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Shifting Rehab Paradigms

H. pylori and Parkinson's Disease
by Viktoriya Friedman

Helicobacter Pylori (H. pylori) is a bacterium often present in upper GI tract in gastric ulcers. This bacterium has been shown to compromise levodopa absorption in the gut, thus limiting its effect. Levodopa with carbidopa (Sinemet) is often a drug of choice for patients with PD and for good reasons.

Sinemet is a dopamine agonist and helps many patients with PD improve mobility, minimize bradi and akinesia. Many patients rely on it heavily for daily functional mobility; thus if the action of this medication is compromised by patient’s enteral system due presence of H. pylori, then the symptoms of PD prevail.

So how prevalent is H.pylori infection in patients with PD? According to Hashim, H. et al, they found 32.9% of their study sample tested positive for H. pylori. Using C-urea breath test (UBT) is a non-invasive and not expensive way to test for presence of H. pylori in the gut. Eradication of this bacterium is also somewhat simple. Usually, the doctor prescribes the “triple therapies,” which includes one proton pump inhibitor and two antibiotics.

Hashim’s study revealed findings at six and 12 weeks to be very positive. Patients who tested positive for H. pylori via UBT and undergone standard tripe therapy eradication improved their mobility, motivation, ADLs, gait, “ON” time and overall quality of life as noted in standardized tests such as PDQ-39, UPDRS and others.

Though association between H. pylori and Parkinson’s disease (PD) is increasingly recognized, still very few patients actually undergo testing and its eradication. As therapists, we should be aware of this finding and advocate for our patients.



1) Hashim, H., Azmin, S., Razlan H., et al. Eradication of helicobacter pylori infection improves Levodopa Action, clinical symptoms, and quality of life in Patients with Parkinson’s Disease. PLosONE9 (11) 2014.

The Other Movement Disorder
by Viktoriya Friedman

Parkinson’s disease is best known for how it manifests itself: presenting with gait and movement dysfunction related to dopamine depletion. What about other movement disorders?

Though diseases such as progressive supranuclear palsy, Lewy body, multiple systems atrophy and corticobasilar degeneration may present similar to idiopathic Parkinson’s disease, there are clinical features that differentiate them. For the first time, in my professional carrier, a patient with a different kind of movement disorder was referred to me – akathisia, which is a scientific word for severe, drug-induced restlessness. The reason for physical therapy: falls

Parkinsonism, related to antipsychotic or neuroleptic medications, presents very similarly to idiopathic PD. Patients display bradykinesia, rigidity and mask-like facies, but they have an underlying psychiatric condition that requires treatment with antipsychotic or neuroleptic medications. Akathisia, on the other hand, presents differently. It resembles severe agitation, leg tapping, and constant movement can be debilitating for patients and can cause imbalance.

It is important for therapists to recognize this manifestation of drug-induced movement disorders by taking a thorough initial history and being aware of medication adjustments. Though akathisia is generally resolved when neuroleptic medications are discontinued or modified, physical therapy for balance and strengthening can be very beneficial. Gait training that focuses on amplitude mitigation and stride-length cadence improvement can help to improve gait rockers. Balance exercises that include dynamic gait and multitasking, pacing and stopping to make safe decisions can improve fall prevention strategies. 

The Health Files: Ethics
by Viktoriya Friedman

The Office of Inspector General (OIG) and the US Department of Health and Human Services (HHS) has been focusing on practice of skilled nursing facilities (SNFs) more closely for over a decade; however, since the 2009 report summarized heavy resource utilization groups (RUGs) overbilling, things have gone downhill. Unfortunately, despite attempts to place greater focus on skilled nursing care and outcome measures by reformulating RUGs, PEPPER reports tracking benchmarks and introducing G codes to track functional outcomes, Medicare payments during 2012 and 2013 have risen continuously, resulting in a staggering $1.1 billion. According to the OIG, almost 80% of that increase is due to “ultrahigh” RUGs. In fact, according to OIG’s 2015 Semiannual Report, the agency recouped $3.35 billion from Medicare overpayments. So who is billing ultra-high RUGs with no apparent improvement in outcomes?  Let’s go to the source.

Rehabilitation professionals are prescribing therapy intensity, duration, frequency and mode. I love my profession, but I am troubled to look into the future because many employers continue to stress high benchmarks for therapy utilization groups, case mix index (CMI) and daily productivity which may be influencing prescription of therapy. The ethical values of our profession are being stretched thinner and thinner.

