Innovative payment model needed for wellness based exercise programs
WPTA PT Connections
April 2018. Vol. 48, Issue 2
Physical therapists have a role in wellness for people with chronic degenerative disease. For people with Parkinson’s Disease (PD), the focus of wellness interventions results in the objective of preserving functional independence with a focus on sustaining walking ability and fall reduction. “I can say that movement therapy for Parkinson's patients is vital. Stretching, stamina, stability and strength training are a must to cope and fight Parkinson's disease.” Dave Stoick, RPh
An example of a well-executed wellness program, operated on a state level in very diverse communities, is the Wisconsin Parkinson Disease Exercise Program (www.exercisepd.com). This program now operates at 11 sites and over the past 15 years has provided more than 500 people with access to exercise interventions tailored to people with PD. Programs are held in a variety of locations including outpatient clinics, gyms and hospitals. The WI PD Exercise Program in its current configuration is a non-profit group offering support for the development of community based exercise groups for people with PD.
For a health condition that is hallmarked by declines in functional independence, this program provides alternatives to movement decline. In one study lasting 10 months, program participants (n= 15) improved walking endurance by 11% (six-minute walk increased 35 meters), plus maintained gait speeds (comfortable 1.03 m/s; fast 1.34 m/s), balance (Berg improved 1 point) and mobility (Timed Up and Go 16 to 14 sec). Participants also self-reported mood improved 38%.3 Exploring the successes and challenges associated with these WI PD Exercise Programs can help others in the profession replicate and improve programs in their own communities.
A 2015 study on high-intensity treadmill exercise with 43 clients with PD who exercised 30 minutes 2.8 days per week for 6 months (80% maximum heart rate, utilizing handhold for safety, forward direction only) found an average change of 3.2 points on participant’s UPDRS-MDS motor score.1 A UPDRS-motor rating scale study (n=37) reports that a change (MDC95) would have to be 11 points; the range on the scale is 0-108.2
Review of the existing programs, research exploring PD exercise and personal experience of the authors highlights the following quality indicators:
There are challenges to sustaining these programs, including that most of the clients are on Medicare. On June 16, 2017 the following email was received from Nevin Laib with the Centers for Medicare and Medicaid Services:
Dr Steffen,
Thank you for contacting the Center for Medicare and Medicaid Innovation (CMMI) to request a meeting.
We understand the potential value of treadmill therapy for patients with Parkinson’s disease. But unfortunately, we are unable to meet with you at this time. Please do not regard this as a negative assessment of your interests or your work. We have limited resources and are unable to meet with all who ask for meetings. In some cases, we determine that requests deal with issues that are outside the scope of our work or address topics that we are not in a position to study at this time. We also make decisions about meetings based on the extent of the opportunity, availability of data, prior evidence base, viability of model designs, and the relative maturity or implementation success of proposed innovations.
CMMI uses meetings with Stakeholders to learn more about innovations in health care delivery and payment and to inform the development of new model tests that show promise of reducing the cost of care while maintaining of improving health care quality. CMMI does not have the authority to fund unsolicited model tests on a noncompetitive basis. We cannot broker relationships between CMMI Awardees and Model Test participants and other potential partners. Announcement about new models are posted on our website at https://innovation.cms.gov/ and circulated via our listserv. We encourage health care innovators to join the CMS Innovation Center listserv (through the website) to receive regular updates about opportunities for engagement, input, and active participation in CMS Innovation Center model tests. Thank you for your interest in CMMI and for your efforts to improve the quality and value of health care for beneficiaries of Medicare, Medicaid, and the Children’s Health Insurance Program.
Sincerely,
Nevin The Stakeholder Engagement and Policy Team2810 Lord Baltimore Drive, Suite 130, Baltimore, MD 21244-2361 Direct: 410.786.1875 Nevin.Laib@cms.hhs.gov
What is needed is a NEW model for payment of “Wellness” that measures attendance, falls, ambulation endurance, gait speed, balance, mobility and client viewpoint. Therapists can measure ambulation endurance, gait speed, balance, mobility and client viewpoint. In a class, measurement of attendance and falls can be done.
