Transcript Cognitive Rehabilitation

Agenda
 Introduction
 Research Evidence
BREAK (10:30-10:45)
 Insurance/Documentation Nuts ‘n Bolts
 Question and Answer
2
Introduction
1. What is cognitive rehabilitation?
2. Who provides cognitive rehabilitation
services?
3. What are different types of cognitive
rehabilitation?
3
What is Cognitive Rehabilitation?
 Cognitive rehabilitation is a systematically
applied set of medical and therapeutic services
designed to improve cognitive functioning and
participation in activities that may be affected by
difficulties in one or more cognitive domains.
(It) is often part of comprehensive
interdisciplinary programs…based upon sound
scientific theoretical constructs and strategic
approaches…
4
Cog Rehab Definition (cont)
 Treatment goals vary depending on the etiology,
extent and severity of injury to the brain, the
timing of treatment, individual differences,
phase of recovery and prospects for restoration
or compensation of a problem with remedial
interventions. Treatments may be process
specific…or skill-based, aimed at improving
performance of particular activities…
5
Cog Rehab Definition (cont)
…The overall goal may be restoring function in
a cognitive domain or set of domains or
teaching compensatory strategies to
overcome domain specific problems,
improving performance of a specific activity,
or generalizing to multiple activities.”

“Cognitive Rehabilitation: The Evidence, Funding and Case for
Advocacy in Brain Injury”, BIA, Nov. 2006
6
Examples of Types of Cognitive
Rehabilitation (CR)
 Executive Functions: Problem-solving & selfmonitoring strategies
 Memory: Training use of external memory aids
(ex. diaries, notebooks or PDAs) & strategies
(ex. imagery)
 Attention: Attention process training; strategies
training (ex. time management)
7
Examples of Types of Cognitive
Rehabilitation (CR)
 Communication: Functional communication
training (ex. listening to directions; asking for
help)
 Task Specific Training (ex. filing tasks; dressing
routines)
 Environmental Modifications (ex. change
lighting; decrease noise)
8
Who provides CR services?
 Certified speech-language pathologists,
occupational therapists, vocational
rehabilitation counselors, neuropsychologists
 May work collectively with patients as part of
a team or individually
 CAUTION: Some service providers claim
expertise in providing these services
9
Research evidence
10
Rational Decision Making
 Requires that clinicians provide an explicit
rationale for clinical choices




Treatment candidacy (who to treat)
Treatment targets (what to treat)
Treatment approaches (how to treat)
Treatment progression and modifications
(measurement—how to measure whether client
behavior is related to treatment)
 Treatment schedules (when/how much to treat)
11
What is evidence-based
practice?
“...an approach to decision making in which the
clinician uses the best evidence available, in
consultation with the patient, to decide upon the
option that suits that patient best.”
Muir Gray (1997)
“…the conscientious, explicit and judicious use
of current best evidence in making decisions
about the care of individual patients.”
Sackett et al. (1996)
12
Making Clinical Decisions
BEST AVAILABLE
EVIDENCE
CLINICIAN
EXPERTISE
CLIENT’S VALUES
AND PREFERENCES
13
Best Available Evidence
 Theoretical knowledge
 Client-generated data
 Empirical evidence (EBP)
14
Traditional Evidence
Classifications
 Class I: One or more well-designed randomized,
controlled trials (RCTs)
 Class II: One or more well-designed, observational
clinical studies with concurrent controls (e.g.,
control or cohort studies), including single subject
designs with multiple-baselines and 2 or more
participants
 Class III: Expert opinion, case series, case reports,
studies with historical controls
Quality Standards Subcommittee of the
American Academy of Neurology (1999)
15
Classifying Practice
Recommendations
 Standard
 High degree of certainty based on Class I or very
strong Class II studies
 Guideline
 Moderate degree of certainty based on Class II or
strong consensus from Class III studies
 Option
 Evidence is inconclusive (e.g., conflicting, expert
opinion)
16
But keep in mind…
 As heterogeneity increases, RCT results are
less applicable
 Evidence from other populations has relevance
 Clinically meaningful outcomes are often
personal and social judgments
Montgomery & Turkstra, 2003
Ylvisaker et al., 2002
17
To be a Critical Consumer: PROBE
(www.asha.org)
 Population: Is the information relevant to your
patient population & circumstance?
 Results: Do you believe the results? Are they
positive and what aspects of the intervention do
YOU believe are responsible for reported
outcomes?
 Objectivity & Bias: Any bias?
 Evidence: Is there scientific evidence to support
the report?
18
Types of evidence reviews & domains
Types: Broad reviews vs. reviews to generate Practice
Guidelines (see below)
Practice Guidelines Topics (www.ancds.org)