Despite the spike in ultrahigh RUG utilization, quality of therapy has not changed in most organizations, nor have patients’ functional outcome measures.  Many therapists still do not even use standardized tests and measures to quantify data. An obvious gap exists between quality and quantity of services provided. Regardless of the flaws in the system, we, therapists, are part of this dilemma. The organizations that hire therapists set expectations and we are “forced” to comply. Or are we not? Do we question if expectations are ethical and if so, what’s next? Do we lose the job or pass on a promotion? When a therapist functions both as a clinician and a financial manager, who has revenue integrity in mind, making ethical decisions can be even more difficult. I am not looking to blame or point fingers, but let’s face it: The bottom line is that prescribing quantity and quality of skilled therapy is in our hands, and patients’ outcomes as well as outcomes of this debate affect the future of this profession.

CMS announced last year a new ACO payment initiative called the Next Generation ACO Model, designed for entities experienced in coordinating care for populations of patients. Next Generation ACOs reflect CMS' commitment to exploring different Medicare payment arrangements that encourage providers to assume higher levels of financial risk and reward while delivering quality care, as this ACO Model is focused even more on value-based contracting2. As the healthcare model changes from reimbursing for services provided to reimbursing for quality of services provided I can’t help but question if most SNFs will continue with the same rehabilitation practices? Will they have new metrics for measuring therapy outcomes? Will reimbursement to those SNFs that change nothing be negatively affected? Will RUGs be still utilized in collaboration with quality metrics to determine reimbursement?   As many already know, in 1998, RUGs were introduced as mutually exclusive categories that reflect levels of resource used in long-term care settings. Standard order or hierarchy exists and each RUG is associated with relative weighting factors and respective reimbursement. Similarly, case mix index (CMI), is used to determine the allocation of resources to care for patients in SNFs. Yes, resident and patient acuity (health and functional status) has a major impact on facility resources requirements (CNA, Nursing and Medical staff staffing), but many SNFs and rehabilitation companies work backwards, by setting benchmarks to be met. In addition to setting benchmarks for therapy utilizations, therapists have productivity benchmarks to meet, which do not take into consideration patient transportation, family consultation, case conferences, and viable clinical documentation. No doubt the cost structure must be reevaluated, so worth of value can be redirected from volume to value. As Chris Hayhurst pointed out in PT inMotion magazine published on July2015 that many therapists are “… frustrated with the disconnect between measuring performance and productivity by volume only and missing the "value" part of the equation.”

CMS is moving forward with the new payment and rewards model. In January 2016, the HHS announced that by the end of 2016, it aims to link 30% of Medicare reimbursements to the “quality or value” of providers’ services, and 50% by the end of 2018. According to HHS Secretary Sylvia Burwell, the goal is “to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients3.”

According to CMS, the Health Care Payment Learning and Action Network will perform the following functions:

·         Serve as a convening body to facilitate joint implementation of new models of payment and care delivery,

·         Identify areas of agreement around movement toward alternative payment models and define how best to report on these new payment models,

·         Collaborate to generate evidence, share approaches, and remove barriers,

·         Develop common approaches to core issues such as beneficiary attribution, financial models, benchmarking, quality and performance measurement, risk adjustment, and other topics raised for discussion, and

·         Create implementation guides for payers, purchasers, providers, and consumers.


Despite major glitches in the system, the show must go on. Some therapists are vocal about making changes in this system. Others are complacent with salary and expectations, but on daily basis, most therapists are faced with ethical dilemmas to stay compliant with productivity, RUG and CMI expectations all while making goals to improve patient outcomes. Despite the fact that many rehabilitation professional organizations joined in to publish a “Consensus statement on clinical judgment in healthcare settings,” which discusses how “decisions regarding patient/client care should be made by clinicians in accordance with their clinical judgment1,” many therapists continue to normalize a routine of seeing most patients for 720min/week and doing house-wide patient screens two weeks prior to CMI assessment period. It surely boosts the reimbursement, but is this normal, ethical, accepted? One solution I found to work is development of specialized programs. As part of specialized program protocols it is paramount to use evidence-based protocols to document progress as well as focus on staff and leadership growth. 


1. Link to: Consensus statement on clinical judgment in healthcare settings

2. Next Generation ACO Model, Centers for Medicare & Medicaid Services.

3. Link:

PEPPER, Anyone?
by Viktoriya Friedman

PEPPER reports have been around in the acute world since 2003, and now they are trickling over to the other worlds of healthcare. “Program for evaluating payment patterns electronic report,” or PEPPER programs, have been recently introduced to skilled nursing facilities.

This report contains data on your SNF’s Medicare claims statistics. Though PEPPER does not identify issues with payments, it does give clues of what areas may be target for an audit. Thus, you get to do your internal review before Big Brother.