The Wisconsin Physical Therapy Association (2017) helped by supporting making of a video (seen here).
To sustain these programs and make them grow we must find a way to get the PT or PTA to be paid like they are on the job. We are losing programs due to limited resources for therapists. “I can tell you sites in Wisconsin that want a program, but we cannot find a way of paying the therapist” Teresa Steffen, PT, PhD. The Wisconsin PD Exercise Programs have been able to sustain the cost of managing the website (coordinated by Danille Parker, PT), fees associated with the sites (paid for by client dues) and marketing the programs (promoted by various associations). The programs do not have a means of providing payment for the physical therapist running the classes.
How would YOU, the therapist and/or administrator, make this into a sustaining system? Think both as a member of an organization and if you were to be hired independently. Who would pay?
What is best for the client? Successful growth of sustainable community-based programs are part of our profession. Please help the profession decide HOW to fund the PT section of the wellness programs. This helps people with Parkinson disease walk and move safely throughout their life.
Give your recommendations to Danille Parker, danille.parker@marquette.edu or Teresa Steffen, terrysteffen123@gmail.edu Please see our website. www.exercisepd.com
References
An example of a well-executed wellness program, operated on a state level in very diverse communities, is the Wisconsin Parkinson Disease Exercise Program (www.exercisepd.com). This program now operates at 11 sites and over the past 15 years has provided more than 500 people with access to exercise interventions tailored to people with PD. Programs are held in a variety of locations including outpatient clinics, gyms and hospitals. The WI PD Exercise Program in its current configuration is a non-profit group offering support for the development of community based exercise groups for people with PD.
For a health condition that is hallmarked by declines in functional independence, this program provides alternatives to movement decline. In one study lasting 10 months, program participants (n= 15) improved walking endurance by 11% (six-minute walk increased 35 meters), plus maintained gait speeds (comfortable 1.03 m/s; fast 1.34 m/s), balance (Berg improved 1 point) and mobility (Timed Up and Go 16 to 14 sec). Participants also self-reported mood improved 38%.3 Exploring the successes and challenges associated with these WI PD Exercise Programs can help others in the profession replicate and improve programs in their own communities.
A 2015 study on high-intensity treadmill exercise with 43 clients with PD who exercised 30 minutes 2.8 days per week for 6 months (80% maximum heart rate, utilizing handhold for safety, forward direction only) found an average change of 3.2 points on participant’s UPDRS-MDS motor score.1 A UPDRS-motor rating scale study (n=37) reports that a change (MDC95) would have to be 11 points; the range on the scale is 0-108.2
Review of the existing programs, research exploring PD exercise and personal experience of the authors highlights the following quality indicators:
- Wellness programs have evidence based interventions. For PD exercise, the WI PD Exercise Programs have been vetted and improved over the course of the last 15 years, continually incorporating both best evidence and experience of the therapy instructors.
- Physical therapists with an understanding of movement dysfunction direct and execute the programs, providing both supervision in real time and training to those assisting in the delivery of the program. Additionally, the involvement of the physical therapists assures that exercise dosage is progressed as the clients continue to engage with the program.
- Client participation outcomes are monitored regularly and used to document the success of the intervention. The Wisconsin PD Exercise Program, recommends that participants are re-assessed every 6 months in a PT clinic.4
- Programs are designed for sustainability – meaning aerobic content is mapped onto equipment familiar to participants and available in many different locations. This allows participants to continue to adhere to program exercises when travelling and working out at home.
- The programs incorporate social support and active community participation to build participants confidence.
There are challenges to sustaining these programs, including that most of the clients are on Medicare. On June 16, 2017 the following email was received from Nevin Laib with the Centers for Medicare and Medicaid Services:
Dr Steffen,
Thank you for contacting the Center for Medicare and Medicaid Innovation (CMMI) to request a meeting.
