The Jimmo agreement settles once and for all that Medicare coverage is available for skilled services to maintain an individual’s condition. Under the maintenance coverage standard articulated in the Jimmo Settlement, the determining issue regarding Medicare coverage is whether the skilled services of a health care professional are needed, not whether the Medicare beneficiary will "improve." Pursuant to Jimmo, medically necessary nursing and therapy services, provided by or under the supervision of skilled personnel, are coverable by Medicare if the services are needed to maintain the individual’s condition, or prevent or slow their decline.
When considering how to approach setting goals for a patient receiving maintenance therapy delivered by a clinician, analyze the at-risk behavior or decline that would result from a lack of skilled intervention.
Physical Therapy Goal Setting:
- The patient will maintain ambulation to 250 feet without loss of balance or shortness of breath utilizing [devise or type of strategy i.e. step to] technique with physical therapy.
- The patient will identify potential fall hazards in path with potential loss of balance 80% accuracy through daily skilled intervention with physical therapy.
- The patient will safely ambulate outside and manage barriers (doors, steps, obstacles) without loss of balance and minimal assistance from a physical therapist.
- The patient will maintain the ability to perform [insert level of performance] sit to stand transfer with the rolling walker.
- The patient will maintain the ability to complete a complex standing task for 5 minutes to allow for grooming/hygiene tasks without demonstrating shortness of breath or excessive fatigue.
- The patient will maintain ____ degrees of lower extremity ROM s/p hip fracture w/o surgical repair to prevent irreversible fixed contracture at the hip joint.
Occupational Therapy Goal Setting:
- The patient will maintain tolerance for ___ splint as applied by occupational therapy and periodic skin assessment for s/s of redness.
- The patient will maintain _____ degrees AAROM UE to reduce risk of fixed bony contracture.
- The patient will tolerate feeding self with minimal assist, occasional verbal cues, and hand under hand technique 100% of meals with occupational therapy to maintain current weight at ______ lbs.
- The patient will maintain the ability to perform toilet transfers at moderate assist level to prevent deterioration due to Parkinson’s disease with significant intention tremors.
Speech Therapy Goal Setting:
- The patient will tolerate a ground diet with no signs/symptoms of dysphagia or aspiration pneumonia with skilled speech therapy intervention.
- The patient will maintain the use of safe swallow strategies as instructed by Speech therapy at each meal to prevent aspiration.
- The patient will perform oral motor exercises to maintain functional oral motor strength for speech and swallowing capabilities daily with speech therapy cuing and supervision.
Per usual, the Medicare law provides for up to 100 days of coverage per benefit period. The Jimmo Settlement confirms that Medicare coverage is available for skilled nursing and therapy that is needed to maintain a person’s condition or slow deterioration, for nursing home, home health, and outpatient therapy.