As your facility receives this report, who should be looking at it? In my opinion, it should be your director of rehab, MDS coordinator, billing personnel, director of nursing and QA manager.

This report includes areas such as therapy services with high ADL scores, non-therapy services with high ADL scores, changes in therapy assessments, ultrahigh therapy rug scores, therapy rugs and 90-plus day episode of care. All of these have been red flags and hot topics for reviews by RACs, MACs and OIG in the past, so no surprise that TMF (a private organization working these statistics) has used these criteria to review.

Once you see a percentile for your facility and how it relates to the state and national averages, you may want to audit areas that fall above 80% and below 20% in order to minimize the risk for improper Medicare billing. Use this tool to be ahead of the game.

Data Mining and Analytics in Healthcare
by Viktoriya Friedman

With use of the Internet increasing exponentially, the amount of data being processed has exploded. Nowadays, even the healthcare business, a world of its own, untouched by the IT phenomena one decade ago, is forced to embrace the Internet. Currently, customer behaviors and preferences, their medical information and  shopping patterns are mostly all online. With this amount of information to process, the need for data mining of this large scale data became more obvious 1. Data mining, a field at the intersection of computer science and statistics,1, 2, 3 is the process that attempts to discover patterns in large data sets. It utilizes methods at the intersection of artificial intelligence, machine learning, statistics and database systems.The overall goal of the data mining process is to extract information from a data set and transform it into an understandable structure for further use.2

Doesn’t this sound fantastic? As a private owner of a physical therapy clinic, I would want to know everyone searching the web to find the right exercises, to minimize joint pain, or to improve their golf swing after a shoulder surgery. As a director of rehabilitation services, I would like to find out who is searching the web to find the best short term rehabilitation center in the area for their loved one. As a physical therapist, I would like to have software that allows me to enter objective data from my evaluation and will yield a set of potential diagnoses to optimize my treatment plan of care. As a mom of two kids who were raised to like organic almond milk, I would hope local stores are making a note of this fact and are sending me some coupons for my future milk purchases. That’s data mining and it’s everywhere.

How can data mining benefit healthcare and how can we embrace this technological phenomenon? Because standardization of data is at the core of data mining, healthcare professionals must embrace and perfect the use of EHR.

Dr. Chid Apte is a director of analytics research in the IBM Research Division at the Thomas J. Watson Research Center in Yorktown Heights, New York.  In one of his publications, Data mining and clinical data repositories: Insights from a 667,000 patient data set, he concluded that data mining technologies “…have the potential to expand research capabilities through identification of potentially novel clinical disease associations2.” Using analytics in healthcare is not only beneficial, but essential. For example, companies such as Edifecs assist in ICD-10 compliance. According to the company, Edifecs ICD-10 Impact Analytics enables healthcare entities to identify ICD-10 impacts based on their historical data. This is a critical first step toward understanding the challenge and determining how to address the ICD-10 mandate. As our healthcare world is striving to become more standardized in evaluations of diseases, treatment techniques and preventive medicine, data mining can be the essential step in maximizing clients’ quality of care and quality of life.




2.       Statistics and Web Analytics – Hypothesis Testing:



by Viktoriya Friedman

In 2004, telemedicine was listed as a key aspect of New York State’s initiative to improve access and quality in health care through advances in technology. Electronic records and electronic drug prescriptions were the other two criteria.

According to Gregory Young, MD,F.A.C.E.P, Medical Director, Western Region of New York State Department of Health, “Telemedicine is a critical part of the future of medicine.” A few years into the initiative, our local government took active role in making this happen. According to Pressconnects, on June 27, 2013, “The Southern Tier Regional Economic Development Council approved an initiative that would allow health care providers in the eight-county region to apply for $2.5 million in funding.”

This initiative, called the Telemedicine and Mobile Technology Fund, is expected to get the green light from the Empire State Development Corp. Board of Directors. Programs such as the Community Revitalization Program and the Rural Initiative Program were established in 2012 using state economic development funds. The Telemedicine and Mobile Technology Fund, the latest in the line of these community revitalization initiatives, would use $2.5 million available from the second round of state funds (2).

Telemedicine means faster and easier access to your healthcare provider. Though, some clients favor remote visits due to difficulties associated with leaving their house, travel expenses and occasional lapses in office schedules, leading to prolonged waiting or on the spot cancelations. Others, like me dislike visiting a germ-ridden waiting room for other reasons. In both cases, a remote access to the medical team is the best solution. Not to say that telemedicine should be used to replace all office visits, but the ones that consists of subjective rather than objective data gathering.

