY
 
The  ITP tells the patient’s story.
The ITP is comprehensive, multidisciplinary,
including the patient input, document.
The initial assessment and plan set the stage for
successful treatment and meaningful outcomes.
It must address the areas of exercise, nutrition,
     psychosocial and other core components/risk
     factors specific to the individual patient.
 
 
 
Duties of the ITP
CMS
 
Why
 
This Photo
 by Unknown Author is licensed under 
CC BY
 
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      Because each MAC across the country enforces this
regulation differently, it is left up to the individual
programs to contact their MAC or AACVPR
Reimbursement Chair to learn how your MAC interprets
these regulations for your facility/location.
 
Exception to The Rules
Program
Certification
CMS
 
Why
 
This Photo
 by Unknown Author is licensed under 
CC BY
 
AACVPR Program Certification
 
 
     The AACVPR Cardiac and Pulmonary Rehabilitation
Program certification process is the only  peer-review
accreditation process designed to review individual
facilities for adherence to standards and guidelines
developed and published by AACVPR and other
professional societies.
 
Out of the 600+ programs submitted in 2018, 254 of
those were denied but eligible for remediation
because of problems with the ITP.
 
 
This Photo
 by Unknown Author is licensed under 
CC BY-SA
 
Top Reasons For Denial
 
 
 
Missing elements/steps
No evidence of progress toward goal
HIPPAA violations
MD signatures and dates greater than 30 days
Clear labeling
 
 
All of these are avoidable
 
This Photo
 by Unknown Author is licensed under 
CC BY-NC-ND
 
Core Elements:
 
1.
Exercise
2.
Nutrition
3.
Psychosocial
4.
Other Core
Components/Risk
Factors as applicable to
individual patient
5.
Oxygen use and
titration (required for
Pulmonary Rehab
application)
 
Four Required Steps
:
 
1.
Assessment
2.
Plan:
 Includes
Goals/Interventions
and Education
including 
initial
exercise prescription
3.
 
Reassessment:
        At least one
4.  
Discharge Plan
 
Individual Treatment Plan
 
 
 
Other Core Components
 
Other Cardiac Core Components/Risk Factors may
include items such as:
Hypertension - Cardiac
Diabetes
Weight Management
Lipids
Co-Morbidities
Other Pulmonary Core Components/ Risk Factors may
include items such as:
Tobacco Use - Cardiac
Environmental Issues
History of Exacerbations
Medication Adherence
 
Starting point
Gather information/behaviors to change and
determine outcomes to measure
Need all the data before you can make the 
Plan
Need an assessment for exercise, nutrition,
psychosocial, oxygen and other core
components/ risk factors that are important to
THIS
 individual patient
 
Example:
 (Exercise) 6 minute walk test
 
ITP Components
Initial Assessment
 
 
What are the 
Goals
?  Patient-centered
What 
Interventions
 (Actions) are necessary to
accomplish the goals established for the patient?
  
Example:  Exercise Prescription
Education
 to assist patient with self-management
Reasonable expectations
Specific, measurable and relevant
Individualize, keep in mind contraindications,
individual abilities, limitations
 
 
 
ITP Components
Plan
 
ITP Components
Re-Assessment
 
An opportunity to determine if your patient is
achieving the goals stated during the initial
assessment
Depending on their progress toward those goals,
what comes next? “Reassess the PLAN”, Set new
goals for the next 30 days, Proceed as planned
It is hard to do a reassessment with minimal
information
Gather information, assess behaviors and set
meaningful patient-centered goals
 
Example:  
Repeat 6-minute walk test
 
Was everything accomplished?
Where to go from here?
Keeping on track, what else might be helpful?
How is the ITP reviewed or revised?
Pose the next clinical question
Constantly evolving
Example:
 the goal to be able to walk 30 minutes
without stopping was 
not
 met…..now what?
Continue with maintenance rehab program,
update ExRx, encourage membership to gym,
establish new long-term goals
 
ITP Components
Discharge Plan
 
 
Cardiac and Pulmonary
Certification Application Requirements
 
HIPAA compliant
A single comprehensive document
Must be completed in the data collection period
Must be for an actual patient that has completed all required
elements and steps.
Must have a complete initial assessment, at least one
reassessment and a discharge plan
Must have the assessment and reassessment data/statements
on the ITP
Reassessments should include 
“progress toward goal”
information
Must include at least one “ACTIVE” core component
For Pulmonary Rehab, ITP must be submitted for a patient
using oxygen
Include 
physician signatures and dates
 at the initial assessment
and at least every 30 days thru discharge
 