Assessment
 Standardized
 Nonstandardized

Intervention





Attention training
Use of external memory aids
Intervention for impaired executive function and metacognition
Intervention for social and behavioral disorders
Instructional techniques
19
Previous Broad Reviews
NIH Consensus report (1999), JAMA (1999)
 Very broad review
 Epidemiological, ICD2 outcomes, underlying
mechanisms, treatment for behavioral and cognitive
sequelae, general models of rehabilitations
 Preferred large RCTs
 Source of individual recommendations not
discernable (e.g., expert opinion versus RCTs)
 Written for physicians
 Identified future research needs
20
Broad Reviews
Cicerone et al. (200o, 2005)
 Target areas:







Attention
Visual perception and construction
Language and communication
Memory
Problem solving and executive functions
Multi-modal intervention approaches
Comprehensive/holistic approaches
21
Cicerone et al., (2000, 2005)
Summary
Substantial evidence for:
 cognitive rehabilitation following TBI, including
strategy training for memory and attention deficits
and functional communication treatment
 cognitive-linguistic treatment following left CVA
 apraxia treatment following left CVA
 Visual-spatial treatment for left neglect following right
CVA
22
Practice Guideline Reviews
 Assessment
 Standardized
 Nonstandardized
 Intervention





Instructional techniques
Attention training
Use of external memory aids
Intervention for social and behavioral disorders
Intervention for impaired executive function and
metacognition
23
Standardized Assessment
Turkstra, Ylvisaker, Coelho, Kennedy, Sohlberg, & Avery (2005)
Test with good reliability/validity:
 ASHA-FACS
 Behavior Rating Inventory of Executive Function
 Communication Activities of Daily Living - Second
Edition
 Repeatable Battery for the Assessment of
Neuropsychological Status
 Test of Language Competence-Extended
 Western Aphasia Battery (i.e., CQ)
24
Standardized Assessment
Practice Guidelines
 Must clarify purposes of assessment and choose
appropriate tools
 Use caution in applying most standardized tests for
persons with TBI
 Consider standardized testing within broader framework
that considers pre-injury characteristics, stage of
development and recovery, life and communication
context
 Integrate cognitive-communication assessments with
those of other professionals whose scope of practice
includes cognitive assessment, particularly
neuropsychology
25
Non-standardized Assessment
Coelho, Ylvisaker, & Turkstra (2005).
 Conversational discourse
 Measures of content and topic management appeared to be
most useful
 Appears to better discriminate individuals with TBI from peers
than does monologic discourse
 Pragmatic rating scales appear useful but require
training and are psychometrically weak
 Interpretation of discourse analyses must consider
context
26
Non-standardized Assessment
Summary
 There is evidence to support the use of discourse measures,
particularly conversations, for discriminating individuals with TBI
from peers
 Impairments of social cognition are a source of long-term
disability, and tools are needed
 There is evidence that collaborative, contextualized hypothesis
testing should be used for planning behavioural intervention and
supports
 There is limited research on the effect of partner competencies,
and existing “checklists” are methodologically weak
 Checklists for evaluating environmental demands need validation
27
Direct Attention Training
Sohlberg, Avery, Kennedy, Coelho, Turkstra, Ylvisaker, & Yorkston (2007)
 Based on the premise that attentional abilities can be
improved by activating particular aspects of attention
through a stimulus drill approach
 Repeated stimulation of attentional systems via graded
attention exercises is hypothesized to facilitate changes in
attentional functioning
 Includes functions related to sustaining attention over
time (vigilance), information processing capacity and
speed, shifting attention, resisting distraction
28
Direct Attention Training
Practice Guidelines
 Treatment gains beyond the clinic were observed only
in studies with
a)
b)
c)
d)
individualized attention exercises
treatment sessions that were 1 hr (vs. 2 hr) in duration
at least weekly treatment sessions
outcome measures that included a range of different tests
sensitive to attention and working memory
e) outcome measures that included activity-based measures
using client self-report data.
29
External Memory Aids
Sohlberg, Kennedy, Avery, Coelho, Turkstra, Ylvisaker, & Yorkston (2007)
 Provide the user with a way to compensate for
memory impairments by using a tool or device
that either limits the demands on a person’s
impaired ability, or transforms the task or
environment such that it matches the client’s
abilities
 Other terms for external aids: cognitive
orthoses, cognitive prostheses, assistive
technology
30
External Aids
Practice Guidelines