One local facility has provided telemedicine for three years. Susquehanna Nursing and Rehabilitation Center (SNRC) offers tele-visits with a movement disorder specialist from the University of Rochester to their inpatient clients and clients in the community living with movement disorders such as Parkinson’s disease.

Dr. Kevin Biglan, associate professor of Neurology at University of Rochester has been researching benefits of telemedicine in clients with Parkinson’s disease for more than five years. He finds that having access to telemedicine allows for better treatment of symptoms, better satisfaction and better quality of life for clients. Dr. Biglan has been working with Susquehanna Nursing and Rehabilitation Center for the past three years.

In our facility, telemedicine visits have prompted better multidisciplinary communication by involving a skilled therapist and a nurse as part of all the visits. Telemedicine allows for “real-time” visits (where a client can be seen when they are having specific symptoms), minimizes travel costs (including stress) and allows clinical staff in our facility easy access to Dr. Biglan, thus optimizing clients’ quality of care.

The downfall of this program is that insurance does not recognize telemedicine in our region, and most clients have to pay for their visits out of pocket. SNRC  holds an annual fundraiser in the month of April, which is Parkinson’s Awareness Month, to assist clients in the community who are not able to pay for the visits.  Our facility has covered the cost of the visits for those clients residing at SNRC or staying here for short-term rehabilitation.  Despite the cost of this program, monthly telemedicine schedule is always full. Providing quality healthcare at a distance is a great solution for many, but can be challenging and easily abused if the correct quality measures are not utilized.  



2. Jon Harris for pressconnects July 27, 2013

Medical Screening
by Viktoriya Friedman


When comparing “non-claims” physicians with physicians who had suits filed against them, the average length of patient encounter time difference was only 3 minutes. The difference in length of visits had an independent effect in predicting the physicians’ claim status (1). This documented finding proves that it is not the length of visit, but the quality of the medical visit that is responsible for positive versus negative encounter. How thorough was your patient’s last doctor’s visit? How thorough was your initial physical therapy assessment of this patient? Is there a chance you overlooked acute cholecystitis and treated your patient for lower quadrant muscle strain because that was on the script from the doctor? In my professional career, I had worked with physicians who had claims against them and those who had patients’ “thank you” notes in the office. I have worked with a variety of rehabilitation professionals as well.

For PTs, just like for physicians, providing quality of care starts with a thorough medical screening process during your initial assessment. On the positive side of this is direct access, which no longer mandates a physician’s referral and allows physical therapists to evaluate and even treat (in some states). In the healthcare environment that is progressively focusing on quality of care provided, the evaluation process which includes the paramount patient interview is frequently skimmed over.

Medicare A doesn’t even reimburse (minutes are not counted towards MDS) for the therapy evaluations and Medicare B reimburses at a service-based rate, so the physical therapist must be self-motivated to spend more than 15-20 minutes since reimbursement is the same regardless of time spent with patient. 

In this case, how much time is adequate? I revert back to my initial point, if you are confident that your 15 minute evaluation covered all the bases, and you effectively communicated with and listened to your patient, it’s enough.

Medical screening is at the root of what we do. Many PTs are so used to being spoon-fed the diagnoses that they eliminate medical screening and differential diagnoses from their initial evaluation process. I had a patient come to me with a script: “PT 3 times per week for LE strengthening secondary to exacerbation of PD.” In retrospect, I am scared to think of what would happen if I didn’t complete a comprehensive evaluation. During my evaluation, findings didn’t jive with the diagnoses. I called his neurologist and asked for radiographic studies of low back but was denied. I called his PCP and asked for the same. PCP agreed and findings were positive for spinal tumor.

In another instance, a young female patient presented a script for foot pain, but was urgently referred back to orthopedics by me based on my evaluation process where she mentioned change in her regular running routine. Imaging was positive for a fifth metatarsal stress fracture and mild osteoporosis.

A healthcare provider who cannot take a good history and a patient who cannot provide on are at risk of giving and receiving compromised care. To improve the quality of care, engage in open-ended questioning, listen actively and allow for a patient-centered environment. Make your patient comfortable enough to share details.

1.       Levinson W, Roter D. Physicians’ psychological beliefs correlate with their patient communication skills. J Gen Intern Med 1995;10:375-9

Healthcare Management
by Viktoriya Friedman

The healthcare management world is filled with clinicians. Unlike the corporate environment where most are trained and obtain a management degree in business, the healthcare hierarchy is built on direct care providers. Though direct knowledge of healthcare is a huge asset, most managers, once they transition into this role, do not feel the necessity to grow as leaders. As healthcare is becoming more structured, it is essential for management, including Directors of Rehabilitation and Nursing to be committed to grow as leaders and determined to build effective teams.