Tips For Success
 
This Photo
 by Unknown Author is licensed under 
CC BY
 
HIPPA Compliant
 
 
HIPAA violations are an automatic denial of the page
Have at least two people look at any uploaded documents to ensure
no violations
 
Common HIPAA; N
ame, date of birth, telephone numbers, fax
numbers, electronic email addresses, social security number, medical
record number, health plan beneficiary numbers, account numbers
 
 
 
 
Missing Steps/Elements
 
 
No active core components
Pulmonary patient not on oxygen
Initial exercise prescription on the ITP
No reassessment
 
Evidence of progress toward goal
 
 
Make sure you provide details about progress – tell
the story!
An opportunity to determine if your patient is
achieving the goals stated during the initial
assessment
Reassess the plan, set new goals for the next 30 days
Data or scores at reassessment are required
It is hard to do a reassessment  with minimal
information
Lack of detail with progress toward goal – check off
boxes, no dates, no data
 
 
MD signatures and dates greater
than 30 days
 
Physician signatures and dates outside of 30 day
rule
New application platform
Establish a schedule of when the ITP’s are signed
(Day 21 each month)
Have a monthly program update meeting with MD
Electronic signature and date – ideal but does it
work for everyone
Pulmonary face to face
 
 
Clear labeling
 
 
Lack of clear labeling of the elements and steps.. help the reviewers
find what you want them to see.
Highlight it, circle it, put flashing lights on it….
Print off the ITP checklist
Make labels or write elements and steps on the ITP
 
 
 
 
Poor quality documents uploaded.
Missing documents.
The wrong requirements.
Correct data collection period.
Review and copy the application.
For pulmonary rehab, the ITP submitted has to be
on oxygen.
Must have one active core component.
Show your finest.
 
 
 
 
Double check, double check,
  
double check
 
Template
 
 
 
AACVPR does 
not
 endorse any ITP or ITP format published by
telemetry or electronic medical record companies.
Stuck in our “old ways”. We have been using the same documentation
forever. Old forms that don’t meet the needs of today and do you
need them.
Network with others in your state/region.
 
 
 
 
 
Template--Facility Specific
 
 
 
Make it work for you and use
it.
ITP is only as good as the
people that use it
 
 
 
This Photo
 by Unknown Author is licensed under 
CC BY-NC-ND
 
Template--EMR
 
EMR all different, even within the same
EMR’s are difficult to find elements.  Some ITP are long up to 40
pages.
Critical labeling.
Talk to your EMR vendor
 
 
Template—monitor co.
 
 
Monitoring company can be customized
Many different features
Reach out to other programs
Bridge to EMR
 
Pr
o
gram
Certification
CMS
 
Why
Good patient
care
 
This Photo
 by Unknown Author is licensed under 
CC BY
 
Patient’s rehab story from initial assessment to
discharge.
Individualized plan.
Discharge include assessment of goals met and
next steps.
Well designed
Makes job easier
Allow better patient management
Better individual and program outcomes.
 
 
 
 
 
 
Good Patient Care
 
2
0
1
8
 
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a
s
u
r
e
s
 
CARDIAC Performance Measures
Optimal Blood Pressure Control at Completion of Cardiac Rehab
Improvement in Functional Capacity at Completion of Cardiac Rehab
Improvement in Depression at Completion of Cardiac Rehab
Tobacco Use Intervention Performance Measure for Cardiac
Rehabilitation
 
PULMONARY Performance Measures
Improvement in Functional Capacity at Completion of Pulmonary Rehab
Improvement in Dyspnea at Completion of Pulmonary Rehab
Improvement in Health-Related Quality of Life at Completion of
Pulmonary Rehab
 
 
Stay Up-To-Date
 
 
Annual report
Web-casts
AACVPR web site
News and Views
Affiliate Meetings
AACVPR Annual Meeting
 
Case Example
 
This Photo
 by Unknown Author is licensed under 
CC BY-NC-ND
 
Is your ITP a “chore” to fill out?
Are you doing double and triple documentation?
Is your ITP a 
functional tool?
Is your patient 
involved
 in the monthly review?
Are you 
measuring
 meaningful information allowing
effective outcomes?
Does your ITP and how it’s utilized in your program
need some help?
 
Quality Improvement Process!
 
Ask the Questions…..
Find the Answers
 
This Photo
 by Unknown Author is licensed under 
CC BY-SA-NC
 
Goakley@boonecohealth.org
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The duties of an Individualized Treatment Plan (ITP) in cardiac and pulmonary rehabilitation encompass a holistic approach involving exercise, nutrition, psychosocial aspects, and individualized components specific to each patient. Compliance with CMS Conditions of Coverage and a thorough understanding of program components are crucial for successful outcomes. Additionally, programs must consider variations in enforcement across regions and seek clarification from relevant authorities to ensure adherence to regulations.