We understand the potential value of treadmill therapy for patients with Parkinson’s disease. But unfortunately, we are unable to meet with you at this time. Please do not regard this as a negative assessment of your interests or your work. We have limited resources and are unable to meet with all who ask for meetings. In some cases, we determine that requests deal with issues that are outside the scope of our work or address topics that we are not in a position to study at this time. We also make decisions about meetings based on the extent of the opportunity, availability of data, prior evidence base, viability of model designs, and the relative maturity or implementation success of proposed innovations.
CMMI uses meetings with Stakeholders to learn more about innovations in health care delivery and payment and to inform the development of new model tests that show promise of reducing the cost of care while maintaining of improving health care quality. CMMI does not have the authority to fund unsolicited model tests on a noncompetitive basis. We cannot broker relationships between CMMI Awardees and Model Test participants and other potential partners. Announcement about new models are posted on our website at https://innovation.cms.gov/ and circulated via our listserv. We encourage health care innovators to join the CMS Innovation Center listserv (through the website) to receive regular updates about opportunities for engagement, input, and active participation in CMS Innovation Center model tests. Thank you for your interest in CMMI and for your efforts to improve the quality and value of health care for beneficiaries of Medicare, Medicaid, and the Children’s Health Insurance Program.
Sincerely,
Nevin The Stakeholder Engagement and Policy Team2810 Lord Baltimore Drive, Suite 130, Baltimore, MD 21244-2361 Direct: 410.786.1875 Nevin.Laib@cms.hhs.gov
What is needed is a NEW model for payment of “Wellness” that measures attendance, falls, ambulation endurance, gait speed, balance, mobility and client viewpoint. Therapists can measure ambulation endurance, gait speed, balance, mobility and client viewpoint. In a class, measurement of attendance and falls can be done.
The Wisconsin Physical Therapy Association (2017) helped by supporting making of a video (seen here).
To sustain these programs and make them grow we must find a way to get the PT or PTA to be paid like they are on the job. We are losing programs due to limited resources for therapists. “I can tell you sites in Wisconsin that want a program, but we cannot find a way of paying the therapist” Teresa Steffen, PT, PhD. The Wisconsin PD Exercise Programs have been able to sustain the cost of managing the website (coordinated by Danille Parker, PT), fees associated with the sites (paid for by client dues) and marketing the programs (promoted by various associations). The programs do not have a means of providing payment for the physical therapist running the classes.
How would YOU, the therapist and/or administrator, make this into a sustaining system? Think both as a member of an organization and if you were to be hired independently. Who would pay?
What is best for the client? Successful growth of sustainable community-based programs are part of our profession. Please help the profession decide HOW to fund the PT section of the wellness programs. This helps people with Parkinson disease walk and move safely throughout their life.
Give your recommendations to Danille Parker, danille.parker@marquette.edu or Teresa Steffen, terrysteffen123@gmail.edu Please see our website. www.exercisepd.com
References
- Schenkman M, et al Effect of High-Intensity Treadmill Exercise on Motor Symptoms in Patients with De Novo Parkinson Disease. JAMA Neurol. 2018Feb 1:75:219-226.
- Steffen T, Seney M. Test-Retest Reliability and Minimal Detectable Change on Balance and Ambulation Tests, the 36-Item Short-Form Health Survey, and the Unified Parkinson Disease Scale in People with Parkinsonism. Physical Therapy. 2008, 88:733-746.
- Steffen T, Petersen C, Dvorak L. Community-Based Exercise and Wellness Program for People Diagnosed With Parkinson Disease: Experiences From a 10-month Trial. Journal of Geriatric Physical Therapy. 2012;35:173-180.
- Duncan R, Leddy A, Cavanaugh J, Dibble L, Ellis T, Ford M, Foreman KB, Earhart G. Accuracy of fall prediction in Parkinson Disease: Six-month and 12-month prospective analyses. Parkinson’s Disease. 2012,237673.