 Universal evidence that external aids helps people
with memory problems and that they can use them
effectively.
 What is strikingly absent is information about how to
train or introduce people with memory impairments to
the use of aids.
 NOTE: Internal memory aids (e.g., mnemonic
strategies) were not considered, as there is good
evidence that these are not effective for individuals
with moderate-severe memory impairments.
31
Executive Functions
Kennedy, Coelho, Ylvisaker, Sohlberg, Avery, Turkstra & Yorkston (2007)
Definition:
 Processes required for the execution of goal-directed
behaviors over time
 Include ability awareness of performance and ability to
monitor and flexibly alter one’s own behavior to solve
problems
i.e., self-awareness, self-monitoring, self-regulation
32
Executive Functions
Practice Standards
 Strong evidence for
 intervention for young and middle-aged adults in the
chronic stage post-injury
 training using step-by-step self-regulatory or selfinstruction techniques will improve problem solving
in personally relevant activities or problem
situations, in young or middle-aged adults
 Strong evidence that positive outcomes will be maintained
33
Executive Functions
Practice Guidelines
 The evidence supports self-awareness training
 for young and middle-aged adults in the chronic
stage post-injury
 to increase general awareness of injury and
knowledge about brain injury, when tailored to the
individual and in large doses
 that includes feedback, while fading and shaping
behaviour, to improve self-awareness, selfmonitoring, and self-control for disruptive behaviors
in specific contexts or activities (no evidence of
generalization)
34
Social & Behavioral Problems
Ylvisaker, Turkstra, Coelho, Kennedy, Sohlberg, Avery, & Yorkston (2007)
Common challenges (often linked with
challenges in executive functions, memory, etc)
 Acting without thinking
 Socially inappropriate comments
 Reduced anger control
Types of Intervention
 Contingency-based (reward systems)
 Antecedent-based (Positive Behavioral Supports)
35
Social & Behavioral Problems
Practice Guidelines
 Behavioral intervention, both traditional
contingency management and PBS
procedures, not otherwise specified, can be
considered a treatment guideline for children
and adults with behavior disorders after TBI
 Literature has significant limitations, e.g.,
inconsistent reports of follow-up, lack of
reports of failures, procedures that work only
in some contexts
36
Instruction
Ehlhardt, Sohlberg et al, 2008
 Many rehabilitation professionals receive little to no
training in the design and delivery of effective
teaching
 Therapy involves teaching and learning; we need to
understand the science of instruction
 Instruction is critical to all the previously mentioned
areas of cognitive rehabilitation
37
Instruction
Recommendations
 Clearly specify intervention targets and/or use of task
analyses when training multi-step procedures
 Constrain errors and control client output when teaching
new (or relearning) information and procedures
 Provide sufficient practice
 Distribute practice
 Use of stimulus variation (e.g., multiple exemplars)
 Use of strategies to promote more effortful processing
(e.g., verbal elaboration; imagery)
 Select and train ecologically valid targets
38
What types of cognitive
rehab did she receive? [McKay)
1. Direct attention training (APT)
2. External memory aid training (Day planner)
3. Executive functions- Problem solving strategy
training (when cooking)
4. Functional communication training (work-related
role play)
5. Task specific training (writing thoughts ahead of
time)
6. Environmental modifications (reduce distractions)
39
Answers…
For Sara, answers #4, 5, and 6 are correct.
However, for other individuals 1, 2, and/or 3
might be the most appropriate.
Cognitive rehabilitation should be evidencebased AND individualized!
40
Insurance Documentation
Nuts ‘n Bolts
41
The “Nuts ‘n Bolts” Objectives
 Provide Overview of Billing and Coding for SLPs
 Provide Overview of Insurance and
Rehabilitation
 Identify current issues in funding for Cognitive
Rehabilitation
 How to use research evidence to support
funding
 Identify future needs and opportunities
42
Coding for SLPs
 International Classification of Diseases – 9 or
ICD-9 (indicates version in use)
 “Designed to promote international
comparability in the collection, processing,
classification, and presentation of mortality
statistics.”
 “Used in assigning codes to diagnoses
associated with inpatient, outpatient, and
physician office utilization in the U.S.”
Center for Disease Control/National Center for Health Statistics
43
ICD-9 Components
Composed of 3, 4 and 5 digits
3 digit codes are usually the heading of a category of
codes that may be further subdivided to provide greater
detail
 Cerebrovascular disease (430 – 438)
 Late effects of cerebrovascular disease = 438