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  1. ITP Treating the Treatment Plan Gayla Oakley RN, CCRP, MAACVPR Dir. Cardiology Services and Prevention Boone County Health Center Albion, Nebraska

  2. o Why How This Photo by Unknown Author is licensed under CC BY

  3. Duties of the ITP The ITP tells the patient s story. The ITP is comprehensive, multidisciplinary, including the patient input, document. The initial assessment and plan set the stage for successful treatment and meaningful outcomes. It must address the areas of exercise, nutrition, psychosocial and other core components/risk factors specific to the individual patient.

  4. Why CMS This Photo by Unknown Author is licensed under CC BY

  5. . CMS Conditions of Coverage Code of Federal Regulations 42 CFR 410.47 (Pulmonary) 410.49 (Cardiac)

  6. Components of a Pulmonary Rehabilitation (PR) program: Physician-prescribed exercise each day Education and Training tailored to individual's needs -documented with signature, date and how it was addressed Psychosocial assessment - Does not need to be performed by a psychologist or psychiatrist. Validated tool or method of assessment, documented with signature, date with interpretation of the results Outcomes assessment- Did interventions/services result in benefit to the patient? An Individualized Treatment Plan detailing how the above components are utilized for each patient. The individualized treatment plan must be established, reviewed and signed by the Medical Director every 30 days Components of a Cardiac (CR) and Intensive Cardiac (ICR) rehabilitation program: Physician-prescribed exercise each day of cardiac rehabilitation Cardiac risk factor modification - including education, counseling, and behavioral intervention, tailored to the patients' individual needs (Note: Other Core Components/Risk Factors section of the ITP) Psychosocial assessment an evaluation of an individual s mental and emotional functioning as it relates to the individual s rehabilitation Outcomes assessment from the start and conclusion of CR/ICR, based on patient- centered outcomes; including exercise performance and self-reported measures of exertion and behavior An individualized treatment plan detailing how components are utilized for each patient. The individualized treatment plan must be established, reviewed, and signed by a physician (MD or DO) every 30 days.

  7. Exception to The Rules Because each MAC across the country enforces this regulation differently, it is left up to the individual programs to contact their MAC or AACVPR Reimbursement Chair to learn how your MAC interprets these regulations for your facility/location.

  8. Why CMS This Photo by Unknown Author is licensed under CC BY

  9. AACVPR Program Certification The AACVPR Cardiac and Pulmonary Rehabilitation Program certification process is the only peer-review accreditation process designed to review individual facilities for adherence to standards and guidelines developed and published by AACVPR and other professional societies.

  10. Out of the 600+ programs submitted in 2018, 254 of those were denied but eligible for remediation because of problems with the ITP. This Photo by Unknown Author is licensed under CC BY-SA

  11. Top Reasons For Denial Missing elements/steps No evidence of progress toward goal HIPPAA violations MD signatures and dates greater than 30 days Clear labeling

  12. All of these are avoidable This Photo by Unknown Author is licensed under CC BY-NC-ND

  13. Individual Treatment Plan Core Elements: Four Required Steps: 1. Exercise 2. Nutrition 3. Psychosocial 4. Other Core Components/Risk Factors as applicable to individual patient 5.Oxygen use and titration (required for Pulmonary Rehab application) 1.Assessment 2.Plan: Includes Goals/Interventions and Education including initial exercise prescription 3. Reassessment: At least one 4. Discharge Plan

  14. Other Core Components Other Cardiac Core Components/Risk Factors may include items such as: Hypertension - Cardiac Diabetes Weight Management Lipids Co-Morbidities Other Pulmonary Core Components/ Risk Factors may include items such as: Tobacco Use - Cardiac Environmental Issues History of Exacerbations Medication Adherence

  15. ITP Components Initial Assessment Starting point Gather information/behaviors to change and determine outcomes to measure Need all the data before you can make the Plan Need an assessment for exercise, nutrition, psychosocial, oxygen and other core components/ risk factors that are important to THIS individual patient Example: (Exercise) 6 minute walk test

  16. ITP Components Plan What are the Goals? Patient-centered What Interventions (Actions) are necessary to accomplish the goals established for the patient? Example: Exercise Prescription Education to assist patient with self-management Reasonable expectations Specific, measurable and relevant Individualize, keep in mind contraindications, individual abilities, limitations

  17. ITP Components Re-Assessment An opportunity to determine if your patient is achieving the goals stated during the initial assessment Depending on their progress toward those goals, what comes next? Reassess the PLAN , Set new goals for the next 30 days, Proceed as planned It is hard to do a reassessment with minimal information Gather information, assess behaviors and set meaningful patient-centered goals Example: Repeat 6-minute walk test

