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The Anatomy of a Rehab Patient The Case Manager’s Dilemma: Who Should You Refer?

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Presentation on theme: "The Anatomy of a Rehab Patient The Case Manager’s Dilemma: Who Should You Refer?"— Presentation transcript:

1 The Anatomy of a Rehab Patient The Case Manager’s Dilemma: Who Should You Refer?

2 Medicare vs Commercial Medicare: – Must be “reasonable and necessary” – Does not say that “if the patient can be treated in SNF, they cannot be seen in an IRF” Commercial: – Totally up to the payer The only MC rule that applies to the commercial patient is that we must count them in our CMS-13 calculations – So, if functional loss and belief that IRF is the best discharge disposition, refer and we will attempt to get prior authorization Worker’s Comp will often approve rehab in spite of patient’s inability to participate at the high level of therapy intensity that Medicare requires This presentation prepared for client use by Images & Associates All Rights Reserved. 2

3 Medicare: Reasonable and Necessary Significant functional loss – Needs assist in several one or areas of function Gait, transfers, bowel and bladder, dressing, eating – Potential for gain (as assessed by the IRF and IRF physician) Need for intensive therapy – 2 therapies – 3 hrs. per day, 5 days per week or 15 hours per week Includes activities of daily living (feeding, grooming, bathing, dressing) Not all about time in the gym let the IRU decide if patient can tolerate Rehab Nursing 24/7 – To reinforce skills from therapy and to teach and coach – To address medical issues and treatment as well as functional issues Interdisciplinary Care – Rehab nursing to reinforce skills from therapy and to teach and coach – Social work/Case Management to address discharge planning and resource needs – Therapy services – Rehab physician Rehab physician supervision – To coordinate the entire team – To work with consulting medical staff – To lead the team in addressing function in spite of or along with medical management This presentation prepared for client use by Images & Associates All Rights Reserved. 3

4 Commercial Insurance Issues Not governed by Medicare requirements except that the CMS-13 diagnostic compliance is calculated on the entire population Each payer may have their own pre-cert requirements – Admissions Coordinator will facilitate this step Significant push to send patients to SNF – Less expensive on the surface; not necessarily so – May need to have physician advocate for patient with insurer’s Medical Director; but….. Commercial Payers can and do approve cases that would not meet MC payment requirements; and – It is appropriate for us to take those patients 4

5 Commercial Patients Does the patient have an IRF benefit? Does the patient have functional loss? Do you believe the patient would benefit from an interdisciplinary treatment plan to help them achieve higher levels of independence? If yes, refer to IRF. Let our clinical assessment staff review the case and make a recommendation. This presentation prepared for client use by Images & Associates All Rights Reserved. 5

6 6 Reasonable Criteria for Admission The CMS-13 Diagnostic Categories (to some extent) Prior Level of Community Activity Significant Functional Loss Potential for Significant Practical Improvement Intensive Therapy Services Rehab Nursing Requirements Requirement for Medical Supervision – Comorbid Conditions – Face-to-face physician visit 3 x per week Requirement for Coordination of Care Approved funding (yes, this is legal) This presentation prepared for client use by Images & Associates All Rights Reserved.

7 GENERAL GUIDELINES Who should be referred to IRF? This presentation prepared for client use by Images & Associates All Rights Reserved. 7

8 What’s in a Diagnosis? Medicare requires that the IRF accept 60% of it’s patients from certain diagnostic categories. – This is a certification requirement, not a coverage requirement – Patients outside these diagnoses are often good candidates for IRF Don’t deny a patient access just because of a diagnosis; but… If they have one of these diagnoses and they have functional loss, it’s likely they will qualify This presentation prepared for client use by Images & Associates All Rights Reserved. 8

9 9 CMS DIAGNOSTIC CATEGORIES Stroke Fracture Femur Spinal cord injury Brain injury Burns Congenital Deformity Amputation Major Multiple Trauma Neurological disorders Polyarthritis – Active polyarticular RA – Systemic vasculidities with joint inflammation – Severe or advanced osteo – 2 or more Joints – Total Joint Replacement if one or more: Bilateral Obesity (BMI > 50) Patient age 85 or over This presentation prepared for client use by Images & Associates All Rights Reserved.

10 Diagnosis% Stroke20.5 Hip Fracture14.4 Major Joint Replacement11.2 Debility9.9 Neurological9.7 Brain Injury7.3 Other Ortho6.5 Cardiac5.0 Spinal Cord Injury4.3 Other11.3 And, just to prove that diagnosis alone doesn’t drive rehab, The Most Common Diagnoses Much overlap with SNFs, but hospital-based units have easy access to patients and physiatrist Medical Directors on hospital staff who can complete pre- admission consultations in the hospital. Freestanding IRFs have sophisticated and aggressive referral development programs.

11 11 Elements of “Reasonableness” Rehabilitation Needs Close Medical Supervision 24 Hour Rehabilitation Nursing Relatively Intense Level of Rehab Services Multidisciplinary Team Approach Coordinated Program of Care Significant Practical Improvement Reasonable Goals Appropriate Length of Stay This presentation prepared for client use by Images & Associates All Rights Reserved.