The ever-growing requirements of our governing bodies, such as CMS and our professional organization, rarely complement requirements mandated by our organizations. Many times this issue is further exacerbated for Directors of Rehabilitation Services when one works for a contract company with expectations not clearly aligned with in-house policy and procedures.

Most of us have worked for a boss that likes to hear themselves talk, as well as the one that assumes everyone will just self-organize and just “get things done.” As I transitioned from being a staff physical therapist to managing the department, I craved to work for a manager that can also lead. I wanted to learn from that, be inspired and grow as a manager.

Initially, I struggled to find peers in the same positions to bounce ideas off of. Most of them, though great clinicians, were managing therapy minutes and not at all focused on growing and developing employees. I knew how to maximize Resource Utilization Groups (RUG). I really wanted to learn how to lead my team.

With seven successful years under my belt, I would suggest taking the following steps for those managers seeking to train as leaders:

1.      Know thyself. Recognize your weaknesses and have measurable, timely goals to eliminate them. If you know your emotions take over when you strongly disagree with a team member, learn how to minimize the negative effect of adrenaline on your body. In the modern world, some of our most important battles are fought with colleagues and even loved ones. Thus, we need brain power. Not only know what helps you communicate most effectively, but dive into questions such as: “Am a leader or a dictator?” “Do I delegate?” “Do I speak more than I listen?”

2.      Ensure you have great people as your key staff. Know natural instincts of your subordinates and develop them accordingly. Many research-based tests exist, as simple as a work performance questionnaire to Myers-Briggs. Use this set of data to understand your team better.

3.      You must know your stuff.  Just like a project manager for an IT team, DOR and DON must know the specs of their jobs and the jobs of their subordinates. This includes knowing the CMS lingo, guidelines and requirements and knowing how to maximize revenue. If you don’t know, please don’t act as if you do; most of your staff will read through you, and you will spend great effort rebuilding respect.

4.      Have a plan if you want to succeed. What are the goals for your organization, your team, your individual staff members and yourself? Is the goal to start an outpatient clinic in your facility, to reach out to community by providing better resources, to maximize communication between departments? How do you get there?

5.       Focus. Learn to prioritize.

6.      Action is the key to take your achieve your goals. Don’t delay

Ineffective communication among healthcare providers leads to disasters. Studies have shown that lack of effective communication leads to serious mistakes in the healthcare world, yet evidence-based leadership and communication training is hard to find. In fact, The Joint Commission in America has reported that the primary root cause of over 70% of sentinel events was communication failure (1). Moreover, The Department of Veteran’s Affairs (VA) National Center for Patient Safety in America has identified communication failure in healthcare as the primary root cause of 75% of more than 7,000 root cause analyses of adverse events and close calls (2, 3).


In healthcare, effective communication requires a wide range of skills such as assertiveness, active listening, etc.

Leadership Toolbox
by Viktoriya Friedman

Not all managers are leaders, and not all leaders are created equal. Though healthcare may be lagging in style of leadership, few managers stand out of the crowd.

Here are few tools for your management toolbox to help you develop your leadership skills:

1. Prioritize. You must assign high to low priority to your tasks. Note: Most people will procrastinate on the more difficult tasks. Doing this will make your to-do list longer and you will feel that you have accomplished nothing in your day. Take care of your high priority tasks first!

2. Know your employees. Though some managers prefer to think about their subordinates as such, many of us do not. They are human beings. If you've read anything about Dale Carnegie or Warren Buffet, our country's top businessman and leaders, you know that they personalized their relationships with their employees. Surprise your employee by signing a funny Birthday card and involve the rest of the team.

3. Stand up for your employees. Have you ever heard one of the employees say, "don't waste your time talking to him; it won't do you any good," speaking about your manager?  As a manager, you must stand up for your team. It's hard to be the middleman between administration and your staff, but that's the assumed role of a manager. Step up!

4. Delay your emails and don't work your life away. Please don't think that just because your email goes out at 11 p.m. on Sunday, everyone will think that you are a much better manager. Spreading a workaholic culture or expectation is wrong. Based on many studies, if you shoot for a "work smarter, not harder" culture, your employees will respect you more.

5. Decide on your style of management. Indecisiveness is bad for employees. Not knowing what to except from their manager is even worse for them. Decide if you must micromanage (not advised) or if you like an open door policy. Whatever you decide, make sure your employees understand your expectations.

Even though most clinical managers have grown into the position and did not obtain it after a completion of a resourceful MBA program, we should strive to be leaders. Healthcare is evolving - so should the management aspect of healthcare.