  18. ITP Components Discharge Plan Was everything accomplished? Where to go from here? Keeping on track, what else might be helpful? How is the ITP reviewed or revised? Pose the next clinical question Constantly evolving Example: the goal to be able to walk 30 minutes without stopping was not met ..now what? Continue with maintenance rehab program, update ExRx, encourage membership to gym, establish new long-term goals

  19. Cardiac and Pulmonary Certification Application Requirements HIPAA compliant A single comprehensive document Must be completed in the data collection period Must be for an actual patient that has completed all required elements and steps. Must have a complete initial assessment, at least one reassessment and a discharge plan Must have the assessment and reassessment data/statements on the ITP Reassessments should include progress toward goal information Must include at least one ACTIVE core component For Pulmonary Rehab, ITP must be submitted for a patient

  20. Tips For Success This Photo by Unknown Author is licensed under CC BY

  21. HIPPA Compliant HIPAA violations are an automatic denial of the page Have at least two people look at any uploaded documents to ensure no violations Common HIPAA; Name, date of birth, telephone numbers, fax numbers, electronic email addresses, social security number, medical record number, health plan beneficiary numbers, account numbers

  22. Missing Steps/Elements No active core components Pulmonary patient not on oxygen Initial exercise prescription on the ITP No reassessment

  23. Evidence of progress toward goal Make sure you provide details about progress tell the story! An opportunity to determine if your patient is achieving the goals stated during the initial assessment Reassess the plan, set new goals for the next 30 days Data or scores at reassessment are required It is hard to do a reassessment with minimal information Lack of detail with progress toward goal check off boxes, no dates, no data

  24. MD signatures and dates greater than 30 days Physician signatures and dates outside of 30 day rule New application platform Establish a schedule of when the ITP s are signed (Day 21 each month) Have a monthly program update meeting with MD Electronic signature and date ideal but does it work for everyone Pulmonary face to face

  25. Clear labeling Lack of clear labeling of the elements and steps.. help the reviewers find what you want them to see. Highlight it, circle it, put flashing lights on it . Print off the ITP checklist Make labels or write elements and steps on the ITP

  26. Double check, double check, double check http://cdn2.hubspot.net/hub/178693/file-390535718-jpg/images/avoiding-pitfalls-resized-600.jpg Poor quality documents uploaded. Missing documents. The wrong requirements. Correct data collection period. Review and copy the application. For pulmonary rehab, the ITP submitted has to be on oxygen. Must have one active core component. Show your finest.

  27. Template AACVPR does not endorse any ITP or ITP format published by telemetry or electronic medical record companies. Stuck in our old ways . We have been using the same documentation forever. Old forms that don t meet the needs of today and do you need them. Network with others in your state/region.

  28. Template--Facility Specific Make it work for you and use it. ITP is only as good as the people that use it This Photo by Unknown Author is licensed under CC BY-NC-ND

  29. Template--EMR EMR all different, even within the same EMR s are difficult to find elements. Some ITP are long up to 40 pages. Critical labeling. Talk to your EMR vendor

  30. Templatemonitor co. Monitoring company can be customized Many different features Reach out to other programs Bridge to EMR

  31. Why CMS This Photo by Unknown Author is licensed under CC BY

  32. Good Patient Care Patient s rehab story from initial assessment to discharge. Individualized plan. Discharge include assessment of goals met and next steps. Well designed Makes job easier Allow better patient management Better individual and program outcomes.

  33. 2018 Performance Measures CARDIAC Performance Measures Optimal Blood Pressure Control at Completion of Cardiac Rehab Improvement in Functional Capacity at Completion of Cardiac Rehab Improvement in Depression at Completion of Cardiac Rehab Tobacco Use Intervention Performance Measure for Cardiac Rehabilitation PULMONARY Performance Measures Improvement in Functional Capacity at Completion of Pulmonary Rehab Improvement in Dyspnea at Completion of Pulmonary Rehab Improvement in Health-Related Quality of Life at Completion of Pulmonary Rehab

  34. Stay Up-To-Date Annual report Web-casts AACVPR web site News and Views Affiliate Meetings AACVPR Annual Meeting

  35. Case Example This Photo by Unknown Author is licensed under CC BY-NC-ND

  36. Ask the Questions.. Find the Answers Is your ITP a chore to fill out? Are you doing double and triple documentation? Is your ITP a functional tool? Is your patient involved in the monthly review? Are you measuring meaningful information allowing effective outcomes? Does your ITP and how it s utilized in your program need some help? Quality Improvement Process!

  37. Goakley@boonecohealth.org This Photo by Unknown Author is licensed under CC BY-SA-NC

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