12 Rehabilitation Needs Does the patient have functional losses that are new or that are exacerbated by this new event? – What was the patient’s prior level of function? – Active in the community (or in the case of a nursing home resident, within the nursing home community)? – How do the new functional losses impact the patient’s ability to return to home/community? Does the patient need therapy interventions to regain that function in a reasonable period of time? This presentation prepared for client use by Images & Associates All Rights Reserved. 12

13 13 Rehabilitation Needs Prior Level of Function – Specific detail of functional level Physical Function – Include how much help in detail – Include devices Community Activity – Specific detail » Driving, shopping, Church, other activities Current Functional Loss – Toileting – Toilet Transfers – Bed to/from Chair Transfers – Lower Extremity Dressing – Ambulation – Stairs – Bathing Greatest weighting for payment Key areas for development of protocols Community Activity must be well documented. This presentation prepared for client use by Images & Associates All Rights Reserved. If patient has minimal to moderate assistance requirements in several of these areas, they should be referred.

14 Close Medical Supervision Need for rehab physician visits to manage functional rehab program and coordinate medical issues Patient requires and receives management of the rehabilitation program BY THE REHAB PHYSICIAN no less than three times per week – Face to Face Visits with the Rehab Physician – Notes address functional issues as well as medical ones – Notes address progress to date and continued needs and potential for functional gains There are orders from the rehabilitation physician written at the time of admission – Include rehab nursing, therapy, etc. Rehabilitation physician synthesizes the interdisciplinary plan of care and specifies the reason for rehab There is evidence in the record that the rehab physician attends and leads the team conference The documentation in the record must be legible! This presentation prepared for client use by Images & Associates All Rights Reserved. 14

15 24 Hour Rehabilitation Nursing Must be specific orders for rehabilitation nursing procedures Nursing plan and daily notes address the patient’s needs related to rehabilitation Rehab nursing staff addresses educational needs – Disease information – Medication management – Bowel and Bladder – Self-Care – Carryover of the skills learned in therapy to the tasks completed with nursing staff Education about medication and equipment use This presentation prepared for client use by Images & Associates All Rights Reserved. 15

16 Relatively Intense Level of Rehabilitation Services Must have multiple therapies – One of which is PT or OT Intensive level of therapy services – At least 3 hrs. of therapy 5 of 7 days – Or, 15 hours per week – Once again, not all of the exercise is “gym” time – Let the IRF decide Brief exceptions policy allows some leeway – Not more than 3 days – Clear documentation of why requirement not met – Should see discussion in team notes – If problematic, consider if patient appropriate for 15 hours per week Standard of care is 1:1 therapy – If group therapy better meets patient needs, must clearly document rationale Should be a transition from patient- centered therapy to patient/caregiver education, DME training and home needs as patient approaches discharge. – Different than the acute hospital interventions that are focused on moving the patient to the next level of care Commercial Payers may have their own interpretation 16 This presentation prepared for client use by Images & Associates All Rights Reserved.

17 17 Interdisciplinary / Coordinated Delivery of Care Patient Focused, Individualized Plan of Care Interdisciplinary Approach – Team goals and objectives – Team communication – Coordination of care ITM at least every week – Standing team meeting once per week suffices – May be state specific issues requiring more frequent meetings, different documentation – Documentation includes key elements Assessing the individual's progress towards the rehabilitation goals; Considering possible resolutions to any problems that could impede progress towards the goals; Reassessing the validity of the rehabilitation goals previously established; and Monitoring and revising the treatment plan, as needed. – Attended by professionals involved in the rehab plan Must include at least: – The rehab physician (not an extender) – RN w/ training and experience in rehab (Not an LVN) and who is familiar with the patient – Social worker or case manager – Licensed therapist from each discipline involved in treating the patient (Not an assistant) and who is familiar with the patient This presentation prepared for client use by Images & Associates All Rights Reserved.

18 18 Significant Practical Improvement Goal of IRF treatment is to enable the patient’s safe return to the home or community-based environment – Generally, goal is community discharge; there are exceptions Does the medical record demonstrate measurable deficits that are likely to improve significantly with an intensive rehabilitation program – Detailed measurements at least weekly in key areas – FIM Scores are not enough, need formal measurements of ROM, strength and detail of progress In the absence of potential for independence, does documentation describe what level of functional improvement can be expected from the plan of care? MYTH: Potential SNF Placement does not preclude IRF admission and does not require immediate discharge! This presentation prepared for client use by Images & Associates All Rights Reserved.

19 Functional Loss & Potential for Improvement What is significant, measurable, reasonable? MEDICARE‘S RESPONSE: Clarification of the terms “significant benefit,” “measurable improvement,” “predetermined and reasonable period of time,” and “nature and degree of expected improvement.” We believe that rehabilitation physicians are typically able to determine from examining a patient what represents “significant benefit” for that patient, what represents “measurable improvement” for that patient, what is a “reasonable period of time” to achieve the expected level of improvement, and what the “nature and degree” of that expected improvement would be. We also expect that the rehabilitation physicians will be able to clearly explain their reasoning in the patient’s overall plan of care, which must be documented in the patient’s medical record at the IRF. This presentation prepared for client use by Images & Associates All Rights Reserved. 19 What this means to us: Medicare accepts that the rehab physician is the best qualified to make a decision about whether a patient is appropriate for IRF If the patient has functional loss that would not be expected to return simply with increased activity, they could and should be referred to the IRF.

20 Should I refer? This presentation prepared for client use by Images & Associates All Rights Reserved. 20


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