To the Editor:
Many nurses don’t realize that certified therapeutic recreation specialists (CTRSs) often oversee long-term care activities departments. Before they begin practicing, CTRSs must have a minimum of a bachelor of science degree and an intensive clinical internship under a licensed or certified therapist. They have traditionally found positions in mental health, rehabilitation, and long-term care settings but have been sorely underused in skilled nursing facilities (SNFs), primarily serving as activities directors or activities leaders.
While all Medicare SNFs already benefit from coverage of therapeutic recreation (also called recreation therapy; RT)—to the extent that the facility and the attending physician determine therapeutic recreation to be medically necessary in a particular resident case—it is rarely requested and poorly documented. Coverage is currently provided within the context of a comprehensive, bundled payment to the SNF itself for its residents’ Medicare-covered stay and through documentation in Section T of the Minimum Data Set (MDS) 2.0. Unfortunately, a tiny percentage of CTRSs have been allowed by directors of nursing, nurse managers, and nursing home administrators to actually take orders and document service in MDS 2.0 Section T during the past 10 years. With the recent push to reduce psychoactive medications in frail older adults, nurse practitioners (NPs) and nurses have a new opportunity to request RT treatment for activity intolerance, anxiety, coping, fatigue, fear, hopelessness, physical immobility, disuse syndrome, diversional activity deficit, chronic pain, impaired memory, confusion, social isolation, safety and many other nursing diagnoses.
MDS 3.0, which will be implemented in October 2010, presents CTRSs working in SNFs a second chance for providing NP- or physician-ordered services. The change that MDS 3.0 represents with regard to therapeutic recreation services is that, for the first time, it will provide a mechanism for specifically recording the time spent providing therapeutic recreation services. Thus, now it will be possible to compile specific data on the provision of therapeutic recreation in the nursing home setting. It is imperative that CTRSs begin recording minutes of service in Section O beginning in October 2010 on the new MDS form. While this new recording procedure will not cause therapeutic recreation services to be considered in assigning a SNF resident to a particular Resource Utilization Group (RUG)—and although it will not be separately billable to the Medicare program—the Centers for Medicare & Medicaid Services (CMS) will be evaluating the impact of this procedure. Moreover, it provides another avenue for interdisciplinary treatment.
Nurses are encouraged to remember that therapeutic recreation furnished during the course of a Medicare-covered SNF stay is already bundled into the comprehensive per-diem payment that Part A (Medicare’s hospital insurance program) makes to the SNF for the covered stay itself. Accordingly, CTRSs who perform such services must look to the SNF (rather than to Medicare or the beneficiary) for support of these services. This support must come from nursing for true implementation.
Please note Section O, Special Treatments and Procedures, is now included as “O-0400. Therapies.” Therapists should record the total number of minutes administered in the past 7 days in Column 1, entitled “Minutes.” In Column 2, therapists record the number of days, in the past 7 days, that therapeutic recreation was administered for at least 15 minutes. In Column 3, they should record the most recent therapy regimen start date, and in Column 4 record the therapy end date. Special treatments and procedures must be provided by certified or licensed personnel and ordered by the physician or NP.
CTRSs, working with Medicare-eligible residents, have a professional duty to provide therapy, not just routine activities. These data will now become nationally available and documented through CMS. Listed below are important steps for nurses to take immediately:
- Educate yourself, your administrator, and your medical personnel about the referral process for RT and the specific protocols CTRSs are able to offer.
- Ask your CTRS to provide an RT referral form.
- Request RT to be added to “routine therapy orders” for newly admitted Medicare-eligible residents.
- The RT in your nursing facility should create a protocol book of available treatments offered. RT has evidence-based guidelines in several areas with nationally endorsed protocols available.
It is rare to be given a second chance in today’s tight health care market, but CTRSs now have the opportunity to record minutes and days of therapeutic recreation service and offer nonpharmacological interventions to complement many nursing diagnoses. We need our colleagues in gerontological nursing to take full advantage of this option beginning this October.
Linda L. Buettner, PhD, LRT, CTRS, FGSA
Professor Recreational Therapy/Gerontology
University of North Carolina at Greensboro
American Therapeutic Recreation Association
Geriatric Treatment Network Co-Coordinator
Greensboro, North Carolina