 Speech & language deficits = 438.1
 Aphasia = 438.11
 Fracture of the skull (800 – 804)
 Fracture of vault of skull, includes frontal bone, parietal bone
= 800
 Closed with other and unspecified intracranial hemorrhage
= 800.3
 Symptoms, signs, and ill defined conditions (796 – 799)
44
Fresh off the press codes!
New Subcategory for 2011:
799.5 Signs and symptoms involving cognition
 New 799.51
Attention or concentration deficit
 New 799.52
Cognitive communication deficit
 New 799.53
Visuospatial deficit
 New 799.54
Psychomotor deficit
 New 799.55
Frontal lobe and executive
function deficit
 New 799.59
Other signs and symptoms
involving cognition
http://www.asha.org/uploadedFiles/ICD-9-CM-Diagnosis-Codes.pdf
45
Billing for Rehab Services
Current Procedural Terminology (CPT)
 Listing of descriptive terms and codes to report
medical and other health care services delivered by a
practitioner.
 Each procedure is associated with a 5 digit code.
 Example: 92506 = Evaluation of speech, language,
voice, communication, and/or auditory processing
disorder
 Codes can be timed or untimed.
 Example: 92507 = treatment of speech, language…;
individual
 97532 = cognitive skills development, each 15 minutes
46
Correct Coding Initiative
 Correct Coding Initiative:
Codes often have
associated components
that will restrict how
and/or in what
combination they are
billed.
 Table 2: Medicare Correct
Coding Initiative (CCI)
Edits and OCE Edits
SLP Codes Paired With
Physical Medicines Codes
CPT
Paired
Procedure With
(one)
(one)
Modifier
Used
92507,
92508,
92526
-59
97032,
97110,
97112,
97150,
97530,
97532
47
Correct Coding Initiative
 Use of the-59 modifier is not
intended to permit speechlanguage pathologists to bill for
physical medicine procedures
(97000 codes). The purpose of
the modifier, in this case, is to
allow billing of 97000
procedures performed by OTs
and PTs on the same day that
SLPs are billing 92507, 92508, or
92526.
 Regarding 97532 (cognitive skills
development), Medicare allows
usage by speech-language
pathologists, but not on the
same day as 92507.
CPT
Paired
Procedure With
(one)
(one)
Modifier
Used
92507,
92508,
92526
-59
97032,
97110,
97112,
97150,
97530,
97532
48
Health Insurance Basics
 Medicare provides the most comprehensive policy
statements and descriptions of how codes can be
applied.
 Medicare Benefit Policy Manual
 Chapter 15, Sections 220 – 230 provide coverage
information for PT, OT, SLP services
 http://www.cms.gov/manuals/Downloads/bp102c15.p
df (not in handouts; will be posted)
49
Important Insurance Concepts
 Skilled care/medically necessary
 Prognosis
 Goal Writing
 Progress/Functional gains
 Compensatory training
 Acquired versus congenital/developmental
50
Now the ugly words for rehab
 Progressive illness
 Chronic condition
 Maintenance
 Co-treatment/duplication of services
 Experimental & Investigational
 Sample policy:
Regence Speech Therapy Utilization Policy
51
Which goal statement is best?
Key difference?
A. Client will perform memory drills for 1
hour per day.
A. Client will independently use an external
memory aid (personal digital assistant
with repeated alarms) to recall when to
take medications 4/5 days a week, per
family member observation/report.
Which progress statement is best?
Key difference?
A. Having mastered use at home, client is
now responding to PDA alarms to cue
scheduled activities at work 80% of the
time when provided with indirect
questioning cues by his job coach.
A. Client is maintaining use of the PDA at
home.
Your Responsibilities as a
Licensed Professional
 Provide competent care
 Know your client’s insurance policy limits
 Remain within authorized visits/time period
 Know if you are “sharing benefits” with another discipline
 Inform your client of your treatment plan and what may be
a non-covered service
 Do not proceed without documented informed consent
 Plan for future needs
 Advocate
 Appeal
54
Future of Cognitive Rehabilitation
 Set back with Tri-Care/VA ruling and recent VA study
 Current status in Oregon
 2009 Senate bill passed requiring insurers to accept
medically necessary treatment for traumatic brain
injury
 2011 bills to be proposed to specify cognitive
rehabilitation and to broaden access under OHP.
 As of 11/10, Regence has “archived” the CR policy!
 http://blue.regence.com/trgmedpol/um/um09.html
(not in handouts; will be posted)
55
Resources
 http://www.asha.org/practice/
 http://www.ncepmaps.org/TBI-Adults.php
 http://www.internationalbrain.org/?q=node/144
 http://www.ancds.org/
 http://www.biausa.org/
 http://www.cdc.gov/TraumaticBrainInjury/index.html
 http://www.tbims.org/combi/list.html
56
Overview of Services
Advocacy Toolkit
www.cbirt.org/resources/services-advocacy-toolkit
Sample items




Power point presentations
Links to Cicerone and ANCDS literature reviews
Insurance documentation strategies
Appeals process strategies
57